Elder Law Prof Blog

Rapid Response Conservatorship Project

The Rapid Response Conservatorship Project from the Center for Elders & the Courts is using technology to create "[a] modernized proactive court process that safeguards the as sets of those placed under a conservatorship." The website offers some information about the project: "NCSC will pilot the two-year project in two courts to develop and refine implementation strategies that can be adopted nationwide. The project will result in highly efficient court processes and has the potential to end the exploitation of conservatorship assets." The website describes 3 phases: planning, implementing and replicating. The project looks at 5 steps: appointing a conservator, using technology and machine learning  to establish a "financial profile" which in turn notifies courts of unusual activities which will then allow courts to take action with the result of "[i]ntegrating monitoring, alerts, and timely resolution into the court management process [which] will improve the administration of justice—and protect the assets of the vulnerable."

Cate Boyko is the project director

 

Is SSA Calling? Nah, It's a Scam

There have been many reports regarding the Social Security scam and according to the FTC the scam is growing like kudzu (i.e. rapidly). According to the FTC, the "scam is now growing exponentially. To compare: in 2017, we heard from 3,200 people about SSA imposter scams, and those people reported losing nearly $210,000. So far THIS year: more than 35,000 people have reported the scam, and they tell us they’ve lost $10 million."

 This week the FTC released a recording of the scam,  This is what a Social Security scam sounds like  so you will know how to better spot it. The recording is 39 seconds-well worth your time for a quick listen. The FTC offers this advice

Here's what to know:

• Your Social Security number is not about to be suspended. You don’t have to verify your number to anyone who calls out of the blue. And your bank accounts are not about to be seized.

• SSA will never call to threaten your benefits or tell you to wire money, send cash, or put money on gift cards. Anyone who tells you to do those things is a scammer. Every time.

• The real SSA number is 1-800-772-1213, but scammers are putting that number in the caller ID. If you’re worried about what the caller says, hang up and call 1-800-772-1213 to speak to the real SSA. Even if the wait time is long, confirm with the real SSA before responding to one of these calls.

• Never give any part of your Social Security number to anyone who contacts you. Or your bank account or credit card number.

Congress Sends $100 Million Alzheimer's Funding Bill to President

This week I'm back in Arizona and again immersed in the world of dementia.  For those following this Blog, you may be aware my "last" parent, my mother, is on the rocky path of neurocognitive decline.  Her path is different from my father's course, and that fact alone constantly makes me wonder "what is going on here?"  Earlier this year, Mom moved into a dementia-specific assisted living center where my father was for three years before his passing in 2017, and in many ways this feels like coming home when I return. I get lots of hugs, from my mother of course, but also from other residents and long-time friends on the staff.  

This center is a important counterpoint to all the stories about poor care in nursing homes.  It isn't fancy --- and the choice of location was my mother's -- first when Dad needed more help, and then when we discussed options with Mom in the face of facts that showed a two story house was just plain unsafe for her as well.  While she wasn't happy about the need to move, at the point of decision she was still able to remember this as a viable choice. 

Every day my sister and I are thankful for the caring staff, the behavioral approach to care (no restraints and lots of activities that entertain and make days just a bit more fun), excellent food and a beautiful setting with lots of places to walk.  The problem with this care center is not the "place."

The problem is the disease.  The tedium of some days, the small and large ways in which someone can be annoyed, frustrated or embarrassed by needing help, the moments when even excellent care and the participation of family members cannot stop someone from crying, falling, hitting out, or sitting in sullen silence -- all of those problems are caused by dementia.   

So it is welcome news to read that the House and the Senate have passed an "historic" spending bill, $100 million (in $20 million annual amounts, over 5 years), in support of dementia resources.  The bill is now before the President. For early details about the bill, read McKnight's coverage, "Historic $100 Million Alzheimer's Bill."

Sounds like a lot of money, doesn't it?  And it is, until you think about the furor over $5 billion for a wall.    

For Nursing Homes Trapped in A Cycle of Failure -- What Solutions Are Available?

Recently I had a chat with a lawyer I've known for years who does a very good job representing large nursing home chains. We found ourselves shaking our heads about a series of news stories reported by central Pennsylvania's Patriot News focusing on care facilities formerly operating as part of the Golden Living chain. See the investigatory report, Still Failing the Frail.

Apparently, even after pressured transfers of the facilities to different companies, presumably companies with better management and better financial resources, many of them "continue to rack up citations with the state Health Department" for substandard practices.    I asked the lawyer whether he knew of any nursing home chain that has been able to pull out of death spiral?  He couldn't remember one.   

There is very little margin when low-income residents depend on Medicaid for payments.  Once a facility is affected by fines and pressures to increase staffing, the margin becomes even tighter.   Few states want to assume the roles of trustee or receivers for such properties.  The article concludes that one necessary step is to increase Medicaid funding.   

Although researchers recommend that nursing homes provide at least 4.1 hours of care per resident per day, it remains an open question whether all nursing homes can afford to do that. 

State and federal governments are the primary payers for the vast majority of nursing home residents. Residents receiving short-term rehabilitation are generally covered by Medicare, administered by the federal government. Long-term residents are generally covered by Medicaid, administered by state governments.

 

The problem is that state Medicaid programs, as in Pennsylvania, pay nursing homes far less than federal Medicare – sometimes as much as a third.

 

Although nursing home advocates and some researchers believe for-profit nursing homes routinely skimp on care in order to paid their profits, there are also genuine concerns about whether Pennsylvania’s Medicaid funding is adequate.

 

Researchers recommend how much of existing Medicaid and Medicare dollars are going to profit and administrative costs in homes. That would help determine whether Medicaid rates need to be raised and, if staffing standards are also raised, how much additional funding they need to provide those levels.

For some states, such as Pennsylvania, the Medicaid funding formula is part of the challenge.  As discussed in the series, other states have been able to create direct payment models to assure better accountability for patient care.  

NYT: Making Annuities Easier to Understand

The more I work in the field of elder law, and teach classes, the more I am convinced that enterprises who market to families and seniors fail to realize greater transparency can help their commercial products and enterprises succeed. 

Thus, it is useful to read a New York Times' column on annuities, one that appears to be the first of a series.  The author, Ron Lieber, begins his column on The Simplest Annuity Explainer We Could Write:

Annuities can be complicated. This column will not be.

 

After I wrote two weeks ago about getting tossed out of the office of an annuity salesman, there was a surprising clamor for more information about this room-clearing topic. One group of readers just wanted a basic explainer on how annuities work. For that, read on.

 

Another group of readers worried that those hearing of my experience might assume that all annuities are bad, and that all people who sell them use subterfuge to do so. Neither of those is true: Next week, I’ll introduce you to some reasonable people who are trying to use certain annuities in new and improved ways.

My thanks to Dickinson Law colleague Laurel Terry for the heads up!

ALFs Too Popular for Resident Safety?

Kaiser Health News recently ran a story about ALFs that focuses on resident safety. Assisted Living’s Breakneck Growth Leaves Patient Safety Behind opens with a story about one resident and then points out

Assisted living facilities were originally designed for people who were largely independent but required help bathing, eating or with other daily tasks. Unlike nursing homes, the facilities generally do not provide skilled medical care or therapy, and stays are not paid for by Medicare or Medicaid.

Dementia care is the fastest-growing segment of assisted living. As these residences market themselves to people with Alzheimer’s and other types of dementia, facilities across the country are straining to deliver on their promises of security and attentive care, according to a Kaiser Health News analysis of inspection records in the three most populous states.

We know that ALFs are regulated at the state level and thus regulations from one state may vary from another. We also know that residents of ALFs are going to need assistance with ADLs. What more do we know?

[Residents] are older and frailer than assisted living residents were a generation ago. Within a year, 1 in 5 experience a fall, 1 in 8 visit an emergency room and 1 in 12 have an overnight hospital stay, according to the Centers for Disease Control and Prevention. Half are 85 or older.

“Assisted living was created to be an alternative to nursing homes, but if you walk into some of the big assisted living facilities, they sure feel like a nursing home,” said [one expert who is] director for mission partnerships with the Alzheimer’s Association.

There is a tension between viewpoints-regulation vs. the environment the facilities market for residents. Residents with dementia may pose a challenge for the ALFs.

Nearly a quarter of the nation’s 30,000 assisted living facilities either house only people with dementia or have special areas known as memory care units. These wings have locked doors and other safeguards to prevent residents from leaving. The facilities often train staff members in techniques to manage behavior related to these diseases and provide activities to keep the residents engaged and stimulated.

These units usually are more expensive, with monthly costs averaging $6,472, compared with $4,835 for regular assisted living, according to a survey by the National Investment Center for Seniors Housing & Care, a group that analyzes elder care market trends. Senior housing investors earned nearly 15 percent in annual returns over the past five years, higher than for apartment, hotel, office and retail properties, according to the center. Beth Burnham Mace, chief economist at the center, said memory care unit construction was outpacing all other types of senior housing.

Aggressive behavior, a hallmark of dementia, is a major problem in assisted living facilities. One national study, published in 2016, found that 8 percent of assisted living residents were physically aggressive or abusive toward residents or staff.

As noted earlier, regulation varies amongst the states. According to one study cited in the article, "only seven states required facilities to have a registered nurse. States required anywhere from two to 30 hours of training for dementia unit workers. A handful of states required no specialized training ... [and]  19 states set minimum staff-to-resident ratios for dementia units, while the others left it to the facilities."

Webinar-Recognizing Elder Abuse

Mark your calendars now for a free webinar from the National Center on Law & Elder Rights on Signs of Elder Abuse, Neglect, and Exploitation. The webcast is scheduled for 2 p.m. on January 16, 2019.  Here is a description of the webinar

Lawyers and others who work with older adults should be aware of potential signs of abuse, neglect, and exploitation. This awareness requires an understanding of abuse signs, as well as the questions to ask when abuse is suspected. As the first part in the forthcoming National Center on Law and Elder Rights (NCLER) Elder Justice Toolkit, this webinar will help lawyers tune in to potential warning … Moresignals and train the audience on key questions to ask when elder abuse is suspected. The fast paced one-hour program will include checklists of physical, behavioral, and emotional signs of abuse, sexual abuse, self-neglect, caregiver neglect, and exploitation. 

To register, click here.

DC Bar's Professional Responsibilities Program Offers Interesting Topics

The DC Bar is offering a CLE program on "Faultlines and Eruptions: Legal Ethic in Perilous Times."  Here are some of the included topics:

Widespread discord in our current culture places unusual stress on professional ethics, and –
unfortunately – the legal profession is not immune.  The past year saw many legal professionals, including famous names in the law, make questionable decisions and breach legal ethics standards, providing both cautionary tales and fodder for analysis.  This challenging and interactive class will explore important developments and looming perils that every lawyer should be ready to face. 
 

Topics include:

• Legal ethics for "fixers"
• Direct adversity vs. "general adversity," and whether it matters
• Sexual harassment as a legal ethics problem, and the profession's vulnerability to "The King's Pass"
• Defying a client for the client's own good
• Fees, referrals, and gaming the rules for fun and profit
• Professional responsibility vs. legal ethics
• The increasing threat to law firm independence and integrity
• The technology ethics earthquake

All topics seem relevant to today's "interesting" times.  

Ohio Supreme Court Addresses Liability of a Surviving Spouse for Nursing Home Debt

University of Cincinnati College of Law Professor of Practice Emerita Marianna Brown Bettman has a very interesting and well-written Blog report on the Ohio Supreme Court's December 12th decision in Embassy Healthcare v. Bell.  The issue is under what circumstances a surviving spouse can be held liable for her deceased husband's nursing home costs under a statutory theory of "necessaries." Lots to unpack here.   

Rob Lowe, Actor & Rob Lowe, Caregiver

The November 30, 2018  print issue of Newsweek ran an essay published earlier in  November by actor Rob Lowe, Who Cares for the Carer. The article explains the juggling required by caraegivers who work and the legislative efforts at both the federal and state levels. Mr. Lowe, in his essay, does acknowledge that his family has financial resources to hire others, and recognizes that many caregivers may not have that same option. Here are some excerpts from his opinion piece:

There are so many little ways a dedicated caregiver can be a game changer—someone who can dramatically increase the chances of a successful outcome for your loved one. It is critical, for example, for patients with a serious illness to have a third party with them at doctor’s appointments. When I was helping to promote an awareness campaign for a new chemotherapy drug in 2002, I came across a startling number: Patients often retain just 10 percent of the information they are being given. Ten percent!

He offers some heartfelt advice to the caregivers:

The people we are talking about—the friends and family members who are out there doing crucial work—are unpaid. Watching a loved one go through an illness, possibly ending in death, is stressful and depressing. Add financial and scheduling burdens, and the load for caregivers is enormous. To them I say, Don’t forget about yourself. When you get on an airplane, the crew says, “Secure your own mask first before helping others.” Why? Because without you taking care of yourself, you can’t take care of anybody else.

He closes with some final recommendations  to caregivers,  "don’t hesitate to get help. That’s why I’ve partnered with EMD Serono and EmbracingCarers.com, where you’ll find invaluable information regarding everything you’ll be, or are, going through."

I like to use real world examples in my classes and when I can use an example of someone my students know, I think it helps them understand the depth and breadth of elder law.

 

Psychiatric Advance Directives Gain Prominence

The New York Times reported last week on psychiatric advance directives in  Now Mental Health Patients Can Specify Their Care Before Hallucinations and Voices Overwhelm Them

"[A]  psychiatric advance directive, a legal document declaring what treatment he does and doesn’t want. Increasingly, patients, advocates and doctors believe such directives (called PADs) could help transform the mental health system by allowing patients to shape their care even when they lose touch with reality. Hospitals must put them in patients’ medical records and doctors are expected to follow them unless they document that specific preferences aren’t in the patients’ best medical interest."

The article notes that not everyone is in favor of these. For example, "some doctors and hospitals are wary that the documents could tie their hands and discourage treatment they consider warranted. Some worry the directives won’t be updated to reflect medical advances. Others question whether people with serious psychiatric conditions are ever capable of lucidly completing such directives."  The article notes that at least 27 states allow for the use of psychiatric advance directives-others may do so as part of the more traditional health care advance directive.  The document is seen as an alternative to involuntary commitment.

CMS now requires health care providers to include in their inquiry about health care directives any psychiatric advance directive (see here requirements that hospitals ask if patients have a directive).  The directive also allows advance permission by the patient for the health care providers to engage with friends or family, particularly important because during a crisis, the person  may "be too unstable or paranoid to give permission."  The article gives examples of what might be authorized by the directive, offers suggestions regarding drafting and signing and shares stories of some individuals who have created these directives.

On a side note, the article notes that the directives are referred to as PAD.  On an unrelated topic, physician-aided dying is also sometimes shortened to PAD. Make sure your students understand the differences.

High Number GA Nursing Homes Receive Medicare Penalties

Yesterday I blogged about a SNF chain in Texas filing bankruptcy.  Today, it's about Georgia's nursing homes. Georgia Health News reported last week that Medicare penalties hit most Ga. nursing homes. According to the article 75% of the SNFs in Ga have been hit with penalties regarding unnecessary hospital readmissions. Twenty-three percent received bonuses for avoiding such a problem.  "Kaiser Health News reported that hospitalizations of nursing home residents, while decreasing in recent years, remain a problem, with nearly 11 percent of patients in 2016 being sent to hospitals for conditions that might have been avoided with better medical oversight. ... The program of bonuses and penalties is intended to discourage nursing homes from discharging patients too quickly. That’s something that is financially tempting, because Medicare fully covers only the first 20 days of a stay and generally stops paying anything after 100 days...." The article includes a link to the bonuses/penalties list, which can be found here.

High Number GA Nursing Homes Receive Medicare Penalties

Yesterday I blogged about a SNF chain in Texas filing bankruptcy.  Today, it's about Georgia's nursing homes. Georgia Health News reported last week that Medicare penalties hit most Ga. nursing homes. According to the article 75% of the SNFs in Ga have been hit with penalties regarding unnecessary hospital readmissions. Twenty-three percent received bonuses for avoiding such a problem.  "Kaiser Health News reported that hospitalizations of nursing home residents, while decreasing in recent years, remain a problem, with nearly 11 percent of patients in 2016 being sent to hospitals for conditions that might have been avoided with better medical oversight. ... The program of bonuses and penalties is intended to discourage nursing homes from discharging patients too quickly. That’s something that is financially tempting, because Medicare fully covers only the first 20 days of a stay and generally stops paying anything after 100 days...." The article includes a link to the bonuses/penalties list, which can be found here.

Texas SNF Chain Files Bankruptcy

The Dallas Morning News ran a story about the largest SNF chain in Texas filing bankruptcy. Texas' largest nursing home operator files for bankruptcy, sparking concerns about patients, jobs explains that "Senior Care Centers, which operates more than 100 facilities in Texas, filed for reorganization in U.S. bankruptcy court for the Northern District of Texas on Tuesday, reporting more than $100 million in debt. It's at least the second troubled nursing care giant in the Dallas area to file for bankruptcy since late last year." What's happening? According to the chain's press release, "high rents and 'burdensome debts'" are to blame.  The chain puts as positive a spin as possible on their situation but others see cause for concern.  A Texas advocacy organization for the long-term care facilities points to the low Medicaid reimbursements. Two facilities owned by the chain were hit last year with violations stemming from Hurricane Harvey. The article notes that the bankruptcy judge has the ability to name a "patient-care ombudsmen to monitor care" as the bankruptcy moves forward, but one has not yet been appointed.

One interesting point in the article-in discussing steps taken by the chain to improve its bottom line, it sought a reduction in rent and now is in debt to one landlord for more than $31 million.

 

Rural & Tribal Justice Webinar Series from DOJ

Mark your calendars for a free webinar on December 13, 2018 from noon-1 from DOJ's Elder Justice Initiative on Resources for Financial Institutions to Prevent & Protect Against Elder Financial Exploitation.

Here is a synopsis from the website:

Bankers, brokers, and investment advisors are often some of the first trusted parties to see signs of financial exploitation. This presentation will support the work already done by financial services members and provide additional information about how to access training programs and support for tellers and other financial professionals who want to report financial exploitation and work collaboratively with others in their communities to prevent it.

Please join us for a webinar on December 13, 2018, at 1:00 p.m. e.t., on Resources for Financial Institutions To Prevent and Protect Against Elder Financial Exploitation with host Judith Kozlowski, J.D., consultant and subject matter expert with DOJ's Elder Justice Initiative, and presenter Lisa Bleier, J.D., Managing Director and Associate General Counsel at the Securities Industry and Financial Markets Association (SIFMA), and leads its Senior Investor Protection efforts. Her primary responsibilities at SIFMA include working with Members of Congress and government regulators on retirement, IRA, and executive compensation matters. Before moving to SIFMA, Ms. Bleier was Vice President and Senior Counsel at the American Bankers Association and worked on Capitol Hill. Also presenting is Billie McNeeley, Financial Exploitation Specialist, Aging & People with Disabilities at the Oregon Department of Human Services, she is a leader in developing and training bank tellers to recognize financial exploitation and move to action. Formerly with the Oregon Bankers Association, she is a national advocate for the role that small banks and credit unions can play in addressing elder financial exploitation.

They will discuss how financial professionals in small and medium-sized firms can use available tools and training to recognize and fight elder financial exploitation. The discussion includes what tellers, back-office professionals, and those in the c-suite can do to address this important issue.

To register for the webinar, click here.

Thinking about New York Time's Article on Guardianships and One Woman's Personal Story

For anyone working in legal fields where adult guardianships may be an option, for anyone teaching elder law, health care law, constitutional law or even landlord-tenant law, a recent New York Times article, "I'm Petitioning . . . for the Return of My Life," is an important read.

On a threshold level, this is a well-told tale of one woman, Ms. Funke, who becomes subject to an intervention under New York adult protective services law, and, eventually, to a full-blown guardianship proceeding.   It can be easy to become enraged on behalf of Ms. Funke as you read details about her past life as a freelance journalist and world traveler, and compare it to the limitations placed on her essential existence under a guardianship. 

The article is a rather classic example of using one tragic story, a human story, to paint a picture of a government process gone wrong.  At several points in the article, the writer, John Leland, offers questions that suggest some conclusions about how unfair the process has been to Ms. Funke.  The writer asks, for example, 

"If you were Ms. Funke, shouldn't you be allowed to withdraw into the covers [of your bed] if you wanted to?  And the clutter in your apartment -- couldn't people understand that a writer needs materials around?  Even if she were evicted, she had money to start somewhere else.  Courts evict people with lots less [than she appears to have]. " 

It's implied that the answers to those questions may outweigh the fact that the protective services intervention prevented the landlord from completing an eviction of Ms. Funke, an eviction that would have forced her out of her apartment of 40+ years.    

Other, less dramatic details in the article suggest that for every Ms. Funke, there may be other people -- an unknown number of people in New York -- who are also very alone and who have also lost control over their lives because of physical frailty, mental decline, depression or other facts, and who are rescued with the help of a protective services intervention. Sometimes the intervention interrupts the decline, usually with the help of family member or friend who volunteers to help, sometimes acting with a measure of authority under a power of attorney, making a guardianship unnecessary. 

The challenge, of course, is knowing when to help (and how far to go), and when to preserve the  individual's right  to make choices that appear unsafe.  Some of the most complex cases involve people who have spent a lifetime on a unique and often solo path, and now have few family members or friends to help them as that path becomes rockier with age or illness, especially when they have no plan for the future.  In the face of such facts, as one person interviewed in the article observes, guardianships are a "blunt instrument."

Something I wrote about last week also figures into the New York situation -- the apparent absence of a guardianship case tracking or monitoring system.  

But another issue I'm concerned with is also suggested.  At one point, an interview with one of Ms. Funke's guardians, a so-called professional (in other words, not a family member or a public guardian) discloses he does not know how far his authority as guardian extends.  For example, would he be allowed to prevent her from marrying?  He responded, he did not know.

It would seem that guardians and other agents, alleged incapacitated persons, -- and family members -- could all benefit from greater information, and to ongoing education on their rights, duties and options.  That was also a theme emerging from article asking the question  "Where's Grandma?" that I linked to last week and that I link to again here.    

My thanks to the several folks who suggested this New York Times article for discussion on our Blog, including my Dickinson Law colleague, international human rights expert, Dermot Groome.    

Grandma Goes Apple... or Apple Goes for Grandma?

Well, I guess it was only a matter of time. I've blogged on numerous occasions about "elder tech" and now it seems Apple, at least its watch, is moving into that market. Kaiser Health News reported In Grandma’s Stocking: An Apple Watch To Monitor Falls, Track Heart Rhythms.

[W]hen Apple unveiled its latest model in September — the Series 4, which starts at $399 — it was clear it was expanding its target audience. This Apple Watch includes new features designed to detect falls and heart problems. With descriptions like “part guardian, part guru” and “designed to improve your health … and powerful enough to protect it,” the tech giant signaled its move toward preventive health and a much wider demographic.

One expert quoted in the article noted that the older generation is used to wearing watches and thus this would be a much easier wearable for them.  Here's how the fall monitoring feature works. "The fall-monitoring app uses sensors in the watchband, which are automatically enabled for people 65 and older after they input their age. These sensors track and record the user’s movements, and note if the wearer’s gait becomes unsteady. ... If a fall is detected, the watch sends its wearer a notification. If the wearer doesn’t respond within a minute by tapping a button on the watch to deactivate this signal, emergency services will be alerted that the wearer needs help."  We all know how falls can lead to devastating complications for older persons.

The heart monitor feature again using wristband sensors  is used  "to monitor a patient’s heartbeat and send alerts if it gets too fast or too slow. Specifically, the app is meant to detect atrial fibrillation, which is a type of arrhythmia, also described as a problem with the speed or rhythm of the heartbeat." The article notes some doctors have concerns that this feature will send folks needlessly to the ER.

The article notes that the FDA has "cleared" but not approved the feature, which means "that means they haven’t faced as much rigorous testing as something that has gained the agency’s formal OK."

More to come.

Kansas Disciplinary Case on Fees

The Kansas Supreme Court released a lengthy disciplinary opinion on November 30, 2018  that concerns, among other things, excessive fees. The case, In re: Crandall, resulted in a 6 month suspension.  The opinion is available here.   The Kansas Supreme Court addressed several procedural issues in its opinion. As far as fees, the court found that "testimony provides clear and convincing evidence and establishes that the representation of [clients] was straightforward and did not require the time and labor needed to justify the amount ... charged." The opinion goes step-by-step through the  provisions of Rule 1.5(a) criteria to determine reasonableness of a fee. The Court found that there was clear and convincing evidence that the attorney had violated Rule 1.5.  The opinion also examines other issues and concludes "that the fees in two cases were unreasonable in violation of KRPC 1.5(a) and that [the attorney] violated KRPC 1.1 (competence), 1.3 (diligence), 1.4(b) (communication), 1.7(a) (concurrent conflict of interest), and 8.4(d) (conduct prejudicial to the administration of justice)."

Several Items Relating to Nursing Homes & Quality of Care

I have collected four  items regarding nursing homes, that  I thought I'd summarize in one  post.

First

Regular readers will recall that Florida now requires SNFs to have generators (after last year's hurricane).  Last month's Health News Florida reported that many nursing hones are seeking extensions of time on the requirement to have generators. Nursing Homes Seek More Time On Generator Requirements notes that "[m]ore than 40 percent of Florida nursing homes are asking health-care regulators for more time to meet backup-power requirements pushed by Gov. Rick Scott after Hurricane Irma last year... But ... the state’s top health-care regulator, said his agency won’t approve waiver requests for deadbeat facilities that haven’t worked over the past several months to carry out emergency backup-power plans."  Slightly more than 25% of the facilities are in compliance and over half of ALFs are.  Some ALFs not in compliance are the focus of penalties, "the state has moved ahead with penalizing a handful of ALFs that aren’t in compliance. In November, the state has entered into settlement agreements with more than a dozen ALF providers across the state to settle allegations that they failed to meet the requirements, according to a review of information on a state website."

Second

The  Washington Post ran an article last month, Overdoses, bedsores, broken bones: What happened when a private-equity firm sought to care for society’s most vulnerable. The article focused on the ownership of of a chain owned by "the Carlyle Group, one of the richest private-equity firms in the world [where], the ManorCare nursing-home chain struggled financially until it filed for bankruptcy in March. During the five years preceding the bankruptcy, the second-largest nursing-home chain in the United States exposed its roughly 25,000 patients to increasing health risks, according to inspection records analyzed by The Washington Post."  The article includes a response from the chain as well as the private equity group:

Carlyle and HCR ManorCare representatives said care at the nursing homes was never compromised by financial considerations. The cost-cutting trimmed administrative expenses, not nursing costs, they said. The number of nursing hours provided per patient stayed fairly constant in the years leading up to the bankruptcy, according to the figures that the company reported to the government.

HCR ManorCare officials also disputed the idea that quality at the homes had suffered in recent years. They said their nursing homes offered excellent service based on the ratings issued by Medicare, the federal government’s insurance program for older Americans. ManorCare homes averaged 3.2 stars in the years before bankruptcy, which was slightly below the U.S. average. Some watchdog groups, such as the Center for Medicare Advocacy, are critical of the five-star rating system, however, because it relies on unaudited data reported by nursing homes.

The article examined complaints in several states, reported on the views expressed by the private euity firm, including the role of Medicare reimbursements and reported that "[a]fter the bankruptcy,  the nursing home chain was bought by Promedica Health, a nonprofit group."

Third

Bloomberg Law reported last week that payroll data is being used to examine staffing. Sparse Nursing Home Staffing to Be Sniffed Out in Payroll Data explains that "[t]he payroll data will be used to identify nursing homes that have a significant drop in staff on weekends or have several days in a quarter without a registered nurse on site, the federal Medicare agency said Nov. 30. Nursing homes must have a registered nurse on site every day for eight hours, the agency said on its website."

Fourth,

In that same vein, Kaiser Health News reported Feds Order More Weekend Inspections Of Nursing Homes To Catch Understaffing. The payroll data mentioned in item #3 plays a role. "The federal Centers for Medicare & Medicaid Services said it will identify nursing homes for which payroll records indicate low weekend staffing or that they operate without a registered nurse. Medicare will instruct state inspectors to focus on those potential violations during visits."  Does this mean there will be a flurry of inspections? No. As the article explains, "[t]he new directive instructs inspectors to more thoroughly evaluate staffing at facilities Medicare flags. The edict does not mean a flurry of sudden inspections. Instead, Medicare wants heightened focus on those nursing homes when inspectors come for their standard reviews, which take place roughly once a year for most facilities."

The Importance of Guardianship Tracking Systems (and a related CLE Program!)

I've been a bit busier than usual lately and haven't felt I could take the time to Blog regularly even though I'm constantly seeing intriguing topics to discuss.  I'm buried in a manuscript with a looming deadline!  Fortunately, I'm seeing that Becky Morgan is keeping everyone updated and I've been benefiting from her regular reports.  I hope to get back to daily posts of my own by January.  

In the meantime, I can report on a smaller, interim task of  serving as a co-presenter for a half-day Continuing Legal Education program at the Pennsylvania Bar Institute on  new developments in Guardianship Practice and Procedure on Friday, December 7.   Among the important developments, the Pennsylvania Courts is nearing completion on its statewide implementation of a Guardian Tracking System or GTS.  In 2014, the Supreme Court's Elder Law Task Force strongly recommended adoption of such a system, having determined just how little was actually known across the state about open guardian cases.  Implementation of the new system began with a pilot in Allegheny County in July 2018.  As of today, 60 counties are "live" in the system.  The remaining 7 counties are scheduled to be included by the end of this month.

With the help of the new tracking system, I learned that we currently have more than 14,000 active guardianships in Pennsylvania.

Key features of the GTS system include:

• Automation:  a means of automatically running a process to check specific aspects of guardianship reports for missing information or other concerns;
• Flagging:  when a concern is detected, the item is automatically flagged, allowing court personnel to review and respond to the potential problem;
• State-wide Court Communications: providing the court system with a means of immediate and cost-effective state-wide communications whenever a judge in one case is alerted to suspicion of neglect or other improper conduct by a guardian; and
• Alerts on Specific Guardians:  when an "alert" is triggered on a specific guardian in one case, the system will generate notices to all of the other courts in the state, alerting them to the potential need for action on that individual in their cases.  

Such a system required entirely new software, new reporting forms, and new court rules to make implementation effective.  We will be talking extensively about the new rules and forms on Friday.  The migration  from the older system of record-keeping imposes a huge learning curve on many involved in guardianship matters, including lawyers.

The need for better systems in Pennsylvania has been highlighted during the last year of controversies surrounding appointment of one particular individual as guardian for alleged incapacitated persons in three Pennsylvania counties.  She is accused of mismanaging cases, plus it turned out she had a criminal history for fraud in another state. 

See also the recent news reports about another Pennsylvania guardianship matter that asks the troubling question "Where's Grandma?" The  reporter on this case, Cherri Gregg, who also happens to be a lawyer, opines that everyone in the case, including the lawyer appointed as guardian, and the family members of the person subject to the guardianship, needed better education about their roles after the grandmother's own children passed away, as the grandmother became more vulnerable, and especially when it became necessary to place her in a nursing home.  

My special thanks to Karen Buck, Executive Director of the SeniorLAW Center in Philadelphia, and the good folks at Pennsylvania Courts' Office of Elder Justice for helping me with my part of the presentation for Friday!