Friday, September 2, 2022
That's the question that was asked in a recent article in the Tampa Bay Times. Is Florida still an affordable place to retire? Amid rising costs, some seniors are reconsidering. Let me set the stage with this excerpt:
Cheaper than Miami or Naples, with destination beaches and a city once nicknamed “God’s Waiting Room,” Tampa Bay has long been hailed as an affordable place to retire in The Sunshine State.
But it’s becoming untenable for many seniors to survive in the area.
While costs are climbing everywhere, Tampa Bay’s prices have outpaced the national average. Area prices rose by roughly 11% in the last year, according to the U.S. Bureau of Labor Statistics, compared to just 9% nationally.
Retirees, who depend largely on fixed incomes, are feeling it.
Read the article and draw your own conclusions. I have.
Thursday, September 1, 2022
The New York Times ran this article last week. Planning for Your Retirement, and for a Child’s Special Needs, All at Onceexplains "[f]or parents of children who have serious disabilities or special needs, the challenges of growing and preserving their wealth are magnified exponentially, and the stakes are much higher. While they are trying to plan for their own retirements, these parents need to simultaneously secure the stability of a son or daughter who will be dependent on them until — and even after — their deaths." The article does a good job of framing and discussing the issues and options and provides good examples.
Wednesday, August 31, 2022
On September 8, 2022, Consumer Financial Protection Bureau (CFPB) Director Rohit Chopra will host a virtual discussion with advocates, service providers, community leaders, and members of the public to explore challenges around nursing home debt collection practices and the impact they can have on the financial wellbeing of caregivers, their families, and friends. We are looking forward to your participation, so please be sure to save the date.
To register, click here
Tuesday, August 30, 2022
Last week the New Yorker newsletter ran this article, When Private Equity Takes Over a Nursing Home. Focusing on the sale of one nursing home, the article discusses the facility before the sale and after.
Nearly a quarter of the hundred-person staff had been with the home for more than fifteen years; the activities director was in her forty-fifth year. But the ownership change precipitated a mass exodus. Within two weeks, management laid out plans to significantly cut back nurse staffing. Some mornings, there were only two nursing aides working at the seventy-two-bed facility. A nurse at the home, who spoke on condition of anonymity for fear of retribution, told me, “It takes two people just to take some residents to the bathroom.” ,
Consider the prevalence of private equity's ownership of nursing homes. According to the article, "Since the turn of the century, private-equity investment in nursing homes has grown from five billion to a hundred billion dollars. The purpose of such investments—their so-called value proposition—is to increase efficiency. Management and administrative services can be centralized, and excess costs and staffing trimmed." Further, "Private-equity firms currently own only eleven per cent of facilities, as a federal report found. But about seventy per cent of the industry is now run for profit."
This is an important article.
Monday, August 29, 2022
Tennessee Bureau of Investigations issued a press release, Columbia Woman Charged with Financial Exploitation of Vulnerable Individuals. "At the request of Adult Protective Services, in August 2021, agents began an investigation into an allegation of financial exploitation of two vulnerable adults. During the course of the investigation, agents developed information that identified ... the now-former manager of a service that provides support to people with intellectual and developmental disabilities, as the individual who used some of her clients’ finances on two dates in July 2021 for her own personal gain.
Tuesday, August 23, 2022
Did you see this article in the New York Times a couple of weeks ago? Embarrassing, Uncomfortable and Risky: What Flying is Like for Passengers Who Use Wheelchairs is compelling and enlightening and makes the reader wonder if there isn't room for a lot of improvements from airlines and airports for these passengers. If you haven't read it, you really must. There is an audio version of the article also available at the same website, but the accompanying photos are also quite compelling. Follow the passenger in the story on his journey from arrival at the airport to arrival at his destination.
Thursday, August 18, 2022
Recently Pennsylvania Bar Association and Philadelphia Bar Association legal ethics committees issued a Joint Formal Opinion addressing ethical considerations in the handling of several related forms of billing for services: flat fee, earned upon receipt, and non-refundable fees. Elder Law attorneys use various forms of such billing.
On the one hand, clients often want to know up front the full cost for services and thus like flat fee billing. On the other hand there can be tensions about whether or when such fees are "earned." The opinion stresses the need for clarity in the client-attorney relationship, so as to assure mutual understanding about when a fee is deemed earned, and to make sure clients are fully advised about the fee structure. With older clients -- and their family members -- it can be especially important to avoid assuming everyone understands mere "labels" for different fee arrangements.
In Joint Ethics Opinion No. 2022-300, the Committees conclude that under Pennsylvania Rules of Professional Conduct and with the guidance of prior opinions:
• Any fee not “earned upon receipt” is deemed an “advance” fee, which may only be deposited into the operating account if the client provides informed consent, confirmed in writing, in accordance with Rule 1.15(i); and,
• When a fee is deemed to be “earned upon receipt,” attorneys may deposit the fee into an operating account rather than a Rule 1.15 IOLTA account or other Trust account, provided that the attorney specifically states in the fee agreement that the fee is intended to be nonrefundable and earned upon receipt.
Hat tip to Rob Clofine, elder law attorney extraordinaire, for sharing this with Pennsylvania lawyers.
Tuesday, August 16, 2022
The Food and Drug Administration issued its final ruling today permitting over-the-counter sales of certain types of hearing aids. The ruling takes effect in 60 days. As FDA explains:
This action establishes a new category of over-the-counter (OTC) hearing aids, enabling consumers with perceived mild to moderate hearing impairment to purchase hearing aids directly from stores or online retailers without the need for a medical exam, prescription or a fitting adjustment by an audiologist.
The rule is expected to lower the cost of hearings aids, furthering the Biden-Harris Administration’s goal of expanding access to high-quality health care and lowering health care costs for the American public. It is designed to assure the safety and effectiveness of OTC hearing aids, while fostering innovation and competition in the hearing aid technology marketplace. . . .
Concurrently with issuing the final rule, the FDA also issued the final guidance, Regulatory Requirements for Hearing Aid Devices and Personal Sound Amplification Products (PSAPs), to clarify the differences between hearing aids, which are medical devices, and PSAPs, consumer products that help people with normal hearing amplify sounds.
This could be "huge" for helping older adults. I know that for many adults, not just the older adults I've worked with, it is terribly frustrating to be unable to hear properly. Plus, I think that for some people, the ability to "try" a wider range of devices, without the time and expense of visiting specialized doctors, may facilitate "realism."
At the same time, I worry that for some older adults, who actually are willing to see their hearing aid doctor, sometimes it was this doctor or specialist who caught the "real" problems, including the potential for mild cognitive impairment. Could we miss those opportunities for more holistic health evaluations?
Sunday, August 14, 2022
Upcoming in November before USSC: Do Residents have Private Rights of Action for Violations of Federal Nursing Home Reform Act?
For those teaching Elder Law, Health Law, and Disability Law Courses this semester, there is a unique opportunity for students to hear relevant oral arguments before the United States Supreme Court. One of the important federal laws that arguably changed -- for the better -- the standards for care in nursing homes was the Federal Nursing Home Reform Amendment of 1987 (FNHRA, adopted as part of OBRA '87). But a long-festering central issue for the provisions known as the "Residents' Bill of Rights" is whether the law provides residents a privately enforceable right of action for alleged violations of the standards. On November 8, 2022, the United States Supreme Court is scheduled to hear oral argument on two key concerns:
- Whether in light of historical cases to the contrary, the Court should reexamine its holding that Spending Clause-related legislation confers a implied right to privately enforceable rights under 42 U.S.C. Section 1983; and
- Whether, assuming Spending Clause statutes ever give rise to enforceable private rights under Section 1983, there are private rights of action for alleged violations of the Federal Nursing Home Reform Act's transfer and medication rules.
The case in question is Health & Hospital Corp. v. Talevski, originally filed in the United States District Court (Northern District) of Indiana. Mr. Talevski, who has dementia, through his wife, alleges that while living in a nursing facility, he was prescribed powerful medications despite his family's objections, which functioned as prohibited "chemical restraints imposed for purposes of discipline or convenience rather than treatment." Further, he alleges he was improperly transferred over their objections away from the local care facility to a different, more distant facility. Federal spending laws are at issue because the state's long-term care facilities are eligible for federal dollars and the state receives federal funding, including Medicaid funding, for such nursing care. In this case, the District Court held that there was no private right of action.
The U.S. Court of Appeals for the 7th Circuit reversed, at 6 F.4th 713 on July 27, 2021, finding that in the Act, "Congress spoke of resident rights, not merely steps the facilities were required to take. This shows an intent to benefit nursing home residents directly." (emphasis in the original). In reaching this decision, the 7th Circuit joined rulings by the 9th (2019) and 3rd (2009) Circuits directly confirming private rights of action under FNHRA.
The Petitioner Nursing Facility seems to be playing to the newest justices on the Court, arguing that a long line of Spending Clause cases willing to recognize a cause of action under Section 1983, including Blessing v. Freestone, 520 U.S. 329 (1997), are incorrectly decided or too generous in their willingness to recognize or infer fact-specific, private rights of action. The Petitioner's argument is supported by an amicus brief, including one submitted on behalf of twenty-two states, resisting the financial implications of accountability asserted by individual patients. The United States has submitted an amicus brief that expresses general support for individual actions, but argues against such a cause of action for nursing home residents.
But, as one legal studies student observed in 2013 about what happens when minimum standards are not adequately enforced by authorities:
Even though conditions in nursing homes have improved since the passing of the Federal Nursing Home Reform Amendment of 1987, the existence of substandard care in nursing homes, which Congress attempted to correct with the statute, still exists today. . . . [A case such as Grammer v. John J. Kane Reg'l Ctrs-Glen Hazel, 570 F.3d 520 (3d Cir. 2009) recognizing the right of residents to bring private actions under 1983] does open the door for state-run nursing homes to be held accountable for abuse and substandard care. . . . Considering that most of us at some point in our future will live the nursing-home experience first-hand, we should keep this topic on our radar.
Susan J. Kennedy, "Conflict in the Courts: The Federal Nursing Home Reform Amendment and Section 1983 Causes of Action," 3 Law Journal for Social Justice 195, 209 (2013). Some ten years later, the resident's case before the Supreme Court appears to have strong amici support, with amici briefs due in mid-September, arguing that without residents' ability to enforce their legal rights, "they will lose a powerful weapon for their protection. This puts them at risk of harm and even death, as abuse, neglect and poor care are rampant in many facilities." Id.
August 14, 2022 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Discrimination, Ethical Issues, Federal Cases, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare, Social Security | Permalink | Comments (0)
Friday, August 12, 2022
The Ocala Star Banner newspaper ran a guest column explaining NORCs. Naturally Occurring Retirement Communities give seniors the help they need to age in place explains that "Naturally Occurring Retirement Communities (NORCs) are self-help communities that started springing up in 1992 with the founding of Community Without Walls in Princeton, N.J. They are not a formal community, but occur naturally in neighborhoods in small cities and urban areas, and are not cohousing. "
The article highlights the versatility of NORCs: "[w]hile NORCs were first identified in urban settings, they can be found in communities large and small. They can be geographically defined by such boundaries as an entire apartment building, a neighborhood or a more rural setting over a large geographical area comprised of one- and two-family homes. Sometimes a NORC is not a physically connected locatioh, , but loosely organized around a church, synagogue or fraternal organizations."
Thanks to Julie Kitzmiller for sending me the link to this article.
Thursday, August 11, 2022
Two recent articles of note on nursing homes-in case you missed them.
Kaiser Health News: Nursing Homes are suing friends and family of residents to collect debts. This article is a result of a "partnership between KHN and NPR exploring the scale, impact, and causes of medical debt in America."
Politico: The Crisis Facing Nursing Homes, Assisted Living and Home Care for America’s Elderly. I've blogged several times about the caregiver shortage, so consider this from the article:
Since January 2020, 400,000 nursing home and assisted living staff have quit, citing pandemic exhaustion as well as the low pay and lack of advancement opportunities typical of the field. The job losses arrive when America already faces an elder caregiver shortage, as 10,000 people daily turn 65 and birth rates decline. The labor shortage gripping America’s workforce across industries is felt most acutely in home health care. According to the Bureau of Labor Statistics, home health and personal care aides are actually the fastest growing industry, projected to grow 33 percent in the next decade, much faster than all occupations. But there still simply aren’t enough workers to fill the demand.
“The numbers alone suggest we’re going to need a lot more people in the caregiving sector than we have now,” says Tara Watson, a fellow at the Brookings Institution and professor of economics at Wiilliams College. “We need to make some changes in order for that to happen.”
Tuesday, August 9, 2022
The Center for Medicare Advocacy announced in their newsletter a few weeks ago that Medicare has announced the development of an appeals process for certain patients on observation status.
As the result of a court case, the Medicare.gov website now alerts a nationwide class of Medicare beneficiaries that they “have appeal rights” when a hospital changes their status from inpatient to outpatient observation, and that the appeal process is currently under development. View the information here (click on “Appeals in Original Medicare” and scroll to “Coming Soon: Appeal when a hospital changes your status from an inpatient to an outpatient with observation services.”).
The “observation” designation can have severe ramifications for beneficiaries. Many will face no coverage for post-hospital nursing home care, which requires a prior “inpatient” hospitalization of at least three days. Time spent in observation status does not count towards the required inpatient stay, even though observation stays can last several days and the care can be indistinguishable from inpatient care.
Monday, August 8, 2022
Kaiser Health News a couple of weeks ago ran an article, Hospices Have Become Big Business for Private Equity Firms, Raising Concerns About End-of-Life Care. "Hospice care, once provided primarily by nonprofit agencies, has seen a remarkable shift over the past decade, with more than two-thirds of hospices nationwide now operating as for-profit entities. The ability to turn a quick profit in caring for people in their last days of life is attracting a new breed of hospice owners: private equity firms." Check this out: "According to a 2021 analysis, the number of hospice agencies owned by private equity firms soared from 106 of a total of 3,162 hospices in 2011 to 409 of the 5,615 hospices operating in 2019. Over that time, 72% of hospices acquired by private equity were nonprofits. And those trends have only accelerated into 2022."
The article explores concerns expressed regarding private equity firms owning hospices, including quality of care and profit margins. It also discusses for-profit vs. non-profit hospices. Check it out!
A recent report from AARP and FINRA reminds us to not blame victims of financial frauds. The new report, Blame and Shame in the Context of Financial Fraud points out that "[t]The practice of victim blaming—assigning responsibility to the targets of a crime rather than to the perpetrators—is not a new practice in American society. But this project unearthed ample evidence that victim-blaming practices can shift, and that although often our words blame fraud victims, it isn’t necessarily our intent to hold them accountable." The report discusses why we blame victims, examined the "dimensions of victim blaming", and "reframing" our habit of blaming the victim. The report gives 5 suggestions for shifting the focus of the conversation and concludes with opportunities for changing the focus.
Friday, August 5, 2022
Ending the week on happy note due to this Washington Post article, A ‘magical’ treatment for seniors with dementia: Horse therapy.
Painting [on the horses] is not mandatory in this equine-assisted learning program, but it is one of the many ways participants are taught to engage with horses, with the goal of stimulating their minds and bodies. Since 2017, Simple Changes Therapeutic Riding Center in Mason Neck, Va., has teamed up with Goodwin Living, a senior living and health-care facility in Alexandria, to introduce residents with cognitive impairment and anxiety to the residents of its barn.
Up to six people at a time participate in the four-week sessions, which include horse identification, grooming, feeding, leading, discussing equine literature, poetry and haiku writing, and making horse treats. The collaboration began when Barbara Bolin, a social worker at Goodwin House Alexandria and a lifelong rider and horse owner, reached out to Corliss Wallingford, the nonprofit equine therapy organization’s executive director.
Read the article and look at the accompanying photos. Doing so will end your week with a smile.
Thursday, August 4, 2022
Last month, Science magazine published an article, BLOTS ON A FIELD? A neuroscience image sleuth finds signs of fabrication in scores of Alzheimer’s articles, threatening a reigning theory of the disease. One researcher recently noted that there were concerns about the 2006 study, including concerns about "image tampering" There is no smoking gun and the article explains how this one expert became concerned. The article has technical materials in it, so read it and form your own opinion.
Wednesday, August 3, 2022
On August 3, 2022, the Pennsylvania Commonwealth Court issued its latest ruling in the long-running case of Friends Boarding Home of Western Quarterly v. Commonwealth, with an en banc opinion rejecting Friends Home's exceptions to the appellate court's earlier three-judge panel ruling. The full court focuses closely on the use of residents' fees to operate the Continuing Care Retirement Community (CCRC) and the argument that because "some" residents receive subsidized care the facility is donating the necessary "substantial" portion of its services. For example:
Between 2014 and 2017, Friends incurred annual operating losses between $386,620-$542,652. In 2018, Friends had an operating deficit of $265,569 and for 2019, $790,069. Friends maintains that these deficits lend additional support that Friends’ rates contain substantial subsidies that benefit all residents, such that it satisfied the requirement that it donates or renders gratuitously a substantial portion of its services.
We recognize that Friends incurs operating deficits that it covers with funds generated from investments and contributions. However, Friends’ argument that its operating deficits prove that it donates a substantial portion of its services by subsidizing all rates is once again refuted by the fact that there are for-profit facilities in the vicinity of Friends Home providing similar services at comparable rates. Even though Friends may incur operating deficits, it has not demonstrated that it donates “a substantial portion of its services” “to those who cannot afford the ‘usual fee.’” HUP, 487 A.2d at 1315 n.9. Thus, we discern no error in the conclusion reached [by the Panel] in Friends Boarding Home in this regard.
My Pennsylvania colleague Douglas Roeder and I recently co-authored an article about the ongoing challenges for nonprofit organizations, especially those who offer fee-based services. The latest ruling from the Pennsylvania Commonwealth Court would seem to deepen the need for certain nonprofits who seek "purely charitable" tax exemptions to carefully consider their charitable mission. I'm also thinking that nonprofit CCRCs would also be well advised to have candid discussions of their charitable missions with both potential residents and current residents. Ultimately, it will be the more solvent residents who make up the difference in support of the charitable mission.
Last week, Kaiser Health News ran a concerning article, ‘True Cost of Aging’ Index Shows Many Seniors Can’t Afford Basic Necessities. "
More than half of older women living alone — 54% — are in a similarly precarious financial situation: either poor according to federal poverty standards or with incomes too low to pay for essential expenses. For single men, the share is lower but still surprising — 45%.
That’s according to a valuable but little-known measure of the cost of living for older adults: the Elder Index, developed by researchers at the Gerontology Institute at the University of Massachusetts-Boston.
A new coalition, the Equity in Aging Collaborative, is planning to use the index to influence policies that affect older adults, such as property tax relief and expanded eligibility for programs that assist with medical expenses. Twenty-five prominent aging organizations are members of the collaborative.
The goal is to fuel a robust dialogue about “the true cost of aging in America,” which remains unappreciated, said Ramsey Alwin, president and chief executive of the National Council on Aging, an organizer of the coalition.
The Index provides data for states, cities and counties, truly a valuable amount of information. Consider in addition the inflation we are currently experiencing. Read the entire article. It's sobering.
Tuesday, August 2, 2022
Provides information and tools for probate court staff that wish to implement more rigorous conservatorship and guardianship monitoring. The series emphasizes important aspects of case management, report tracking, responses to potential fraud and abuse, and financial monitoring, including comparing assets, expenses and budgets over time and highlighting common problem areas to look out for. Intended for courts across the country and thus necessarily general in nature, the videos are particularly helpful to courts that currently lack local training resources. A separate series of videos for conservators helps them understand their role and how to prevent misuse of resources.
Next is a series for conservators.
In this short five-part video series, [the National Center for State Courts] provides information and tools for those who are thinking about becoming a conservator or conservators who have already been appointed by a court. The series gives an overview of what conservatorships are, the conservator’s responsibilities and role in protecting assets, why courts monitor expenses, and which expenses are allowable. Intended for the public and courts across the country and thus necessarily general in nature, the videos are helpful as an additional training resource but do not replace specific requirements and guidelines set by the local court.
Friday, July 29, 2022
Last month, CMS issued an advisory that it had "Issue[d] Significant Updates to Improve the Safety and Quality Care for Long-Term Care Residents and Call[ed] for Reducing Room Crowding."
[CMS] issued updates to guidance on minimum health and safety standards that Long-Term Care (LTC) facilities ... must meet to participate in Medicare and Medicaid. CMS also updated and developed new guidance in the State Operations Manual (SOM) to address issues that significantly affect residents of LTC facilities. The surveyors who use these resources to perform both routine and complaint-based inspections of nursing homes are responsible for determining whether facilities are complying with CMS’ requirements.
A fact sheet on the updated guidance, also released last month, is available here.