Elder Law Prof Blog

Cognitive Aging, Maturity and Guns

Yesterday I wrote a blog post about gun use that several of my friends correctly characterized as heartfelt.  Of course, legal research is merited, and I find that my view echoes what is written in a key section of a very recent opinion:

Beyond these significant safety concerns, contemporary scientific research increasingly sheds light on the relative immaturity and incomplete cognitive development of young adults. California cites to evidence that young adults are less mature than older adults, which leads them to take more risks and behave more reactively than their elders. Young adults are thus quicker to anger than older adults and more vulnerable to intense mood swings and to making instinctive, rather than considered, decisions. This cognitive immaturity makes young adults more likely to use firearms in situations of significant emotional arousal or perceived threat, or other situations that require rapid, complex information processing. Other Circuits have credited similar evidence to uphold regulations on firearms affecting 18 to 20-year-olds. NRA, 700 F.3d at 208; Horsley v. Trame, 808 F.3d. 1126, 1133 (7th Cir. 2015). The semiautomatic rifle regulation helps to “ensure that access to these weapons is restricted to mature individuals who have successfully completed safety training,” such as members of law enforcement and the military, “furthering the public safety objectives and ensuring that the Founding Era balancing of Second Amendment rights with safety concerns continues today.” Jones, 498 F. Supp. 3d at 1328.

Unfortunately, this is from the dissenting opinion in Jones v. Bonta, decided by the 9th Circuit with an opinion issued less than two weeks before the shooting in Uvalde, Texas.  Sigh.  

Or, as the always astute Professor Naomi Cahn observes, "The irony of the timing of such a ruling is beyond distressing." 

When It Comes to Guns, Age Matters

I suspect I'm not alone in thinking about guns this morning in the wake of the Texas shooting at a grade school in Uvalde Texas.  This post reflects matters I've been thinking about for a long time.  Indeed, thirty years ago I considered making gun violence a core academic research topic, until I realized how potent is the lobby supporting gun sales, and therefore gun ownership.

First, this morning I listened to a young man, David Hogg, speaking to an NPR interviewer about his own frustrations in opposing gun violence.  He urged legislators at state and national levels to do at least "one thing" to move forward on gun safety legislation.  My first reaction was "one thing?"  How is that going to help?  

Second, I heard a bit more about the background of the 18 year old shooter in Texas, as well as the background of the similarly-aged shooter in Buffalo New York.   More memories.  In one of my previous lives, I volunteered for a neighborhood tutoring program in New Mexico.  My first two students, in high school, had been sent to the program by judges trying to help youths in crime-related incidents.  One young man attended once -- and then disappeared.

I managed to have a good session with the other student, a junior in high school, who at my request wrote a short essay about what he saw as his future.  The 500 word piece was quite well written, and gave us something we could definitely use to gently work to improve his reading and writing skills.  The focus, however, proved to be a window into the bleak outlook of a young man who was involved in a so-called gang.  To put it simply, he saw no future for himself after high school.  He said with utter confidence that his high school "had" to graduate him regardless of whether he did any more work, as long as he merely attended class.  I didn't want to believe that, but he had plenty of evidence to support his hypothesis. He didn't have any post graduation plans.  He had equal confidence that he probably wasn't going to make it to age 21.  The following week during our tutoring session, he was creative in his resistance to my role as a tutor.  He turned in his next essay, but it was written entirely in what was some sort of "tagger's script," the stylized script he used when spray-painting his messages on public building.  Tagging was his only crime at that moment.  

I eventually decided to volunteer for younger students, and in fact I had a two-year working student-tutor relationship with a grade school boy who was in the program at his mother's insistence.  Actually, I got to know the whole family, including his parents and a sister who also sometimes attended our reading sessions (and she helped turn reading into a competitive adventure).  To mark the success of his "graduation" from the program, we went to a Phoenix Suns basketball game, because the opposing team that day had a player much admired by my student.  At his comparatively "youthful" age, he had written about his plans for the future, including somehow, against all genetic odds, planning to "grow" tall enough to be a professional basketball player, like his idol, Nate Archibald.  We talked about coaching as an alternative -- just in case.

I remember the difference in these individuals as I listen to the troubled histories of the two "boys" who bought guns as part of their 18th birthday celebrations.  I don't know what happened to most of the other the students involved in the tutoring program.  The second student dropped out of the program for reasons I never learned, but I later saw his name in the newspaper when he was accused of being the driver in a car-jacking where his "friend" shot the woman who resisted having her car taken.  Sadly, that student's essay was prophetic, as any true dreams for a future may have ended with that crime.

So, if we are going to do at least "one thing," could we -- should we -- focus on raising the threshold age for gun ownership?  Should we give young people in their late teens more  time to grow older (and "taller" or more mature) and thus to reach a point where the future seems brighter?  I'm not suggesting they cannot participate in shooting sports, hunting, and the military, where we hope their use and skill building would be supervised by knowledgeable people. I am suggesting making it unlawful for them to "own" or at least to purchase guns until they are older. Research suggests that substantially more crimes of gun violence against others are committed by individuals between the ages of 17 and 21.  There is research to support restricting gun ownership (and therefore gun sales) to individuals over 21 as one step forward in terms of safety. 

For example, in June 1999, a "collaborative report" under the auspices of the U.S. Department of Justice noted in part:

In 1996, 26,040 people in the United States were killed with guns.  In 1997, offenders age 18, 19, and 20 ranked first, second, and third in the number of gun homicides committed.  Of all gun homicides where an offender was identified, 24 percent were committed by this age group, which is consistent with the historical pattern of gun homicides over the past 10 years.  

Other statistics suggest that gun-related suicide death rates are highest for females age 45 to 64 and for males age 75 and older, statistics that point to another form of age-specific gun tragedies. Age matters.

That first boy who "disappeared" after the first tutoring session?  I later learned he had been killed in a neighborhood shooting.  Would younger adults support delayed lawful-ownership as one form of protection against gun violence?   Certainly, more is needed on so many other levels including mental health supports. But could "one thing" -- at least -- include blocking gun sales to people who are still in the process of learning to plan for the future, for their futures?  

 

Residents Are Asking a Lot of Questions -- Tough Questions -- about CCRCs

It is Sunday, and I'm looking at a long list of things to do next week, with grading exams at the top of my list.  Significantly, however, in the last six to eight months, at increasing rates, I'm hearing from current and prospective residents of Continuing Care Retirement Communities (CCRCs, also sometimes called Life Plan Communities).  Here are examples of some of the most often asked questions:

• "The company that runs my CCRC is about to engage in development of a new CCRC.  Is the money I've already paid in the form of an admission fee, or the money I continue to pay as monthly service fees, going to support this new development?"
• "During the lock-down associated with protecting residents and the public from COVID-19, we were asked to give up services that were the very reason we choose this community.  But now that we are no longer locked down, the services either are not returning or the fees we are charged are actually increasing.  Is there some effective way to object to this disconnect between the promises and the delivery of services?"
• "My parents are thinking about moving into a CCRC.  On the one hand, I like the idea of the active community they are choosing.  But on the other hand, the amount they are expected to pay in the form of an admission fee is astounding.  Why are some communities calling this a refundable fee and others are saying it isn't a refundable fee? What are the protections for the 'refundable' fee?"
• "We have just learned that our nonprofit CCRC is being transferred to a for-profit company as the owner-operator.  How is this likely to impact my wife and I as residents?"

Answers to many of these questions depend on the state's laws governing this form of senior living operation and, even more, on the particular contracts between the resident and the provider.  State regulators have concerns here too.  For those looking for legal assistance in their particular community, I sometimes recommend looking for attorneys in the caller's home state, someone who understands CCRCs from a resident perspective. I first wrote about the need for attorneys who understand resident perspectives in 2006.  

Sometimes "elder law" attorneys have this expertise, but not always.  Plus, it can be important to consult with an attorney who understands consumer protection laws, and not "just" CCRC law.  Finally, if litigation is actually on the horizon, the choice for legal advice can depend on whether the attorneys have expertise in litigation or dispute resolution and not "just" contract law. 

So, all of this is a short way of saying that even though, as an legal academic,  I often write about the importance of resident rights in CCRCs, and even though I believe the future of CCRCs is very much tied to the answers, I'm not in a position to respond to individual questions. The very fact that I'm writing this Blog Post is a potential indication that something important could be going on in the industry.  Perhaps that "something" should be addressed by the industry itself, especially if it wants the CCRC concept not just to survive, but thrive.  In my opinion, it is not enough for the industry to say that "every CCRC is different."  

RFP: Washington State Seeks Expert Consultation to Develop CCRC Regulations with Heightened Consumer Protections

I'm always interested when I start getting lots of calls or emails about a certain topic in aging.  Today I was hearing from a lot of people wanting to talk about Continuing Care Retirement Communities (CCRCs, sometimes also called Life Plan Communities or LPCs). It is safe to say that all forms of senior living operations are facing new challenges after being hit hard by the lockdowns and staffing problems of the last two years with COVID-19.

But one of the most interesting set of calls was from the State of Washington, where residents have been using their time together during COVID to think carefully about the need for certain key protections for consumers who put their money and trust into CCRCs.  The Washington Continuing Care Residents Association (WACCRA) has worked carefully, calmly and diligently to reach the ears of legislators and regulators in the state.  I had the pleasure of hearing from  members and residents of CCRCs in Washington last October and speaking at their annual meeting. 

Today, I heard that the  Office of Insurance Commissioner in Washington has initiated a Request for Proposals for a time-sensitive research project:

This project is designed to assess federal and state authorities regulating continuing care retirement communities (CCRCs) and provide a report with recommendations on creating a legal framework for shared regulatory oversight of CCRC products under Chapter 18.390 RCW, which may achieve heightened consumer protections.

Interested researchers -- with background in regulatory systems for CCRCS -- should act quickly as the deadline for submissions is May 23, 2022.   

Click HERE FOR THE FULL DETAILS!  

Filial Friday: Virginia Governor Blocks Attempt to Repeal Virginia Filial Support Law

As is true with several U.S. states, Virginia has a filial support statute that can obligate adult children to support their parents.  The key language of VA Code Ann. Section 20-88 provides:

It shall be the joint and several duty of all persons eighteen years of age or over, of sufficient earning capacity or income, after reasonably providing for his or her own immediate family, to assist in providing for the support and maintenance of his or her mother or father, he or she being then and there in necessitous circumstances. 

 

If there be more than one person bound to support the same parent or parents, the persons so bound to support shall jointly and severally share equitably in the discharge of such duty. . . .

 

This section shall not apply if there is substantial evidence of desertion, neglect, abuse or willful failure to support any such child by the father or mother, as the case may be, prior to the child's emancipation or, except as provided hereafter in this section, if a parent is otherwise eligible for and is receiving public assistance or services under a federal or state program. . . . 

There are few modern cases applying this law. In Peyton v. Peyton, an "unreported" Virginia chancery court decision from 40 years ago, the court applies the law to obligate one brother to reimburse another brother $8,000, representing half of the past out-of-pocket expenses for their mother's care in a nursing home. A careful reading of the Peyton case reveals one of the challenges of applying filial support laws when used to collect "back" expenses; here the second son was willing to pay a portion of their mother's monthly costs going forward but he was not successful in arguing a statute of limitations should apply to prevent liability for multiple years of back claims. 

As with other American states that have had forms of filial support laws, Virginia's law was enacted as an alternative to public welfare laws because the common law generally found no legal duty for adult children to support indigent parents.  But, in Virginia, again as in most American states, the filial support laws are largely dormant, misunderstood or ignored, especially after Social Security, Medicare, and Medicaid laws were enacted on a federal level beginning in the 1960s.  

Virginia's  statute was amended decades ago to restrict use of the law by the state to seek reimbursement for its costs in providing public services (such as "medical assistance" a/k/a Medicaid).  However, unlike the filial laws of most states, Virginia's law permits criminal prosecution as a misdemeanor for "any person violating the provisions of an order" of support under this statute, with a fine not exceeding $500 or imprisonment in jail for up to 12 months.  I find no reported cases of criminal enforcement actions.

Recognizing that other states (including neighboring Maryland in 2017) had recently taken formal action to repeal filial support laws as outdated or impractical, Virginia Senator Adam Ebbin introduced 2022 Senate Bill 389 to repeal Virginia's law. Senator Ebbin's bill passed with no dissenting votes in the Virginia Senate.  The final vote in the Virginia House, on March 11, 2022, supported repeal with 81 voting in favor, and only 16 members voting in opposition to repeal. In other words, repeal was not a controversial measure; rather it appeared to be part of an attempt to clean-up hoary laws, and it attracted strong bipartisan support.

Nonetheless, Virginia Governor Glenn Youngkin (sworn into office in January 2022) vetoed the repeal on April 11, 2022.  His reasoning for preserving filial support laws is unique, at least in my 20-some years of experience researching filial support laws (see e.g., Filial Support Laws in the Modern Era: Domestic and International and International Comparison of Enforcement Practices for Laws Requiring Adult Children to Support Indigent Parents, 20 Elder Law Journal 269 (2013)).  

The governor's veto statement explains:

"Primarily, the Commonwealth's filial responsibility law supports those who care for their elderly parents.  In establishing a bankruptcy budget, the court allows for necessary and reasonable expenditures and the repeal of Section 20-88 could prevent an individual from covering these expenses within the budget of their debtor.  For those undergoing bankruptcy proceedings, there is a grave risk of unforeseeable and unintended consequences, which may harm people going through some of the most difficult times in their lives."

On the one hand, in today's torn asunder political scene, no one should be surprised that a newly elected governor of one party would be vetoing legislation sponsored by a member of the other party -- and that is true here, with a Republican governor vetoing a bill proposed by a Democrat.  

But what about the proffered reason for the veto?  Virginia's law does not "primarily" support those who care for their elderly parents.  Rather, it creates an obligation for adult children. Is there any precedent for a theory that Virginia's filial support law permits some type of sheltering of assets for a debtor in bankruptcy court, to provide a means of financial support for the (also) destitute parent?  Certainly I find no modern cases on Lexis or Westlaw suggesting such use or even a need for such use.  

There is a reported case from 1938 in Virginia.  In Mitchell-Powers Hardware Co. v. Eaton, 198 S.E. 496 (Supreme Court of Appeals, VA 1938), the court addressed a question of whether a transfer of valuable stock by a debtor to his sister was voidable as an invalid gift.  Was this an invalid attempt to defeat a legitimate creditor's lien against the asset? The court recognized that under Virginia's predecessor version of Statute 20-88, the debtor "could" have an obligation to assist his sister in the care of their elderly mother. The appellate court remanded the case for a jury determination of whether the mother was actually destitute and in need of the son's financial support. (The sister had further transferred the stock in question onward to the debtor's son).  This hardly seems a persuasive case for characterizing filial support laws as necessary "support for those who care for their elderly parents."

New Florida Law on Visitation for Health Care Facilities

NPR among other news agencies, reported on a new law signed by the Florida governor about 2 weeks ago, New laws let visitors see loved ones in health care facilities, even in an outbreak. As the U.S. News article, DeSantis Signs Hospital Visitation Bill, Other Legislation, explains, "[t]he visitation bill requires that health care facilities, including nursing homes, allow in-person visits during end-of-life situations and in most other cases. DeSantis and other state health officials said the measure was inspired by hospitals limiting visits during the coronavirus pandemic... Under the law, health care facilities have to establish visitation rules that include infection control and education policies for visitors. The policies cannot be more stringent than safety rules applied to the facility's staff and may not require proof of any vaccination or immunization. A health care center can suspend in-person visitation for specific people if they violate rules."

 

AARP BankSafe Initiative Training for Retail

AARP has launched a new initiative to fight gift card scams. This is a super important project!  According to the website, 

With gift card fraud, a scammer may pretend to be someone they are not in an attempt to convince the unsuspecting person to pay them in gift cards. This type of scam can take many forms: • The scammer, claiming to be from “tech support,” says there is something wrong with a person’s computer, and that the person will need to pay in gift cards in order for tech support to fix the problem. • Posing as a user of a dating site, the scammer says they have an emergency and need another site user to help them by buying them gift cards. • Through a phone call the scammer pretends to be a relative in trouble who needs their target to send them gift cards. • Claiming to be from the IRS or Social Security, the scammer states that the person has a fine or owes back taxes that can only be paid by gift card. • The scammer impersonates the target’s utility company and threatens to shut off service unless they pay an overdue bill with gift cards.

More information about the scam and the training of retail employees is available here.

Bill Introduced to Repeal Medicaid Estate Recovery

A bill, Stop Unfair Medicaid Recoveries Act, has been introduced in Congress to repeal Medicaid Estate Recovery and to limit liens.  The bill, HR 6698 addresses the elimination of estate recovery this way:

“(6) Notwithstanding any preceding provision of this subsection, no adjustment or recovery of any medical assistance correctly paid on behalf of an individual under the State plan may be initiated, maintained, or collected on or after the date of the enactment of this paragraph. Not later than 90 days after such date, a State shall withdraw any lien in effect as of such date with respect to such medical assistance correctly paid.”

The full text is available here.  Information about the bill, including the sponsor and co-sponsors, is available here. Thanks to attorney Jim Schuster for alerting us to this legislation.

Colorado Aid-In-Dying Cases Update

Earlier this week I blogged about a recent development with the Oregon statute.  In a recent story in the Colorado newspaper, it's reported that there has been an uptick in requests for aid-in-dying in Colorado. Number of patients who sought medication to end their lives under Colorado’s aid-in-dying law on the rise offers this information:

Last year, 222 people obtained prescriptions for the lethal doses of medication, which they must ingest themselves after getting approval from two physicians who certify that they have a terminal illness and fewer than six months to live. That brings to 777 the five-year total prescriptions since the End-of-Life Options Act was passed, according to a recently completed report on the law by the Colorado Department of Public Health and Environment.  The department tracked how many of those 777 prescriptions were dispensed — 583 — but is not required to follow up with patients’ families or doctors to find how many of those patients actually took the medication.

More data is available in the article, as well as the report from the Colorado Department of Public Health and Environment. The article also discusses a study from a researcher at the University of Colorado School of Medicine. 

Challenge to Residency Requirement in Oregon Medical Aid-in-Dying Statute

The Associated Press reported that Oregon ends residency rule for medically assisted suicide.  A lawsuit challenging the residency requirement had been filed and as a result of a settlement, "Oregon will no longer require people to be residents of the state to use its law allowing terminally ill people to receive lethal medication, after a lawsuit challenged the requirement as unconstitutional. ...  [T]he Oregon Health Authority and the Oregon Medical Board agreed to stop enforcing the residency requirement and to ask the Legislature to remove it from the law."  The suit addresses an issue faced by doctors who "had been unable to write terminal prescriptions for patients who live just across the Columbia River in Washington state. [Even though] Washington has such a law, providers can be difficult to find in the southwestern part of the state, where many hospital beds are in religiously affiliated health care facilities that prohibit it."  The article indicates that advocates intend to challenge the residency requirement in other states with aid-in-dying laws.    Stay tuned.

Aging in Place Village Model Has Its Limitations

According to a recent article in Kaiser Health News, Despite Seniors’ Strong Desire to Age in Place, the Village Model Remains a Boutique Option, "[t]wenty years ago, a group of pioneering older adults in Boston created an innovative organization for people committed to aging in place: Beacon Hill Village, an all-in-one social club, volunteer collective, activity center, peer-to-peer support group, and network for various services.  Its message of “we want to age our way in our homes and our community” was groundbreaking at the time and commanded widespread attention. Villages would mobilize neighbors to serve neighbors, anchor older adults in their communities, and become an essential part of the infrastructure for aging in place in America, experts predicted."  Fast forward to now. where even though "there are 268 such villages with more than 40,000 members in the U.S., and an additional 70 are in development ... those numbers are a drop in the bucket given the needs of the nation’s 54 million older adults. And villages remain a boutique, not a mass-market, option for aging in place."

What exactly is a "Village" you ask? The article explains the concept: "[they] share common features, although each is unique. Despite their name, physical structures are not part of villages. Instead, they’re membership organizations created by and for older adults whose purpose is to help people live independently while staying in their own homes. Typically, villages help arrange services for members: a handyman to fix a broken faucet, a drive to and from a doctor’s appointment, someone to clean up the yard or shovel the snow. Volunteers do most of the work." They also offer educational and social events and facilitate introductions to other residents of the village.   

The question posed by the article is whether this concept can have widespread acceptance and adoption with various socio-economic groups, especially given their costs. The article discusses some options pursued by existing villages, in addition to discussing the hurdles.

 

2022 Adult Guardianship Guide

The National Association for Court Management announced the release of the updated Adult Guardianship Guide.

The executive summary points out  the

Issues identified in this guide which are critical for planners to consider include: • Strengthening protections and enhancing rights of persons subject to guardianship • Identifying alternatives to guardianship including supported decision-making • Providing meaningful due process including access to counsel
• Identifying opportunities for modification, termination, and restoration of rights • Identifying, tracking, and documenting the number of guardianship cases and adoption of data standards • Implementing meaningful guardianship monitoring • Formalizing a process for bringing complaints or concerns to the attention of the court • Developing response protocols for abuse, neglect, or exploitation • Developing readily accessible materials for the public including clear, plain language forms and informational resources • Developing and institutionalizing training programs and materials for judges and court staff, judicial officers, managers, staff, and volunteers to include specialized training to recognize and identify abuse, neglect, and exploitation • Developing and institutionalizing training programs for guardians • Maintaining and strengthening relationships between the courts and the local probate bar while promoting the importance of court-community collaboration • Regularly evaluating guardianship processes and outcomes.

The guide includes several appendices and resources. The section on the future offers this "This Guide challenges court managers to make efforts that will lead to improvements in the way courts handle cases involving our most vulnerable adults. NACM underscores the need for prioritization and funding of the management of guardianship cases, while offering practices and models that can be implemented—some at little or no cost—to bring court practices in line with recommendations of the Fourth National Guardianship Summit and the NPCS."

If you go through the NACM website, although the guide is free, you may have to set up an account to download it. It will be posted on the National Center for State Courts website (I checked on 2/22/22 and the updated guide had not yet been posted).You can download the 76 page guide directly here.

 

On an unrelated note, University of Illinois College of Law is looking for a Dean of Students & Assistant Dean for Academic Administration.  For info about the position or to apply, "submit a resume, cover letter, and the names and contact information of three professional references at : https://jobs.illinois.edu/academic-job-board/job-details?jobID=159975&job=assistant-dean-for-student-services-dean-of-students-college-of-law-159975 by March 31, 2022. For assistance with the application system, please email [email protected]."

The cool part of the job-you get to work with elder law Rockstar, Professor Richard Kaplan!

 

Slam the Scam Day

What will you be doing on Slam the Scam Day? Being a safe and smart consumer?  The SSA Inspector General announced in a press release that Slam the Scam day will be held on March 10, 2022.

Slam the Scam Day is an initiative to raise public awareness of the pervasive scams that continue to plague the nation and is part of the Federal Trade Commission’s National Consumer Protection Week, (NCPW) happening March 6-12, 2022. The initiative, which began in 2020 to combat Social Security-related scams, is now expanding to include other government imposter scams. In a government imposter scam, someone claims to be an SSA, or another government employee, and may ask for personal information, demand payment, or make threats. These scams primarily use the telephone, but scammers may also use email, text messages, social media, or U.S. mail.

The focus of this year's initiative is spotting the scams. "SSA OIG provides resources on its website and posts tips and warnings on social media platforms.  There will be webinars and social media chats to give the public information that empowers them to Slam the Scam."

 

Maine Releases Elder Justice Roadmap

A couple of weeks ago Maine's Governor released the new Elder Justice Roadmap.

Two years of work went into developing the road map, resulting in "the 21-member Elder Justice Coordinating Partnership [identifying] challenges to the prevention of, detection of, and response to elder abuse in the State of Maine and [developing] strategic priorities across the public and private sectors to prevent and respond to elder abuse. These recommendations, contained in the Elder Justice Roadmap, range from improvements in direct victim services, public and professional education, public policy and data collection and evaluation." 

The snapshot of the roadmap leads off with noting that  "There is a health, justice, financial, and social crisis facing Maine: • Research shows that one out of ten adults aged 60 and older have experienced abuse in the past year. That means tens of thousands of older Mainers experience elder abuse every year. • Abuse is most often committed by a trusted person, including intimate partners, adult children, and other family members. • The adverse health and broad economic impacts of elder abuse are well documented."  The snapshot notes that "[t]he Roadmap contains recommendations to achieve three desired results: 1. Decrease the incidence of elder abuse; 2. Increase the number of elder abuse victims who seek and receive help in stopping abuse; and 3. Improve the multidisciplinary response to elder abuse."

The full 122 page roadmap is available here.

 

Podcast on Nursing Home Neglect

The National Consumer Voice for Quality Long-Term Care is offering a podcast with Dr. Laura Mosqueda on Nursing Home Neglect: Preventing It and Getting Help. Here's a description of the podcast:

The pandemic has renewed concerns about the quality of care that residents receive in some nursing homes, and many family members have reported significant decline in the condition of their loved ones. Neglect and abuse of older adults is a long-standing problem that is under-reported and has not received the necessary attention and response from policymakers, yet it results in needless and preventable suffering and harm.

In this episode with Dr. Laura Mosqueda, a professor of Family Medicine and Geriatrics at the Keck School of Medicine at the University of Southern California, we talk about neglect, which is the failure to provide goods and services to an individual that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect may or may not be intentional.

The link to the podcast is here. You can subscribe to the podcast series from this page as well as find information about the Consumer Voice's YouTube channel.

SNF Staffing Standards-New Report

Yesterday I blogged about California's consideration of tying Medicaid funding for SNFs to certain quality of care benchmarks. Today I wanted to let you know about a new report released by the National Consumer Voice for Quality Long-Term Care. State Nursing Home Staffing Standards SUMMARY REPORT opens noting that

"Chronic understaffing has been a serious problem in nursing homes for decades and has been exacerbated by the COVID-19 pandemic. While there are numerous factors contributing to this problem, one major cause is the lack of adequate minimum staffing standards at both the state and federal levels. Minimum standards ensure that staffing will not fall to a level that would be harmful to residents. Local, state, and national advocates have pushed for minimum staffing standards for years. Knowledge of the range of state staffing requirements can be very useful in these efforts. To that end, the focus of this summary report is to present staffing requirements from each state and analyze how they compare to each other and to levels recommended by research conducted for the federal government. This information can also be helpful to policymakers, researchers, and the media.

The report discusses the connection between staffing and quality care, the research on minimum staffing standards, laws and regs at both state and federal levels, an analysis of state staffing standards, recent developments, and concludes with this

Twenty years after the CMS study found that at least 4.1 hprd of direct care nursing staff time are needed just to prevent poor outcomes, state staffing requirements, with a few exceptions, are nowhere near that recommended level. Only the District of Columbia requires this overall level of staffing, and only six states mandate the presence of a registered nurse 24 hours a day regardless of facility size. Despite what is known about the relationship between staffing levels and quality care, staffing standards in almost every state remain severely low. Residents have waited decades for adequate staffing around the clock. Every day that passes without sufficient staffing jeopardizes their health, safety and welfare. Ongoing and robust advocacy is needed at both the federal and state levels to provide residents with the care to which they are entitled and that they deserve.

The full report is available here, a summary here, Appendix A (guide to state staffing standards) here, and Appendix B (state staffing standards comparison) here.

California Reconsidering Criteria for SNF Medicaid Funding

Well, as I write this, it looks at though the world is heading for another COVID surge.  Thus, this recent article from Kaiser Health News is particularly timely. After ‘Truly Appalling’ Death Toll in Nursing Homes, California Rethinks Their Funding opens with this sobering statistic: about 1 of every 8 of those California residents who died due to COVID resided in SNFs which translates to roughly 9,400, with an added  56,275 SNF residents with confirmed COVID who survived it.  As a response, the article notes, that the Governor's office is looking into a proposal that ties SNF funding to performance, with "those that meet new quality standards would get a larger share of state funding than those that don’t."

There will be several hurdles, and the industry is gearing up to oppose it while families of those who died are prepared to support it.  For example, the CEO of  California Association of Health Facilities, doesn't think the facilities should bear the blame, since "residents naturally at higher risk than the rest of the public, [and] facilities were forced to accept hospital transfer patients who had not been tested for the virus, they couldn’t get adequate supplies of personal protective equipment, and they suffered as staff members got covid in the community and then brought it into work."  The counter-point from various studies notes that SNFs "with fewer nursing staff members experienced significantly higher covid infection and death rates. That devastating outcome is bolstering a two-decades-long argument by patient advocates that nursing homes must hire more workers."

Staffing is not the only issue, and the article explores others, including the profits made by the various chains.  California is not alone in considering actions to improve quality of care.  I'm sure there will future blogs on this topic.

California Aid-in-Dying Statute Revisions

You may have already read about this, but just in case....  Kaiser Health News has reported about changes to California's aid-in-dying law.   New California Law Eases Aid-in-Dying Process explains that "in October, Gov. Gavin Newsom signed a revised version of the law, extending it to January 2031 and loosening some restrictions in the 2015 version that proponents say have become barriers to dying people who wish to avail themselves of the law." This change becomes effective in 2022. 

With the original law, as an example, "patients who want to die must make two oral requests for the medications at least 15 days apart. They also must request the drugs in writing, and two doctors must agree the patients are legally eligible. After receiving the medications, patients must confirm their intention to die by signing a form 48 hours before ingesting them."

Now, with the changes, "the revised law reduces the 15-day waiting period to just two days and eliminates the final attestation [and] requires health care facilities to post their aid-in-dying policies online. Doctors who decline to prescribe the drugs — whether on principle or because they don’t feel qualified — are obliged to document the patient’s request and transfer the record to any other doctor the patient designates."

The article offers poignant examples, provides statistics, and discusses the approach of insurance companies for coverage of the prescription ("[M]ore than 60% of those who take the drugs are on Medicare, which does not cover them. Effective life-ending drug combinations are available for as little as $400.")

NY Times Investigation Into CMS Appeals Process for SNFs

The New York Times published the results of an investigation into SNF deficiencies in How Nursing Homes’ Worst Offenses Are Hidden From the Public opens with 3 examples of errors and notes "[s]tate inspectors determined that all three homes had endangered residents and violated federal regulations. Yet the federal government didn’t report the incidents to the public or factor them into its influential ratings system. The homes kept their glowing grades."

Describing the results of the investigation, the article notes

that at least 2,700 similarly dangerous incidents were also not factored into the rating system run by the federal Centers for Medicare and Medicaid Services, or C.M.S., which is designed to give people reliable information to evaluate the safety and quality of thousands of nursing homes.

Many of the incidents were uncovered by state inspectors and verified by their supervisors, but quashed during a secretive appeals process, according to a review of thousands of pages of inspection reports and nursing home appeals, which The Times obtained via public-records requests. Others were omitted from the C.M.S. ratings website because of what regulators describe as a technical glitch.

Knowing the importance of the results of the inspections, the article offers that "[o]n-the-ground inspections are the most important factor in determining how many stars homes receive in Medicare’s rating system. The reports that inspectors produce give the public an unvarnished view inside facilities that house many of the country’s most vulnerable citizens."  

Despite the importance of such info, the system isn't transparent.  "On the rare occasions when inspectors issue severe citations, nursing homes can fight them through an appeals process that operates almost entirely in secret. If nursing homes don’t get the desired outcome via the informal review, they can appeal to a special federal court inside the executive branch. That process, too, is hidden from the public." Even though CMS may prevail, the results don't always end up on the compare website.  Why not?  "Jonathan Blum, the chief operating officer for C.M.S., said that citations are omitted during state-level appeals to be fair to nursing homes that are disputing inspectors’ findings. He acknowledged that even after appeals are exhausted, some citations still don’t appear on Care Compare. He said C.M.S. is 'working to correct this issue.'"

The article offers an excellent overview of the inspection requirements and process, as well as pointing out some of the limitations of the process.

This is a really important report and I plan to make it required reading for my students. You need to read it also!

Thanks to my friend and colleague, Professor Bauer, for sending me the link to the article.

Is Guardianship Replaceable?

The most recent issue of BIFOCAL (the publication of the ABA Commission on Law & Aging) contains an article by David Godfrey, Replacing Guardianship / Conservatorship.  He identifies three areas where folks may need help: "health care decisions, personal care decisions and financial management" and notes that the assistance provided often comes from "family and concerned friends."  Mr. Godfrey analyzes each area and discusses the options to provide support.

For health care decisions, he note family consent statutes will work, except "when the person has no identifiable family or friends willing to assist, when there is conflict between family members, or when the person making the choice appears to be committing abuse. It is possible for laws to be structured so that state actors can select someone to have legal authority to consent to health care under those
circumstances." (citations omitted).  For Personal Care Decisions,  "[these choices often have a low risk of harm...  and  choices  simply need to be made to keep the person happy, safe, and with appropriate nutrition. Where there are challenges in personal care decisions, support by family and friends will most often replace guardianship." Noting the increase in disputes regarding visitation, he references a trend where  folks "are increasingly being advised to leave specific written directions on contact or visitation in the event of a decline in capacity, to replace the use of guardianship to resolve concerns about contact or visitation."  He notes that living arrangements is a hybrid of personal and legal issues. ". Powers of attorney, authorized signers on financial accounts, and trusts are planning tools that can replace guardianship. When those options are not available, laws can be created to allow courts to issue limited protective orders, to approve leases, sales, or purchases of property, or
approve occupancy or admissions agreements, and are limited in scope to just that one issue, with oversight by the court and accountability to the court." 

Finally, for financial decisions,  he discusses various devices that empower another to make financial decisions for a person and oversight mechanisms such financial management professionals or giving family members access to view the person's account statements online.  He discusses protective arrangements and the risk of elder abuse and offers this conclusion:

Successful planning and legal alternatives can replace many guardianships. In many states, laws and practices need to be changed to allow more alternatives. All of these can fail. No one tool is a guarantee of safety. Criminals have used every tool in the box to abuse and exploit. Everyone needs to be urged to plan for incapacity; we are all only one health care event away from needing help meeting our basic needs and protecting ourselves from harm. Currently, we fail to plan more often than plans fail. Guardianship becomes the replacement for failure to plan, or for plans that have failed. It is time to turn that on its head and replace guardianship.