Traditionally, Medicaid has paid for long-term care in a nursing home, but because most individuals would rather be cared for at home and home care is cheaper, all 50 states now have Medicaid programs that offer at least some home care. In some states, even family members can get paid for providing care at home.
Medicaid is a joint federal-state program that provides health insurance coverage to low-income children, seniors, and people with disabilities. In addition, it covers care in a nursing home for those who qualify. Medicaid home care services are typically provided through home- and community-based services “waiver” programs to individuals who need a high level of care, but who would like to remain at home.
Medicaid’s home care programs are state-run, and each state has different rules about how to qualify. Because Medicaid is available only to low-income individuals, each state sets its own asset and income limits. For example, in 2019, in New York an applicant must have income that is lower than $845 a month and fewer than $15,150 in assets to qualify. But Minnesota’s income limit is $2,250 and its asset limit is $3,000, while Connecticut’s income limit is also $2,250 but its asset limit is just $1,600.
States also vary widely in what services they provide. Some services that Medicaid may pay for include the following:
In-home health care
Personal care services, such as help bathing, eating, and moving
Home care services, including help with household chores like shopping or laundry
Minor modifications to the home to make it accessible
In most states it is possible for family members to get paid for providing care to a Medicaid recipient. The Medicaid applicant must apply for Medicaid and select a program that allows the recipient to choose his or her own caregiver, often called “consumer directed care.” Most states that allow paid family caregivers do not allow legal guardians and spouses to be paid by Medicaid, but a few states do. Some states will pay caregivers only if they do not live in the same house as the Medicaid recipient.
To find out your Medicaid home care options, feel free to email or give me a call.
The Centers for Medicare & Medicaid Services (CMS) has released the 2019 federal guidelines for how much money the spouses of institutionalized Medicaid recipients may keep, as well as related Medicaid figures.
In 2019, the spouse of a Medicaid recipient living in a nursing home (called the “community spouse”) may keep as much as $126,420 without jeopardizing the Medicaid eligibility of the spouse who is receiving long-term care. Called the “community spouse resource allowance,” this is the most that a state may allow a community spouse to retain without a hearing or a court order. While some states set a lower maximum, the least that a state may allow a community spouse to retain in 2019 will be $25,284.
Meanwhile, the maximum monthly maintenance needs allowance for 2019 will be $3,160.50. This is the most in monthly income that a community spouse is allowed to have if her own income is not enough to live on and she must take some or all of the institutionalized spouse’s income. The minimum monthly maintenance needs allowance for the lower 48 states remains $2,057.50 ($2,572.50 for Alaska and $2,366.25 for Hawaii) until July 1, 2019.
In determining how much income a particular community spouse is allowed to retain, states must abide by this upper and lower range. Bear in mind that these figures apply only if the community spouse needs to take income from the institutionalized spouse. According to Medicaid law, the community spouse may keep all her own income, even if it exceeds the maximum monthly maintenance needs allowance.
The new spousal impoverishment numbers (except for the minimum monthly maintenance needs allowance) take effect on January 1, 2019.
TO LEARN MORE ABOUT THE BENEFITS OF MEDICAID PLANNING click here.
Home Equity Limits:
In 2019, a Medicaid applicant’s principal residence will not be counted as an asset by Medicaid unless the applicant’s equity interest in the home is less than $585,000, with the states having the option of raising this limit to $878,000.
In order to qualify for Medicaid, a nursing home resident’s income must not be above a certain level. Most states allow individuals to spend down their excess income on their care until they reach the state’s income standard. But other states impose an “income cap,” which means no spend-down is allowed.
ITHACA, N.Y. — Most nursing homes had fewer nurses and caretaking staff than they had reported to the government for years, according to new federal data, bolstering the long-held suspicions of many families that staffing levels were often inadequate.
The records for the first time reveal frequent and significant fluctuations in day-to-day staffing, with particularly large shortfalls on weekends. On the worst staffed days at an average facility, the new data show, on-duty personnel cared for nearly twice as many residents as they did when the staffing roster was fullest.
The data, analyzed by Kaiser Health News, come from daily payroll records Medicare only recently began gathering and publishing from more than 14,000 nursing homes, as required by the Affordable Care Act of 2010. Medicare previously had been rating each facility’s staffing levels based on the homes’ own unverified reports, making it possible to game the system.
The payroll records provide the strongest evidence that over the last decade, the government’s five-star rating system for nursing homes often exaggerated staffing levels and rarely identified the periods of thin staffing that were common. Medicare is now relying on the new data to evaluate staffing, but the revamped star ratings still mask the erratic levels of people working from day to day.
Stan Hugo with his wife, Donna, who is a resident at the Beechtree
Center for Rehabilitation and Nursing in Ithaca, N.Y. Mr. Hugo
tracks staffing levels at the skilled nursing facility.
At the Beechtree Center for Rehabilitation & Nursing here, Jay Vandemark, 47, who had a stroke last year, said he often roams the halls looking for an aide not already swamped with work when he needs help putting on his shirt.
Especially on weekends, he said, “It’s almost like a ghost town.”
Nearly 1.4 million people are cared for in skilled nursing facilities in the United States. When nursing homes are short of staff, nurses and aides scramble to deliver meals, ferry bedbound residents to the bathroom and answer calls for pain medication. Essential medical tasks such as repositioning a patient to avert bedsores can be overlooked when workers are overburdened, sometimes leading to avoidable hospitalizations.
“Volatility means there are gaps in care,” said David Stevenson, an associate professor of health policy at Vanderbilt University School of Medicine in Nashville, Tenn. “It’s not like the day-to-day life of nursing home residents and their needs vary substantially on a weekend and a weekday. They need to get dressed, to bathe and to eat every single day.”
David Gifford, a senior vice president at the American Health Care Association, a nursing home trade group, disagreed, saying there are legitimate reasons staffing varies. On weekends, for instance, there are fewer activities for residents and more family members around, he said.
“While staffing is important, what really matters is what the overall outcomes are,” he said.
While Medicare does not set a minimum resident-to-staff ratio, it does require the presence of a registered nurse for eight hours a day and a licensed nurse at all times.
The payroll records show that even facilities that Medicare rated positively for staffing levels on its Nursing Home Compare website, including Beechtree, were short nurses and aides on some days. On its best staffed days, Beechtree had one aide for every eight residents, while on its lowest staffed days, there was only one aide for 18 residents. Nursing levels also varied.
The Centers for Medicare & Medicaid Services, the federal agency that oversees nursing home inspections, said in a statement that it “is concerned and taking steps to address fluctuations in staffing levels” that have emerged from the new data. This month, it said it would lower ratings for nursing homes that had gone seven or more days without a registered nurse.
Beechtree’s payroll records showed similar staffing levels to those it had reported before. David Camerota, chief operating officer of Upstate Services Group, the for-profit chain that owns Beechtree, said in a statement that the facility has enough nurses and aides to properly care for its 120 residents. But, he said, like other nursing homes, Beechtree is in “a constant battle” to recruit and retain employees even as it has increased pay to be more competitive.
Mr. Camerota wrote that weekend staffing is a special challenge as employees are guaranteed every other weekend off. “This impacts our ability to have as many staff as we would really like to have,” he wrote.
New rating method is still flawed
In April, the government started using daily payroll reports to calculate average staffing ratings, replacing the old method, which relied on homes to report staffing for the two weeks before an inspection. The homes sometimes anticipated when an inspection would happen and could staff up before it.
Payroll records at Beechtree show that on its highest staffed days, it had one aide for every eight residents, but there was only one aide for 18 residents at the lowest staffing level.CreditHeather Ainsworth for The New York Times
“They get burned out and they quit,” said Adam Chandler, whose mother lived at Beachtree until her death earlier this year. “It’s been constant turmoil, and it never ends.”
Medicare’s payroll records for the nursing homes showed that there were, on average, 11 percent fewer nurses providing direct care on weekends and 8 percent fewer aides. Staffing levels fluctuated substantially during the week as well, when an aide at a typical home might have to care for as few as nine residents or as many as 14.
A family council forms
Beechtree actually gets its best Medicare rating in the category of staffing, with four stars. (Its inspection citations and the frequency of declines in residents’ health dragged its overall star rating down to two of five.)
To Stan Hugo, a retired math teacher whose wife, Donna, 80, lives at Beechtree, staffing levels have long seemed inadequate. In 2017, he and a handful of other residents and family members became so dissatisfied that they formed a council to scrutinize the home’s operation. Medicare requires nursing home administrators to listen to such councils’ grievances and recommendations.
Sandy Ferreira, who makes health care decisions for Effie Hamilton, a blind resident, said Ms. Hamilton broke her arm falling out of bed and has been hospitalized for dehydration and septic shock.
“Almost every problem we’ve had on the floor is one that could have been alleviated with enough and well-trained staff,” Mrs. Ferreira said.
Beechtree declined to discuss individual residents, but said it had investigated these complaints and did not find inadequate staffing on those days. Mr. Camerota also said that Medicare does not count assistants it hires to handle the simplest duties like making beds.
In recent months, Mr. Camerota said, Beechtree “has made major strides in listening to and addressing concerns related to staffing at the facility.”
Mr. Hugo agreed that Beechtree has increased daytime staffing during the week under the prodding of his council. On nights and weekends, he said, it still remained too low.
His wife has Alzheimer’s, uses a wheelchair and no longer talks. She enjoys music, and Mr. Hugo placed earphones on her head so she could listen to her favorite singers as he spoon-fed her lunch in the dining room on a recent Sunday.
As he does each day he visits, he counted each nursing assistant he saw tending residents, took a photograph of the official staffing log in the lobby and compared it to what he had observed. While he fed his wife, he noted two aides for the 40 residents on the floor — half what Medicare says is average at Beechtree.
“Weekends are terrible,” he said. While he’s regularly there overseeing his wife’s care, he wondered: “What about all these other residents? They don’t have people who come in.”
This article was produced in collaboration with Kaiser Health News, an editorially independent program of the Kaiser Family Foundation. The author is a reporter for Kaiser Health News.
A version of this article appears in print on , on Page A1 of the New York edition with the headline: Nursing Homes Routinely Mask Low Staff Levels. Order Reprints | Today’s Paper | Subscribe
Nursing home neglect and abuse is often difficult to detect, and families should be on the lookout for common warning signs for physical, emotional and financial abuse.
Common warning signs of physical abuse are:
Untreated bedsores, pressure sores, wounds, cuts, bruises, or welts
Abnormally pale complexion
Bruises in a pattern that would suggest restraints
Excessive and sudden weight loss
Fleas, lice, or dirt on or in the room
Poor personal hygiene, unpleasant odors or other unattended health problems
Torn clothing or broken personal items
Bleeding around private parts
Bruises around the breast/genital region
An unexpected look of fear from the elder when aide may be present
Common warning signs of emotional abuse are:
Intimidation through yelling and threats
Ignoring the patient
Isolating the patient from other residents and/or activities
Terrorizing the patient
Mocking the patient
Financial exploitation is another form of abuse. An unscrupulous caregiver may:
Misuse checks, accounts, or credit cards
Steal money, steal checks, or steal belongings
Authorize withdrawals or transfer of monies
Steal the patient’s identity
No family is exempt from any of these possibilities. Abuse affects the rich and poor. Suffering sustained by the elderly ranges from financial, to emotional and physical. Abuse escalating to physical can result in severe infections, amputations, dehydration and, unfortunately, death. A lawsuit should be filed on behalf of your loved one to get the justice your family deserves. Compensation may cover the costs of treatment and recovery, as well as compensation for non-financial hardships such as pain and suffering.
If you suspect elder abuse of any kind speak up and demand answers of those in charge.
Feel free to contact me for more information or inquire about a lawsuit.
WHEN IT COMES TO BEDSORES, PRESSURE SORES, DECUBITUS ULCERS IT’S OFTEN HELPFUL TO READ WHAT OTHERS HAVE ASKED. YOU MAY BE ABLE TO BENEFIT FROM SOME OF OUR FREQUENTLY ASKED QUESTIONS BELOW.
If the patient was at a hospital first and then a nursing home which do we sue?
It always depends on individual and medical circumstances but the possibility exists that both are liable. Often an injury begins in a hospital, may not be reported and/or is overlooked or neglected on intake at the second facility where it may get worse or lead to infection and other medical issues.
What if the patient is too ill to appear in court?
This is not an issue and often the case with bedsore victims. For bedsore and pressure sore lawsuits there’s a legal team that includes experienced bedsore litigators, and medical professionals that can testify based on patient medical records and treatment or lack of and improper treatment. As well as other expert witnesses that look into hospital procedures, policy and practices and determine if any federal violations were evident or standards of procedure were not met. Medical records and pictures of wounds are used.
How much does it cost to sue?
There is no fee to you unless we win. When we accept a case we put in the resources and hours of our bedsores legal team because we are confident of a successful outcome based on the facts of the case. If we take on your case it’s because we see huge upside financial potential for the victim or family of the victim. We work on contingency–no upfront fee or time billed to you. When you win we get an agreed upon portion of the award. NOTE: Most firms generally work this way for these lawsuits as it is usually cost prohibitive for client on hourly or other fee basis as expenses get incurred for expert witnesses, medical experts, trial prep, trial, review etc.
Will beginning a lawsuit get better care for the victim?
Once a hospital or nursing home knows a bedsore lawsuit is possible, often the care and treatment of the patient improves. This is because now they know they are under scrutiny and may be even further liable legally if not giving the proper care and medical attention after the sores have been documented by family and bedsore lawyers. Additionally, our law firm will let you know the standards of care that is necessary for you or your loved one. We can even help guide you on the best way to discuss issues with the doctor or staff and get the desired results.
I want to sue – does it take long? Does my dad have to appear in court?
Timing of a case varies. With expertise and experience and a hands-on approach we move swiftly. The size of our firm allows us to focus on cases so they don’t get lost in the shuffle. Unlike some other law firms, our legal team of attorneys, paralegals, research assistants, medical experts and more, have the experience and knowledge to avoid time lags. Many times cases are seattled before even going to court. Of course, the plaintiff has a say in this decision and we do what is best for our client.
Do I need money to sue-what does contingency mean?
You will not need to lay out any money. We handle all of our bedsore and pressure sore negligence or malpractice cases on a contingency fee basis. That means that we only charge a legal fee if we are successful and recover money for you. Our fee is typically 33 1/3% of the net recovery after the costs and disbursements that we advance are deducted. The contingency fee may be even lower depending on the facts of the case and the reason the sores happened. With a free consultation, a bedsore law firm that advances all of the necessary costs, and a contingency fee arrangement, you get our reputable law firm with no out of pocket expenses.
How do I know if I have a good bedsore lawsuit? The nurse said the sores were caused by my father.
Don’t put much credence in the opinion of anyone that isn’t a legal expert. Even a medical professional or doctor doesn’t have the legal knowledge and they or facility administrator may even try to persuade you against a bedsore or pressure sore lawsuit. Such tactics aren’t new. Don’t be a victim twice. Consult with legal professionals when medical ones let you down. Then you can use your best judgement on how to proceed with your lawsuit.
Pressure Ulcers and Bedsores can progress quickly and can be deadly. The first thing you should do is remove pressure from the area and speak to a nurse on duty to begin to remedy the situation. Be aware that the nurse may not have a full understanding of these injuries and you will need the attention of a wound care specialist and medical doctor.
Yes, you can sue! Pressure Ulcers are often a sign of neglect and sometimes a sign of abuse or malpractice. They occur when someone is immobile and there is not adequate blood flow. Then the affected tissue dies and an ulcerated sore develops.
In a nursing home or hospital it is the responsibility of the nursing staff to check and turn the patient regularly. There are laws in place that protect patients and you should know that these injuries are not the fault of the patient. The patient is the victim. If a loved one you know is suffering they may have a valuable, financially rewarding lawsuit. In the New York area, millions of dollars have been awarded to pressure sore victims and their families.
The National Pressure Ulcer Advisory Panel (NPUAP) defines a pressure ulcer as a “localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear.” Illustrations of common locations of pressure ulcers are shown below:
These injuries can lead to further medical problems, infections, sepsis, amputation and even death. Whether malpractice, abuse or neglect it is simply unjust and unnecessary for it to happen to an innocent patient.
Call today for a free consultation to find out the value of a lawsuit or for more information: 212-268-8200, or 800-278-2960
Some states make it harder for those caring for an aging parent, according to a new survey.
Caring.com conducted a national survey to determine which states offer the best overall cost of living, and accessibility to senior support programs and resources for caregivers.
While some states were praised for providing an affordable and helpful environment for caregivers, other states inevitable ended up at the bottom of the list.
“It hasn’t always been so expensive, but the cost of caring for our parents is so out of control now that it has the capacity to actually bankrupt families,” Jim Miller, a senior advocate and author of SavvySenior.org, said in the report. “I think that’s why it’s so important to consider these costs far in advance of needing to provide care so you’re prepared instead of panicked.”
These 10 states, in descending order, were deemed the most expensive for caregivers by Caring.com:
While the state is expensive for seniors, the availability of senior care support and services ranked 13th overall. The median cost for a home health aide was $4,500 more than the national average. Nursing home expenses were $24,00 more than the national average, according to caring.com.
9. New Hampshire
The state ranked 44th for cost of living. Costs for a nursing home stay for a year were over $100,000, well above the national average. The state did rank well for offering accessible senior programs and caregiver resources.
For your aging parent to live in a nursing home in Delaware, expect to pay the median price of $127,750. The state ranked 28th in the survey for senior and caregiver programs and support.
7. New York
Earning a good rank for senior support and services, the state offers numerous resources for caregivers and seniors. While the costs for a home health aide and assisted living are competitive, the median for a nursing home is well above the national average by over $40,000.
Having a conversation about moving — whether it’s with a relative, even a spouse — brings up lots of anxiety. Here’s how to go about it.
By PETER FINCH
Dawn and John Strumsky agree about most things, a tendency that has served them well in 45 years of marriage. But there was one subject where they did not see eye to eye for the longest time: their retirement future.
Ms. Strumsky wanted desperately to move into a retirement community, to live as “a princess” unburdened by the cooking, cleaning or yardwork required at their Maryland home. Mr. Strumsky didn’t just resist the idea, he detested it. During one argument with his wife, he shouted, “By God, I’ll sit in the burned-out, firebombed ruins of this home before anybody pulls me out!”
Mr. Strumsky, 78, tells that story with a laugh. Because, as he puts it, “I’ve done a 180 on this.” He finally gave in to his wife’s wishes, and in 2011 they moved to Charlestown, a retirement community outside Baltimore. Today, it might have no bigger fan than John Strumsky. One measure of his devotion: He’s the author of an exhaustive, 364-page history of Charlestown that management hands out to prospective residents.
His reluctance to move into a retirement community was not unusual. People often vow they’ll never do it, for any number of reasons. They fear giving up their independence. They can’t bear leaving their home. They don’t like confronting their own mortality. This can lead to bitter squabbles with members of their family and other loved ones who want them to move.
“I’ve heard more than one adult child say, half-jokingly, ‘If Mom doesn’t check in to a retirement home, I’m going to need to,’” said Katherine Pearson, a specialist in elder law and a professor at Pennsylvania State University’s Dickinson Law School.
So how do you persuade an unwilling senior to at least consider it? The key is to be patient, said Tom Neubauer, executive vice president at Erickson Living, which operates 19 retirement communities. “Inherently there’s a sense of denial, particularly as it relates to aging, and you’re trying to defeat that.”
He likened the process to helping a high school student choose a college: “You can’t just hand them a brochure and say, ‘This is where you’re going.’ It’s a journey.”
Mr. Neubauer’s mother, Betty, moved into a retirement home three years ago. He had started encouraging her about three years before that. The discussion, he said, was less about “You need to do this” and more about “How do we maximize your years in retirement?”
Ms. Strumsky desperately wanted to move to a retirement community. One of her goals: Eliminate the work of maintaining their home.CreditAndrew Mangum for The New York Times
He focused on “really getting her to reflect on her life as she knew it,” he said. “I got her to recognize that the stairs in her house were pretty steep, that the weather had more of an impact on her ability to get out and do things, that she wasn’t pursuing all her hobbies as much anymore because people weren’t driving at night. It ended up being very easy.”
It’s best to start the retirement-home conversation with broad, open-ended questions, said Brad Breeding, founder of myLifeSite.net, a website that helps consumers research retirement communities. “What does peace of mind mean to you in this stage of your life?” he suggested. “What kinds of concerns do you have for your future?”
Let’s say a senior’s No. 1 goal is staying in her home. “O.K., in the next conversation I’ll start to talk about ‘What would we do if you had a fall in your home?’ Or ‘What would happen if you had a stroke?’” Mr. Breeding said.
One way to make retirement communities more attractive is to frame the move as a gift to their children. “It’s really removing the responsibility of caring for the parents, of not having to make frantic, last-minute arrangements if something changes in their health,” said Lesley Sargent, a residency counselor at the Sagewood retirement community in Phoenix.
Part of the problem is that many people hear “retirement community” and think “nursing home.” Today’s typical continuing care retirement community, or C.C.R.C., is a far cry from the sterile nursing-home environment of previous generations. While the communities usually have some hospital-like rooms for people who need more advanced care, most of their residences look and feel like ordinary apartments.
The best way around that objection is to let someone see firsthand. “You can always go for a meal just to experience what it’s like,” said Lindsay Hutter, chief strategy and marketing officer at Goodwin House, a senior living and care organization in Virginia.
The ideal approach: Create a social occasion where the senior you’re trying to convince can dine with friends, or friends of friends. With seniors, Ms. Hutter said, “our observation is that peers have a much greater influence than their children do.”
Some retirement communities let potential residents spend a few nights to see how they like it. Others offer rental programs that let seniors stay longer. Like a lot of C.C.R.C.s, Goodwin House will let nonresidents join a waiting list — known as its “priority club” — that allows them to use its restaurants and participate in activities. If they decide the community is not for them, the $1,000 waiting list fee is refundable.
The Centers for Medicare and Medicaid Services (CMS) has clarified when a transfer penalty begins for Medicaid applicants who are seeking home and community-based services. The penalty period begins when the applicant would begin receiving services were it not for the penalty period.
After Congress passed the Deficit Reduction Act of 2005 (DRA), CMS issued a guidance letter that a penalty period would not start to run until the date the “individual is eligible for Medicaid and is receiving institutional level of care services” [emphasis added]. But home and community-based services only become “services” once applicants are enrolled in the state’s waiver program and Medicaid is providing coverage. This caused a “Catch-22” for Medicaid applicants who were applying for home and community-based waivers: The penalty period would not begin to run until the applicants began receiving waiver services, but the applicants could not begin to receive waiver services until the penalty had run.
On April 17, 2018, CMS finally issued a new guidance letter, changing the start date of the penalty period to the date the “individual is eligible for medical assistance under the State plan and would otherwisebe receiving institutional level [of] care services” (emphasis added). This means that an applicant for home and community-based services will be eligible once the applicant meets the financial and non-financial requirements for Medicaid eligibility and the level-of-care requirements.
A new federal law is designed to address the growing problem of elder abuse. The law supports efforts to better understand, prevent, and combat both financial and physical elder abuse.
The prevalence of elder abuse is hard to calculate because it is underreported, but according to the National Council on Aging, approximately 1 in 10 Americans age 60 or older have experienced some form of elder abuse. In 2011, a MetLife study estimated that older Americans are losing $2.9 billion annually to elder financial abuse.
The bipartisan Elder Abuse Prevention and Prosecution Act of 2017 authorizes the Department of Justice (DOJ) to take steps to combat elder abuse. Under the new law, the federal government must do the following:
Create an elder justice coordinator position in federal judicial districts, at the DOJ, and at the Federal Trade Commission
Implement comprehensive training on elder abuse for Federal Bureau of Investigation agents
Operate a resource group to assist prosecutors in pursuing elder abuse cases
The law requires the DOJ to collect data on elder abuse and investigations as well as provide training and support to states to fight elder abuse. The law specifically targets email fraud by expanding the definition of telemarketing fraud to include email fraud. Prohibited actions include email solicitations for investment for financial profit, participation in a business opportunity, or commitment to a loan.
The law also addresses flaws in the guardianship system that have led to elder abuse. The law enables the government to provide demonstration grants to states’ highest courts to assess adult guardianship and conservatorship proceedings and implement changes.
“Exploiting and defrauding seniors is cowardly, and these crimes should be addressed as the reprehensible acts they are,” said Senator Chuck Grassley (R-Iowa), a co-sponsor of the legislation, adding that the legislation “sends a clear signal from Congress that combating elder abuse and exploitation should be top priority for law enforcement.”