Article: Nursing Homes Routinely Mask Low Staff Levels

Via New York Times By Jordan Rau

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.

Nursing Home Abuse Lawsuits >

“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

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When Is A Guardian Required for an Adult?

Guardianships are set up to protect and help people in need, such as an elder or loved one unable to care for their own financial or health related well being. When is it required? What is the process?

When is a Guardianship Required For An Adult?

It may be necessary to petition a court to appoint a legal guardian for persons: Who have a physical or mental problem that prevents them from taking care of their own basic needs; Who as a result are in danger of substantial harm; and Who have no person already legally authorized to assume responsibility for them. Under some circumstances, it may be necessary for a court to appoint an emergency guardian, who can act on your behalf during a crisis (such as immediately following a car accident) until you regain your ability to make your own decisions.

Free Will

How is a Guardian Appointed?

The precise procedure will vary to some degree from jurisdiction to jurisdiction. The typical steps are as follows:The person seeking the appointment of a guardian files a petition with the probate court for the jurisdiction where the allegedly legally incapacitated person resides. This petitioner is often a relative, an administrator for a nursing home or health care facility, or other interested person. A petition is ordinarily accompanied by medical affidavits or other sworn statements which evidence the person’s incapacity, and either identifies the person or persons who desire to be named guardian or requests the appointment of a public guardian.The court arranges for any necessary evaluation of the allegedly legally incapacitated person. Often, this will involve the appointment of a “guardian ad litem”, a person who is appointed to provide an independent report to the court on behalf of the allegedly legally incapacitated person.

If appointed, the guardian ad litem will meet with the allegedly incapacitated person, inform that person of his or her legal rights, and report back to the court on the person’s wishes. The guardian ad litem may also speak to the petitioner, to health care providers, and to other interested individuals in order to provide the court with full information about the allegedly incapacitated person’s condition and prognosis. Depending upon state law, the court may appoint a doctor or professional to examine the allegedly incapacitated person. If the person contests the appointment of a guardian, a trial is scheduled during which sworn testimony will be given, and at the conclusion of which the judge will decide if the petitioner met the requisite burden of proof for the appointment of a guardian. The allegedly incapacitated person is ordinarily entitled to appointed counsel, if unable to afford a private attorney.If the allegedly incapacitated person consents to the petition, or is unable to respond to inquiries due to disability, the court will hold a hearing at which witnesses will provide sworn testimony to support the allegations in the petition. If the evidentiary basis is deemed sufficient, the guardian will be appointed.If a guardian is appointed, the judge will issue the guardian legal documents (often called “letters of authority”) permitting the guardian to act on behalf of the legally incapacitated person.What Are a Guardian’s Duties?The guardian makes decisions about how the person lives, including their residence, health care, food, and social activity. The guardian is supposed to consider the wishes of the incapacitated person, as well as their previously established valued, when making these living decisions. The guardian is intended to monitor the legally incapacitated person, to make sure that the person lives in the most appropriate, least restrictive environment possible, with appropriate food, clothing, social opportunities, and medical care.A guardian may be required to post a bond, unless the requirement is waived by the court. In most jurisdictions where bond is required, waivers are routine.

What’s the purpose of court supervision?

The court supervises the guardian’s choices on behalf of the ward. After the initial appointment of a guardian, an initial review is usually scheduled, followed by annual reports by the guardian to the court. The purpose of this supervision is to ensure that the legally incapacitated person is in fact benefiting from the most appropriate, least restrictive living environment possible, with appropriate food, clothing, social opportunities, and medical care.

Avoiding Guardianship:

It is possible to avoid the necessity of a guardianship through estate planning. A good estate plan will include a medical power of attorney which will enable a trusted individual to make health care decisions for you in the event of incapacity, and a general durable power of attorney to permit a trusted individual to manage your personal affairs. To a considerable extent, those documents can specify how you wish to live, and how you wish to be treated, in the event of disability – whereas a court or guardian may make decisions with which you would disagree. In most cases, when these documents have been executed in accord with the laws of your state, it will not be necessary for your loved ones to seek the appointment of a guardian or conservator should something happen to you – something that can be cumbersome and emotionally taxing at an already difficult time.

Should My Parents Give Me Their Home?

Many people wonder if it is a good idea to give their home to their children. While it is possible to do this, giving away a house can have major tax consequences, among other results.

When you give anyone property valued at more than $14,000 (in 2016) in any one year, you have to file a gift tax form.  Also, under current law you can gift a total of $5.45 million (in 2016) over your lifetime without incurring a gift tax. If your parents’ residence is worth less than this amount, they likely won’t have to pay any gift taxes, but they will still have to file a gift tax form

While your parents may not have to pay taxes on the gift, if you sell the house right away, you may be facing steep taxes. The reason is that when property is given away, the tax basis (or the original cost) of the property for the giver becomes the tax basis for the recipient. For example, suppose your parents bought the house years ago for $150,000 and it is now worth $350,000. If they give their house to you, the tax basis will be $150,000. If you sell the house, you will have to pay capital gains taxes on $200,000 — the difference between $150,000 and the selling price. The only way for you to avoid the taxes is for you to live in the house for at least two years before selling it. In that case, you can exclude up to $250,000 ($500,000 for a couple) of their capital gains from taxes.

Inherited property does not face the same taxes as gifted property. If you were to inherit the property, the property’s tax basis would be “stepped up,” which means the basis would be the current value of the property. However, the home will remain in your parents’ estate, which may have estate tax consequences.

Beyond the tax consequences, gifting a house to you can affect your parents’ eligibility for Medicaid coverage of long-term care.  There are other options for giving a house to children, including putting it in a trust or selling it to them. Before your parents give away their home, they should consult with your elder law attorney, who can advise them on the best method for passing on their home.

To read more articles about gifting from Brian A. Raphan, P.C. click here.

 

Financial Abuse of the Elderly: Sometimes Unnoticed, Always Predatory

Caution to elders and family members of elders. This happens too often:

Via The New York Times 11/27/15 Elizabeth Olson

It was only after Mariana Cooper, a widow in Seattle, found herself with strained finances that she confessed to her granddaughter that she was afraid she had been bilked out of much of her savings.

Over three years, Ms. Cooper, 86, had written at least a dozen checks totaling more than $217,000 to someone she considered a friend and confidante. But the money was never paid back or used on her behalf, according to court documents, and in early November the woman who took advantage of Ms. Cooper, Janet Bauml, was convicted on nine counts of felony theft. (She faces sentencing on Dec. 11.)

Ms. Cooper, who lost her home and now lives in a retirement community, is one of an estimated five million older American residents annually who are victimized to some extent by a caregiver, friend, family member, lawyer or financial adviser.

With 10,000 people turning 65 every day for the next decade, a growing pool of retirees are susceptible to such exploitation. As many as one in 20 older adults

said they were financially mistreated in the recent past, according to a study financed by the Justice Department.

Traditionally, such exploitation, whether by family, friends or acquaintances, often has been minimized as a private matter, and either dismissed with little or no penalty or handled in civil court.

Even when the sums are large, cases like Ms. Cooper’s are often difficult to prosecute because of their legal complexity and because the exploitation goes unnoticed or continues for long periods. Money seeps out of savings and retirement funds so slowly it draws attention only after it is too late.

Ms. Cooper, for example, wrote her first check, for $3,000, in early 2008, and later gave Ms. Bauml her power of attorney. In early 2012, after Ms. Cooper realized that Ms. Bauml was not going to repay her in time for her to afford a new roof for her house, she told her granddaughter, Amy A. Lecoq, about the checks. She later called the police.

Ms. Bauml maintained that Ms. Cooper gave her money for services she provided as a home organizer or as loans.

Later, testing by a geriatric mental health specialist found that Ms. Cooper had moderate dementia, which showed her judgment had been impaired.

The diagnosis “helped the jury to understand why she would keep signing all these checks to this woman as loans when she was never being paid back,” said Page B. Ulrey, senior deputy prosecutor for King County, Wash., who pressed the case against Ms. Bauml.

The case was challenging in part because Washington State does not have an elder abuse statute, said Ms. Ulrey, who is one of a small but growing number of prosecutors around the country with the specific duty of prosecuting those who take financial advantage of elders, whether it is connected to investments, contracts or other fraud.

As the number of complaints grows, more municipalities are trying to combat such abuse, which is often intertwined with physical or sexual abuse, and emotional neglect.

Some organizations also have set up shelters, modeled on those for victims of domestic abuse. In the Bronx, for example, the Weinberg Center for Elder Abuse Prevention at the Hebrew Home in Riverdale started such a shelter in 2005. Since then, 14 other such shelters have been opened in various long-term care operations around the country to deal with urgent cases of financial abuse.

One such woman, who agreed to talk only if she was not identified by her last name, stayed at Riverdale after she was threatened with eviction. A neighbor discovered that the woman, a 73-year-old widow named Irene, had not paid her rent in six months because relatives living with her had been withdrawing money from her account and leaving her short of funds.

“I had to leave with one small suitcase,” Irene said. “They were abusing me.”

She was later able to move to federally subsidized housing away from the abusive situation.

To help elders in financial and other distress, more municipalities, using federal funds, are training law enforcement officers, prosecutors, and social workers how to spot the sometimes subtle signals that may indicate someone has been swindled.

“We see many cases where someone convinces an older person to give them the power of attorney, and then uses that authority to strip their bank accounts, or take the title of their home,” said Amy Mix, a lawyer at the AARP Legal Counsel for the Elderly, which works with the Adult Protective Services division in the District of Columbia government as well as the city’s police department.

In the most recent fiscal year, 934 cases of abuse were reported in Washington. About one-quarter of those were financial exploitation, according to Sheila Y. Jones, chief of Adult Protective Services. “And they involve millions of dollars,” she said.

But many cases are not counted officially because older people are reluctant to pursue legal remedies against relatives and friends. Louise Pearson, 80, a retired government computer analyst, declined to press charges against a security guard in her building who had befriended her and later obtained $30,000 from her savings.

“There was something about him you just had to take to,” Ms. Pearson said.

When she finally asked Malika Moore, a social worker at Iona Senior Services in Washington, for some assistance with her shaky finances, the social worker realized that the situation was serious.

One clue, she said, was that, “When I opened her refrigerator, it was empty.”

Ms. Moore was able to get Ms. Pearson home-delivered meals, and after the bank confirmed that she was missing savings, help to find a conservator to handle her money. Ms. Pearson, who now lives in a housing complex for the elderly, said, “I get money whenever I need it, and more than I did before.”

In Seattle, Ms. Cooper’s granddaughter expressed determination to educate others on the warning signs of financial abuse. “I wish we had known some of the red flags,” she said.

But even though she’s a trained social worker, it’s not surprising she missed the signs. She was deeply involved in caring for her mother, Ms. Cooper’s daughter, who was fighting cancer and died shortly before the period when her grandmother was writing the checks.

“Our family saw her regularly,” Ms. Lecoq said, “but we just didn’t see indications of what was going on.”

In retrospect, she might have been more suspicious with “my grandmother suddenly having a new friend and a friend who got so close so fast.”

Once Ms. Lecoq and her husband, John, recognized what had happened, they pushed for prosecution. Ms. Ulrey, the prosecutor, said the case required medical tests and search warrants for both the victim’s and the suspect’s financial accounts.

Ms. Cooper was unable to recover her lost money and worries about how long she will be able to pay for her retirement home. “She’s ashamed and embarrassed and feels guilty,” Ms. Lecoq said of her grandmother. “But I tell her: ‘You were a victim of a crime.’”

To help older people, families and friends should be on the lookout for some of the warning signs of financial abuse. These include not being able to cover normal expenses; paying for excessive, unexpected gifts to others; and signing over power of attorney or transferring property to unrelated individuals. 

To learn more about protecting the savings of the elderly and helping them avoid being exploited financially, these publications are worth reading: 

JASA PETS Project: Helping NYC Seniors and Their Animal Companions

There is a little-known program in New York City that’s helping to keep some senior citizens’ pets where they belong — in their loving homes, and out of animal shelters. It’s the JASA PETS Project, and it’s making a difference for many NYC seniors and their pets.

JASA PETS Project: Helping NYC Seniors and Their Animal Companions.

JASA

Following a heart bypass operation, Ms. B. — a former teacher who lives alone with Lady, her two-year-old Dachshund — was feeling isolated, depressed, and useless. Already involved with the JASA Pets and Elder Team Support (PETS) Project, a group of international students was recruited to help Ms. B. care for her dog. In return, she has begun to work with them to improve their English conversational skills. The connection with the students has restored Ms. B. into a vibrant, involved educator interacting with a group of students who, in turn, are helping her dog.

Ms. H. suffers with multiple sclerosis. Isolated and bedridden, she relied upon her two cats for companionship. Sadly, last year one of her beloved cats died and shortly thereafter, her other cat, Foxy, wandered outside her apartment building and disappeared. Distraught over the loss, Ms. H. contacted JASA PETS. The Project Coordinator immediately posted flyers throughout the neighborhood and dispatched a team of volunteers to search for the missing cat. After two days, Foxy found her own way home, and was discovered scratching at her door. Ms. H. was thrilled that her companion was safely home, but also profoundly appreciative for the support she received from the PETS Project team throughout the ordeal.

These are just two of the many heart-warming successes that have been created by JASA PETS. JASA, the Jewish Association for Services for the Aged, is a social service agency dedicated to enhancing the lives of elderly New Yorkers. It is committed to creating innovative programs to meet the evolving and expanding needs of the aging. JASA created the PETS Project in 1997 to address the needs of elderly pet owners whose capacity to care for their pets has been compromised by frailty, illness, and/or inadequate income.

In recognition of the critical role that pets play in the lives of older people — particularly those who are homebound — the program is designed to keep seniors and their pet companions together. Studies show senior citizens with pets suffer less from depression, require fewer doctors’ visits, and have lower blood pressure than those without animal companions.

Often, increasing age and declining health create obstacles to providing proper care for pets. Seniors afflicted with arthritis lose the ability to walk their dogs or groom long-haired cats; fixed incomes often cannot be stretched to cover routine veterinary bills; and pet owners with complex health problems may refuse hospitalization because they have no one to care for their animals in their absence.

How JASA PETS Can Help

The JASA PETS Project matches volunteers with elderly pet owners to provide assistance tailored to the needs of each client. By matching a volunteer with an elderly client, the program provides for the care and well-being of both the senior and the pet.

The client-volunteer teams are overseen by a full-time coordinator, a social worker with prior work experience in pet care, who conducts an initial in-home assessment and is fully involved in the service plan, including reviews of pet care routines. Volunteers help with dog walking, litter box cleaning, emergency feeding, shopping for pet food and supplies, transportation to veterinarians and groomers, training, and pet sitting.

In some instances, a skilled volunteer is able to assist with administering medication to sick pets. In addition, the program provides foster care during client hospitalization periods and participates in pet placement after the death of the human companion. A small relief fund has been established to assist clients who cannot afford to pay for needed pet services and/or their own expenses. The availability of this fund helps relieve financially strapped seniors from the need to make financial choices that compromise their health or the health of their pets.

The program also provides seniors with information about low-cost pet care and will help them make arrangements for their pets in their will. And it can assist in finding a good adopter for a pet if a client dies or can no longer keep a pet.

For some clients, the program helps them through one of the most difficult situations imaginable — the loss of a pet. Such was the recent case of Ms. M., an isolated, homebound client who agonized for several weeks over the difficult decision to put her terminally ill companion cat, Samantha, to sleep. The JASA PETS team visited Ms. M. regularly, coordinated efforts with two veterinarians, assisted in the planning for burial services, and called her daily to provide support. When Samantha died naturally on May 23, the PETS team was there within 30 minutes to console Ms. M. An informal but meaningful memorial service was held at her apartment, and the JASA team took Samantha’s body to the burial provider that had been designated by Ms. M. The team continued to provide bereavement support to help their client through the mourning period.

JASA PETS is making a difference in the lives of many seniors and their pets. The program has been praised by other organizations that serve the senior population. Mary Dodd, Director of the Homebound Unit of the Carter Burden Center for the Aging, says, “On behalf of the Burden Center, I would like to extend my gratitude to the Project. The Project provides unique and vital services to the most vulnerable and forgotten segment of our society. It is imperative that the program be celebrated and receive the continuing support needed to sustain its existence.”

Wendy Golub, Director of Programs at The Caring Community, says, “The PETS Project provides a unique service to the seniors in our community. We at The Caring Community have enjoyed and profited from working with them as they are not only responsible and reliable, but collegial and a pleasure to work with.”

The program is available to senior citizens — regardless of race or religious affiliation — who are sixty years of age or older and are unable to fully provide for the care of their pet companions. Currently, JASA offers this program to residents of Manhattan only. However, it is the aim of PETS eventually to expand the program to include the five boroughs.

To contact JASA PETS for services, simply call (212) 273-5217 to schedule a meeting at the client’s home. Once the client has provided information about the pet and any pet care concerns, the client will be matched with a volunteer to assist them in addressing those concerns.

If you are interested in volunteering for the JASA PETS Project or making a contribution, please contact Paul Domin, Project Coordinator, at pdomin@jasa.org or call (212) 273-5217.

The JASA PETS Project is funded by the Tuttle, Leibovitz, and Ahimsa Foundations.

– See more at: http://www.animalalliancenyc.org/media/ootc/2006-09/aao.htm#sthash.ZCRvYkuD.4t8krsYb.dpuf

Bed and/or Chair Rest + Neglect = Bedsores

Article by Brian A. Raphan. Published 3/17/15 in ‘THE DOCTOR WEIGHS IN’

When a patient develops pressure ulcers, it is often a sign of neglect and can even be the result of hospital malpractice, nurse malpractice or nursing home negligence.

Any time a patient is confined to a bed or chair for a period of time and not provided proper and adequate care, the risk of pressure ulcers increases.

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 the stages of pressure ulcers are shown below:

stages of bedsores

Sadly, pressure ulcers are the underlying cause of mortality and morbidity for several thousand patients across the country each year. Researchers analyzing the national Medicare Patient Safety Monitoring System (MPSMS) database found that the nationwide incidence rate for hospital-acquired pressure ulcers was 4.5 percent. The five states with the highest incidence rates are New York (5.2%), Missouri (5.3%), New Jersey (5.3%), Massachusetts (5.5%) and Pennsylvania (5.9%).

The federal government, in its first year of a federal initiative to improve patient safety, recently imposed penalties aimed at reducing preventable harm. Five states saw a significant percentage of hospitals being penalized: New York, where 26% of hospitals were penalized by having their Medicare reimbursements cut by 1%; Missouri, 25%; New Jersey, 37%; Massachusetts, 22%; and Pennsylvania, 25%.

In New York State, penalized hospitals included some well-known healthcare facilities, such as Beth Israel Medical Center and New York University Langone Medical Center.

All sedentary patients are vulnerable, but the elderly and patients whose skin condition has been compromised are especially at risk. Pressure ulcers are most common on bony prominences with little protective fat or muscle (such as heels, hips, shoulders, and tail bones), and they develop when patients stay in one position for too long without shifting their weight. The constant pressure against the skin reduces blood flow to contact areas. The skin begins to break down and the tissue dies, possibly in a matter of hours. Friction and shear caused by sliding down in the bed, or being moved improperly from a stretcher to a bed can exacerbate the problem. Pressure ulcers slow a patient’s recovery, can lead to other issues and infection and prolong hospital stays. The total annual cost for treating pressure ulcers in the U.S. is estimated at $11 billion. However, pressure ulcers (also known as bedsores and decubitis ulcers) are preventable.

To prevent pressure ulcers and damage to the skin, recent NPUAP recommendations can be summarized in seven steps:

prevent bedsores

Because these seven steps are so easy to follow, when a patient develops pressure ulcers, it is often a sign of neglect and can even be the result of hospital malpractice, nurse malpractice or nursing home negligence.

Upon admission to a hospital for another health concern the issues can go unnoticed, allowing further damage to take place in a relatively short time. This also creates liability on the part of the hospital.

In many lawsuits that we handle, the hospital is dealt a bad hand by receiving a patient from a nursing home where a skin breakdown or pressure ulcer has already begun. At times, due to dementia for example, a patient may not be able to express or know how to communicate pain upon entering the hospital. However, this is no excuse for not identifying a high-risk patient and making regular daily assessments.

To be clear, pressure ulcers are not the fault of the patient. The patient is a victim. Medical negligence by a hospital, doctor, nurse, aide or medical technician is unacceptable and may be the cause of pain and suffering, or even result in death. It is simply not acceptable for patients to develop bedsores or pressure ulcers while they are in the care of medical professionals and receiving medical care and treatment at a facility.

There is no doubt that hospitals and staff, from talented skilled doctors, nurses and medical professionals to support staff and administration, do their best to help and treat patients. However, protocols exist in every facility, and perhaps, it is just a matter of every individual being a bit more aware, and caring just a little more, when dealing with the elderly and at-risk patients.

By Brian A. Raphan (Principal Attorney, Law Offices of Brian A. Raphan, P.C.

Download a Free Bedsore Legal, Medical & Treatment Guide

Some Potential Problems With SSA’s New Trust Guide

Social Security News

As previously reported, the Social Security Administration (SSA) recently instituted a nationally uniform procedure for review of special needs trusts for Supplemental Security Income (SSI) eligibility, routing all applications that feature trusts through Regional Trust Reviewer Teams (RTRTs) staffed with specialists who will review the trusts for compliance with SSI regulations.

The SSA has also released its Trust Training Fact Guide, which will be used by the RTRTs and field offices when they evaluate special needs trusts.  In an article in the July/August 2014 issue of The ElderLaw Report, New Jersey attorney Thomas D. Begley, Jr., and Massachusetts attorney Neal A. Winston, both CELAs, discuss the 31-page guide in detail and caution that while it is a significant step forward in trust review consistency, it contains “a few notable omissions or terminology that might cause review problems.”  Following is the authors’ discussion of the problematic areas:

• Structured Settlements. The guide states that additions/augmentations to a trust at/after age 65 would violate the rule that requires assets to be transferred to the trust prior to the individual attaining age 65. It does not mention that the POMS specifically authorizes such payments after age 65, so long as the structure was in place prior to age 65. [POMS SI 01120.203.B.1.c].

• First-/Third-Party Trust Distinction. Throughout the guide, there are numerous references to first-party trust terms or lack of terms that would make the trust defective and thus countable. These references do not distinguish between the substantial differences in requirements for first-party and third-party trusts.

• Court-Established Trusts/Petitions. This issue is more a reflection of an absurd SSA policy that is reflected accurately as agency policy in the guide, rather than an error or omission in the guide itself. This section, F.1.E.3, is titled “Who can establish the trust?” The guide states that creation of the trust may be required by a court order. This is consistent with the POMS. It would appear from the POMS that the court should simply order the trust to be created based upon a petition from an interested party. The potential pitfall described by the guide highlights is who may or may not petition the court to create a trust for the beneficiary. It states that if an “appointed representative” petitions the court to create a trust for the beneficiary, the trust would be improperly created and, thus, countable. Since the representative would be considered as acting as an agent of the beneficiary, the beneficiary would have improperly established the trust himself.

In order for a court to properly create a trust according to the guide, the court should order creation of a trust totally on its own motion and without request or prompting by any party related to the beneficiary. If so, who else could petition the court for approval? The plaintiff’s personal injury attorney or trustee would be considered an “appointed representative.” Would a guardian ad litem meet the test under the guardian creation authority? How about the attorney for the defendant, or is there any other person? If an unrelated homeless person was offered $100 to petition the court, would that make the homeless person an “appointed representative” and render the trust invalid? The authors have requested clarification from the SSA and are awaiting a response.

Until this issue is resolved, it might be prudent to try to have self-settled special needs trusts established by a parent, grandparent, or guardian whenever possible.

• Medicaid Payback/Administrative Fees and Costs. Another area of omission involves Medicaid reimbursement. The guide states that “the only items that may be paid prior to the Medicaid repayment on the death of the beneficiary of the trust are taxes due from the trust at the time of death and court filing fees associated with the trust. The POMS, [POMS SI 01120.203.B.1.h. and 203B.3.a], specifically states that upon the death of the trust beneficiary, the trust may pay prior to Medicaid reimbursement taxes due from the trust to the state or federal government because of the death of the beneficiary and reasonable fees for administration of the trust estate such as an accounting of the trust to a court, completion and filing of documents, or other required actions associated with the termination and wrapping up of the trust.

While noting that the guide, in coordination with training, “is a marked improvement for program consistency for trust review,” Begley and Winston caution advocates that “the guide should be considered as a summarized desk reference and training manual and not a definitive statement of SSA policy if inconsistent with the POMS.”

Regards,

Brian A. Raphan, Esq.

The Law Offices of Brian A. Raphan, P.C.

www.RaphanLaw.com

Medicaid Update: 2015 Medicaid Income and Resource Levels

The New York State Department of Health has released important information about the new Medicaid income and resource levels for 2015, which will take effect on January 1, 2015.

Medicaid 2015

The following lists the updated Medicaid income and resource levels for 2015:

  • Income level for one person: $825 for 2015 (Was $809 for 2014)
  • Income level for two people: $1,209 for 2015 (Was 1,192 for 2014)
  • Resource level for one person household: $14,850 for 2015 (Was $14,550 for 2014)
  • Resource level for household of two people: $21,750 for 2015 (Was $21,450 in 2014)
  • Minimum monthly maintenance needs (income) allowance: $2,980.50 for 2015 (Was $2,931 for 2014)
  • Maximum community spouse resource allowance: $119,220 for 2015 (Was $117,240 for 2014)

Remember, there is still a 5 year look back. For a free more info on how planning for Medicaid can protect your assets, feel free to contact us.

medicaid@raphanlaw.com or 212-268-8200

What Happens to a Medicaid Recipient If the Spouse at Home Dies First?

Senior Couple Square

When one spouse is in a nursing home and applying for Medicaid, planning has to take into account the possibility that the spouse who is not in the nursing home (called the “community spouse”) may pass away first. This is because the community spouse’s death may make the spouse in the nursing home ineligible for Medicaid.

In order to qualify for Medicaid, a nursing home resident can have only a limited number of assets. Careful planning can allow the resident’s spouse to maintain some assets. However, if that community spouse passes away first and leaves those assets to the nursing home resident, the resident suddenly would be over Medicaid’s asset limit.

While the community spouse can write a will that disinherits the Medicaid resident, most states have laws that allow spouses to claim a portion of their deceased spouse’s estate regardless of what the will says. This is called the elective or statutory share. The amount the spouse can claim varies from state to state.

A spouse can disclaim his or her elective share, but if a Medicaid recipient disclaims the inheritance, it is considered an uncompensated transfer of assets and the recipient may receive a period of Medicaid ineligibility. To avoid this, the community spouse will most likely need a will that addresses this issue. One option is for the community spouse to create a will that leaves the nursing home spouse exactly the amount of the elective share. Another option may be to create a special trust that contains the elective share. You should talk to your elder law attorney to determine the best course of action for you and your spouse.

For more information about Medicaid, including a FREE GUIDE to Medicaid’s Asset Transfer Rulesclick here.

This month we are offering AARP members discounted rates and free initial phone consultation to help determine if you can benefit from medicaid planning. Email: medicaid@RaphanLaw.com

Regards, Brian

Maybe it’s time for a geriatric care manager

Geriatric care

Why do we hear so much about geriatric care management these days? It’s because there are so many benefits they can provide to seniors and care givers. Let’s first clarify the term: A professional Geriatric Care Manager (GCM) is a health and human services specialist who helps families who are caring for older relatives. The GCM is trained and experienced in any of several fields related to care management, including nursing, gerontology, social work, psychology, and logistics of health care and often finances relating to the elderly. They are trained to assess, plan, coordinate, monitor and provide services for the elderly and their families. Although not lawyers, they are often aware of legal issues elders may be soon facing.

The benefits to you, the child or care giver of the elder range from saving time (vetting out various needs), saving money (knowing financial pitfalls of some decisions in advance), making better care decisions (with insight from someone who has seen it all) and most importantly –reducing stress.  The stress of being alone in the decision making process, relief of now being informed about your various options and what may be right for the specific needs of the elder, ranging from doctor decisions, how to provide care, assisted living, home care and nursing care options. Doing it alone takes an enormous amount of time, energy, resources and self reliance.

According to Gladys Harris Geriatric Care Manager of The Olive Group, you may need a Geriatric Care Manager if:

•    A person has limited or no family support available

•    Family has just become involved with helping the individual and needs direction regarding available senior services

•    A person has multiple medical or psychological issues

•    A person is unable to live safely in his / her current environment

•    Family is either “burned out” or confused about care solutions

•    Family has a limited time and / or expertise in dealing with loved one’s chronic care needs

•    Family is at odds regarding care decisions

•    Individual is not pleased with current care providers and requires advocacy

•    Individual is confused regarding his / her own financial and / or legal situation

•    Family needs education and / or direction in dealing with behaviors associated with dementia

Gladys is a recommended resource of ours and helps families and elders in New Jersey. They offer a unique combination of compassion, knowledge, a ‘can-do’ attitude and a wide range of services which also include:

Solution Focused Counseling: Life transitions are a common reason for counseling. We focus on empowering individuals to find solutions in their life by figuring out what a person’s goals are, and supporting them to find ways to achieve those goals.

Care Coordination: Our holistic assessment includes a physical, psychological and social functioning evaluation of the older adult, as well as a home safety inspection. Based on the assessment, we will develop a customized client care plan to identify private and public resources available to support the older adult. We coordinate the support systems needed to keep the older adult safe and happy at home.

Wellness Monitoring: Regular visits with the older adult to help ensure that they receive the best care available. During our visits we ensure older adults are receiving help with things that they want done, computer skills, organize photos, plan family events, etc.

Accessibility Issue Resolution: Aging-in-place often requires making changes to the home to help maintain independence.  This may be de-cluttering, home improvements, home safety inspection

Relocation Services: We support families during transitions from home to another location or facility.   These services include cleaning, de-cluttering, downsizing, and setting up in the older adult’s new home.

Cost savings is also a key component to good geriatric care management. You can learn more about it and find out more about the range of services by clicking here: www.TheOliveGroup.llc.com

Regards,

Brian

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