A Reporting Primer

Hold My Hand

   In the previous post we talked about the distinctions between unacceptable quality of care issues in residential facilities and criminal abuse or neglect. With regard to elder abuse, regardless of where it takes place, or whether it is or is not criminal, here is an excellent site that offers resources for elders, families and friends: 

http://www.helpguide.org/mental/elder_abuse_physical_emotional_sexual_neglect.htm

    In addition, I promised to offer state-by-state, information and instructions for reporting abuse and neglect, particularly in residential care. The following link offers this information and may be downloaded as in portable document format: 

http://www.americanbar.org/content/dam/aba/migrated/aging/docs/MandatoryReportingProvisionsChart.authcheckdam.pdf

The moral arc of the universe bends at the elbow of justice.  -Martin Luther King, Jr.

       As we discussed last week, If you suspect a family member, friend or neighbor is suffering neglect or abuse in residential care, report it immediately to supervisory staff in the facility, to medical personnel, to the management of the facility. If there are indications the neglect and/or abuse rises to generally accepted definitions of criminal behavior, go a step further. Report the matter to law enforcement and government agencies, keeping in mind timeliness is critical. With government agencies, use telephone reporting, e-mail or electronic forms advisedly. By this I mean, even detailed electronic messages with attachments may not receive the attention they deserve.

  If this is a criminal matter, reporting effectively and immediately may very well be a question of life or death for the patient. Memorialize all conversations you have in writing. In this telecommunications era, many of us have lost touch with the local post office. This is a time to certify correspondence and mail it, return receipt requested. Keep hard copies of everything you send and receive, including mail receipts. Purchase some inexpensive file folders or a ring binder, a hole punch and an inexpensive photo album. Organize your documentation and evidence, to have it immediately accessible.

     Finally, follow through promptly, if possible, in person. Do not be intimidated; you are interested in getting at the truth and arriving at an outcome for someone who needs your help. Personally I am not merely persistent, I'm tenacious, like a bulldog with a bone. Whether it is your nature to confront problems head-on, or not, this is the time not to be swayed. This is the time to persevere.

Justice, A Single Word

All the great things are simple, and many can be expressed in a single word: freedom, justice, honor, duty, mercy, hope.

Winston Churchill

So you are in long-term care or you have a family member (or very close friend)  in one of the following types of care facilities: 

Nursing Home

Hospital Long-Term Care Unit

Home for the Aged

County Medical Care Facility

Adult Foster Care 

Assisted Living Facility

     Whether or not you placed the patient in the facility, the patient appears to decline dramatically and unexpectedly. You suspect something is wrong, or the patient tells you something is wrong. You may be this person's only advocate, while you are in a tailspin. In addition time is not on your side. Report immediately. Begin the reporting process with supervisory and management personnel of the facility. Memorialize meetings with written correspondence. 

      Speak with everyone else closely involved. Speak with medical personnel and the patient's medical providers. Step up the frequency of visits and the visibility of guests, even if you must enlist the help of other friends and family. Make the times and dates of visits unpredictable. Visitors should maintain journals and carry cameras. Don't hesitate to talk to neighboring residents, their friends and family about the level of care Look at the patient. This is very important. No-one wants to demean or intrude on a patient's privacy, but injuries, bruising, and sores may be hidden under gowns, pajamas, robes, socks and shoes. Someone of the same sex, who is close to the patient must check the patient frequently. Weight loss is concerning, so see that the patient is regularly weighed and does not show signs of dehydration.

 Ask yourself and others close to the patient, whether management or supervisory staff can and will readily correct the issues. Look for classic signs of neglect or abuse, while deciding whether there is criminality involved. There is a language to learn, and there are steps to be taken, the sooner the better. Here are some legal guidelines regarding criminal issues, together with examples:

a) What is criminal neglect?

Is the patient experiencing any of the following: a) suspicious or questionable injuries or death; b) unexpected and serious weight loss; c) severe dehydration; d) painful bed or pressure sores.

b) What is criminal assault and/or battery?

As disgraceful as it is, employees of residential care and skilled nursing facilities assault and batter residents every day.You may have to ask the right questions, because a fearful patient may endure abuse, rather than reveal it. If a patient is fearful, anxious, or talks about being hurt or bullied, listen carefully and observe. If there is widespread or serious bruising, bruising at unlikely sites, sprains or broken bones, or signs of over-medication, criminal acts may have occurred. Employees of nursing homes and residential health care facilities may not: a) threaten or strike patients; b) use unauthorized physical or chemical restraints. 

c) Mental abuse is abuse!

Certain levels of bullying, reprisal and threats rise to the level of criminal behavior or preface criminal acts. Mental abuse is as unacceptable as physical abuse.

d) What constitutes criminal financial exploitation? 

Nursing home and residential health care employees may not: a) wrongly remove funds from a resident's person, checking or savings account; b) accept or obtain a "loan" or "gift" from a resident; c) use a resident's personal information illegally to obtain credit cards (i.e., commits identity theft.) 

e) Define criminal sexual conduct.

No employee of a residential healthcare facility or nursing home may engage in unlawful sexual conduct with a patient (that is to say, sexual contact was non-consensual.) That distinction aside, any sexual contact between an employee and a patient/resident, consensual or not, should be a firing offense.

     If you are not satisfied with responses, or with the timeliness of responses, you may have to know how and where to report in your state and county. In a subsequent post we'll talk about reporting in Colorado and state-by-state.

An Ounce of Prevention

   

Fast Times at Sunny Vale

Before agreeing to place yourself or any patient in a residential care facility, there are important questions to ask. It is not always obvious or easy to ask the right questions, because marketing personnel are extremely skillful at 'selling' you on a facility, its amenities and standards of care. A decision maker must focus on facts, not fiction. Is the corporate mission posted? Are there community standards posted? If so, don't take them at face value. The name, Sunny Vale Assisted Care and a lovely motto, such as "A Restorative Community," are meaningless. Was there a cute day care facility, where pre-school children were abused in your community? Didn't it have a sweet name, like Button Tree Farm?  We're always so polite in speaking with sales people and managers; remember, this is not a social occasion, any more than it was a social occasion, when we chose our children's day care facilities.

     Consult consumer ratings and publications, local, as well as national. Know the staff-to-patient and the supervisor-to-staff ratios for a specific facility. How does the outside of the building (not the landscaping or building facade) look? Is trash, garbage and bio-hazardous waste properly contained? Does it appear to be removed on an appropriate schedule, or is it overflowing -- is the containment area clean? Walking the premises inside, how does the facility look and smell. There should be no lingering or pervasive smell of urine, feces, or other unpleasant smells in hallways, rooms or waiting areas. Is the facility well lighted, night and day? Is it attractive and well-maintained in appearance? Is there video surveillance? Where, and are the cameras both maintained and used? Who manages and dispenses medications, and is the dispensary well-staffed and secure? 

     Ask management for the facts of recruitment, training standards and vetting of staff. Do staff members rely on a day of orientation, or are training workshops and demonstrations substantive. Are they ongoing and how often is continuing education offered? What about emergency preparedness for management, supervisors and other staff? What are the benchmarks for quality of care in the facility, and how well are they being met. How are benchmarks measured? -How often and by whom? Ask to speak with other residents or their family members concerning the quality of care, meals, recreational opportunities -- don't hesitate to be nosy.

      Here is a patient bill of rights. If you are going into long-term care, have a close friend or family member entering care, know the following: 

1. No patient may be denied appropriate care on the basis of race, religion, national origin, sex, age, handicap, marital status, sexual preference, or source of payment. 
2. Any patient may inspect and obtain a copy of his or her medical records, upon demand. No third party may receive a a copy of the patient's medical records without the patient's express authorization, except as required by law or third party contract.
3. Every patient or resident is entitled to privacy, to any extent feasible, in treatment and caring for personal needs. Care for personal needs will be delivered with consideration, respect, and full recognition of the patient's individuality and dignity. 
4. A patient or resident is is entitled to adequate, appropriate, care. The patient has the right to full information about his/her medical condition, proposed treatment and prospects for recovery, unless medically contraindicated by the physician in the medical record. 
5. A patient or resident is entitled to examine and receive an explanation of his/her bill. Also, he/she is entitled to know who is responsible for, and who is providing, his/her care.
6. A patient or resident has the right to associate and have private communication with his/her physician, attorney or any other person. A patient has the right to send and receive personal mail unopened, unless medically contraindicated.
7. No patient's or resident's civil and religious liberties shall be infringed. The facility shall encourage and assist in the exercise of patients' civil and religious rights.
8. Every patient or resident is entitled to be free from mental and physical abuse. Every patient shall be free from physical and chemical restraints, unless authorized by his/her physician, or necessitated by emergency to protect the patient.
9. A patient or resident has the right to retain and use personal clothing and possessions, space permitting. At the request of a patient, a nursing home shall provide for safekeeping of personal property and funds. However, the nursing home shall not be required to provide for the safekeeping of property which would impose an unreasonable burden on the nursing home.
10. The nursing home must provide the patient with meals which meet the recommended dietary allowances for the patient's age and sex. The menu may be modified according to special dietary needs.
11. A nursing home, its owner, administrator, employee, or representative shall not discharge, harass, retaliate or discriminate against a patient because a patient has exercised rights protected by law. (Reporting violations of the above rights or quality of care issues is protected by law.)

     Whether you are helping a loved one enter independent living, assisted living or nursing care, you are his or her best hope in ensuring these rights are protected. It is important to know your own rights and those of others. 

     Be vigilant on behalf of your loved one. Be present. Be in touch frequently. Even people in independent settings are vulnerable.In the next post, we'll make a distinction between unacceptable conditions and criminal negligence or abuse in long-term care. Meanwhile prevention begins with each of us.

Longevity For Better or Worse

Longevity

   Longevity, excellent fortune in some cultures, is so for elders who are reasonably well, active, financially independent, creatively involved and/or pursuing work they love.  You are in good company, if the Old Folks Home and the Nursing Home evoke ugly specters from America's past. We've progressed from the almshouse to the old folks home or nursing home, to care which is meant to encourage the highest level of independence, dignity of choice and quality of life we can achieve. Overcoming history, however, is a painfully gradual process, rife with errors and failures. Enter the Assisted Living Facility. Even with the advent of assisted care, Medicaid has come under fire for having a tendency to keep people in nursing homes.

 Assisted living facilities (ALFs) gained tremendous popularity in the 1990s, as part of the continuum of care for people who did not require skilled, around-the-clock nursing care, but were not able to live independently. The idea was to provide supervision and help with activities of everyday life (including, for some, personal care, as well as the supervision/dispensing of medications by trained staff.) Assisted living was widely promoted as a philosophy of care and service intended to honor "independence and dignity." It sounded like a fine idea to keep nursing homes from being society's dumping grounds.

    If you have not watched the PBS documentary, "Living and Dying in Assisted Care," do so. Better yet, ProPublica has published a four-part series. I provide links here: 

http://www.propublica.org/article/emeritus-1-the-emerald-city

http://www.propublica.org/article/emeritus-2-theyre-not-treating-mom-well
http://www.propublica.org/article/emeritus-3-a-sinking-ship
http://www.propublica.org/article/emeritus-4-close-the-back-door

    
     This is greed's horror story, real and pervasive. One thing is crystal clear; economically disadvantaged Americans, who cannot readily move from one facility to another are worse off than their prosperous counterparts. The same is true for those whose families are neither knowledgeable nor vigilant.    Many well-meaning family members believe they can fulfill or share among them, the role of caregiver, regardless of what the role will entail. It is a daunting business, and soon becomes extremely burdensome. From experience and observation, there is a third category, families who, simply, place their elderly into the hands of others, relieved to be shut of the problem. These folks just walk away, visiting rarely, if at all.
     For millions of elderly each year, "Assisted Living" becomes assisted dying. Abused, neglected, despondent, over- and wrongly medicated people fade, wither and die. Although it was first published in 2008, here is a condensed version of what consumers need to know about Assisted Living:
http://newoldage.blogs.nytimes.com/2008/10/20/10-things-to-know-about-assisted-living/?_r=0
        My desire is to write an informative blog one that stressed stress the importance of issues of aging and elder law for everyone. It isn't simply that we're all going to be older some day; it is that we all have older people in our lives, people we love, whose concerns are our concerns.
       In another post we'll talk about about a plan of action for elders already in assisted living facilities, their intimate friends/family. To begin, here is a state-by-state mandatory reporting link from The American Bar Association:
http://www.americanbar.org/content/dam/aba/migrated/aging/docs/MandatoryReportingProvisionsChart.authcheckdam.pdf

Reality Bytes

In discussing economic recovery from the Great Depression, Franklin D. Roosevelt made the following statements to Congress: ".. in addition to these immediate tasks of relief and of recovery we have properly, necessarily and with over-whelming approval determined to safeguard these tasks by rebuilding many of the structures of our economic life and reorganizing it in order to prevent a recurrence of collapse." 
     Currently, the Dodd-Frank Wall Street Reform and Consumer Protection Act, signed into law by President Obama a little more than three years ago has yet to be implemented. Regulators now claim the provisions of Dodd-Frank will be implemented, beginning this month.

"We can never insure one-hundred percent of the population against one-hundred percent of the hazards and vicissitudes of life. But we have tried to frame a law which will give some measure of protection to the average citizen and to his family against the loss of a job and against poverty-ridden old age. This law, too, represents a cornerstone in a structure which is being built, but is by no means complete.... It is...a law that will take care of human needs and at the same time provide for the United States an economic structure of vastly greater soundness." -- Franklin D. Roosevelt, August 14, 1935

     Today we are in the grips of an argument over Social Security we should have retired months ago. President Obama proposes the government tie Security benefits to the Chained Consumer Price Index. According to Mr. Obama this is a technical matter. First, he argues, the proposed change will not cause benefits to be cut; it is a merely a slowdown in the rate of benefit increases. The problem is Cost of Living Adjustments are not benefit increases; they prevent benefit decreases over time, due to inflation. We call this payment reduction. 

     Second Mr. Obama contends the change will not result in higher taxes. The fact is, the current formula is designed to avoid bumping taxpayers into higher income brackets, while they are not earning more in actual dollars (i.e., post-inflation income.) Under President Obama's proposal, the CPI will land taxpayers in higher brackets more quickly. People will pay more taxes, although they actually are not making more actual money. We call this a rise in taxes.

  With regard to the federal deficit, Obama's budget proposal will not pass. Republicans will not close tax loopholes, nor will they eliminate deductions for the nation's top earners. Is this a presidential gambit? Or is the President, as he contends, trying anything and everything to get to a compromise with Republicans? One thing is certain, if the budget does not pass, we'll hear nothing more of the CPI. The GOP will be the obstructive ones, because, after all, Mr. Obama is bucking his own party, to try to accommodate some of their demands. 

     Someone once said, "Comparisons are odious." Roosevelt declared, "Among our objectives I place the security of the men, women and children of the Nation first." I'll let you draw your own conclusions about the genuine and the disingenuous.

The Pinnacle of Abuse

 

   What, to your way of thinking would be the height of abuse in a prison setting, or in a case of assault? Unquestionably it would be the use of drugs to subdue an unwitting victim, particularly, if death ensued. Nonetheless elder abuse and the abuse of younger, disabled people by prescription is not a possibility in this country. It is commonplace. If you are, as I was, under the impression Medicare is a gatekeeper, it is not. Think about the implications; we are left to our own devices.

The physicians of one class feel the patients and go away, merely prescribing medicine. As they leave the room they simply ask the patient to take the medicine. They are the poorest class of physicians. Ramakrishna

     Medicare does amass data regarding the kinds and numbers of medications physicians prescribe. However, even if it monitored providers, it does not regulate them. All the more reason why patients, families and caregivers should be informed regarding all medications (interaction with other medications and with supplements, allergic reactions, side effects, appropriateness, potential for abuse.) For more information and updates, regarding risky drugs for elderly patients, The American Geriatrics Society Beers pocket guide is a vital tool. It is a pocket reference, easy to download and print: 

http://www.americangeriatrics.org/files/documents/beers/PrintableBeersPocketCard.pdf

        Following years of investigation, ProPublica filed a FOIA (Freedom of Information Act) request with Medicare, and eventually received its data. (The data contained no patient information, in the event you were wondering.) In addition to uncovering alarming facts and figures about over- and inappropriate prescribing, ProPublica put the Medicare prescriber data into a database. It is worthwhile, if only it equips you to frame the right questions. It is a powerful tool and a step in the right direction for everyone, including the medical community:

http://www.propublica.org/article/prescriber-checkup-faq

        Here's to greater transparency -- ProPublica advocates making Medicare and Medicaid provider prescription and diagnostic activity a matter of public record. 

     Meanwhile here's to us, to arming ourselves with knowledge, participating in our care and in the care of those we love.

  

Feeding The Vulnerable

Where is our Summer going so quickly, and what will Fall bring? One thing we know it may bring is decreased levels of food security for millions of Americans. The USDA's Supplemental Nutrition Assistance Program (SNAP) benefit levels have been in place, since the passage of the ARRA in 2009. Let's be clear; the current eligibility and benefit levels were originally scheduled to phase out, as the economy recovers. Nonetheless the program was and has remained inadequate to meet the needs of the nation's poor. Benefit levels will be cut back in November 2013, because SNAP was stripped from the recent Farm Bill, which passed the House of Representatives last week. We can already anticipate the contentious process of a bitterly divided Congress drafting and enacting separate food assistance legislation.  

"The big majority of Americans, who are comparatively well-off, have developed an ability to have enclaves of people living in the greatest misery almost without noticing them."~ Gunnar Myrdal   

     Republicans will continue to allude to big government and excessive spending; the rhetoric has its own terminology. Just the term food insecurity has become the brunt of brutal humor! We are talking about hunger, malnutrition, dumpster-diving desperation, people! It translates to stunted physical and intellectual growth in children, disease at any age and premature death in the elderly. 

     The term entitlement comes with an onus that sticks like simple syrup to certain government programs. It does not matter whom these programs serve, the rationale behind the program or, for that matter, how efficiently the program runs. Contrary to the rhetoric surrounding so-called entitlement programs, over 90% of SNAP benefits go to disabled, elderly and working poor. Here are some facts from Feeding America:

1. Who receives assistance? To qualify for SNAP benefits, a household must have a gross income at or under 130% of the federal poverty guideline. 
2. How poor is poor? Slightly more than 80% of households currently receiving SNAP benefits are actually at or below 100% of the poverty line. That translates to an income of $19,530 for a family of three in 2013. These households receive a little over 90% of all SNAP benefits awarded. 
3. How much lower does it go? More than half the households receiving SNAP benefits have gross incomes at or below 75% of the poverty line, or $14,648 for a family of 3 in 2013. 
4. What is the financial picture for an average SNAP household? It is a gross income of $744 monthly; a net income after the standard deduction of $338 per month. This does not take into consideration deductions for child care, medical expenses, cost of shelter and "countable" resources. Anyone who has applied for nutritional assistance knows that a vehicle, insurance policy, bank account , or other common asset, will count against their household, in determining benefit level. 
5. What happens, when earnings return or increase? Flexibility is inherent in SNAP; a certain percentage of households recover financial stability; once that occurs, benefits stop and/or are recovered. 
6. How will the cutbacks affect the average SNAP household? A household of three will experience a reduction of $240 to $300 annually, in lost food assistance. Keep in mind these households are currently hard-pressed.

     To dispel any doubts about program integrity, SNAP is well-run. A high percentage (approximately 92%) of tax dollars go to target recipients. In 2011 SNAP's error rate was 3.80%, an all-time low for the program and exceptionally low by comparison to other government programs. Food stamp trafficking, an ugly reality of the 90s, has dropped precipitously in recent years, because of aggressive enforcement by the USDA.  

      Last, but, by no means least, SNAP benefits represent a leg up, rather than a handout for unemployed or underemployed individuals. Recipients of SNAP benefits are truly in need:  90% of SNAP benefits have been expended by recipient households by the third week of each month. More than half of SNAP households will turn to food banks for assistance at least six months of any given year. An average SNAP household's benefit per person is a little more than $130, less than $1.50 per person per meal. Periodic reporting is required by law, and any significant increase in income or assets, as well as any significant decrease in expenditures, must be reported within a ten-day window. Benefits diminish or cease within weeks of any significant change.

   This is only part of a rather grim picture. A little more than half the Americans who are deemed 'food insecure' are eligible for SNAP; nearly one third are not income-eligible for any federal food assistance. 

    In short it is the most vulnerable Americans, the disabled, including veterans, the very young and the elderly, who are most at risk here. Working poor, unemployed, single parent families will see grocery prices continue to rise, while SNAP benefits shrink or disappear. I've wondered aloud, and continue to wonder aloud, where is the outrage?