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the state failed. it's their responsibility to ensure the safety of the residents and were obligated to have a plan in place when they shut down the facility

California has volunteer Ombudsmen to save money. If I were a family member I'd be suing the facility and also reaping huge profits from California.

Yes, it's worse. There's an elderly, confused man wandering the streets due to their negligence.

Again, the owners of the home and the State are responsible for this debacle and I certainly hope that they are held accountable. They'll probably fire some low-level worker and blame everything on Obama anyway...

The department that licenses group homes, assisted living facilities, and nursing homes was responsible for ensuring the safety of the residents. The owners are also responsible.

Everything should have been in place on the date that the facility was shuttered. There's absolutely no excuse for this behavior. NONE.

I can't even begin to imagine how horrible it was there for the residents.

yup. just keeps getting worse.

So, this situation is happening now in Vegas (from my blog):

So, today I'll tell you the story about the nursing home administrator who is trying to force his staff to put a patient onto a bus and send him to live with his family in another state, about a 12 hour bus ride. The patient is incontinent of both bowel and bladder and wears a brief - he has stage 4 decubitus ulcers (bedsores) on his buttocks and is a paraplegic.

So - to recap, the patient can't walk, shouldn't be in a seated position, shouldn't remain in a dirty brief, and has no ability to get off the bus during stops.

The reason that the administrator wants the patient discharged so badly is because he doesn't have the money to pay for his room & board in a nursing home and probably won't qualify for Medicaid. The administrator doesn't want to wait and see about the Medicaid, so he tried to force his staff to send the patient away on a bus. This is illegal on so many levels, as well as a human rights violation.

Of course, the staff members who he's bullying have nothing in writing and it's a given that, if anyone reports his actions to the State, no one will back them up. One worker took a stand this week and told him "NO." The administrator responded by rescinding his permission for a scheduled vacation until she complied with his demands. She walked off the job (and reported him to the state). There will be an investigation, but the only way this administrator can be stopped is for someone to tape the administrator and submit it as evidence to the state. I'm not sure of the legalities of taping someone without their knowledge...

All of this is happening in NV, a state that has gotten itself into trouble for providing greyhound therapy itself:

http://www.sacbee.com/nevadapatientbusing/

Greyhound therapy happens everywhere. The "rule" is that the patient must have a safe discharge. The definition of "safe" is to be determined.

Putting a patient on a buss isn't necessarily a bad thing. The patient must be able to travel and if he/she requires an escort, it must be provided (or arranged). In addition, services must be set up at the other end and the patient must have a place to stay.

So, places that want to circumvent the law can buy the ticket, leave it on the patient's bed stand, and then claim he left AMA. Or simply hope it gets overlooked during survey time.

In the NV case, they decided that only a few out of the hundreds of discharges were unsafe and fired a few people who probably had nothing to do with it. The pressure a social worker receives from his/her supervisor is amazing - you desperately need your job like anyone else, yet you will lose your license if you participate in these situations.

The woman (above) quit/was fired and is now unemployed; I'm sure she's worried - as anyone would be - but luckily her leaving that job won't matter in the long run. Right now, today, there are only listings for open social work jobs one of the worst companies ever. Across the country, nearly every one of their facilities rates poor - or absolutely horrible - at caregiving. This company is located in maybe 10 states and has no incentive to raise its standard of care because it is paid the same amount per patient regardless of how well it rates.

Depending upon how desperate she is, she might have to leave one sucky-ass job and go to another for awhile.

anonymous says

Who defines the "rule" ?

The Centers for Medicare & Medicaid Services (CMS):

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Discharge-Planning-Booklet-ICN908184.pdf

anonymous says

Sounds like if the patient runs out of insurance or other means to pay in a lot of cases they are dumped out to someplace of questionable reputation etc.

That's a huge problem. Patients who can't pay and don't qualify for help (state or local programs - such as Medicaid or Direct Assistance) can be served a 30-day notice. However, if they lack the ability to pay the $6,000/month it costs in a nursing home, they might not be able to afford living anywhere else either. Family members might not be able to care for them - or there might not be any family members. So, a medical facility can serve a 30-day notice every month but unless the patient has a safe place to go that is able to meet his needs, he's not going anywhere. At least in theory.

That's when a facility either chooses to treat the patient appropriately and either keep him there or to pay for him elsewhere. A nursing home can also simply wait for the patient to get sick enough to be admitted to the hospital and refuse to take him back. This move might cause a catastrophic lack of referrals from the hospital to which the patient was sent - and word gets out, so other facilities might join in this silent embargo. The nursing home will have to choose between the lesser of the two evils - taking the patient back or losing it's ass. They usually take the patient back.

But, there's always the facility that doesn't give a shit about patients and dumps them out. These places are playing the numbers game; they're hoping that the patients/families are too stupid to report them and that the annual survey won't catch the problem. This is often the case, especially since the recession started and states began massive cutbacks in services such as nursing home/assisted living oversight. For example, in Utah there used to be two teams that audited nursing homes - one in the north & one in the southern half of the state. This was cut back to one team that travels all over. I doubt that the state saves much, what with travel expenses and all, but that comes out of a different fund and doesn't look as bad. But I digress; the one team is overwhelmed and overworked. I've seen them in action and they do the bare minimum, miss lotsa problems and never notice "red flags."

anonymous says

I questioned them at length about what would happen if they or someone else could not pay the full amount each month.

Patients who can't pay the full amount, but have income, are often discharged to group homes or individual care homes. These places are often staffed by extremely low-paid caregivers who get 2 or 3 days off per month, probably aren't in the country legally so they keep their mouths shut, and hope they're not caught & deported. These places usually offer personal care that is supposed to be as good as a skilled nursing facility. Supposed to be...

Either way, if the patient can't afford the entire amount, patients are usually discharged. The facility is able to do so if the patient agrees, the plan is quantifiable and considered to be safe, and transportation is provided. The patient must be able to access medical care, medications, and equipment that is necessary to meet his needs.

Another method is to "encourage" a patient to walk out AMA. I worked for a nursing home for a short period of time where the administrator would direct staff to leave cash on the bedside stand and even drop patients off at casinos or crappy motels. She lost her job (there, still working in the industry although suffered a huge pay cut) and a patient nearly died. She truly didn't care and was forcing staff to perform one illegal act after another, dared us to report her to the state and to the company by bragging that she made the company "one point five million dollars a month so who are they going to believe? Me - or you?"

They believed me. (yay!)

Your entire post is the reason I wrote my book. Thanks!

the medicare site was updated to include actual survey results (the "cleansed" ones) a year ago. and it still runs behind... but it's a start.

elliemae says

The department that licenses group homes, assisted living facilities, and nursing homes was responsible for ensuring the safety of the residents. The owners are also responsible.

Everything should have been in place on the date that the facility was shuttered. There's absolutely no excuse for this behavior. NONE.

I can't even begin to imagine how horrible it was there for the residents.

Sounds like typical government incompetence to me.

anonymous says

Unfortunately my brother was given/took Power-of-Attorney and did not exactly do a stellar job of researching all of the options concerning divestiture of assets.

What were the mistakes here?

anonymous says

Had everyone taken a few steps back and paused, things would have turned out much differently for the families and a lot of bitter feelings would not have had a chance to take place.

Not necessarily. divestiture of assets must occur 36 - 60 months ahead of time in order for assets to be protected. This law was enacted in 2006. So, it's possible that even if you had met with an elder law attorney it would have been too late.

The rule is the period of ineligibility starts either 1) the date of transfer (36 to 60 months), or the date that the patient applies for Medicaid and is otherwise eligible. So if you transfer assets in January 2010 and apply for assistance in January 2013, your period of ineligibility starts in January 2013. Once the money would have been spent on a patient's care, he might be eligible. That's little consolation for someone who has no money and needs to be placed - they don't qualify for Medicaid. Either the family pays out of pocket or the patient limps along until the ineligibility period is over.

anonymous says

The house could have been retained and used as a rental.

Houses can be kept, and used as rentals. However, the income must not be paid to the patient or it's considered to be an income stream available to pay for room & board. If the patient has Social Security income of $1,000 and the house is rented for $1000, he will have $2,000 available to pay toward his share of cost. For those states that have a cap on income, the rental amount can render them ineligible for Medicaid.

There are no adjustments for upkeep on the home, including house payments, taxes, assessments, etc. All of the income is available to the patient if paid in his name. If not paid to him, the income must be reported as income to a family member on their taxes or they face penalties. It happens.

Regardless of who receives the rental income, a patient who owns a home is able to qualify for Medicaid as long as his other assets don't exceed $2,000. The Medicaid asset recovery rules require that states place a lien on the patient's home when he dies, and recoup the monies that the program paid on his behalf. Families are welcome to satisfy the liens and keep the home, but if they aren't able or willing to do so the house will have to be placed for sale in order for the liens to be satisfied.

Any equity above & beyond the amounts that Medicaid paid out will remain part of the patient's estate. For example, if the Medicaid program paid $60,000 on the patient's behalf and the home sells for $100,000, his estate will receive $40,000 (less closing costs and realtor fees. The Medicaid program does not absorb those fees.

The only instance in which asset recovery rules don't apply is when the home is occupied by the patient's spouse, by a handicapped dependent, or if a family member lived in the home for the 2 years leading up to the time that the patient was placed in a nursing home and can prove that they provided assistance with the patient's activities of daily living. This is hard to do, because most people don't keep meticulous records of what they do to help a parent or relative.

Many people end up selling the house, paying cash and waiting for the money to run out - then applying for Medicaid. However, since the Medicaid program pays less for room & board than a private pay patient is charged (amounts set by the state), it's often a better deal for the family to carry the cost of the house maintenance and taxes, then sell the house or otherwise satisfying the lien when the patient dies.

The monies paid out by Medicaid are not only a lesser rate - the program also doesn't charge interest on amounts paid. I'll use a nursing home in Las Vegas as an example:

Private pay rate: $286.00/day ($8,580/mo)
Medicaid rate: $200/day ($6,000/mo)

So, an interest-free loan of $6,000/month is a better deal than to pay $8,580 out of pocket. And that doesn't count the ancillary charges for the private-pay patient - such as oxygen, incontinence supplies, toiletries, etc - which can easily add up to $600+ per month. Medicaid pays these expenses in the daily rate...

I'm not saying that elder law attorneys can't help - they can - but they're best utilized a few years before the placement. Estate planning attorneys aren't appropriate for this type of assistance, even if they think they know what they're doing.

All of this - and more - is covered in my book.

These issues are very complicated - and nursing homes will attempt to force family members to do their bidding because they are "power of attorney."

That, too, is a crock of shit. A POA is responsible for assisting the patient within his ability to pay - and anyone can call & ask for a priest.

I had a lovely conversation with a nursing home business office today - the patient was discharged several months ago and the home is dragging their feet in sending an accounting of the patient's funds as well as holding onto their monthly income to satisfy a past-due amount. After I reminded the biz office woman that it was illegal to withhold the patient's money when she's no longer a resident, that refusing to cooperate would cause me to call and file a complaint with the state agency that oversees nursing homes... she changed her tune.

But she was a real bitch about it. I actually have met the owners, and they'll be receiving a letter about her comments. She forgot to place me on "hold" and I was on a speaker phone, so the family was able to hear the comments about how the nursing home really feels about them.

This will be fun.

My book is the Nursing Home Survival Guide (linked below my photo on left). It's available on Amazon.

sorry - gots a meeting. later tonight

anonymous says

Appreciate your input on this. You have never mentioned the title of your book, is that not allowed on this site?

I would think it would be allowed, since Patrick gave the book a 5 star review on Amazon.

Interesting info posted here by elliemae. Makes me wonder if the book has a chapter on asset hiding.

I guess you could buy the book and see if there's a chapter on asset hiding.

Truthfully, there is no chapter on asset hiding. I don't advocate doing anything illegal to become eligible for Medicaid. However, as long as there are legal loopholes, they should be utilized. An experienced elder law attorney can help a person become eligible for Medicaid using such tactics.

My book isn't just about payment. It's about how to maneuver through the system, what each department does and how nursing homes and patients/families can partner to make the experience a better one. Getting there is just the beginning - making it a positive experience and ensuring that the patient receives appropriate care is important too.

My suggestion that people allow Medicaid to pay, and then reimburse from the sale of the house at a substantially lower rate than if the patient paid privately, isn't new. It makes financial sense - but nursing homes don't mention this option most of the time because they make less profit on a Medicaid patient.

Nursing homes love to say that they barely break even or even lose money on their Medicaid patients - but they're full of shit. Between the guaranteed income stream, the accompanying tax write-offs, grants for updating systems... plus bilking the shit out of the Medicare system, nursing homes are highly profitable.

They just need to treat the patients better and patients/families need to be empowered to force the nursing home staff to act appropriately.

elliemae says

Nursing homes love to say that they barely break even or even lose money on their Medicaid patients - but they're full of shit. Between the guaranteed income stream, the accompanying tax write-offs, grants for updating systems... plus bilking the shit out of the Medicare system, nursing homes are highly profitable.

I agree. That's why I have some publicly traded nursing homes/assisted living stocks on my watch list.