The Buffalo News has an article about the difficulty of middle class families to afford nursing home care.    The article talks about how elderly or infirm people seeking to spend down or transfer assets to qualify for Medicaid are finding it increasingly difficult because of changed rules, and a new law will make it even tougher.  The changes, designed to minimize government spending by reducing the number of people eligible for aid, are hitting many middle-class families in the pocketbook.

To ensure they qualify, families of residents or future residents routinely try to legally manipulate their assets to evade the financial limits. To remain eligible, the maximum Medicaid-countable assets you can have are $104,400.

Of the 120,000 residents in nursing homes in New York, 75 to 78 percent are on Medicaid, said Richard Herrick, president and CEO of the New York State Health Facilities Association. As a result, nursing home care consumes about 14 percent of the approximately $49 billion New York State annual budget for Medicaid, or about $7 billion, he said.

To qualify for Medicaid, an individual must disclose all assets — from bank accounts to vacation homes — to the county Department of Social Services. A single individual can have up to $13,050 in assets.

If the individual is married to a “community spouse,” a person who is not in a facility, the spouse can keep between $74,824 and $104,400, depending on the total assets they had before going into a nursing home. The community spouse can also keep a house and a car.

To determine the length of the penalty period, the county looks at how much money a Medicaid candidate has gifted for less than fair market value within the look-back period.  To calculate a penalty period, a person can divide the total amount of money they moved around during the look-back period by the average monthly cost of skilled nursing for their region, Beinhauer said. For Western New York, the average monthly cost is $7,066.

For example, if a person gave $100,000 to his children before applying for Medicaid, they would have a little longer than 14 months to wait before the government started paying.

That’s not to say all gifts will cause delays. Beinhauer said certain gifts can be justified.

“If you can establish a pattern of gift making and you were in good health when you made the gift, for example, you could argue that gift should not be considered a sanctionable transfer,” he said.

Prepaying burial costs and funeral expenses is an easy way to spend down money legitimately,  Burial-related costs for a spouse, son, daughter or sibling are not counted as part of one’s assets.

A house can also be transferred in several ways so that the transaction is exempt. If a child is living with a parent for two or more years or a sibling for at least a year, the applicant can transfer the deed without the house counting as an asset.

Nursing home residents may be at risk from rape and other sex crimes.  Julie Appleby reports in USA Today that there are registered sex offenders living among the elderly and vulnerable in nursing homes.  According to a 2006 report by a U.S. Government Accountability Office, at least 700 registered sex offenders live among the estimated 1.5 million people in long-term care facilities.  And even more concerning is the fact that few residents and families are even aware of the danger.  Very few states have regulations concerning the notification of facilities and residents that a sex offender lives among them.

Recently more states have begun to evaluate the issue and consider legislation to require notification, and a subcommittee of the U.S. House of Representatives held a hearing on the matter. 

Ray McDaniel believes that all facilities should be required to notify residents and their families if any residents are on the sex offender registry.  McDaniel’s 18-year-old daughter was admitted to a nursing home in 2005.  10 days later another resident, who was a registered sex offender, raped her.  McDaniel had no idea that a sex offender lived in the facility because no one was required to tell him.

As a result of McDaniel’s daughter’s rape, the state of Ohio is close to passing a bill that would require facilities to post notice that a resident was a sex offender.

Oklahoma, California, Illinois, Minnesota, Oklahoma, and some counties in Florida either have or are considering some form of legislation related to long-term care residents who are registered sex offenders.


There’s so much talk about how the state conducts surprise inspections in nursing homes.  This article indicates that inspections didn’t come as a surprise to at least one nursing home in Kentucky.  I suspect that this happens more often than the nursing home industry would ever admit, and I suspect they’d like to keep it that way.

I know when I worked in long-term care, we sort of had an idea of when the annual survey team would show up, but we were surprised by complaint teams (or maybe i wasn’t high enough on the food chain to be aware of it) – but anytime a state survey team came in the front door, a call would go out over the facility wide intercom ; "Dr. Black, line one" or "paging Dr. Black, line one" – something crazy like that – and boy, did people start to scramble.  In five minutes or less, the place looked and smelled clean, if it wasn’t already, and the residents were changed and tidied up as quickly as possible. 

I just wonder how surprised most Administrators are . . .

The Milwuakee Journal had an excellent 2 part series on nursing homes recently.  They can be found here and here.

The Journal describes how dozens of nursing homes in Wisconsin have been cited for improper care after the deaths of 56 residents since 2005 – a period marked by a dramatic surge in serious violations around the state.  Neglect was noted after hundreds of elderly or disabled nursing home residents were found with bruises, broken bones or pressure ulcers – some so deep they tunneled to the bone.   In hundreds of cases, reports document how inadequate training, lack of supervision and understaffing contributed to a rising number of injuries.

The Journal Sentinel built a database from thousands of pages of nursing home regulatory records over the past 3 1/2 years. Among the findings:

• Health care violations that put patients in jeopardy or resulted in harm spiked 34% the past three years.

• Dozens of homes are cited repeatedly for serious violations.  Many of the homes cited multiple times are owned by out-of-state corporations.

• Deaths and injuries are occurring at a time of significant worker turnover. In one case, a problem home reported nursing staff turnover rates as high as 257% last year while it led the state in serious citations.

• Families are often kept in the dark about citations issued after the deaths of their loved ones. Four families learned from the Journal Sentinel that serious citations had been issued months and even years after their loved ones were buried. 

Uunprecedented growth and profits in the industry is expected to continue. Last year, the federal government spent about $75 billion on nursing home care through the Medicare and Medicaid program.

The ownership and operation of Wisconsin nursing homes has changed dramatically. Locally owned mom-and-pop operations have given way to out-of-state for profit corporations that own clusters of homes. 

Health care experts cite other factors that have affected nursing home care.   The increase in pressure iulcers are a major concern and a leading indicator of neglect.   Pressure ulcers occur when nursing home residents are left in one position too long. The ulcers get worse when people are forced to lie in their own waste which is common in uunderstaffed facilities.  Without immediate attention, the ulcers can be life threatening.

High turnover rate is an major problem.  The aides do not get paid well and are typically asked to do the work of 2 or 3 aides.  Most aides don’t stay at one facility for long. The Journal Sentinel found that turnover for full-time nursing assistants at Wisconsin nursing homes can be as high as 200%, with an average of 42% last year.   Many nursing assistant jobs start at less than $9 an hour.

"It’s a hard job, but it’s better than working at McDonald’s," said Jim Wilson, administrator at Oak Park Nursing and Rehabilitation in Madison.   The turnover of full-time professional nurses who monitor residents’ care is also high. Among the homes cited repeatedly for serious violations, the turnover rate for full-time registered nurses averaged 57% last year with some homes reporting turnover as high as 300%. The state’s average turnover for full-time registered nurses in all nursing homes was 32%.

Staff turnover can directly affect care, said Julie Eisenhardt, a spokeswoman for the union representing nursing assistants. Inspection records back that up.

Sava Senior Care, a Georgia-based corporation, operates 185 homes nationally. Two of its four homes in the state have been cited with serious violations at least three times since 2005.
Even when large fines or other enforcement actions are imposed against nursing homes after serious injuries or deaths, families might never know about them. Neither federal nor state law requires that families be notified.

A Journal Sentinel analysis found that nursing homes in Wisconsin were cited for poor care after the deaths of 56 residents since 2005. But Nursing Home Compare doesn’t offer any details about those deaths.   The Web site also doesn’t mention anything about corporate ownership, meaning that consumers would be unable to determine if the nursing home was owned by an out of state corporation or even one with a history of violations and fines.  "Figuring out who is accountable for poor care can be very difficult," said Alice Hedt, executive director of the National Citizens’ Coalition for Nursing Home Reform. "Consumers often don’t know who owns and operates a facility. Unless a facility tells them, there is no public way to find that out."   For consumers, knowing who owns a home is important if they want to determine whether the same problems are showing up in multiple homes owned by the parent corporation.

The number of nurses and aides on staff to help residents is a key factor in determining whether quality care is being provided, according to experts.   "The higher the staffing, the better the quality," said Charlene Harrington, a professor of sociology and nursing at the University of California in San Francisco.   Staffing numbers provided by Nursing Home Compare are merely a two-week snapshot from the most recent inspection – and in an industry that has widespread staff turnover, those numbers can’t always be trusted, Hedt said.

William A. Hyman wrote an article in McKnight’s Long Term Care News on July 24, 2008 about the dangers of bed rails and the problem with entrapment.

Bed-rail entrapments and deaths continue to occur in nursing homes, other facilities and in the home because rail and bed designs that are clearly dangerous continue to be used. Such rails may be in your inventory, or in the inventory of your rental supplier.

The U.S. Food and Drug Administration has recognized and reported on the problem of lethal entrapments for over 10 years, but it has not ordered recalls. Some manufacturers have designed safer rails yet not replaced those already in use. And despite the publicity efforts of the FDA, The Joint Commission published articles and others, there continues to be a lack of practical understanding of the nature of this hazard and how to recognize a dangerous bed.

The time to end lethal bed-rail entrapments is now, and the way to do it is to remove from the inventory those bed-rail systems that are unreasonably dangerous, and to insist that suppliers provide beds that at least meet current guidelines.

It is now 13 years since the FDA’s Safety Alert on the dangers of entrapment in bed rails, and other parts of hospital and nursing home beds (1). This alert was directed to Home Healthcare Agencies, Hospices, and Nursing Homes, among others. It was based, in part, on already published work and reports to the FDA of deaths and injuries associated with beds and bed rails, the latter going back to publicly available data since 1985. The FDA alert triggered a number of related reports and announcements in the clinical literature (2- 4).

Read More →

S.C. to post Medicaid payments to doctors, nursing homes online 

South Carolina is now posting how much the local nursing home or doctor gets in Mediciad reimbursements.

"We are pleased to be able to offer the public a way to track how their money is spent in the Medicaid program," Emma Forkner, director of the state Department of Health and Human Services, said in a statement. "This kind of spending transparency is key to ensuring accountability from government agencies and those who get paid by them."

The move by DHHS, which administers the $5.4 billion Medicaid program, will help DHHS locate "unusual billing patterns"  and hopefully detect fraud.  

The site also provides information about dentists, hospitals and any of the other nearly 30,000 health care providers in South Carolina who participate in the Medicaid program. It includes their reimbursements as well as the number of patients they saw. More than 800,000 South Carolinians receive Medicaid, the health insurance program for the poor and disabled.

To access the data, go to and click on Medicaid Transparency Database.


Pearce Adams wrote an article for the Independent Anderson Mail about an administrator of an assisted living facility stealing from his residents.  He was arrested on Wednesday and charged with exploitation of a vulnerable adult.

Robert Dunmoyer, 57, was allowed to post a $25,000 bond in Anderson Municipal Court the attorney general’s office made the recommendation, citing Robert Dunmoyer’s "cooperation" with the investigation.   Dunmoyer, former administrator with the Magnolia Residential Care center in Anderson, tricked a 75-year-old resident to give Dunmoyer power of attorney for the man. That step gave Dunmoyer legal authority to handle the man’s bank accounts and investments.

Supposedly, Dunmoyer took responsibility for his actions after he got caught.  He made excuses for his behavior stating that he was having personal problems from a divorce that “created the state of mind” that allowed him to steal and take advantage of his resident. 

Dunmoyer had taken “approximately $100,000 from (the elderly man’s) account with them,” and charged the man $9,500 to handle his stocks, the report states.

Ken Moore, representing the state unit that investigates nursing home and assisted living home crimes, testified that between July 2007 and April, Dunmoyer withdrew $60,000 without the consent of the elderly man.

The discrepancy between the amount mentioned in court and that listed in the incident report was not addressed. Moore said Dunmoyer “told us what he did and why he did it” and was cooperating with authorities.

I stumbled across this article from the New York Times which I found interesting regarding violence against nurses being a serious issue – especially in terms of workplace violence.  It reminded me that in all the talking we do about abuse and neglect of patients, we sometimes forget that nurses and aides, and really anyone providing "front-line" care to patients in a health care setting, are at risk for abuses as well.

The article points out that workplace violence is 12% higher in for nurses and personal care aides than in the private sector, which may not sound like a lot, but certainly seems like a high risk if you work in this field.  The article goes on to say that the most dangerous setting is psychiatric facilities and nursing homes due in part to patient confusion.  However, the author also points out that part of the problem in these settings is the long wait time for services in places like nursing homes and emergency rooms.  This is made worse still by the nursing shortage.

"Nurses say the persistent nationwide nursing shortage is making matters worse, because understaffing increases the risk of violent incidents. And nurses cite the fear of assault as a reason for low morale, especially if they feel that management does not share their concern."

We have to remember that often times, our clients, our family members, our patients (whatever angle you look from) are quite often not the only victims in these situations.  Many times, too many times, the people who provide the care are victims as well – if they don’t have enough support, then they effectively have an increased risk of being harmed.  Interesting, isn’t it – without enough staff, we know the care of the resident’s suffers, but we forget that short staffing affects the staff as well.

I, myself, when working at a nursing home, have been cornered in my office by an elderly lady who was furiously swinging at me.  I was a social worker, the resident was in my office because she had been disruptive all day and the nurse’s simply couldn’t watch after her anymore.  I realized right quick that part of the fear is that they might injure you (its amazing what sort of strength a demented, angry 95 pound woman can have), and part of the fear becomes that you might injure them in trying to protect yourself.

I don’t know what the solution is, but I am reminded again, as I often am, about a discussion with a friend about one way to keep plenty of good staff is to pay them well – pay them to continue to care, pay them to be accountable for the care they provide.  Of course, I know that money is not the absolute solution, but Management types should certainly know that if they have good staff, they should pay them to stay – and while thy’re there, they have to listen to and support them emotionally.  If Management sees their front line staff as just another warm body, then eventually morale becomes such that you have just that, another warm body.

It takes a certain, special kind of person to care for patients of all kinds, nursing home residents included.  The article reminded me that we have to remember that caregivers are sometimes victims as well, and often through no fault of their own.  And, like the residents they care for, they should have some measure of safety as well.  Thoughts?

Online Nursing Home Resource Provided by IQ Nursing Homes.  IQ Nursing Homes announces the launch of their new website, a comprehensive online research tool for nursing home residents and concerned family members.

(EMAILWIRE.COM, July 17, 2008 ) New York – IQ Nursing Homes announces the launch of their new website, a comprehensive online research tool for nursing home residents and concerned family members. A national nursing home directory, up-to-date nursing home news, nursing home deficiency reports, and legal resources for victims of nursing home abuse and elder neglect cases are now just a click away on one easy to navigate site.

With increased life expectancies in today’s society leading to higher numbers of nursing home residents, IQ Nursing Homes recognized the need to create a free, complete online nursing home resource. Careful research is imperative to ensure that the nursing home to which you entrust your loved one’s care is reputable and safe. When you visit IQ Nursing Home’s national directory to locate elder care facilities in your area, you can also check nursing home deficiency reports to make sure the facility you choose provides the best care possible to its residents.

In addition to directories and information, IQ Nursing Homes provides a way for nursing home employees, residents, and their families to combat elder abuse and neglect. These are serious, prevalent problems that can result in physical and emotional suffering. Painful bed sores, broken hips, and even death are among the afflictions the nursing home residents face at the hands of negligent or abusive caregivers. Resources to help individuals recognize and report these problems are available on the IQ Nursing Homes website, including signs and symptoms of abuse and neglect and an anonymous abuse report form.

If abuse is suspected, a free nursing home abuse case evaluation is also available on the site. IQ Nursing Homes has partnered with expert nursing home lawyers and law firms throughout the country with the goal of putting a stop to the victimization of the elderly. By holding negligent and abusive staff members accountable for their actions and making it financially devastating for nursing homes to allow abuse and neglect to occur, this epidemic can be put to an end.

Be IQ Smart. Visit to learn more.

This press release was issued through GroupWeb EmailWire.Com. For more information on unlimited press release distribution service, go to

House subcommittee passes nursing home arbitration bill (07/17/08 McKnight’s Long Term Care News)

The House Judiciary Subcommittee on Commercial Law and Administrative Law Tuesday approved the Fairness in Nursing Home Arbitration Act, which would outlaw signing an arbitration agreement as a prerequisite to admission in a nursing home.

Republicans on the subcommittee voted against the measure but came up short in a 5-4 vote. Some members tried to add amendments that would remove some of the sting for nursing homes. Rep. Chris Cannon (R-UT) tried to add language that would exclude physicians and providers in nursing homes from the bill, ensure the bill would not be retroactive, as well as other provisions. All these amendments were shouted down in voice votes.

The subcommittee’s approval moves the bill one step closer to becoming law. Long-term care advocates oppose the legislation, arguing that arbitration agreements allow them to channel limited Medicare and Medicaid resources to providing quality care instead of funding lengthy court trials.  

Of course, no Medicaid or Medicare money actually goes to defending lawsuits since insurance companies pay for the defense of the claim.  What is really needed is a bill that mandates minimum amounts of insurance for each facility–something in the amount of 10% of gross revenues.