Category Archives: Nursing Home

The Scary Truth Behind Netflix’s “I Care a Lot”

I Care a Lot is a recently released Netflix film that follows the fictional account of a nursing home administrator who systematically exploits the elderly for financial gain. There are dramatic scenes of Marla Grayson (the nursing home administrator) with her wall of mugshots of her elderly residents. It shows a dramatic insensitivity that the residents are nothing more than cash cows to the nursing home system.

More chilling is the twisted use of the court process to declare these individuals as incapacitated, as a way to strip them of their rights to make decisions on their own. In essence, they become victims of a system that is supposed to protect them, robbing them of all decision-making power and their assets.

How Real Is Elder Abuse?

Can this happen in real life? The unfortunate answer is, “Yes”.

While the wall of elderly mugshots and a corrupt physician may be overly dramatic, there is an uncomfortable reality of nursing homes denying their residents basic rights and abusing the court guardianship system and the medical assistance process in order to get paid.

According to the National Council on Aging, up to five million older Americans are abused every year, and the annual loss by victims of financial abuse is estimated to be at least $36.5 billion.

Certainly, there are many well-run and well-meaning nursing homes, but there are also some nursing homes that are neither. For these nursing homes, their operating process is to cut off the resident’s family, deny them access, or grant access to only those who will align with their goal of keeping the resident at the nursing home and facilitate the nursing home’s wish to be paid.

How Can This Kind of Elder Abuse Happen?

A little background explanation is in order here. Let’s look at the typical process that an older adult might go through to end up at a nursing home.

For example, if your mom is over 65 years of age and has more than a 3-night stay at an area hospital, then she will generally be eligible to receive Medicare benefits. These benefits will pay for her hospital stay and then her nursing home rehabilitation stay—for the first 20 days in full, and then typically up to 100 days, with a co-pay expected from days 21–100. (A 100-day period is not guaranteed though.)

The key here is that the decision to move your mom from the hospital to the nursing home for rehabilitation would be made quickly. It is often the discharge planner at the hospital who makes the recommendation for rehabilitation at an area nursing home of their choice. As such, this is a guaranteed, temporary payment source for area nursing homes.

So, let’s say that your mom goes to nursing home rehabilitation for the 100 days that are covered by Medicare. Then, it’s time for your family to meet and make a big decision. What’s next? Should mom come back home, go to an assisted living facility, or stay at a nursing home?

The Nightmare Nursing Home Situation

At this point, a problem could arise between the nursing home and your family. What if your family and your mom’s health care agent want to take her home, but the nursing home recommends that she stay there? That is when the nightmare could begin.

If the nursing home wants to keep your mom, then they might say something like, “Your mother is better off staying here. She gets agitated when your family talks about taking her home.” Thus, the nursing home views your family as “agitators” who are upsetting their resident. Of course, this ignores the fact that your mom might want to come home, and she becomes complacent only when she is not reminded of the option to come home (i.e., she gives up).

Then the nursing home will demand payment. If your mom’s power of attorney holder does not use your mom’s money to pay the nursing home, then the nursing home will file for guardianship. This will strip your right, as your mother’s child, to be her agent.

The nursing home will have the court appoint a random attorney to control your mom’s money, and they will appoint the local Department of Social Services to make health care decisions for your mom. The goal of the random attorney will be to sell all of your mom’s assets and apply for medical assistance (i.e., Medicaid) to continue to pay for her nursing home stay. The goal of the Department of Social Services representative will be to just keep your mom at the nursing home where “she is safe.”

It is not unheard of that the nursing home will cut off access to your mom’s medical information or cut off your contact with mom all together. This issue has become even more pronounced during COVID-19.

It is not unheard of that the nursing home, when it files for guardianship, “conveniently”:

does not list you and your family members as interested persons
fails to mention that your mom has a power of attorney holder or health care agent (when they know of both)
tells you not to worry about your mom’s guardianship hearing and that you don’t have to attend
blindly files your mom’s medical assistance applications without knowing her assets, in order to have Medicaid pay the nursing home. (Please keep in mind that the medical assistance reimbursement, while it is not as high as the private pay rate, is substantial.)

The nursing home will often characterize this new guardianship filing as an “emergency” guardianship filing, not because there is any emergency with your mom, but because they want to get paid as soon as possible. The nursing home does not want a non-payment situation that could result in your mom’s discharge. (Although, from your family’s perspective, a non-payment situation leading to discharge would be just fine, if you wanted to take your mother home anyways.)

Adult Guardianship Issues in Maryland

In order to have a successful filing for a guardianship petition, in Maryland you need two physician certificates to prove that your mom is unable to make financial or health care decisions on her own.

Here are some questions about guardianship that you might have, along with my responses:

Is it possible that there could be corrupt physicians gaming the system to fraudulently declare your mom as incapacitated, as shown in I Care a Lot? That I have not seen.
Is there a lot of grey area when it comes to meeting the guardianship standard? Yes.
Are there cases when such a certificate is completed by a physician in 5 minutes, based solely on the first certificate? Yes.
Have there been circumstances of a physician completing certificates for guardianship in full, before even meeting the individuals or never meeting them? Yes (but that is rare, from my point of view).

The more common issue is not whether your mom needs help or not, but whose decision is that to make and what right does the nursing home have to make that decision.

Local Elder Law Firm Expertise

I’ve been in practice for over 19 years, and I don’t think there has been a single incident of a parent saying that they want to go to a nursing home. Nursing home placements are contemplated as a last resort when nothing else works.

The issue in many cases is that the nursing home becomes a third party in a battle over where mom is going to reside in her final days. Oftentimes, mom’s voice becomes irrelevant. But make no mistake, at the heart of this process, the nursing home’s concern is how it’s going to be paid.

The nursing home will frame the context to say that mom is “safer” there than at home. This argument will be used by the nursing home to convince the court that she should continue to stay there. The nursing home will have access to her medical records and the financial resources to hire a physician to articulate this position.

At our elder law firm, we are often involved in fighting these decisions. That means that we fight to get access to your mom’s medical records (which may lead to a separate battle of their release) and fight to maintain your right to make decisions for mom.

If the court appoints a random attorney as guardian of the property, as stated before, their sole role is to sell mom’s assets. If there are jointly held assets, an attempt will be made to sell them. If there are gifts of assets or transfers within the last 5 years, they will come under scrutiny, and depending on if there are assets to fund this random attorney in litigation, there will be an effort to have these gifts undone or otherwise transferred back.

The next thing you know, you are being cast as the “bad guy” for not returning these gifts, and now litigation begins with your mother’s guardian of the property and you to get these assets back. The reason why the guardian of the property may go after these transfers is that these transfers may be barriers for the nursing home to be paid by Medicaid. Gifts within 5 years are penalized transfers and will be barriers for the nursing home to be paid. As such, they will likely be pursued.

At the heart of these transactions is the court process, which will be used to try to keep mom at the nursing home, sell all of her assets, have strangers appointed as her guardian, and have this third-party attorney go after you, if you are involved in transactions that prevent the nursing home from being paid.

This is not the storyline of I Care a Lot. But the core issue of the nursing home being paid and abusing the judicial system to meet their needs is very real. And the nightmare, while not as dramatic as the plot of I Care a Lot … is very real.

We Care a Lot

At the Law Office of Adam J. Roa, we understand how scary and overwhelming these issues can feel for your family. As an experienced elder law firm in Maryland, we are here to guide you and fight for you. Please call us for a consultation at (410) 296-8166 x292.

COVID-19 Maryland Nursing Homes

We understand that there is a lot of anxiety regarding nursing homes during this COVID-19 pandemic.

But, just as before COVID-19, seniors are still failing in their health. Many of them will need 24-hour care that can be provided through a live-in aide (very expensive) or through placement at a nursing home.

If Your Loved One Needs Nursing Home Care During COVID-19

However, as of now, many nursing homes in Maryland are not accepting new residents. While nursing homes are taking precautions by separating the COVID-19 residents from those who do not have COVID-19, many facilities are still not admitting any new residents.

As a result, some hospitals are keeping their patients longer than normal because they can’t locate an available nursing home. If a patient has a delayed discharge from the hospital for this reason, then issues can arise with Medicaid and with who is paying for that extended stay.

If Your Loved One Starts Nursing Home Care During COVID-19

For those nursing homes accepting new residents, they will be asking for information relating to your family’s level of assets and income. Be prepared to provide that financial information, as well as providing a copy of the financial power of attorney and advance directive.

If the nursing home wants you to sign the nursing home contract, no matter how nice the director of admissions is, tell them that you need your elder law attorney to review the contract first before it is signed. This is a normal request, and it will help you avoid potential problems in the future, such as having your loved one get involuntarily discharged from the nursing home, or having the nursing home seeking immediate payment from you if the Medicaid application is denied.

If Your Loved One Stays in a Nursing Home During COVID-19

For existing residents of nursing homes, there is a very real issue of staff shortage to address current needs. Staff shortage can often lead to nursing home negligence issues.

Because most nursing homes are not open for family visitations, there is a very real concern of family members not being in a position to determine if the nursing home is still properly caring for their loved one.

One possible solution to this is that many nursing homes will allow for private duty aides/attendants to visit your loved one to provide their care. This is normally a welcome solution for a nursing home that is dealing with a shortage of staff. This can also provide a direct link of information that normally would not exist. This could include not only insight for medication and care, but also open up the possibility for telephone or video calls. Some nursing homes only extend the visiting privileges to certain nurses/aid agencies, while others have less stringent requirements.

We’re Here to Help During COVID-19

We understand that these are uncertain times. Now, more than ever, is when your loved ones need you to be their advocate in planning for the future.

As an experienced elder law firm in Maryland, we’re happy to guide you through the issues of nursing home cases. Please call us at (410) 296-8166 x292.

Another Win!

We have another nursing home win! In this matter, the nursing home worked with the client (before we were hired) to file the Medicaid application for her disabled husband. Client knew little of what was involved with the Medicaid application and relied on the nursing home to complete the application and file it. During the application process the nursing home kept on telling the client everything was fine.

After being denied twice for Medicaid and 9 months later, the nursing home gave the client a bill in excess of $100,000 and told her to pay it or else they would discharge her husband. In a move even bolder than that, in a moment of crises as he was being taken to the hospital, they literally had her sign a form as she was rushing out the door to the hospital. That form was an acknowledgement of discharge that could bypass all of the Federal and State regulations for discharge.

Next was the suit by the nursing home against client and her disabled husband in excess of $100,000. Never mind that it was entirely the nursing home’s fault that the nursing home application was denied, and the fact that client did not sign the nursing home contract, the nursing home and their attorneys still sued the disabled husband and client. We immediately filed a motion to dismiss and asked for sanctions. A few days before the motions hearing, the nursing home attorneys filed a motion to dismiss the matter (with prejudice) and paid our attorney fees. I would consider that to be a win!

Medicaid Mess

Filing for Medicaid

Filing for Medicaid (called Medical Assistance in Maryland) is a very paper intensive process. Often times it is the children of the parent who ends up trying to gather the mountain of information needed for the application process. Given the five year look back requirement, the burden is often high on that family member.

Medical Assistance Penalty Transfers

Because of the strict rules governing Medical Assistance penalty transfers, those transactions that occurred that were innocent at the time could be devastating for eligibility now. It is very common for an aging parent to live with her child and their family. It is also very common for that parent to co-mingle her social security income and pension income to the child’s bank account to help pay for the house expenses. But, in the eyes of Medical Assistance, that transfer from mom’s account to her son’s account will be treated as a Medical Assistance penalized transfer. This can be a real mess if this type of transfer was routine and had occurred over the course of several years.

The Cost of Transferring Money

A penalized transfer is a penalty imposed by Medical Assistance that provides that for every $6,800 transferred or gifted out of mom’s account it will result in one month of Medical Assistance eligibility which will start only when you file for benefits. So, in this case, assume that mom’s social security income was $1,500 a month and this arrangement of her giving her income to her son for the family’s expenses occurred over every month over the last 4 years. That’s $72,000 worth of transfers! Those transfers will result in approximately 10 1/2 months of Medical Assistance ineligibility.

Medical Assistance: Application Processing Time

That penalty start date will not even start until you file for Medical Assistance (at a time when the parent cannot have more than $2,500 worth of assets). Given that a Medical Assistance application may take many months to process, you could receive a denial notice 5 months after you apply. In the meantime, the nursing home bills are accumulating at $11,000 a month. Once that application is denied, the nursing home will expect payment in full or threaten to start the discharge process. They will also take a hard look at who signed the nursing contract and if there was a child who signed the contract they will put pressure on that child to pay the outstanding balance. It is a mess.

Detangling the Medicaid Mess

Our office can help a family unwind and get rid of this mess. Medical Assistance rules are complicated and harsh. However, our office is good at taking complex Medical Assistance “messes” and getting Medical Assistance eligibility. We recently handled a case with facts very similar to the facts mentioned above and obtaining full Medical Assistance eligibility with a determination of zero penalized transfers. Naturally, the client was pleased.

Falls at a Nursing Home

Standard of Care to Prevent Falls

Nursing homes and assisted living facilities are under a duty to care for their residents.

This includes a standard of care when it comes to their residents who are at risk of falling. When a nursing home or assisted living facility breaches that standard of care and a resident is harmed, there may be a legal case against that facility.

Often the fall was completely avoidable and should have been prevented. Nursing homes and assisted living facilities are being paid lots of money to take care of loved ones. It is their responsibility to mitigate falls. It is their job. A single fall can be a life altering event, affecting a person’s quality of life for the rest of his or her life.

The Grand Bargain

Nursing homes and assisted living facilities are supposed to be safe havens for our parents and loved ones when living in the community is no longer viable. In essence you are trusting the facility to take care of your parent at a time when you cannot take care of them yourself. It is a grand bargain: the facility is paid handsomely for their care in return for taking every precaution to make the living arrangements safe. In some case, unfortunately, that trust is blatantly violated.

Nursing Staff Negligence

At some nursing homes and assisted living facilities, the nursing staff and aides are underpaid, untrained, overworked, and have high turnover. Mistakes are often repeated and not corrected. Their mistakes only comes to light when disaster strikes and a family member is willing to fight back and say that is not right.

Nursing homes and assisted living facilities want to limit their exposure to “accidents” and will want the resident to sign an arbitration clause to avoid a court trial. Do not sign the arbitration agreement. Signing an arbitration clause is akin to insuring less of a recovery and less accountability for the facility. Often times the facility will ignore the problem, pretend the issue does not exist, or blame the resident. Nursing homes and assisted living facilities know that their residents often suffer from dementia, are weak or physically unstable. These are not unknowns to nursing home or assisted living management, and they are obligated to take measures to address these risks.

Taking Legal Action for Nursing Home Neglect

How do you know when it is time to get an attorney involved? The nursing home or assisted living facility has to have breached their standard of care to the resident (i.e., it was their fault, their staff was negligent in their action or inaction, etc.). Next, the resident has to be harmed to a significant extent. How much harm is enough? The harm at issue does not have to be permanent but must be significant.

Nursing home and assisted living facilities are big business in Maryland with the average cost of assisted living facilities at $4,000–$6,000 per month and nursing home costs at $8,000–$11,000 per month on average. Sometimes the facility does not hold up their end of the deal. Do not let the nursing home or assisted living facility get away with their behavior. For the sake of your loved one and countless others at their facility, someone needs to take a stand.

Recommendation #1: Document Everything

Take diligent notes of the negligent behavior (dates, names of those involved, witnesses, etc.). Unfortunately, not everyone has a photographic memory. Always document the issue. This helps establish your case when a judge gets involved.

Feel free to give our office a call for a consultation.