The Legal Checkup Blog

Wrongful Intent to Discharge Is Elder Abuse

Posted by Judith Flynn on Mon, Jun 09, 2014 @ 10:06 AM

I just received confirmation from a new client that the nursing home has rescinded its notice of Intent to Discharge her grandmother.  While this is great news, and our advocacy has paid off, this case represents a disturbing trend.

 

This is the third case in the past six months in which I was hired to advocate against a wrongful notice of Intent to Discharge an elderly resident of a nursing home on the basis of non-payment.  In all three cases, MassHealth coverage was in place, but there was an outstanding balance ranging from $6,500 - $13,000, for a period prior to the MassHealth approval.  In all three cases, the amount owed represented the Patient Paid Amount (PPA) for a period prior to the time when the client received a notice from MassHealth informing them of their duty to pay a set amount each month.

 

Most people are aware that there is a duty to pay something each month under the Medicaid regulations based on their income less any allowed deductions (the PPA).  Clients are certainly advised of this when working with an elder law attorney and most nursing homes will inform clients of this duty when they are assisting with the application.  (As a side note, I advise against using the nursing home or a non-attorney service that they may refer you to, but that is a separate topic.)  There are instances when the client is not informed in advance, however, through no fault of their own. 

 

By the time the client receives a notice informing them that MassHealth benefits have been approved, and detailing the amount that must be paid each month RETROACTIVELY to the date of eligibility (which could be as much as four months prior to the date of application), the funds may not be there to pay the outstanding PPA.  If a client is not informed that they must hold the funds or pay an estimated PPA each month while the application is pending, they may not have the funds available by the time they receive the notice from MassHealth.

 

In all three of these cases, the balance was owed not because funds were gifted and not due to misappropriation of funds.  The clients were simply not informed that they would need to pay a PPA back to the date of requested eligibility.  The nursing home assisted with the application in one case, and referred the clients to a Medicaid service in both other cases.  Nobody told the client to pay an estimated PPA while the application was pending or to hold the monthly income pending the approval from MassHealth.

 

In the most recent case, when MassHealth ultimately issued an approval notice and indicated the resident's duty to pay a PPA each month going back a couple of months, the nursing home continued to bill for the outstanding balance.  They sent a threatening letter to the resident's granddaughter, who managed the resident's checking account.  She tried to explain the situation to the nursing home administrator, and showed the bank records documenting where the funds went - they were not gifted - they were used to purchase items her grandmother needed.

 

When the granddaughter explained that she had four children and worked full time and barely made ends meet, and simply did not have the funds to pay the nursing home the outstanding amount, the nursing home issued a Notice of Intent to Discharge the resident for non-payment.  My client's grandmother is still mentally competent, so the law required that the nursing home staff serve the notice on her directly.  Imagine the fright my client's 88 year old grandmother experienced when she was handed a notice informing her she was going to be discharged from the facility that had been her "home" for the past two years.

 

To make matters worse, the notice indicated that the facility planned to discharge the resident to her granddaughter's home 30 days later (the law requires 30 days notice).  My client had informed the facility that she could not take care of her grandmother and, furthermore, that the setup and amount of stairs in her three-level condominium was an unsafe environment.  Her grandmother would require two people to assist her with transfers in and out of bed or up and down the stairs to the bathroom.  The facility knew that a discharge to my client's home would not be safe.  They knew that my client worked two jobs to make ends meet.  They knew that she did nothing wrong in this process, and that they had actually failed to inform my client that they were filing a conversion from community MassHealth to long-term care MassHealth on her grandmother's behalf, so she should either pay an estimated PPA from that point on or hold the funds pending the approval.  While they are not solely to blame either, they are more responsible for the situation than my client, yet they issued this notice to try to bully my client to find a way to pay the outstanding balance.  I find this tactic to be nothing short of elder abuse!

 

The time, energy, and expense the facility expended to pursue a wrongful discharge of this resident would have been better spent developing a better system to ensure that this problem does not happen again with another resident.  I am not un-sympathetic to these facilities.  I know that they suffer as a result of the delays and abuses in the MassHealth system.  So do my clients. But, I suggest that we would all fare better if we communicated in a collaborative manner to address these recurring issues, rather than defensively on a case by case basis.

 

Tags: long-term care, elder law, duress, Elder Financial Abuse, family, nursing home, rights, admission agreement, Medicaid, exploitation

"Of course he was admitted -- he has been in the hospital for four nights..." (Beware "Observation Status")

Posted by Judith Flynn on Wed, Aug 21, 2013 @ 07:08 AM

Once again I have encountered the infuriating problem of "Observation Status."  A client's loved one was admitted to a Boston hospital as a result of a crisis.  I instructed my client to confirm that his father had been formally "admitted" to the hospital, and his response was a bit incredulous.  "Of course he was admitted -- he has been in the hospital for four nights!"  His response was completely logical, of course, but my concern was realized when my client confirmed that the hospital still had his father listed on "Observation Status." 

In general, Medicare will only provide coverage for skilled rehabilitation services at a nursing home if the patient had a minimum of a three-night stay and is transferred directly from the hospital to the nursing home.  My client's father could not safely return home, and would need to be placed in a skilled nursing facility, so we advocated for his status to be changed (for him to be "admitted") and ensured that he had the required three-night stay before being transferred to the nursing home.  (Just to be clear - staying at the hospital on "Observation Status" for three nights does NOT qualify as a three-night stay.  One must be "admitted" before midnight for that night to qualify.)

Unfortunately, most people are not working with an attorney and do not find out about this problem until much later when they are charged for various prescriptions and services they received in the hospital or, worse, when they receive a huge bill from the nursing home.  It is far more difficult to successfully appeal the "Observation Status" at that point, but an appeal should be pursued.

On November 3, 2011, the Center for Medicare Advocacy and the National Senior Citizens Law Center, filed a nationwide class action lawsuit to challenge this illegal practice on the basis that it violates the Medicare Act, the Freedom of Information Act, the Administrative Procedure Act, and the Due Process Clause of the Fifth Amendment to the United States Constitution. (Bagnall v. Sebelius, No. 3:11-cv-1703, D. Conn)

In the meantime, you need to know your rights and advocate for yourself.  There are a number of self-help packets (and a wealth of information on this and other topics) on the Medicare Advocacy website at http://www.medicareadvocacy.org.  Call me at 781-681-6638 if you need advocacy to protect your rights on this or a related issue, or you can find an elder law attorney in your area through the website of the Massachusetts Chapter of the National Academy of Elder Law Attorneys at www.massnaela.org

Education is the best defense!  Please share this information with your friends and family to prevent them from being the next unsuspecting victim of this illegal practice.

                           

Tags: long-term care, elder law, Legal Check Up, Medicare, skilled services, improvement standard, nursing home, rights, admission agreement, Medicaid, long-term care planning

Know Your (Nursing Home) Rights BEFORE You Sign

Posted by Judith Flynn on Mon, Oct 17, 2011 @ 00:10 AM

Marylou’s mom had a stroke and lost the use of one side of her body. Marylou wanted her mom to be moved to the nursing home in her neighborhood so she could visit her daily. She was told that they had a bed available, but that she would need to sign the Admission Agreement and some other documents right away, and to agree to pay privately for at least six months. Marylou obliged, and promptly signed all the documents that she was presented by the nursing home administrator.

It was not until two years later, after her mom had passed away, that the nursing home threatened to sue Marylou for an unpaid balance for her mother’s care. Marylou discovered that one of the documents she signed was an agreement to guarantee payment for her mother’s care. Marylou’s mom was on MassHealth for most of her stay, and her income was paid to the nursing home each month. If Marylou had not provided a personal guarantee for payment, she would not be facing a lawsuit.

Just recently I met with Tom, whose mother suffered significant injuries from an accident in a nursing home. Tom was inquiring about a potential lawsuit against the facility, but a review of the Admissions Agreement that Tom signed on his mother’s behalf revealed that he waived that right before she even moved into the facility. One of the provisions in the contract was an agreement to submit any dispute to arbitration rather than to a court of law.

Nursing homes are specifically prohibited from requiring residents to agree to arbitration or requiring a third party to guarantee payment for a resident’s care, but they can seek such guarantees on a “voluntary” basis. The problem is that people usually do not realize the significance of what they are “voluntarily” signing.

Had Marylou or Tom consulted an attorney before they signed the Admissions Agreement, they would have known their rights and ensured that any objectionable provisions were removed from the Agreements.

The message here is not that nursing homes are bad. In fact, most facilities train their staffs to properly disclose prospective residents’ rights. You must advocate for your own rights, however, and in order to do that you must first understand that you need independent review and representation in the nursing home admission process.

Nursing home residents are protected under federal and state laws. The Nursing Home Reform Law (known as OBRA ’87) promoted individualized care and protection for residents of any nursing home that participates in Medicare or Medicaid, regardless of their source of payment. Massachusetts nursing home residents are further protected by the consumer protection statutes enacted by the Attorney General (AG). The AG regulations provide that any violation of OBRA ’87 and similar laws intended to protect nursing home residents is a violation of the consumer protection statute, and the resident may be able to collect attorney’s fees and costs in addition to multiple damages.

Here are some of the protections these laws provide:

*Potential residents may not be forced to waive important rights or agree to unfair terms (such as an agreement to provide a third-party guarantee for payment or to submit any dispute to arbitration). The reality, however, is that folks are overwhelmed and want the available bed for their loved one, so they sign whatever they are asked to.

* Nursing homes are prohibited from discriminating against potential residents based on source of payment. They can ensure that they will get paid, but they can not discriminate against someone who will need to apply for Medicaid (MassHealth). The reality is that some nursing homes do give preference to potential residents who have the ability to pay privately. Some facilities will even request a guarantee from the resident or the resident’s family that they will privately pay for a certain period of time – say six months.

* Discharge of a resident for behavior or mental health problems is quite common and it is accomplished by a practice known as “dumping” where the facility sends the resident out for a psychiatric “evaluation,” and then refuses to readmit the resident. In reality, families do not know that the refusal to readmit is a violation of the law and triggers their rights to an appeal.

* A proposed transfer from one room to a non-Medicare certified bed requires 30 days written notice and the resident has the right to appeal and refuse the transfer. In reality, when Medicare coverage ends nursing homes frequently claim that certain beds are non-Medicaid rooms and for private pay only. In some cases, no written notice is issued and the family does not know that one should have been issued, much less that there is a right to appeal.

* For rehabilitation therapies, Medicare reimbursement rules do not require “progress.” The resident must need “skilled nursing services” or “skilled rehabilitation services” and even if the resident is not making progress, the facility has the obligation to provide services to “maintain” the resident’s condition and ensure that the resident’s ability to perform Activities of Daily Living does not diminish.

The reality is that residents are frequently terminated from this benefit because they are not making progress, and the families do not know that they have the right to appeal.

These are just a few of the common issues. If you are faced with the need to place a loved one in a nursing home, be sure to have the contracts reviewed by an Elder Law Attorney before you sign to ensure that you and your loved one are properly protected.

Tags: long-term care, elder law, Medicare, termination of benefits, skilled services, improvement standard, nursing home, rights, admission agreement, contract