“You’re just a piece of garbage,” one
evicted nursing home resident said. “They’ll kick you right out on the curb.”
Nov. 29, 2019, 3:30 AM CST By Katie
Engelhart
BISHOP,
Calif. — When Jamie Moore arrived home on a Thursday evening in March, she was
surprised to find her mother-in-law in her living room. Glenda Moore, 67, had
been sitting in her wheelchair for hours. Without anyone to help her to the
bathroom, she’d had an accident. She was also having trouble breathing. “It was
awful,” Jamie Moore recalled.
Glenda
Moore told Jamie that she had been discharged from the Bishop Care Center
nursing home, in Bishop, California. She had been living at the nursing home —
a sprawling brick building on the side of a state highway — for several weeks,
recovering from a back surgery that unexpectedly left her unable to walk much
or take care of herself.
Several
days earlier, nursing home administrators had shown Glenda Moore a letter from
Medicare, explaining that her rehabilitation coverage was ending. She was
unable to pay the nursing home’s more-than-$7,000 monthly fee, so, thinking she
had no other options, she left. (A relative dropped her off at Jamie’s home,
where Glenda Moore had lived previously, without telling Jamie.)
“They
pushed her out and she was not ready,” Jamie Moore, who has worked as a nursing
assistant, said. “She was not ready at all.”
As the
family later learned, Glenda Moore had the right to appeal the Medicare
decision, or to apply for Medicaid — and, if she qualified (which she later
did), to stay in the nursing home on Medicaid for as long as she needed nursing
care. Instead, Moore’s family said, Moore became one of thousands of Americans
discharged against their wishes or evicted from nursing homes each year. (The
Bishop Care Center maintains that Moore's health had improved and that she
voluntarily left the facility, and points out that they gave her a document
noting her right to appeal the Medicare decision.)
Nationally,
long-term care ombudsmen, who advocate for elderly and disabled residents of
nursing homes and assisted living facilities, received 10,610 complaints about
discharges and transfers in 2017, up from 9,192 in 2015. The ombudsmen, whose
work is federally mandated and state-funded, receive more
complaints about discharges and transfers than any other grievance.
The
complaints likely expose just a small fraction of the problem, said Kelly
Bagby, vice president at the AARP Foundation, a nonprofit that serves
vulnerable people over 50.
“Most
people don’t even know they have rights,” she said. And many complaints never
result in a formal state investigation.
Advocates,
experts and the federal government say that nursing homes
tend to evict low-income, longer-term residents who receive Medicaid, to make
room for shorter-term rehabilitation patients who are covered by Medicare.
Medicare reimburses nursing homes at a higher rate than Medicaid, so it’s more
lucrative for facilities to house Medicare patients who stay for short stints
before recovering and moving elsewhere.
“Society’s problems are manifesting themselves on the doorsteps
of nursing homes.”
In
California, for example, the average state Medicaid reimbursement for a nursing
home is $219 per day, according to the California Association of Health
Facilities, while Medicare may reimburse more than $1,000 per day, but only for
up to 20 days, when patients must begin paying part of the fees. (Medicare
coverage ends completely after 100 days.) Advocates say that eviction notices
are often handed out around the 20-day mark.
“It is
illegal to discriminate against residents based on payment source, but it
happens all the time,” said Tony Chicotel, attorney at the California Advocates
for Nursing Home Reform, a nonprofit that supports long-term care residents in
the state. “It feels like there’s just a tidal wave of cases.”
Chicotel
said he receives calls every day from panicked residents or family members
being threatened with discharge from a long-term care facility.
Deborah
Pacyna, director of public affairs at the California Association of Health
Facilities, a trade association representing nursing homes, told NBC News that
improper and illegal discharges are “a really rare thing,” and that the issue
is exaggerated by media attention.
She
added that California’s Medicaid program, Medical, does not provide “adequate
funding” to care for many patients with complicated health issues and
behavioral disorders. “Medicare pays more. Those people are rehab patients;
they’re in and out,” she said. “That is how they break even,” she added of
nursing homes. “Society’s problems are manifesting themselves on the doorsteps
of nursing homes.”
Nursing
homes are legally permitted to evict residents under several conditions: if a resident’s health
improves sufficiently; if his presence in a facility puts others in danger; if
the resident’s needs cannot be met by the facility; if he stops paying and has
not applied for Medicare or Medicaid; or if the facility closes. Facilities are
obligated under federal law to give 30 days’ notice, in writing, and also to work
with the resident on a transition plan.
Bagby,
of the AARP, said that while some residents are issued formal discharge letters
with advance notice, others are asked or pressured to leave with “no due
process rights, no notice.”
In one
case in Los Angeles, in April 2018, Ronald Anderson said he was woken at night
by the nursing home staff at the Avalon Villa Care Center and told he was being
evicted. Anderson, 51 at the time, had moved into the facility over a year
earlier to recover from a partial foot amputation. He said he was loaded into a
van and dropped off on a sidewalk in downtown Los Angeles, which has one of the
largest homeless populations in the country, according to a report from the California Department of
Public Health.
Anderson,
who is diabetic, was left in a wheelchair without his insulin or testing
supplies — on a street cluttered with tent encampments and broken glass. The
Department of Public Health report noted that he could have slipped into a coma
or died.
“You’re
just a piece of garbage,” Anderson said, from the Union Rescue Mission homeless
shelter in Los Angeles where he now lives. “They’ll kick you right out on the
curb.”
Avalon
Villa Health Care, which runs the nursing home, later paid $450,000 to settle a civil complaint filed by the Los Angeles city
attorney in response to Anderson’s case and other evictions of homeless
residents, with the money going toward civil penalties, hiring and training
Avalon Villa staff and finding temporary housing for the facility’s homeless
residents. The city attorney set up an emergency hotline and invited members of
the public to report cases of resident abandonment.
A
lawyer for the Avalon Villa Care Center told NBC News that the facility
“strongly disputes that it has inappropriately discharged any patients” and
“rejects the allegations of the city attorney.”
The
Rev. Andy Bales, director of the Union Rescue Mission, said “resident dumping”
from nursing homes and hospitals is so common that the shelter set up a
security camera outside — which Bales calls “the dump cam” — to capture
evidence of it. He said he is aware of at least four instances from the last
year in which people have been dropped off on nearby streets by hospitals or
nursing homes — though he believes the number is higher. As a result of the
security camera, he said, “They won’t dump them off in front of us anymore.”
California’s
long-term care ombudsmen received 1,404 complaints about nursing home evictions
in 2018, up from 1,022 in 2014. Several lawsuits concerning nursing home discharges have
recently been filed in the state.
Molly
Davies, a California long-term care ombudsman, said that in addition to
receiving more complaints about evictions, “there has also been an uptick in
the egregiousness of some of these cases.”
In some instances, she and other experts
said, nursing homes drop residents off at a low-cost motel and pay for a night
or two. “We’ve seen cases with residents who have dementia put into a van and
dropped downtown onto the streets, without the ability to care for themselves,”
she said.
The
California Department of Public Health does not track where nursing homes
discharge patients, according to a department spokesman, nor does the
California long-term care ombudsman program. In some instances, however,
routine state inspections and inspections following complaints uncover
problems.
In a
2018 incident, described in a California Department of Health and Human
Services report, a Rosemead nursing home discharged a resident to a hotel
without any medical equipment and without ensuring that the hotel was “a safe
environment.” The female resident still required assistance with activities
such as using the toilet and bathing, and was found to lack “the capacity to
make her needs known.” The nursing home received a federal “deficiency” citation.
In
another case that resulted in a deficiency citation, a nursing home resident
who “needed extensive assistance” to move between locations in his bedroom was
discharged to a motel — and, a few days later, ended up in a hospital for
emergency care.
These
practices are not unique to California. In Maryland, one nursing home resident
was dropped off in Baltimore, a city she had never been to, according to the
state attorney general’s office. In another instance, a Washington County
Sheriff’s deputy accused a nursing home of discharging a resident to a storage unit
on a hot summer day.
Even
when residents appeal eviction decisions through a state process and win the
right to return to a nursing home, that nursing home sometimes refuses to
readmit them, a group of plaintiffs told the Ninth Circuit Court of Appeals
found in July. The case is still pending, but the appeals court agreed with the
plaintiffs that federal law does not allow “meaningless show trials that allow
nursing homes to persist in improper transfers and discharges.”
The
California Department of Health Care Services, the California Department of
Public Health and the federal Centers for Medicare & Medicaid Services all
declined to comment, citing department policy not to comment on pending
litigation.
In
2016, the Centers for Medicare & Medicaid Services strengthened regulatory requirements
around nursing home discharges and transfers, specifying that residents cannot be
evicted for nonpayment while they are in the process of applying for Medicaid
or appealing a Medicaid denial. A year later, the agency announced an initiative to prevent illegal
nursing home discharges, acknowledging that “some discharges are driven by
payment concerns, such as when Medicare or private pay residents shift to
Medicaid as the payment source.”
So far,
the agency has approved $784,630 for a program in California that focuses on
training nursing home staff on discharge regulations, a spokeswoman said in an
email. The agency also provided $84,00 for a smaller project in Montana. Beyond
that, the agency is not acting directly to address illegal evictions but is
instead encouraging states “to propose projects that seek to address
facility-initiated discharges that violate federal regulations,” the
spokeswoman said by email.
Advocates
for nursing home patients said more is needed. They want both federal and state
agencies to do more to enforce existing rules on evictions.
“We
haven’t seen any change in practice,” said Davies, the California long-term
care ombudsman. “We haven’t seen a reduction in inappropriate transfers and
discharges. There are certain enforcement tools that they have that they aren’t
using consistently.” These tools, she said, include substantial fines.
But the
federal government has made changes that reduced fines against nursing homes
that harm or endanger residents. Nursing homes used to receive fines for each
day a violation was observed, but after a change the Trump administration
implemented in July 2017, nursing homes are now usually fined just once per
retroactive violation.
Robyn
Grant, director of public policy and advocacy at the National Consumer Voice
for Quality Long-Term Care, an advocacy group, says this change can affect the
way illegal evictions are punished. For instance, a nursing home that evicts a
patient and refuses to readmit the person may be fined one time, instead of
every day that the resident is denied access to a bed.
In the
first 18 months following the change in guidelines, nursing homes across the
country paid about $47 million less in fines for all violations compared to the
previous 18-month period, said Dr. David Gifford, senior vice president of
quality and regulatory affairs at the American Health Care Association, the
nursing home industry’s main lobbying group.
Gifford
told NBC News that the change was not about saving the industry money, but was
meant to ensure consistent standards. He said the new fine structure
incentivizes nursing homes to report violations and improve resident care.
After
she left the Bishop Care Center nursing home in March, Glenda Moore grew
sicker. Over the following weeks, she cycled among her son and
daughter-in-law’s home, several emergency rooms and another nursing home an
hour away. According to her son and daughter-in-law, she was diagnosed with a
bladder infection and pneumonia.
“I
don’t want to be a burden on the kids,” Glenda Moore told NBC News in an
interview in April. “I had retirement insurance, I had Medicare, I thought I
was completely covered. That doesn’t count for anything … I had no idea.”
In May,
her family appealed her discharge from the center. At a hearing conducted by
the California Department of Health Care Services, the nursing home’s
administrator said Glenda Moore had left willingly, according to the state’s
summary report.
The
state’s hearing officer ultimately found that the facility “failed to meet all
of the regulatory-mandated discharge planning requirements.” However, the
hearing officer ruled in favor of the nursing home, noting that Glenda Moore
agreed to leave and was given paperwork notifying her of her right to appeal
Medicare’s noncoverage decision.
By late
July, her weight had dropped to about 80 pounds. She was hospitalized, and on
Aug. 2 she died from acute renal failure and cardiopulmonary arrest.
Her
family believes she wouldn’t have become so sick if she had been able to stay
in the Bishop Care Center for a few weeks longer, until she was more stable.
Jamie
Moore said her mother-in-law’s experience has changed the way she thinks about
her own retirement.
“I
never thought about it much until now. It scares the crap out of me,” she said.
“The system is the system. What are you doing to do?”
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