The blog reports information of interest to seniors, their families, and caregivers. Recurrent themes are asset and decision-making protection, and aging-in-place planning.
Wednesday, January 27, 2021
IRS Contests Value of Prince Estate, Who Died Without A Will Claiming Estate Worth $163.2 Million
Monday, January 25, 2021
Florida Investigates Nursing Home Reportedly Funneling Vaccines to Rich Donors
The State of Florida is investigating allegations that an upscale West Palm Beach nursing home diverted scarce COVID-19 vaccinations meant for residents and staff to members of the facility’s board of directors and donors.
Wednesday, January 20, 2021
Potential Miracle Treatment Promoted by Feds for SNFs
COVID-19 monoclonal antibodies are now widely available for use by skilled nursing facilities — and early results show promise, according to long-term care pharmacy leaders. Kimberly Marselas, writing for McKnight's Long-term Care News outlined the great news in her article, A potential ‘miracle’? Feds push monoclonal antibody treatments toward SNFs. The following is an annotated reprint of her excellent article.
The Department of Health and Human Services’ (DHS) Project SPEED, or Special Projects for Equitable and Efficient Distribution, aims to get monoclonal treatment to COVID patients in non-hospital settings with priority populations, including nursing homes and assisted living facilities [some links added]. It goes beyond an earlier pilot spearheaded by CVS Health that targeted nursing homes and patients at home in seven cities with rapidly rising COVID rates.
The program is now open to any licensed pharmacy, said Chad Worz, PharmD, CEO and executive director of the American Society of Consultant Pharmacists, during an online update last week. He said LTC pharmacies around the country are beginning to add the therapeutic drugs, which mimic the body’s natural immune response, to their formularies.
As word spreads about availability, Worz expects increasing demand from skilled nursing providers who see antibodies as a way of mitigating COVID symptoms and preventing hospitalizations.
On the same webinar, T.J. Griffin, R.Ph., senior vice president of long-term care operations and chief pharmacy officer at PharMerica, said he is working closely with two nursing homes in Chicago and San Antonio that have used antibodies on a total of 70 patients since the program’s launch.
“The medical directors of both places have called it a miracle,” Griffin said. “So far, none of these patients have gone back to the hospital.”
Because most clinical data on monoclonal antibodies comes from hospitals, there’s not much evidence about its success in nursing home residents. But Griffin said he is working to gather and report information to HHS, and urged others to document and share patient responses.
Use protected during public health emergency
One pharmacist on the call noted a facility he worked with declined to administer the antibodies, citing liability concerns. But Worz said federal PREP Act protections would apply to skilled facilities that administer them safely and effectively and monitor for anaphylactic shock.
Arnold Clayman, ASCP’s vice president of pharmacy practice and government affairs, said infusion could be handled by staff members with an infusion license where required. Non-skilled facilities, or those without nurses to spare, could also tap into a separate program being led by the National Home Infusion Association in 46 states and Washington, D.C.
To date, only bamlanivimab, widely known as BAM, has been made available to LTC pharmacies. But Worz is also advocating for doses of Regeneron’s version, which requires pharmacists to compound casirivimab and imdevimab.
Both types of monoclonal antibodies received Emergency Use Authorization in mid-November with initial shipments sent to hospitals. But many said they were simply too busy treating severe COVID cases to deliver the outpatient therapy. As of late December, just 20% of the available antibodies had been used.
“That’s the reason they’re pushing it to long-term care, because (HHS) saw stockpiling in hospitals,” Worz said.
Wider use covered by CMS
Pharmacies can order for weekly delivery, or arrange for an emergency shipment in the case of a known outbreak, but Worz said HHS is tracking inventory to ensure the potentially life-saving product doesn’t continue to sit unused.
Medicare and Medicaid coverage of the use of monoclonal antibody therapy for COVID-19 treatments extends to beneficiaries in nursing homes at no cost during the public health emergency.
AMDA — The Society for Post-Acute and Long-Term Care Medicine, which initially expressed skepticism about the efficacy of antibody treatments in nursing homes because of a lack of data, has now partnered with ASCP to assist with Project Speed.
John Redd, M.D., MPH, chief medical officer, Office of the Assistant Secretary for Preparedness and Response at HHS, previously told McKnight’s that medical directors and physicians who care for long-term care patients are “crucial” to expanded delivery of the antibody treatment.
“We intend to engage them with every phase of the rollout,” he said. “This therapeutic is intended to treat patients with COVID-19 risk factors who are early in their disease, which includes the majority of residents of long-term care facilities.”
Monday, January 18, 2021
Surprise! New Law Bans "Surprise" Medical Billing
“It seemed like déjà vu,” wrote Modern Healthcare’s Rachel Cohrs, “another mid-December bipartisan compromise on banning surprise medical bills negotiated behind closed doors is announced just days before a crucial end-of-year government funding deadline....[But] [u]nlike their 2019 failure, lawmakers this year succeeded in sealing the deal." The surprise billing ban takes effect in 2022.
Surprise bills occur:
“when an out-of-network provider is unexpectedly involved in a patient’s care. Patients go to a hospital that accepts their insurance, for example, but get treated there by an emergency room physician who doesn’t. Such doctors often bill those patients for large fees, far higher than what health plans typically pay,"
explained Sarah Kliff and Margot Sanger-Katz, writing for the The New York Times.
According to Kliff and Sanger-Katz:
Academic researchers have found that millions of Americans receive these types of surprise bills each year, with as many as one in five emergency room visits resulting in such a charge. The bills most commonly come from health providers that patients are not able to select, such as emergency room physicians, anesthesiologists and ambulances. The average surprise charge for an emergency room visit is just above $600, but patients have received bills larger than $100,000 from out-of-network providers they did not select.
The new law will make those surprise bills illegal. Instead of charging patients, health providers will now have to work with insurers to settle on a fair price. The new changes apply to doctors, hospitals and air ambulances. The law does not apply to ground ambulances.
The new law requires insurers and medical providers who cannot agree on a payment rate to use an outside arbiter to decide. The arbiter would determine a fair amount based, in part, on what other doctors and hospitals are typically paid for similar services. Patients could be charged the kind of cost sharing they would pay for in-network services, but nothing more. Several states have set up their own arbitration systems, and have found that most price disputes are negotiated before an arbiter is involved.
By the way, an excellent description of the legislative path for this welcome consumer protection, is provided by Modern Healthcare’s Rachel Cohrs, who has recited the work and effort expended both in support, and in opposition to the bill. It is an interesting read.
Friday, December 4, 2020
Wife Had Authority to Transfer Property to Herself Under a Power of Attorney
Ralph Lindvig’s Will gave his wife, Dorothy Lindvig, a life interest in his property and, on her death, transferred the property to his brothers. Mrs. Lindvig suffered from mobility issues due to childhood polio. Mr. Lindvig also named Mrs. Lindvig as his agent under a power of attorney. The power of attorney gave the agent the authority to transfer real estate for the purposes of estate planning, including transfers to the agent. It also provided authority to make gifts subject to the approval of a court in order to minimize taxes and maximize the estate for beneficiaries.
Mr. Lindvig entered a nursing home. To help pay for his care, Mrs. Lindvig sold portions of his property to his brother. She also transferred mineral rights and property to herself. Mr. Lindvig died, and Mrs. Lindvig was the personal representative until her death a year later.
After Mrs. Lindvig’s death, Mr. Lindvig’s estate filed a petition to set aside the transfer of the mineral rights and the property because the transfers diminished the size of Mr. Lindvig’s estate and were not approved by a court. Ms. Lindvig’s estate argued that the transfers were made for consideration in the form of marital contributions and were not gifts. The court determined that the transfers were within Mrs. Lindvig’s authority, and Mr. Lindvig’s estate appealed.
The North Dakota Supreme Court affirmed, holding that the transfers were not gifts because Mrs. Lindvig required support and Mr. Lindvig had an obligation to support her from his property. According to the court, “because the transfers in this case were not gifts, the power of attorney’s gifting provisions do not apply” and Ms. Lindvig “had authority to make the transfers under the power of attorney’s real estate transfer provision.”
Monday, November 16, 2020
A Trustee Has a Duty to Preserve Trust for Beneficiaries, Not to Ensure Payment of Alimony to Grantor’s Ex-Wife
"...the trust and trustee owed no duty to Kathleen as a creditor of a trust beneficiary (Phillip). “Persons who may incidentally benefit in some manner from the performance of the trust are not beneficiaries of the trust and cannot enforce it.” Restatement (Third) of Trusts § 48 cmt. a (Am. Law. Inst. Oct. 2020 Update). The Iowa Academy of Trust and Estate Counsel raised this concern. And the amicus implores us to find that Scott had no duty to Phillip’s creditors when he, acting in his capacity as trustee in compliance with the terms of the trust, decided what distributions to make and to whom. The undisputed duty of loyalty of a trustee is to the beneficiaries of the trust, not the creditor of any beneficiary. Restatement (Third) of Trusts § 78(1).
First, both Kathleen and Scott confirmed that the trust purpose was twofold. One purpose was to qualify Phillip for Medicaid benefits, which required Phillip to maintain a limited net worth of $2000 and a limited monthly income. The second purpose was to ensure that Phillip’s sons retained the family real estate. To effectuate this purpose, Kathleen admits in her brief that after all real estate was transferred to the trust she “disclaimed and surrendered any and all interest she may have in the Trust.” Also with those goals in mind, Scott maintains he fulfilled his obligations as trustee in the manner he was supposed to; he stopped making income distributions to Phillip so that his father could remain eligible for Medicaid nursing home coverage. Then after the qualification for Medicaid, he transferred the trust assets to the beneficiaries to preserve their interests in the family real estate. Scott notes that he relied on the advice of several attorneys in taking these actions.
. . .
Kathleen acknowledged the trust goals that Scott followed. But at trial and in her brief, she argues in his role as trustee, his failure to pay her interfered with her contract between herself and Phillip. But Kathleen is not a creditor of the trust. Even the jury found the trust owed her nothing. Thus, Scott, operating as trustee, owed Kathleen no fiduciary duty. See Iowa Code §633A.4202(1) (“A trustee shall administer the trust solely in the interests of the beneficiaries, and shall act with due regard to their respective interests.”).
[Second], drilling down to the specific improper conduct of Scott as agent, Kathleen argues Scott “felt entitled to pick and choose which bills ultimately got paid.” It then follows, under Kathleen’s theme, Scott was not acting on behalf of or in Phillip’s best interest. And Kathleen emphasizes that Scott testified he did not like that his father was ordered to pay alimony because he thought it was unfair. So does refusing to pay the principal’s creditor amount to improper conduct by the agent under an interference-of-contract claim? If we step back from this case, we would plow new ground to hold that an agent acting under a power of attorney must pay all bills of the principal or risk a claim of interference with a contract by a creditor. An agent, acting for the principal, might decide to prioritize which bills to pay, and if a creditor finds the action wrongful, the remedy is breach of contract. The motives of Scott in preserving assets for his father’s care and upholding the estate plan, which all parties acknowledged in this case, is not improper under his role as agent. Scott exercised financial discretion to protect his father’s legal rights, and Kathleen failed to prove his sole motivation was to defeat the alimony contract. [citation omitted, emphasis added]. Thus, the record does not support a finding of wrongful conduct against Scott as an agent for Phillip.
Wednesday, November 11, 2020
Feds Fail to Unlock Nursing Home “SLUSH FUND” to Fight COVID19
A Gray Media investigation has blown the lid off of one the nursing home industry’s most guarded secrets—it’s called the Civil Monetary Penalty Reinvestment Fund.
Nearly half a billion dollars of federally collected nursing home fines have flowed into the fund and now these monies are reportedly languishing in state coffers, accruing interest instead of being used to battle the coronavirus pandemic.
Families for Better Care’s executive director Brian Lee calls the fund nothing more than a “slush fund” for nursing homes.
He says owners tap into the fund so they can offset operational costs and pad profits all in the name of so-called improvement. He recalled one instance when “a nursing home that had been fined hundreds of thousands of dollars received a $27,000 grant to buy a bread-making machine, to build a snack stand and to train staff on how to stock the shelves.” Lee visited the facility and was surprised by what he discovered. “I expected the aroma of fresh-baked break to greet me when I walked in the door. I got the exact opposite,” he said. “I was immediately bowled over by the smell of urine and feces.”
Lee argues that the fund should be unlocked immediately by the Trump administration so nursing homes can acquire molecular rapid testing machines to prevent COVID19 spread, not so they can be held in reserve for some unhatched profit scheme.
And the industry largely agrees.
Mark Parkinson, the American Health Care Association’s president and chief executive officer, told Gray Media that the funds “should be utilized to improve patient care.”
Nursing home fines should become part of the pandemic solution by “curbing infection-related problems, residents' falls and accidents, and abuse and neglect” rather than, as Parkinson describes, “frivolous” improvement projects that “should have been paid for through the nursing homes’ annual budget.”
But, there is this: CMS last year approved grants to nursing homes to buy an antique popcorn machine, create song playlists for residents and build gardens. Awesome.
Tuesday, November 10, 2020
Good Idea: Rhode Island Lifespan Respite Project Work Initiative Increases Access to Respite Care While Training Nursing Students
The project recently received national attention from recognition ARCH National Respite Network and Resource Center. Hopefully this type of program will soon be a common solution across the country.
Thursday, October 22, 2020
Music and Memory Program Means Fewer Meds, Better Behaviors
![]() |
| Photo 174795833 © Ljupco | Dreamstime.com |
The Impact of Music and Memory on Resident Level Outcomes in California Nursing Homes studied 4,107 residents in 265 nursing homes over a three-year period. Debra Bakerjian, PhD, APRN, RN, and her team found that M&M was associated with reductions in psychotropic medications, reduced behaviors, improved mood, less pain, and fewer falls. It is the largest study of M&M to date.
The odds of antipsychotic use declined by about 11%, of antianxiety medications by 17%, and antidepressants by 9% per quarter. In addition, the odds of residents exhibiting aggressive behaviors declined by 20% per quarter, depressive symptoms by 16%, reported pain by 17%, and falls by 8%.
The authors found the reduction in antipsychotics to be “particularly noteworthy, given the documented significant reduction in the use of antipsychotics statewide before the start of this study.”
The M&M program advocates the use of personalized music for older adults with dementia and other cognitive or behavioral symptoms with the goal of improving their quality of life. According to the authors, “While there are a few proven non-pharmacological interventions, activities and music therapy have been shown to decrease overall agitation in nursing home residents.” They cited a 2018 systematic review and meta-analysis that found receptive music therapy, including listening to the participant’s favorite music, was more effective at decreasing agitation and behavioral problems than interactive music therapy.
The authors found that M&M was frequently housed within in the activities department “with limited involvement from other departments.” However, they noted, “Encouraging other departments, especially nursing, to use M&M with residents could increase the frequency and duration of use and overall successful sustainment of the program.”
The project was supported by the Centers for Medicaid & Medicare Services Civil Money Penalty funds as well as the National Institutes of Health’s National Center for Advancing Translational Sciences. It was sponsored by the California Association of Health Facilities.
Click here for more information on the findings above and more details about the study.
Thursday, October 15, 2020
Judge Can Not Impose an ‘Unusual’ Condition on a Reversal of a Default Judgment in a Nursing Home Breach of Contract Lawsuit
Nursing homes are proficient in protecting themselves from risk of loss where Medicaid is concerned. Spouses and children of the Medicaid applicants often find themselves being sued to recover for delays in seeking and obtaining Medicaid.
Courts and the law are often sympathetic to the cause of the nursing home, particularly when admission agreements include provisions making family responsible. In a recent case, the "sympathy" crossed a line towards activism on behalf of the institution. Fortunately, on appeal, the ship of equity was righted.
George Brown entered a nursing home and signed an admission agreement, agreeing to apply for Medicaid benefits to pay for his care. Mr. Brown did not submit the necessary information to complete his Medicaid application, so his application was denied. The nursing home sued Mr. Brown and his wife, Gloria Brown, for breach of contract and her for lack of spousal support. Ms. Brown appeared at the initial hearing and argued that Mr. Brown had dementia and did not knowingly sign the agreement. In addition, she claimed he was mistreated at the nursing home.
The judge informed Ms. Brown that she needed to file an answer to the nursing home’s complaint. Ms. Brown never filed an answer, and the judge entered a default judgment against her. Six months later, Ms. Brown filed a request to remove the default judgment because she had been in the hospital and therefore unable to answer the Complaint. The judge granted her request to vacate the default judgment on the condition that she waive any claims against the nursing home to the extent the monetary recovery amount exceeded the amount Mr. Brown owed to the nursing home. The court, in effect, protected the nursing home from any risk of losing more than it was owed! Ms. Brown refused the condition and appealed.
The Massachusetts Appeals Court reversed, holding that the condition imposed by the judge was inappropriate. Care One Management, LLC v. Brown (Mass. Ct. App., No. 19-P-1165, Oct. 7, 2020). Because the judge did not find that the nursing home suffered any prejudice from the default or the delays, there existed no authority for the court to , in essence, protect the nursing home. According to the court, although the judge made passing reference to Ms. Brown’s delay in fighting the default judgment, the judge “did not explain how or why such factors impacted [the nursing home’s] claim, and did not evaluate and explain whether and to what extent [the nursing home] suffered any prejudice, before imposing the unusual condition on the removal of the default judgment.”
The legal system worked to restore balance in this case. The wife, though, has attendant cost and expense for which she will never be compensated. This is just one unavoidable cost of institutional care, dutifully protected by the legal system.







