Aging in Place: Use of Inappropriate Psychotropic Medications More Likely in SNFs with Over-Worked Staffs

New evidence suggests a link between overwork staffs in nursing facilities and the inappropriate use of psychotropic and antiphsychotic medications. Dutch researchers recently reported the results of a new study designed to identify possible patient and non-patient causes behind prescribing psychotropic drugs. The study included a sample of nearly 350 nursing home residents with a psychotropic drug prescription and dementia, according to an article published in McKnight's Long-Term Care News.  

The findings, published in International Psychogeriatrics, showed that the more patients and years of experience a physician had, as well as the higher the nursing staff's workload, the more likely the patient was to receive inappropriate psychotropic drug prescriptions.  Less appropriate prescriptions were also identified when residents had more severe anxiety, a diagnosis of dementia other than Alzheimer's, and more time spent with a physician.

Older residents and those with more severe aggression, depression and agitation were more likely to receive appropriate psychotropic prescriptions. 

The link between more pronounced symptoms and more appropriate prescribing “implies that physicians should pay more attention to the appropriateness” of prescriptions when symptoms are less obvious, the researchers said. The researchers also acknowledged that some of their findings may seem counterintuitive, and require more research before concrete recommendations are made.

Of course, this new evidence only supports the argument for planning to "Age In Place." For more information regarding Aging in Place planning, and the use of an Aging in Place suitable estate plan, go here.  

For more regarding negative health outcomes of the use of such medications in skilled nursing facilities, see Antipsychotics and Psychotropic Drugs Increase Fall Risks in Nursing Homes.

Post-Irma Death Toll at Florida SNF at 9 as Provider Sues State Over Medicaid Ban

McKnight's Long Term Care News reports: 

The death toll from the Florida skilled nursing facility that lost its air conditioning following Hurricane Irma rose to nine residents on Tuesday, as the provider geared up for a legal battle with state officials over its loss of Medicaid funding.

Carlos Canal, 93, is the ninth resident from The Rehabilitation Center at Hollywood Hills whose death officials have blamed on the soaring temperatures inside the Hollywood, FL facility after the air conditioning went out. Canal died of pneumonia with a 105 degree fever, his daughter told the Miami Herald.

This week also brought continued vitriol between The Rehabilitation Center and Florida Governor Rick Scott's (R) administration.The provider filed a lawsuit late Tuesday requesting an injunction against the state's orders to cut Medicaid funding from the facility, claiming the abrupt funding cut and admissions moratorium violated its due process, according to a news service report.

“With the stroke of a pen, [the Agency for Health Care Administration] has effectively shut down Hollywood Hills as a nursing home provider in Broward County,” the suit reads. “These illegal and improper administrative orders took effect immediately and without any opportunity for the facility to defend itself against unfounded allegations.”The lawsuit also argues that the facility followed its emergency preparedness plans while dealing with the air conditioning loss.

Scott disputed that claim in a statement issued Tuesday, saying the facility erred in not calling 911 sooner or evacuating residents to its partner hospital.“No amount of finger pointing by the Hollywood Hills Rehabilitation Facility … will hide the fact that this healthcare facility failed to do their basic duty to protect life,” Scott said. “Through the investigation, we need to understand why the facility made the decision to put patients in danger, whether they were adequately staffed, where they placed cooling devices and how often they checked in on their patients.”

Aging in Place- Male Family Caregivers are Breaking Stereotypes

There are 40 million family caregivers in the United States helping with everyday activities and personal tasks ranging from bathing, dressing, wound care and medication management to transportation and finance.  The “typical” family caregiver is a 49-year old woman who takes care of a relative.  Men are not traditionally seen as caregivers.

A recent AARP Public Policy Institute  report suggests the the tradition is changing; men are increasingly filling care giving roles.  The report, Caregiving in the U.S., found that men represent 40 percent of all family caregivers.  That means that 6 million males serve as family caregivers.

Jean Accius, a Ph.D. with the AARP Public Policy Institute has penned an article explaining the ramifications gleaned from the pertinent data:

"These husbands, brothers, sons, sons-in-law, partners, friends, and neighbors are joining—either by choice, obligation, or necessity—the army of family caregivers providing care across the country. Male family caregivers are performing medical and nursing tasks as well as a range of personal care activities." 

In many cases, male family caregivers are caring for a spouse or partner. The PPI report shows that spousal caregivers in general face unique challenges, in part because they may lack an adequate support network.

There were notable differences, however, between males caring for a spouse and those caring for a parent.  Male caregivers, according to the report, provide more hours of care, and are more likely to be primary caregivers with little to no support from other family members, compared to male family caregivers taking care of a parent or other relative.

Men caring for a spouse reported having been a caregiver for a longer period of time than other unpaid male family caregivers (5.1 years compared to 3.9).

Dr. Accius reported:

"...the study found that male family caregivers were more likely (66 percent) to be working compared with female caregivers (55 percent). The large majority of employed male caregivers were working 40 or more hours per week at the time of caregiving. 

Regardless of gender, caregiving responsibilities often require family caregivers to make workplace accommodations. The study found that nearly two-thirds (62 percent) of male family caregivers had to make changes in the workplace as a result of their caregiving responsibilities [reference omitted].  Moreover, their caregiving duties affected their work in other significant ways:

• Nearly half (48 percent) of male family caregivers went in late, left early, or took time off to provide care.
• About 15 percent of male family caregivers took a leave of absence or went from working full time to part time to provide care.
• Less than 10 percent of male family caregivers turned down a promotion (8 percent), received a warning about their performance or attendance (7 percent), or retired early or gave up working entirely (6 percent).
• Nearly two-thirds (62 percent) of male family caregivers indicated that their caregiving experience was moderately to very stressful.
• Almost half (46 percent) of male family caregivers experienced moderate to severe physical strain due to caregiving responsibilities.

Qualitative studies indicated that younger men had more “difficulties” in the caregiving role and communicated particular “psychological stress” when having to choose between work responsibilities and caregiving responsibilities. [reference omitted].  More than one-third (37 percent) of male family caregivers did not inform their employers about their caregiving responsibilities. The percentage of male family caregivers who did not inform their supervisors was even higher for millennials (45 percent).

Despite this trend, though, considering the aging of the population, increases in life expectancy, and shrinking families, the supply of family caregivers is unlikely to keep pace with future demand.  Aging in place planning, therefore, is extremely important.  The planning shoul consider the unavailability of typical caregivers, and should consider the unavailability of family caregivers. 

Half of Most Dangerous Nursing Homes Remain Treacherous for Residents After Homes Are Cleared By Regulators

The Centers for Medicare and Medicaid Services (CMS), sets the federal standards for nursing homes and determines whether they are in compliance based on inspections performed primarily by state health departments. States license facilities and have  authority to revoke the licenses.  CMS designates "special focus status" to the poorest-performing facilities out of more than 15,000 skilled nursing homes. In an arbitrary system befitting government bureaucracy, the federal government assigns each state a set number of special focus status slots, roughly based on the number of nursing homes. Then state health regulators pick which nursing homes to include.

More than 900 facilities have been placed on the watch list since 2005. But the number of nursing homes under special focus at any given time has dropped by nearly half since 2012, primarily because of federal budget cuts negotiated by President Barack Obama and Congress. This year, the $2.6 million budget permits only 88 nursing homes to receive the designation, though regulators identified five times as many facilities, 435, as warranting such scrutiny. California and Texas each has six slots, the most of any state. Twenty-nine states have just one.

Especially troubling is that more than a third of operating nursing facilities that graduated from the watch list before 2014 continue to hold the lowest possible Medicare rating for health and safety, a one of five possible stars, according to an analysis performed by Kaiser Health News (KHN).  But worse, nursing homes that were forced to undergo such scrutiny often slide back into providing dangerous care, according to a KHN analysis of federal health inspection data. According to KHN, of 528 nursing homes that graduated from special focus status before 2014 and are still operating, slightly more than half — 52 percent — have since harmed patients or put patients in serious jeopardy within the past three years.These nursing homes are in 46 states. Some gave patients the wrong medications, failed to protect them from violent or bullying residents and staff members, or neglected to tell families or physicians about injuries. Years after regulators conferred clean bills of health, levels of registered nurses at these facilities tend to remain lower than at other facilities.

Yet, despite recurrences of patient harm, nursing homes are rarely denied Medicare and Medicaid reimbursement. Consequences can be dire for patients  According to a KHN analysis, in 2012, Parkview Healthcare Center’s history of safety violations led California regulators to designated Parkview nursing home, a “special focus facility,” requiring it to either fix lapses in care while under increased inspections or be stripped of federal funding by Medicare and Medicaid — a financial deprivation few homes can survive. After 15 months of scrutiny, the regulators deemed Parkview improved and released it from extra oversight.

But a few months later, Elaine Fisher, a 74-year-old who had lost the use of her legs after a stroke, slid out of her wheelchair at Parkview. Afterward, the nursing home promised to place a nonskid pad on her chair but did not, inspectors later found. Twice more, Fisher slipped from her wheelchair, fracturing her hip the final time. The violation drew a $10,000 penalty for Parkview, one of 10 fines totaling $126,300 incurred by the nursing home since the special focus status was lifted in 2014.

The cost to injured residents is incalculable.  Fisher "used to go to bingo every day and she was very involved in the nursing home,”  her son-in-law, Eric Powers, told KHN. Although Fisher moved to a different nursing home for better care, Powers related that “after this whole thing, she has to be on painkillers. She’s mainly in her room all the time. It’s the saddest thing in the world.”

In 2010, NMS Healthcare of Hagerstown, Md., left the watch list after 10 months.  Last year, Maryland’s attorney general sued the facility and its owner, Neiswanger Management Services (NMS), alleging that they evicted frail, infirm and mentally disabled residents “with brutal indifference” when their health coverage ran out or the facility had the opportunity to get someone with better insurance.

Among those evicted was Andrew Edwards, who was told by NMS that he was being discharged to an assisted-living center, according to the lawsuit. Instead, in January 2016, the staff sent him to a crowded, unlicensed Baltimore City row house where the owner confiscated his bank card and withdrew $966 over his objections, the lawsuit said. Although NMS said it had arranged for his outpatient kidney dialysis, “that was false,” Edwards said in an interview. He ended up in an emergency room after he missed his treatment.

NMS maintains it stopped referring patients to that owner when told of the conditions. This month, CMS expelled the Hagerstown nursing home from Medicare and Medicaid after citing it for more violations. The company is closing the facility. NMS, which still runs other homes in Maryland, has sued state regulators, claiming they are vindictively trying to drive the chain out of business.

Too few nurses, particularly registered nurses, provide care at some of the most troubled homes, KHN’s analysis showed. Registered nurse staffing was still 12 percent lower than at other facilities, even three years after the homes were released from the watch list.

In 2009, Pennsylvania health regulators released Golden LivingCenter-West Shore in Camp Hill after 17 months of supervision. The company said in a recent statement that when a home was put on that list, “we mobilize the resources necessary to help get that LivingCenter back into compliance.”

But data from Medicare’s Nursing Home Compare website show the facility has among the worst nurse-to-patient staffing ratios in the nation, with registered nurses devoting an average of 12 minutes for each patient daily. The state average is 58 minutes daily per patient.

Golden LivingCenter-West Shore was fined $59,150 in 2015 after being cited for, among other violations, "allowing a resident’s feeding tube to become infested with maggots." Also, according yo KHN, Golden Living agreed to pay $750,000 to settle three cases involving patient injuries from falls that occurred after extra oversight ended, court records show.

Last year, Golden Living sold its Pennsylvania homes to Priority Healthcare Group.  Priority is following a common strategy for shedding an unwanted reputation: changing the facility’s name. In California, Parkview — where Fisher slipped out of her wheelchair — is being rebranded too, as Kingston Healthcare Center.

CMS defended the program to KHN, saying that "nursing homes on the watch list showed more improvement than did comparably struggling facilities not selected for enhanced supervision."  In other words, putting 88 facilities on the watch list meant that they showed more improvement than the 435 other facilities deserving special focus status, but which were permitted to continue with no special oversight or ultimatum.  That is a defense of a program that asks advocates and critics to applaud what appears to be a system in failure, if CMS is, as it appears to be, acknowledging that th 435 other facilities aren't improving as a result of a failure by the government to demand that they improve, or implement stricter oversight, or threaten to stop Medicare/Medicaid reimbursement.  

“CMS continues to work to improve oversight to prevent any facility from regressing in performance,” reads a CMS statement to KHN.  

Some nursing homes on the watch list do maintain improvements. After Evergreen Nursing Home in southern Alabama was designated a special focus facility in 2005, the owners brought in new managers and added nursing supervisors.  Medicare now rates Evergreen a five-star facility. 

But even prolonged supervision does not guarantee progress. Poplar Point Health and Rehabilitation in Memphis stayed on the watch list for 2½ years until 2009. A federal lawsuit brought last year claims that Poplar and its owner, Vanguard Healthcare, regularly provided “nonexistent, grossly substandard, worthless care” as far back as 2010. Vanguard, now in bankruptcy court, declined to comment to KHN.

Our seniors simply deserve better.  Aging in Place planning is vitally important if you hope to avoid the risks of institutional care.  If you want to learn more about Aging in Place planning, go here.

Article: Philip Seymour Hoffman’s $12 Million Estate Planning Mistake

Attorney John M. Goralka has written an excellent article for Kiplinger, entitled, Philip Seymour Hoffman’s $12 Million Estate Planning Mistake.   The article teases, "A few moves could have saved the loved ones of actor Philip Seymour Hoffman a lot of money. Even if you don’t have a $35 million estate, like Hoffman’s, there are some things you could learn from it."  Attorney Goralka is correct.

The article: 

Philip Seymour Hoffman was one of my favorite actors. He starred in Charlie Wilson's War, Hunger Games, Pirate Radio and many more major movies. His roles covered a wide range, from a priest in Doubt to a coach of the Oakland A's in Moneyball, which evidenced his unique ability as an actor.

The lack of planning results in his estate owing estate tax of approximately $12 million. If Philip had married Mimi, his family would have saved approximately $12 million and paid no estate tax whatsoever.

Philip also stipulated that funds were to be used for his kids to visit major metropolitan areas for the express purpose of providing his children with access to the arts. This is an example of an incentive provision or trust to help motivate his kids to become the adults that Philip wanted them to become.

The use of a will requires probate, resulting in delays, additional costs and public proceedings. For example, the probate costs for “ordinary services” in California, where I’m based, amount to largely statutory fees, resulting in approximately $376,000 for the first $25 million in estate value and an additional "reasonable amount" to be determined by the court for the remaining $10 million of estate value if that probate is based in California. Those fees are based upon the gross value of the assets without any reduction for liens, selling costs or mortgages. In addition to the statutory fees for ordinary services, extraordinary fees are paid for services related to the sale of real property or a business, tax matters, debt collection or negotiation.

Additional costs for a "living probate" or guardianship for each of the three children may also be required. In California, this typically would require a court appearance and fees every two years until they each turn 18. Fees can be substantial and will vary based widely upon the circumstances and needs of the minor child and the value, type and number of assets involved. They would receive any share of assets to be distributed to them at that time. Not a good age to receive significant wealth. Complete access to funds may result in his kids becoming the trust fund kids Philip hoped to avoid.

An average probate in California without litigation or other issues takes between nine months and 1.5 years. Philip's probate will almost certainly take longer due to the size and complexity. After the probate is completed, Philip's estate will be at risk after distribution to Mimi if she is sued, challenged by her creditors or even in a later divorce if she remarries. That legacy may also be reduced by a second estate tax on her death.

Philip could have provided for Mimi with a Personal Asset Trust, which would help protect her from divorce, lawsuits by predators or fortune hunters, creditors and even a second estate tax imposed on Mimi when she dies.

The original article is available here.