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Written by Chris Hawkins SeniorLiving.Org Expert on Senior Care & Assisted Living
The first wave of baby boomers—those born between 1946 and 1964—made
it to age 65 in 2011. Now a person turns 65 every 10 seconds. By 2030,
the number of persons 65 and older will reach 71.5 million.
Many in this enormous human wave will need affordable living options once they stop working and there are several HUD programs to help seniors. Because let’s be honest: many folks are not as prepared for retirement as they would like to be.
A
survey by the Insured Retirement Institute found that “70 percent of
middle-income Boomers are not confident in having enough money to live
comfortably in retirement.” In an Associated Press poll, among families
with incomes below $50,000, only 35% said they felt financially ready
for retirement; 66% of those in higher income households felt ready.
With the recent economic collapse, many older adults find themselves in
an unexpected position entirely.
A recent AARP Public Policy Institute Study found that:
Another
daunting issue facing retirees is the cost of senior living options.
Senior living is a general term that includes all kinds of
senior-centered housing: independent living, assisted living, nursing
homes, home care, and others.
Here’s a sample of
what you can expect in senior living costs. The median U.S. cost for a
private room in a nursing home is $81,030 a year; in 2007, the median
annual cost was $65,700. The average yearly cost in an assisted living
facility is $39,600.
Now let’s look into the future.
If
you are currently living in Virginia, for example, and needed assisted
living care the median amount you would pay is $41,775 a year, according
to a Genworth Financial long-term care survey. In 10 years, you would
pay $68,047. A private room in a Virginia nursing home would now cost
$82,125 a year; in 10 years, the price tag goes up to $133,773.
Even
if you never need senior living care, you may find yourself in a
position where you have to make a lifestyle change. Asking yourself the
important questions is a great place to start.
Retirement Living Considerations
It
may be years after you retiree that you need to make a major living
change. But it’s better to plan now and initiate changes on your own
rather than being forced by circumstances in the future.
Here are some questions to think about as you prepare for your retirement:
Where do I want to live when retired?
Where can I afford to live after I stop working?
Should I downsize and move into an apartment or condominium?
Do I want to live in a senior community with people my age?
Should I rent?
Do I still feel safe in my current neighborhood?
Do I want to be closer to family?
Does my health (or my spouse’s) require special living arrangements such as assisted living or a nursing home?
Could I afford the cost of assisted care?
Can friends and family provide assistance with daily living if I need it?
If
your current or future financial circumstances call for a drastic
reduction in cost of living, HUD may have a program that can help.
The
U.S. Department of Housing and Urban Development (HUD) creates
affordable housing for citizens across the country by funding programs
for rent assistance, home ownership, and assistive services for seniors
and the disabled.
HUD helps more than 900,000 seniors with
affordable housing through its programs. There are three types of
affordable rent programs: public housing, multifamily subsidized
housing, and voucher housing programs.
Public Housing is owned and run by local Public Housing Agencies (PHAs).
Multifamily Subsidized Housing is privately owned housing that is subsidized by HUD and provides tenants with affordable housing.
Housing Vouchers provide rental assistance to individuals and families for housing in the private market.
*Several important things to keep in mind with HUD programs:
The waiting lists are often long (from two to five years), especially in metro areas.
For those in need of assisted care, HUD options are limited. HUD programs are designed primarily for independent seniors.
Because one Public Housing Agency (PHA) doesn’t have the housing you’re looking for, doesn’t mean another one won’t.
We’ll
look at HUD housing options, especially as they pertain to seniors. And
we’ll look at how to qualify, and how to search for HUD-sponsored
housing in your area.
Housing Choice Voucher Program (formerly Section 8)
The
Housing Choice Voucher Program (HCVP) provides rent vouchers for
housing in the private market to low income individuals, families, the
elderly and the disabled. It is the largest assisted housing program
administered by HUD.
These vouchers are linked to specific properties run by local Public Housing Agencies (PHAs). There are two kinds of vouchers: tenant-based and project-based.
Tenant based vouchers (TBVs) move with the renter. Project based
vouchers (PBVs) are assigned to particular units and buildings and are
not transferable.
Who is Eligible?
There is no
age requirement. Families or individuals who meet the extremely
low-income requirements (30% of the area’s median), and very low income
(50% of area median) based on total gross income. In some cases, those
with low income (80% of area median) are eligible.
Income such
as pensions, retirement accounts, IRAs, insurance annuities, and assets
such as real estate, cars, etc. ARE counted when assessing eligibility.
Housing
Depending
on your location, housing options can include single-family homes,
townhouses and apartments. Individuals can pick anywhere they want to
live as long as the owner agrees to rent using the program’s guidelines.
Rent Amounts
Rental amount is calculated by using the greatest of:
30% of monthly adjusted income
10% of monthly income
The welfare rent in as-paid states
Or the PHA minimum rent ($25 or up to $50).
PHAs pay the property owner directly and the residents pay the difference to the property owner.
How Do I Apply?
Apply
at your local PHA. They will collect information on family income (tax
returns, bank statements, Social Security, etc.) assets, and family
composition. Medical expenses, health insurance payments, prescriptions
and future medical expenses are taken into consideration.
Once
you apply, you are placed on a waiting list. Because of the demand,
waiting lists are often several years long. Ask your application to be
pre-qualified for income—that way you know ahead of time if you qualify.
And ask about local preferences (e.g. you are involuntarily displaced,
paying more than 50% rent, etc.).
This
HUD program assists first time homebuyers who need help meeting their
monthly mortgage payment and other expenses. These expenses include
mortgage principal and interest, mortgage insurance, real estate taxes, and homeowner’s insurance among others.
Who is Eligible?
First-time homeowner
No family member has owned or had ownership interest in their residence for at least three years
No family member has any ownership interest in any residential property
Employment not required for elderly or disabled families or individuals but must meet certain income requirements
Must complete the PHA’s homeownership counseling
Any other PHA requirements
Finding Housing
Assistance
by the PHA is not given in finding a home. The applicant must find an
approved financing source to purchase the home. The home must pass an
inspection by the PHA and an independent inspector before the family can
purchase.
Payment Amount
The monthly tenant
payment is generally 30% of the family's adjusted monthly income. The
PHA will make the voucher payment to either the lender or the family.
There is no time limit to receive assistance under this program for the
elderly and disabled.
The
rent-assisted housing in this program is designed specifically for
seniors and the disabled to live as independently as possible but who
may need some assistance with activities of daily living (ADLs) such as
dressing and bathing. Common features of these communities include
housekeeping, transportation, referral services, and counseling.
The types of services and amenities will vary by housing community.
Established
by HUD in 1959, the Section 202 program is the only program within HUD
to provide housing exclusively to seniors. HUD provides loans to
private, nonprofit organizations to finance the construction of
supportive housing for very low-income seniors and provides rent
subsidies.
Who is Eligible?
Those 62 and older
with very low household income (50% of area median). The average
resident age is 79. The average yearly income is $10,018.
Type of Housing
Typically,
one-bedroom apartments with kitchen and bath, plus special features
such as grab bars, ramps, nonskid flooring, etc. Other features include
housekeeping, transportation to health care, home-delivered meals. Rent Amount
Rental amount is calculated by using the greatest of:
30% of monthly adjusted income
10% of monthly income
The welfare rent in as-paid states
Or the PHA minimum rent ($25 or up to $50).
How Do I Apply?
Contact the individual housing community you are interested in. You can find housing by state here: http://www.hud.gov/apps/section8/
Wait
lists are usually at least a year. Preferences for admission include
those currently paying 50% of their income in rent; the involuntarily
displaced; and those living in substandard housing.
Congregate Housing Services Program (CHSP)
This
program, started in 1978, provides funds to Section 202 housing
communities to “help frail and persons with disabilities avoid premature
or unnecessary institutionalization.” This limited but valuable program
provides funding to 51 public housing agencies and private assisted
housing owners.
These communities provide residents at least one
hot meal per day in a group setting, 7 days per week. Other non-medical
services provided include housekeeping, personal assistance,
transportation and social services.
Contact your local PHA to see if the program is available at area elderly housing locations.
Multifamily Rental Housing for Moderate-Income Families (Section 221 (d) (3))
This
program funds “multifamily housing for moderate-income households,
including projects designated for the elderly.” Some of the housing is
designed specifically for the elderly and handicapped.
Who is eligible?
Anyone
can occupy a home that is insured under this program and are “subject
to normal tenant selection.” There are no income limits.
Type of Housing
These are multifamily housing units: apartments, condominiums, duplexes, etc.
Rent
Rent is based on a flat approved HUD amount, not on a tenant’s percentage of income.
Supportive Housing for Persons with Disabilities Program (Section 811)
This
purpose of this program is to enable those with disabilities to live as
independently as possible in a housing environment that provides
supportive services. Services may include personal assistance; meals;
housekeeping; counseling; training in independent living skills;
recreation and transportation.
HUD awards funds to private
non-profit organizations to be used to finance the construction or
rehabilitation of supportive housing for persons with disabilities.
There are two types of funding programs: 1) projects funded by capital
advances and 2) those funded by Project Rental Assistance.
Who is Eligible?
Those
who are 18 and older who are physically, mentally, emotionally and/or
developmentally disabled. Households must be very low-income (50% of
median income) with at least one adult member with a disability.
The
Project Rental Assistance Program residents must be extremely
low-income (30% of median income) with at least one adult member with a
disability
Median household income for residents is $9,204.
Housing
Group
homes of eight or fewer units are single family structures that combine
multiple bedrooms with a kitchen and shared living area. There is at
least one bathroom for every four residents.
Condominium or cooperative units are independent living facilities that can be cooperatively owned by the residents.
Independent
living complexes consist of 16 or fewer units where each dwelling
contains a kitchen and bathroom. This housing may also contain
congregate dining, laundry, and community areas.
Rent Amount
Rent is determined at 30% of adjusted monthly income.
Public
housing is rental housing for low-income families, the elderly and
those with disabilities. HUD administers funding to local PHAs that
manage the housing. Over 1 million families live in public housing.
Who is Eligible?
Low-income families (80% of median) and individuals including the
elderly and those with a disability. Income limits will vary based on
area. Your local PHA can provide those limits.
Once you are accepted in public housing, you must live in the community where you are accepted.
Type of Housing
Public housing can include everything from single-family homes, to duplexes to high-rise apartments.
Rent Amount
Rent is referred to as Total Tenant Payment (TTP) and calculated using the greatest of:
30% of monthly adjusted income
10% of monthly income
The welfare rent in as-paid states
Or the PHA minimum rent ($25 or up to $50)
You may stay in the property as long as you comply with the lease.
How Do I Apply?
Contact
your local public housing agency to apply. You will need to provide
proof of income such as tax returns, bank statements, Social Security
award letters, etc. Preferences are usually given to the elderly and
disabled.
Key Definitions, Eligibility And Additional Resources
Activities of Daily Living (ADLs):
Activities necessary for one to maintain independence. These typically
include eating, dressing, bathing, toileting, and transferring.
Fair Market Rents(FMRs)
are gross rent (rent plus utilities) estimates used to determine
payment amounts for the Housing Choice Voucher program. These rent
estimates are used as a guide for determining initial rental payments
based on unit size.
Public Housing Agencies (PHAs): Over 2,600 state, regional, and local
HUD-funded agencies that serve the housing needs of its low-income and very low-income residents.
Adjusted Income: Annual
income - deductions = adjusted income. Deductions include dependents;
status as elderly or disable family; unreimbursed expenses for
childcare, medical expenses (elderly and disabled only); and disability
assistance.
Extremely Low Income: income does not exceed 30% of an area’s median family income.
Very Low-Income: their incomes do not exceed 50% of an area’s median family income.
Low Income: their incomes do not exceed 80% of an area’s median family income.
Moderate Income: incomes that are no more than 115% of an area’s median family income.
Note:
Income limits are adjusted for family size and for areas with unusually
high or low family income housing-cost-to-income relationships.
Determining Income and Eligibility
When
applying for any of HUD’s housing programs, you will be asked to
provide proof of income and assets to determine eligibility. Qualifying
income and assets are combined when determining income eligibility.
Income and assets include all amounts that are derived in a 12-month period to which any member of the family has access to.
Income Sources
HUD counts the following main sources when considering income for its programs:
Full amount of income (before deductions) from salaries, wages, tips
Business net income
Interest, dividends, and other net income of any kind from real or personal property
The
full amount of periodic amounts received from Social Security,
annuities, insurance policies, retirement funds, pensions, disability or
death benefits
Stocks, bonds, Treasury bills, certificates of deposit,
Individual retirement and Keogh accounts
Retirement and pension funds
Cash held in savings and checking accounts, safe deposit boxes, homes, etc.
Cash value of whole life insurance policies available to the individual before death
Equity in rental property
Personal property held as an investment
*If
the total value of assets is less than $5,000, then that number is used
in the calculation. If the total value of assets is worth $5,000 or
more, the amount of the assets is determined by using the greater of:
The actual income from the assets
A
percentage of the value of net family assets based on the passbook
savings rate. Each HUD field office determines their own passbook
savings rate based on average savings account rates. Most PHAs use 2%.
Example 1: You have assets totaling $20,000 and annual income totaling $40,000.
$20,000 x 2% = $400
$400 assets + $40,000 annual income = $40,400 total income
Example 2:
Upon retirement, you receive a lump-sum payment of $10,000 from your
pension plan. You then receive periodic pension payments of $500 a
month. The $10,000 is treated as an asset as are the monthly $500
pension payments.
$10,000 + $500 x 12 (months) = $16,000
Income Deductions
An elderly household is entitled to an automatic $400 household deduction.
Medical
deductions including services of a physician, health care professional,
hospital or health care facility; medical insurance premiums;
prescription and non-prescription medicines; dental expenses; eye
glasses and examinations; periodic payments of medical bills; et al.
Disability assistance expenses
Dependent deductions
Child care deductions
HUD Income Limits: An Example
HUD
has established Median Family Income (MFI) limits for metropolitan and
non-metropolitan areas across the U.S. These MFIs are used to calculate
eligibility in the various HUD programs.
Here’s an example of an income limit calculation for the Washington DC Metro Area that includes nearby counties in Maryland and Virginia.
Area’s Median Income= $107,500
2012 Income Limit Category
1 Person
2 Person
3 Person
4 Person
Very Low (50%)
$37,650
$43,000
$48,400
$53,750
Extremely Low (30%)
$22,600
$25,800
$29,050
$32,250
Low (80%)
$49,200
$56,200
$63,250
$70,250
You’ll
notice that the percentages don’t always equal the income limit
amounts. For example, 80% of $107,500 is $86,000, not $70,250.
In
their calculations, HUD compares an area’s 4-person family incomes to
that of the US median family income. They also look at the Fair Market
Rent (FMR) costs for the area.
This
list does not provide waiting list info, availability, eligibility and
tenant selection. But it will provide a listing of properties by state
and by HUD program (Section 202, Section 811, etc.) that
finances/subsidizes each property. This will give you an idea of the
type of services offered and potential eligibility.
You can also go to HUD’s Rental Assistance page for links to the various programs:
If
you’re not sure where to start in your search, try calling a
HUD-sponsored housing counseling agency in your area. These counselors
provide advice on buying a home, renting, credit issues, foreclosures
and other housing related issues.
TED JEORY meets a group of East End pensioners who
are refusing to fade away. With a positive outlook, these redoubtable
Geezers are now reaching out to today’s youth.
The Geezers' inspirational work with local schools and universities has just won a string of awards []
In London’s East End a group of retired butchers, truckers,
builders, undertakers and boxers are redefining what it is to be men
growing old. They have seized life by the horns and confronted the
spectre of loneliness head on.
Meet The Geezers, a club of can-do pensioners whose inspirational
work with local schools and universities has just won a string of awards
and sparked curiosity about their success nationwide.
Their aim is that sometime, somewhere, an energetic Geezers Club will be opening near you.
When David Cameron set out his idea of Britain’s Big Society last
year his words were largely met with a Big Shrug: few knew what he
really meant. If the PM is still trying to illustrate the vision he
would do well to look the Geezers’ way.
The club was set up five years ago after research from Age Concern in
the London borough of Tower Hamlets showed that few men were turning up
to their day centres. While women were being catered for with classes
in dressmaking, line dancing and how to be a grandmother none of the
activities interested men.
Yes, there were worthy talks about men’s health and eating well
but they didn’t capture the imagination of retirees. Instead, many
widowers were hanging around in pubs and betting shops or, even sadder,
some were seen simply leaning against roadside railings watching the
traffic go by.
So a few old friends took matters into their own hands and decided to recapture the things that made them laugh.
They formed their own club, asked for £1 a week subscriptions and
sought public funding. They play indoor bowls once a week (an activity
so popular that many cancel their hospital appointments rather than miss
out) and have regular outings and social gatherings.
However, those are the bread-and-butter ingredients. What makes
The Geezers extra-special is their other work. They have won £20,000 in
awards and grants while their industry and creative energy has attracted
the attention of artists and academics.
Their latest accolade was a cheque for £5,000, handed to them last
year by Attorney General Dominic Grieve for a project they undertook
with the local Bow Boys comprehensive school. The prize was from the
Awards for Bridging Cultures organisation for a touching short film
called Bow: Now And Then, which chronicles the reflections of the two
different generations growing up in the East End.
Nowhere else in Britain has there been such dramatic change in terms
of demographics and urban development. Decimated by Hitler’s Luftwaffe,
what was once the engine room of London’s river-borne trade and a centre
of Cockney life is now a skyline of gleaming skyscrapers and a defining
picture of multiculturalism.
A combination of City expansion from the west, Canary Wharf
growth from the south and a wave of mass immigration from Bangladesh has
contributed heavily to what social researchers have termed the “white
flight” of traditional inhabitants to the suburbs of Essex. In short,
older, whiter generations feel alienated in what they see as their own
manor. The youngsters, meanwhile, look towards their elders as if they
are aliens.
The Geezers’ film was an attempt to address that. They teamed up with
Andy Porter from media charity Hi8tus and produced a montage of talking
heads and sights and sounds from today and yesteryear.
At just over 15 minutes, the film is a collection of themes about
growing up. Each scene juxtaposes tales from life then with teenage
thoughts from today.
While Geezers talk about playing in bomb craters, kicking
footballs made of paper in traffic-free side streets and courting their
sweethearts in Epping Forest, today’s youth chat about computer games,
hang around housing estates and chat up girls by text message.
With so much concern about violent gang culture in modern Britain and
especially inner-city London, the discussion about “territory” was
perhaps the most illuminating. Today’s postcode gangs are a modern
version of a problem that has always existed.
Johan Campo Marin, 16, recounts in the film how he and his cousin
were asked “what end?” or what postcode, they were from as they walked
through the Elephant & Castle district in South East London. When
they replied Tower Hamlets, they were chased by a gang.
To the older generation that was nothing new. Even venturing on
to the other side of a railway bridge in their day risked trouble.
However, 81-year-old Ted Lewis, a former Billingsgate fish market porter
and amateur featherweight boxer, said there was an honour to their
day’s toughness.
“We would have gang fights,” he says. “A neighbourhood would bring
their champion and we would have our champion and the two would fight
each other. If you kicked someone you were a coward. You had to stand up
and fight properly.”
Ted, a former Liberal Democrat councillor, is one of the stars of the
film and when The Geezers met the boys again at their school last
month, he was still showing off his strength and boxing skills.
“It’s been wonderful getting involved with them,” he said,
reflecting on the film. “I found that we can talk to these young
children and they can also talk to us.” Johan agrees: “We thought they
would be really boring but after talking to them we just thought they
were really just the same as us.”
Jim Morris, the head of the pupils’ year group at school, adds: “The
great thing is that it broke down the barriers and stereotypes that both
groups came with. They couldn’t understand the world in which The
Geezers used to live as children when there was so much more space to
play and where they were free to roam.”
So what next for The Geezers? They have aready helped form a women’s
group called The Bow Belles and five years after their first meeting,
the local phenomenon they have created is, they hope, set to spread
across Britain. Chief Geezer Ray Gipson, 70, an ex-lorry driver,
football referee and another former Lib Dem councillor, says they have
already worked with the University of East London on renewable energy
projects and they even made a wind turbine that lit a sign over Tower
Hamlets boasting “Geezer Power”.
Ray wants more men from around Britain to follow their example.
“People just seem to let men grow old and senile,” he says. “We just
didn’t want to have a talking club. We wanted to be talking about doing
something and then actually doing something.”
Question: Is there information already available on the 2015 Medicare Part D plans?
Yes. The Centers for Medicare and Medicaid Services ( CMS ) has recently released their standard limits for basic Medicare Part D prescription drug plan coverage. A chart comparing the CMS Medicare Part D defined standard benefit parameters from 2011 through 2015 is available at Q1Medicare.com/2015, and here are a few highlights of the changes to basic 2015 Medicare Part D plan coverage:
The Donut Hole discount will increase for generic drugs: Next year, if you reach the Donut Hole phase of your Medicare Part D plan coverage, the 2015 generic drug discount will increase from 28% to 35% and your 35% discounted drug cost will count toward meeting your 2015 total out-of-pocket maximum or Donut Hole exit point. So if your generic medication has a retail cost of $100, you will pay $65, and the $65 will count toward your out-of-pocket spending limit.
The Donut Hole discount will increase for brand-name drugs: The 2015 brand-name drug discount will increase from 52.5% to 55% and you will receive credit for 95% of the retail drug cost toward meeting your 2015 total out-of-pocket maximum or Donut Hole exit point (the 45% you spend plus the 50% drug manufacturer discount). So if you have a brand-name medication with a retail cost of $100, you will pay $45 for the medication, but get credit for $95 toward meeting your out-of-pocket spending limit.
The standard initial deductible will increase: During the initial deductible, you are responsible for paying 100% of your drug costs before your Medicare Part D prescription drug plan coverage begins. The 2015 initial deductible will increase $10 to $320 from the current 2014 value of $310 (these are the same changes we saw from 2011 to 2012). This means that if you have an initial deductible in 2015, you will pay slightly more before your plan coverage begins. However, some 2014 Medicare Part D plans currently exclude generic drugs from their deductible and we expect this practice to continue in 2015. Please note that about half of the Medicare Part D plans offered in past few years have had an initial deductible. Click here to see an overview of the 2014 Medicare prescription drug plan landscape.
The initial coverage limit will increase: This is the negotiated retail dollar value of your prescription drug purchases used to determine when you enter into the 2015 Donut Hole or Coverage Gap phase of your Medicare Part D plan. Medicare beneficiaries will enter the 2015 Donut Hole or Coverage Gap when the total negotiated retail cost of their prescription drug purchases reaches the initial coverage limit of $2,960, a $110 increase over the 2014 initial coverage limit of $2,850.This means you will be able to buy slightly more medications before reaching the 2015 Donut Hole (assuming the retail cost of your medications does not change next year).
You can see how the retail value of your medications is changing over time by viewing our retail drug pricing history found at the bottom of the cost-sharing information for any of your covered Medicare Part D plan drugs – you can click here for an example of Atorvastatin 10mg found on the AARP MedicareRx Saver plan formulary in Florida).
Total Out-of-Pocket Costs or TrOOP will increase: TrOOP is the actual dollar figure you must spend to get out of the Donut Hole or Coverage Gap, excluding monthly premiums. The 2015 TrOOP threshold will increase by $150 to $4,700 from the current 2014 value of $4,550 (again, the same as the change between 2011 and 2012). As noted above, the brand-name medication purchases in the Donut Hole are discounted by 55%, but you will receive credit of 95% of the retail drug price toward meeting the 2015 TrOOP threshold.
Our 2015 Donut Hole calculator shows how these changes will affect your 2015 drug spending budget. To help you visualize how these 2015 plan changes may impact your prescription drug spending next year, we have launched our 2015 Q1Medicare.com PDP-Planner or Donut Hole calculator found at PDP-Planner.com/2015. Our PDP-Planner allows you to enter your estimated retail prescription drug costs (based on your current spending) and preview what you can expect to pay throughout the different phases of your 2015 Medicare Part D plan coverage. To get you started, you can click hereto see an example of the 2015 Medicare prescription drug plan phases for someone with $800 per month retail medication expense. At the bottom of the chart, we provide different scenarios for generic and/or brand-name drug purchases.
Question: Will all 2015 Medicare Part D prescription drug plans follow these new plan limits?
No. The Medicare Part D defined standard benefit parameters are released each year by Medicare and set minimum limits for next year’s standard Medicare Part D prescription drug plan coverage. However, Medicare Part D providers are allowed to deviate from the defined standard benefits when designing their 2015 plans and, with Medicare’s approval, offer Medicare Part D prescription drug plans with more enhanced features such as a $0 initial deductible or coverage in the Donut Hole.
Question: When can we see the actual details of the 2015 Medicare Part D and Medicare Advantage plans?
October 1st. The 2015 annual Open Enrollment Period will begin on October 15th and continues through December 7th. However, the marketing period for 2015 Medicare plans will begin on October 1st and actual Medicare Part D and Medicare Advantage plan details will become available at this time or a little earlier. If you would like us to send you a notification when the 2015 Medicare Part D plan information becomes available, please click here to sign-up for our free email 2015 Reminder Service. We will not share your email information with anyone.
Question: Will Medicare plans that have a low quality star rating be discontinued in 2015?
Medicare Part D or Medicare Advantage plans that earned a quality star rating of lower than 3-stars for three years in a row will be terminated at the end of 2014. We will learn which plans will be discontinued in late-September.
The following story is original to ProPublica. This is part 1 and part 2 of a series on assisted living facilities.
Joan
Boice needed help. Lots of it. Her physician had tallied the damage:
Alzheimer’s disease, high blood pressure, osteoporosis, pain from a
compression fracture of the spine. For Joan, an 81-year-old former
schoolteacher, simply getting from her couch to the bathroom required
the aid of a walker or wheelchair.
The Alzheimer’s, of course, was
the worst. The disease had gradually left Joan unable to dress, eat or
bathe without assistance. It had destroyed much of the complex cerebral
circuitry necessary for forming words. It was stealing her voice.
Joan’s
family was forced to do the kind of hard reckoning that so many
American families must do these days. It was clear that Joan could no
longer live at home. Her husband, Myron, simply didn’t have the stamina
to provide the constant care and supervision she needed. And moving in
with any of their three children wasn’t an option.
These were the
circumstances that eventually led the Boice family to Emeritus at
Emerald Hills, a sprawling, three-story assisted living facility off
Highway 49 in Auburn, Calif. The handsome 110-bed complex was painted in
shades of deep green and cream, reflecting its location on the western
fringe of the craggy, coniferous Sierra Nevada mountain range. It was
owned by the Emeritus Corp., a Seattle-based chain that was on its way
to becoming the nation’s largest assisted living company, with some 500
facilities stretching across 45 states. Emeritus at Emerald Hills promised
state-of-the art care for Joan’s advancing dementia. Specially trained
members of the staff would create an individual plan for Joan based on
her life history. They would monitor her health, engage her in an array
of physically and mentally stimulating activities, and pass out her 11
prescription medications, which included morphine (for pain) and the
anti-psychotic drug Seroquel (given in hopes of curbing some of the
symptoms of her Alzheimer’s). She would live in the “memory care” unit, a
space designed specifically to keep people with Alzheimer’s and other
forms of dementia safe.
At Emerald Hills, the setting was more
like an apartment complex than a traditional nursing home. It didn’t
feel cold or clinical or sterile. Myron could move in as well, renting
his own apartment on the other side of the building; after more than 50
years of marriage, the couple could remain together.
Sure, the place was expensive — the couple would be paying $7,125 per month — but it seemed ideal.
During
a tour, a salesperson gave Myron and his two sons, Eric and Mark, a
brochure. “Just because she’s confused at times,” the brochure reassured
them, “doesn’t mean she has to lose her independence.”
Here are a few things the brochure didn’t mention:
Just
months earlier, Emeritus supervisors had audited the facility’s process
for handling medications. It had been found wanting in almost every
important regard. And, in truth, those “specially trained” staffers
hadn’t actually been trained to care for people with Alzheimer’s and
other forms of dementia, a violation of California law.
The
facility relied on a single nurse to track the health of its scores of
residents, and the few licensed medical professionals who worked there
tended not to last long. During the three years prior to Joan’s arrival,
Emerald Hills had cycled through three nurses and was now employing its
fourth. At least one of those nurses was alarmed by what she saw,
telling top Emeritus executives — in writing — that Emerald Hills
suffered from “a huge shortage of staff” and was mired in“total
dysfunction.”
During some stretches, the facility went months without a full-time nurse on the payroll.
The
paucity of workers led to neglect, according to a nurse who oversaw the
facility before resigning in disgust. Calls for help went
unanswered. Residents suffering from incontinence were left soaking in
their own urine. One woman, addled by dementia, was allowed to urinate
in the same spot in the hallway of the memory care wing over and over
and over.
The brochure also made no mention of the company’s
problems at its other facilities. State inspectors for years had cited
Emeritus facilities across California, faulting them for failing to
employ enough staff members or adequately train them, as well as for
other basic shortcomings.
Emeritus officials have described any
shortcomings as isolated, and insist that any problems that arise are
promptly addressed. They cite the company’s growing popularity as
evidence of consumer satisfaction. They say that 90 percent of people
who take up residence in assisted living facilities across the country
report being pleased with the experience.
Certainly, the Boice family, unaware of the true troubles at Emerald Hills, was set to be reassured.
“We were all impressed,” recalled Eric Boice, Joan’s son. “The first impression we had was very positive.”
And
so on Sept. 12, 2008, Joan Boice moved into Room 101 at Emerald Hills.
She would be sharing the room with another elderly woman. After a
succession of tough years, it was a day of great optimism.
Measuring
the dimensions of his mother’s new apartment, Eric Boice sought to
recreate the feel of her bedroom back home. He arranged the furniture
just as it had been. He hung her favorite pictures in the same spots on
the wall. On her dresser, he set out her mirror and jewelry box and
hairbrush.
Joan, 5-foot-2 and shrinking, had short snow-and-steel
hair and wintry gray-blue eyes. Eric looked into those eyes that day at
Emerald Hills. He thinks he might have seen a flicker of fear. Or maybe
it was just confusion, his mom still uncertain where, exactly, she was.
A Reform Movement Winds Up on Wall Street
The Emeritus Corp., the assisted living corporation now entrusted with Joan’s life, sat atop an exploding industry.
Two
decades earlier, Keren Brown Wilson had opened the nation’s first
licensed assisted living facility in Canby, Ore., a small town outside
of Portland. Wilson was inspired by tragedy: A massive stroke had
paralyzed her mother at the age of 55, forcing her into a nursing home,
where she was miserable, spending the bulk of her days confined to a
hospital bed.
Wilson aimed to create an alternative to nursing
homes. She envisioned comfortable, apartment building-style facilities
that would allow sick and fragile seniors to maintain as much personal
autonomy as possible.
“I wanted a place where people could lock
the door,” Wilson explained. “I wanted a place where they could bring
their belongings. I wanted a place where they could go to bed when they
wanted to. I wanted a place where they could eat what they wanted.”
These
“assisted living” facilities would offer housing, meals and care to
people who could no longer live on their own but didn’t need intensive,
around-the-clock medical attention. The people living in these places
would be called “residents” — not patients.
It took Wilson nine
years to persuade Oregon legislators to rewrite the state’s laws, a
crucial step toward establishing this new type of facility. After that,
states across the country began adopting the “Oregon model.”
But
what began as a reform movement quickly morphed into a lucrative
industry. One of the early entrants was Emeritus, which got into the
assisted living business in 1993, opening a single facility in Renton,
Wash. The company’s leader, Daniel Baty, had his eyes on something much
grander: He was, he declared, aiming to create a nationwide chain of
assisted living facilities.
Two years later, Baty took the
corporation public, selling shares of Emeritus on the American Stock
Exchange, and piling up the cash necessary to vastly enlarge the
company’s footprint. Many of Emeritus’s competitors followed the same
path.
The company’s rapid growth was, at least in part, a
reflection of two significant developments. Americans were living
longer, with the number of those in the 65-plus age bracket ballooning
further every year. And this growing population of older Americans was
willing to spend serious money, often willing to drain their bank
accounts completely to preserve some semblance of independence and
dignity — in short, something of their former lives.
As
the assisted living business flourished, the federal government, which
oversees nursing homes, left the regulation of the new industry to the
states, which were often unprepared for this torrent of expansion and
development. Many states didn’t develop comprehensive regulations for
assisted living, choosing instead to simply tweak existing laws
governing boarding homes.
In this suddenly booming, but
haphazardly regulated industry, no company expanded more aggressively
than Emeritus. By 2006, it was operating more than 200 facilities in 35
states. The corporation’s strategy included buying up smaller chains,
many of them distressed and financially troubled, with plans to turn
them around.
Wall Street liked the model. Market analysts touted
the virtues of the company and its stock price floated skyward. One of
the corporation’s appeals was that its revenues flowed largely from
private bank accounts; unlike hospitals or nursing homes, Emeritus
wasn’t reliant on payments from the government insurance programs
Medicare or Medicaid, whose reimbursement rates can be capped. As the
company noted in its 2006 annual report, nearly 90 percent of its
revenues came from “private pay residents.”
In filings with the
Securities and Exchange Commission and in conference calls with
investors, Emeritus highlighted many things: occupancy rates; increasing
revenue; a constant stream of complex real estate deals and
acquisitions; the favorable demographic trends of an aging America.
“The
target market for our services is generally persons 75 years and
older who represent the fastest growing segments of the U.S.
population,” Emeritus stated in a 2007 report filed with the SEC.
Today,
the assisted living industry rivals the scale of the nursing home
business, housing nearly three-quarters of a million people in more than
31,000 assisted living facilities, according to the U.S. Department of
Health and Human Services.
Keren Brown Wilson, the early and
earnest pioneer of assisted living, is happy that ailing seniors across
the country now have the chance to spend their final years in assisted
living facilities, rather than nursing homes. But in her view, the rise
of assisted living corporations — with their pursuit of investment
capital and their need to please shareholders — swept in “a whole new
wave of people” more focused on “deals and mergers and acquisitions”
than caring for the elderly.
She speaks from experience. After her
modest start, Wilson went on to lead a company called Assisted Living
Concepts, and took it onto the stock market. Wilson left the company in
2001, and it has encountered a raft of regulatory and financial problems
over the last decade.
“I still have a lot of fervor,” said
Wilson, who now runs a nonprofit foundation and teaches at Portland
State University. “I believe passionately in what assisted living can
do. And I’ve seen what it can do. But for some of the people, it’s just
another job, or another business. It’s not a passion.”
“A Phenomenal Deal”
Joan
Boice, born Joan Elizabeth Wayne, grew up in Monmouth, Ill. It was a
tiny farm belt community, not far from the Iowa border. Her father, a
fixture in the local agriculture trade, owned a trio of riverfront grain
elevators on the Mississippi and a fleet of barges. As a teenager, she
spent her summers trudging through the fields, de-tasseling corn.
In
1952, accompanied by a friend, Joan packed up a car and followed the
highway as far west as it would go. Then in her early 20s, she was
propelled by little more than the notion that a different life awaited
her in California. In a black-and-white snapshot taken shortly after she
arrived, Joan is smiling, a luxuriant sweep of dark hair framing her
pale face, gray waves curling in the background. It was the first time
she’d seen the Pacific.
Joan had been a teacher for two years in
Illinois, and she quickly found a job at an elementary school in
Hayward, a suburb of San Francisco. In certain regards, her outlook
presaged the progressive social movements that were to remake the
country during the next two decades. She viewed education as a “great
equalizing force” that could help to remake a society far too stratified
by class, race and gender.
“She was just free-spirited and confident,” Eric, her son, said.
Joan
met Myron Boice through a singles group at a Presbyterian church in
Berkeley. On their wedding day, Joan flouted convention by showing up in
a blue dress. The Boice children came along fairly quickly: Nancee,
then Mark, then Eric.
Myron Boice was a dreamer. A chronic
entrepreneur. He sold tools from a van. He made plans to open
restaurants. He had one idea after another. Some worked; others didn’t.
Joan’s
passion for education never dissipated. Even in her late 60s, she
continued to work as a substitute teacher in public schools. After
retirement, she began volunteering with a childhood literacy program.
But
age eventually tightened its grip, and hints of a mental decline began
surfacing around 2005. Eric grew worried when she couldn’t figure out
how to turn on her computer twice in the span of a few months. Then she
forgot to include a key ingredient while baking a batch of Christmas
cookies. The cookies were inedible.
The elderly couple was still
living in the San Francisco suburbs, when, in late 2006, a doctor
diagnosed Joan with Alzheimer’s. As her mind deteriorated, Myron
struggled to meet her needs. The situation was worsened by the fact that
none of the children lived nearby. Mark was in Ohio. Nancee was about
an hour away in Santa Cruz. And Eric and his wife, Kathleen, were
roughly two hours away in the foothills of the Sierra.
“We
offered my parents to come and live with us,” Eric recalled. But Myron
said no. He and Joan wouldn’t move in with any of the kids. The family
patriarch refused to become a burden.
A physician encouraged Joan
and Myron to consider assisted living. It made sense. And so Myron sold
their home in 2007 and the couple moved into a facility called The
Palms, near Sacramento. The move put them approximately 40 minutes away
from Eric and Kathleen.
“They were very attentive to every single
thing she needed,” Kathleen Boice said of the staff at The Palms. “They
actually re-taught her to eat with a fork and a knife.”
By 2008,
however, Myron wanted a change. He wanted to be closer to his son and
daughter-in-law and grandkids. He wanted different meals, a new
environment. Myron began hunting for a new place to live, a search that
led to Emeritus at Emerald Hills in Auburn.
Emeritus opened the
Emerald Hills complex in 1998. It was, in many ways, a classic Emeritus
facility, situated in a middle-class locale that was neither
impoverished nor especially affluent. It was a sizable property, capable
of housing more than 100 people.
In part because of its appetite
for expansion, Emeritus was in the early stages of what proved to be a
period of enormous stress. In 2007, the company had made its biggest
acquisition to date, buying Summerville Senior Living Inc., a
California-based chain with 81 facilities scattered across 13 states.
The
purchase — which expanded Emeritus’s size by roughly one-third — helped
the company make another major leap, bouncing from the low-profile
American Stock Exchange into the big leagues of commerce, the New York
Stock Exchange. News of the Summerville deal propelled the company’s
stock to a new high. Emeritus was poised to become the nation’s No. 1
assisted living chain.
But
the timing for this bold move turned out to be wretched. The real
estate market was freezing up, and it would soon collapse, plunging the
nation into an epochal recession. For Emeritus, the economic slowdown
and then the housing crash posed direct challenges. Its services didn’t
come cheap, so many people needed to sell their homes before they could
afford to move into the company’s facilities. With the real estate
market calcified, Emeritus’s customer pool shrank.
“Our stock
price plummeted,” recalled Granger Cobb, Emeritus’s chief executive
officer, who joined the company as part of the Summerville deal. The
company’s occupancy rates had been trending skywards. Now they went
flat.
At Emerald Hills, the economic slowdown that summer was making life tough for Melissa Gratiot, the lead sales agent.
“It was way harder to move residents in,” she remembered.
But
there was some good news. She was close to a significant sale, this one
to a couple. Gratiot worked the pitch. She talked with the family. She
emailed. She gave them a tour of the facility’s memory care unit, called
The Emerald City. She told the family she’d received approval from
higher ups to offer the family “a phenomenal deal.”
Gratiot closed
the sale. On Aug. 29, 2008, Myron and Eric signed the contract, and the
family opened its wallet: A $2,500 initial move-in fee; $2,772 for
Joan's first two weeks in Room 101; another $1,660 for Myron.
There
had been one oversight, though. No one at Emeritus with any medical
training had ever even met Joan, much less determined whether Emerald
Hills could safely care for her.
Correction (7/29): An
earlier version of this story stated that Emeritus at Emerald Hills had
failed a company audit of its memory care unit before Joan Boice moved
in. It has been corrected to say an audit found flaws in the facility’s
medication handling process before Boice moved in. The memory care unit
was audited while Boice was living there and failed nearly every
important test.
PART 2 -- "They're Not Treating Mom Well"
When
the ambulance crew arrived, about 8:20 p.m., Joan Boice was in the TV
lounge, face-down on the carpet. Her head had struck the floor with some
velocity; bruises were forming on her forehead and both cheeks. It
appeared she’d lost her balance and fallen out of a chair.
But no
one at the assisted living facility could say precisely how the accident
had occurred. No one knew how long Joan had been splayed out on the
floor. She had defecated and urinated on herself.
Worried that
Joan might have injured her spine, the emergency medical personnel
gently rolled her over and placed her on a back board. They pumped
oxygen into her nostrils.
It was Sept. 22, 2008 — just 10 days after Joan had first moved into Emerald Hills.
No
Emeritus employees accompanied Joan to the hospital. And even though
Joan’s husband, Myron, was living in the facility, the Emeritus workers
didn’t immediately alert him that Joan had fallen and hurt herself.
Joan, confused, injured, and nearly mute, ended up in the local hospital
by herself, surrounded by strangers.
California
law requires assisted living companies to conduct a “pre-admission
appraisal” of prospective residents, to ensure they are appropriate
candidates for assisted living.
But Emerald Hills took Joan in
without performing an appraisal. It wasn’t for lack of time. The Boices
had signed the contract to live at Emerald Hills more than two weeks
before Joan moved in.
Joan, then, had taken up residence in the
memory care unit at Emerald Hills. The unit — referred to as a
“neighborhood” by the company — is a collection of abouta dozen small
apartments on either side of a central hallway. At each end of the
hallway are heavy doors equipped with alarms, which sound when anyone
enters or leaves. The alarm system is meant to prevent residents from
simply walking off.
On the day Joan moved into Room 101 in the
unit, a company nurse named Margaret “Peggy” Stevenson briefly looked
her over. The nurse realized that Joan needed to be monitored closely to
keep her from falling — she wrote it down in her cursory assessment —
but facility records show she didn’t craft any kind of detailed plan for
her care and supervision.
Stevenson, asked years later about Joan, said she could recall nothing about her or her stay at Emerald Hills.
Kathleen
had immediate suspicions about Joan’s fall. The family, she said, had
warned the facility not to leave Joan sitting in a chair without
supervision because she was liable to try to stand up, lose her balance,
and topple to the floor. Joan had fallen several times during an
earlier stay in an assisted living facility near Sacramento, but the
staff had developed a specific plan to address the issue.
Despite
the warning, Kathleen said that when she visited Emerald Hills during
Joan’s first days there she often found her mother-in-law sitting in a
chair alone.
The recent track record at Emerald Hills featured a
host of falls similar to Joan’s, and ambulances were often called to
take the injured off to the hospital. Falls are a particular hazard for
the elderly, and assisted living facilities like Emerald Hills are
required to report them to state regulators.
Internal company records documented 112 falls at Emerald Hills in 2008. Some residents fell repeatedly.
Consider the case of one Emerald Hills resident, 83-year-old Dorothy “Dottie” Bullock.
On
April 5, 2008, an Emeritus employee discovered Bullock “on the floor in
a semi-seated position” in the memory care unit, according to a state
report. She “was unable to tell” the worker what had happened to her.
The incident was described as a fall in state records. Emerald Hills
sent her to the hospital.
On April 7, Bullock, back at Emerald
Hills, fell again, according to the handwritten log of her personal
attendant, who was hired by Bullock’s husband to give her extra help.
On
April 8, Bullock, complaining of pain, was hauled by ambulance back to
the hospital. Doctors concluded that she’d fractured her pelvis, but
soon returned her to Emerald Hills. She fell again on April 12.
Bullock would fall again months later, for the final time.
Emeritus
records show Bullock tumbled in front of her apartment and was found on
the carpet with her aluminum walker beneath her. Blood spilled from her
nose and a “bump” developed on her forehead, according to the company
documents. The impact broke a vertebra in Bullock’s neck and crushed her
nasal bones and sinus structures, hospital records show. A CT scan
revealed possible fractures of both eye-sockets and the base of the
skull.
Dottie Bullock died in the emergency room.
While
Emeritus recorded the fatality in its internal logs, the company did not
report her death to state regulators, a violation of California law.
The state requires assisted living facilities to file reports on all
deaths, even those believed to be from natural causes, so that it can
look into suspicious or troubling incidents.
Emeritus said it lacked information about Bullock’s death and thus could not say why it had occurred.
Bullock’s personal attendant, Julie Covich, says Bullock was not supervised properly.
“I
think there was neglect,” said Covich, who usually visited Emerald
Hills once or twice a week to help out Bullock. “I would go in there and
never see a caregiver.”
“It was hard to find anyone that was running the place,” she said. “It was crazy.”
“Heads on the Beds”
In
early 2008, the year Joan Boice entered Emerald Hills, Emeritus rolled
out a new business campaign. The company dubbed it the “No Barriers to
Sales” effort.
The concept was straightforward: Move as many
people as possible into Emeritus facilities. Wall Street was looking
closely at the company’s quarterly occupancy numbers and a few
percentage points could propel the stock price upward or send it
tumbling down.
With the housing market foundering, Emeritus needed to step up its sales efforts.
In
case there was any confusion about just how seriously the company took
this new campaign, a company vice president sent a blast email to
facility directors across California. In the body of the email, the vice
president got right to it:“SALES and your commitment to sales is your
highest priority right now.” Facility directors, the message concluded,
would be “held responsible for census and occupancy growth.”
Emeritus employees across the country realized they were entering a new era.
“There
was a different sense of urgency. The tone was different,” said a
former Emeritus manager who ran a facility at the time. “The message
from above was put as many people as possible in the beds and make as
much money as possible. That’s what they said. Verbatim. Honestly.”
According
to Lisa Paglia, a regional executive in California at the time, Budgie
Amparo, the company’s top official for quality control, was openly
critical when a Northern California facility declined to admit someone
who did not have a doctor’s evaluation.
Such evaluations, which
are designed to keep out seniors with problems that assisted living
facilities aren’t equipped to handle, are required under a California
law known as Title 22.
But on a conference call with roughly half a
dozen California managers, Paglia said, Amparo declared that the
Northern California facility should have admitted the resident.
“Our priority,” Amparo declared, according to Paglia, “is to get the heads on the beds.”
The
issue arose again in October 2008 during a training session for
approximately 25 facility directors and salespeople held at an Emeritus
property in Tracy, Calif. During the seminar, a company vice president
reiterated Amparo’s instruction to disregard California law, according
to court records and interviews.
The mandate prompted something of a staff revolt.
At least one facility director spoke out at the meeting: His license to operate the facility was at stake, he said.
An
employee who worked at the Tracy facility eventually alerted California
regulators. The state dispatched an investigator, and state records
show that the investigator met with employees who confirmed that a
company official had approved the practice of admitting someone without a
doctor’s report. The investigator reviewed a random sample of seven
resident files, finding that two people had been moved in illegally,
documents show.
Amparo,
a nurse whose full title is executive vice president of quality and
risk management, denies directing employees to violate the regulation.
In a written statement, Emeritus said, “Neither Budgie Amparo nor any of
our other officers issued a directive to violate Title 22 or any other
law. Emeritus does not condone allowing residents to move in without the
proper documents.”
Emeritus eventually fired Paglia, and lawyers
for the company have since portrayed her as a poor worker who failed to
do her job competently. Along with two other former Emeritus employees,
Paglia sued the company alleging wrongful termination, and wound up
settling on secret terms.
For assisted living chains such as
Emeritus, there is a powerful business incentive to boost occupancy
rates and to take in sicker residents, who can be charged more.
Emeritus,
for its part, rejects any suggestion that a quest for profits has
tainted its admission practices. But in interviews, former Emeritus
executives described a corporate culture that often emphasized cash flow
above all else. The accounts of the executives, who spoke independently
but anonymously, were strikingly consistent.
“It was completely
focused on numbers and not human lives,” said one executive, who worked
for Emeritus for more than three years and oversaw dozens of facilities
in Eastern states.
The company’s emphasis on sales and occupancy
rates, the executive said, transformed the workforce into “a group of
people who were grasping at every single lever they could pull to drive
profitability.”
Emeritus operates a sophisticated, data-driven
sales machine. There are occupancy goals for each facility, as well as
yearly company-wide goals. The company tracks dozens of data points —
including every move-in and move-out of residents — in a vast database.
It posts a monthly snapshot of each facility’s sales statistics on an
internal website, allowing employees to see which strategies are most
successful.
Sales specialists are instructed on how to use
psychology to persuade potential customers to sign on. One
suggestion: Give the customer “a sense of control and choice by offering
two possible options.” A 2009 Emeritus sales manual, which runs 181
pages, encourages sales people to generate publicity by hosting seminars
on Alzheimer’s or organizing charity efforts in the event of a natural
disaster like a “flood or earthquake.”
Emeritus motivates its
workforce with a broad range of financial incentives. There are bonuses
for hitting monthly occupancy goals. Bonuses for hitting yearly
occupancy goals. Bonuses for boosting overall earnings. And the money
doesn’t just go to sales people: The company hands out checks to
maintenance workers, nurses, facility directors and other workers.
Nurses
play a key role in assisted living, providing much of the hands-on
care. But nurses at Emeritus facilities are also expected to be deeply
involved in increasing revenue by making sales.
During more than a
year of reporting, ProPublica and PBS Frontline spoke to 10 facility
directors who said nurses were required to participate in weekly
conference calls focusing on little but economics. Those accounts are
backed by an internal Emeritus document that lays out the agenda for the
weekly calls and that shows an overarching concentration on finances.
Doris
Marshall was at the forefront of Emeritus’s efforts to have nurses play
the dual roles of caregivers and salespeople. After receiving her
nursing license in 1984, Marshall had spent many years tending to
patients in the emergency department of a Southern California hospital,
and she’d later gone on to help run a nursing school.
But Marshall
was intrigued by the assisted living business and in March 2008 she
signed on to supervise 10 Emeritus properties scattered across Northern
California. Amparo, the company’s head nurse, convinced Marshall to take
the job, telling her nurses “had a voice” at Emeritus.
Marshall
was to oversee the well-being of roughly 800 elderly people. But her job
description went well beyond that: She was to help with “marketing” and
“attaining financial goals.” Her job, in the end, actually involved
very little nursing.
Instead, she said, she was drawn into
Emeritus’s evolving strategies aimed at upping its revenues. The company
planned to bring in more seniors with Alzheimer’s and dementia because
they could be charged more, she said. Her boss gave her a digital
tracking tool showing how much more money Emeritus could make by
admitting sicker, frailer residents.
By the fall of 2010 Marshall was worn out and disillusioned. She quit.
Emeritus’s
extraordinary drive to put heads in beds — perhaps routine in, say, the
hotel industry — has distorted the admissions process at some
facilities, records and interviews show. Since 2007, state investigators
have cited the company’s facilities more than 30 times for housing
people who should have been prohibited from dwelling in assisted living
facilities.
A 2010 episode at an Emeritus facility in Napa
highlighted the perils of improperly admitting people. The facility
rented a room to a 57-year-old woman with an eating disorder,
depression, bipolar disorder and a history of suicide attempts. The
woman, who was distraught over the death of her husband, taped a note to
her door saying she wasn’t to be disturbed and committed suicide,
overdosing on an amalgam of prescription painkillers.
The state’s
investigation into the death was scathing: the woman should never have
been allowed to move in; the staff had missed or ignored bulimic
episodes and her obvious weight loss; no plan of care was ever developed
or implemented despite the resident’s profound psychological problems.
Emeritus,
asked to respond to the state’s investigation, said only that the woman
had overdosed on drugs she had brought into the facility on her own,
and that as a result they could not be faulted in her death.
“She Barely Even Talked to Us”
In
the aftermath of her fall in September 2008, Joan returned to Emerald
Hills. But the staff, inexperienced and often exhausted, worried about
her.
“She couldn’t walk, she couldn’t feed herself, she barely
even talked to us, and her health wasn’t that good,” recalled Jenny
Hitt, a former medication technician at Emerald Hills.
But if concern was abundant at Emerald Hills, expertise was in short supply.
Alicia
Parga ran Joan’s memory care unit. On some weekends, she managed the
entire building — not only the wing of residents with dementia, but the
rest of the three-story assisted living facility, one that could hold a
total of more than 100 residents.
After Parga started on the job,
it took Emeritus roughly 18 months to give her any training on
Alzheimer’s and dementia. The state regulations were hardly substantial:
Someone such as Parga was obligated to get six hours of training during
her first four weeks on the job. But even that requirement wasn’t met.
Emeritus
has insisted that Emerald Hills had properly trained personnel to care
for Joan and others, and they described Parga as a woman deeply invested
in tending to the residents.
But Parga, who had barely earned a
high school degree, wasn’t even familiar with the seven stages of
dementia. Though she was responsible for the well-being of 15 or more
seriously impaired people, as well as the supervision of
employees, Parga was paid less than $30,000 per year.
Catherine Hawes, a health care researcher at Texas A&M University, conducted the first national study of assisted living facilities.
In her view, training is absolutely crucial. A well-educated employee
can “interpret non-verbal cues” from people like Joan, intercept seniors
before they wander away from the building, or keep residents from
eating or drinking poisonous substances.
“You can do great care,” she said. “You just — you’ve got to know how.”
Other
than the Emeritus employees working in the memory care unit at Emerald
Hills, only one person saw Joan enough to know what kind of daily care
she was getting: Her husband, Myron.
He was worried. And he did his best to sum up his concerns to his son Eric:
“They’re not treating Mom well.”
Jonathan Jones is a former religion reporter for MediaNews Group and is the son of a Presbyterian minister.
