The U.S. Government Accountability Office ("GAO") issued a July 28, 2011 transcript (GAO-11-842T) of testimony from Kay L. Daly, GAO Director of Financial Management and Assurance, and Kathleen M. King GAO Director of Health Care before the U.S. House of Representatives' Subcommittee on Government Organization, Efficiency and Financial Management, Committee on Oversight and Government Reform entitled "Improper Payments: Reported Medicare Estimates and Key Remediation Strategies."

Hyperlinks to the full report and a summary are below:
Highlights Page (PDF) Full Report (PDF, 30 pages) Accessible Text

SummaryThe GAO has designated Medicare as a high-risk program because of its size, complexity, and susceptibility to improper payments.

In 2010, Medicare covered 47 million elderly and disabled beneficiaries and had estimated outlays of $516 billion.

The Centers for Medicare & Medicaid Services (CMS) is the agency in the Department of Health and Human Services (HHS) responsible for administering the Medicare program and leading efforts to reduce Medicare improper payments.

This testimony focuses on estimated improper payments in the Medicare program for fiscal year 2010 and the status of CMS's efforts to implement key strategies to help reduce improper payments.

This testimony is primarily based on previous GAO reporting related to governmentwide improper payments, Medicare high-risk challenges and program integrity efforts, and CMS's information technology systems intended to identify improper payments.

The GAO supplemented that prior work with additional information on the nature and extent of Medicare improper payments reported by HHS in its fiscal year 2010 agency financial report. GAO also received updated information from CMS in February 2011 and, in select cases, as of July 2011, on its actions related to relevant laws, regulations, guidance, and open recommendations pertaining to key remediation strategies.

For fiscal year 2010, HHS reported an estimate of almost $48 billion in Medicare improper payments, representing about 38 percent of the total $125.4 billion estimate for the federal government.  However, this Medicare improper payment estimate is incomplete because HHS has yet to develop a comprehensive estimate for the Medicare prescription drug benefit.  The improper payment estimate includes both overpayments and underpayments.

Causes cited include inadequate documentation, medically unnecessary services, coding errors, and payment calculation errors. It is important to recognize that the $48 billion is not an estimate of fraud in Medicare.

Because the improper payment estimation process is not designed to detect or measure the amount of fraud that may exist, there may be fraud that is not reflected in HHS's reported estimate.

The CMS faces challenges in designing and implementing internal controls to effectively prevent or detect and recoup improper payments.  In 2010, CMS established the Center for Program Integrity to serve as its focal point for all national Medicare program integrity issues.

Based on past work, the GAO identified five key strategies to help reduce fraud, waste, and abuse and improper payments in Medicare, which CMS has reported initiating actions to address.

GAO has made recommendations to strengthen CMS's implementation of these strategies, some of which the agency has not implemented. (1) Strengthen provider enrollment standards and procedures. Strong standards and procedures can help reduce the risk of enrolling providers intent on defrauding the program. CMS has taken action to implement provisions of the Patient Protection and Affordable Care Act by screening providers by levels of risk and providing more stringent review of high-risk providers, but has yet to implement certain GAO recommendations in this area. (2) Improve prepayment reviews. Prepayment reviews of claims help ensure that Medicare pays correctly the first time.

According to CMS, as of July 1, 2011, CMS has begun applying predictive modeling analysis to claims and plans to expand Medicare prepayment controls. However, CMS has not implemented GAO's recommendation to improve prepayment reviews.

(3) Focus postpayment reviews on vulnerable areas.

Postpayment reviews are critical to identifying payment errors and recouping overpayments. In March 2009, CMS began instituting a national recovery audit contractor (RAC) program to help the agency supplement its postpayment reviews. CMS has also developed information technology to help it better identify claims paid in error, but GAO recently reported that the systems are not being used to the extent originally planned and made several recommendations to address the issues.

(4) Improve oversight of contractors.

CMS has taken action to improve oversight of prescription drug plan sponsors' fraud and abuse programs, which addresses GAO's recommendation, but is still developing specific performance statistics.

(5) Develop a robust process to address identified vulnerabilities.

Having mechanisms in place to resolve vulnerabilities that lead to improper payments is critical. While CMS has begun actions in this area, it has not developed a robust corrective action process for vulnerabilities identified by Medicare RACs as GAO recommended.
For more information about a Miami-Dade, Broward and Palm Beach County home health care agency for seniors, Alzheimer's patients, sufferers of dementia and other family members needing home health care services or in-home health aides, contact Brian Gauthier at A Family Member HomeCare (954) 986-5090 or visit www.afamilymemberhomecare.com.

• Florida is cutting spending on K-12 education by $542 per pupil compared with last year. The state also has cut $13 million from the state’s school readiness program that gives low-income families access to high quality early care for their children. The cut means over 15,000 children currently participating in the program will no longer be served. Florida also reduced by 7 percent the per-student allocation to providers participating in the state’s universal prekindergarten program for 4-year-olds, which will mean that classrooms have more children per teacher.
• Florida’s cuts in funding for the state’s universities has led to tuition hikes of 15 percent for the new school year, bringing the cumulative tuition increase since 2009 to 52 percent.
• Florida reduced Medicaid payment rates by 12 percent for most hospitals, by 6.5 percent for nursing homes, and by 4 percent for centers that provide medical care to people with developmental disabilities.
• Florida cut state higher education spending and raised state university tuition for undergraduates by 8 percent. State universities are increasing tuition by another 7 percent to offset cuts in funding. This comes on the heels of tuition hikes equaling over 30 percent since the 2009-10 school year. The state has also cut a university merit-based scholarship program by 20 percent.

This Health News Florida Story cautions on the importance of designating a health care surrogate . . . after five years in Tampa General Hospital, witnesses said they offered to pay for private-duty nurses if a mother would accept her daughter’s discharge to her home. She said no.




Health News Florida:  $9.2 million Tampa General Hospital bill caps strange tale

By Carol Gentry
7/28/11 © Health News Florida

When Tampa General recently filed a $9.2 million claim against the estate of a penniless woman, it left itself open to criticism. But a look at Hillsborough probate court records offers perspective.


They describe what one court officer described as a "very special case, very difficult."  Among other things, it provides a cautionary tale for those deciding on a health-care surrogate.


Tameka Campbell, in her mid-20s when she was admitted to Tampa General, spent five years there only because the hospital could not find any place that would take her. It couldn't get financial help from the state, records show, nor cooperation from Campbell's mother.


The case is a good example of a paradox of the health-care system: A dying patient can be kept alive on a ventilator with a feeding tube almost indefinitely, yet there are few places for such a patient to go for care and often no way to pay for it.


So the patient remains in the most expensive place of all: a hospital.


Health News Florida reported the $9.2 million claim against Campbell's estate on Tuesday, adding that it may be a record for a hospital stay but that no one could be found who keeps track. After that report, the Guinness Book of World Records said it doesn't have a category for the size of hospital bills because they are private. Also, a spokeswoman said, hospital charges are arbitrary, subject to manipulation.


Details of the Campbell case would have remained a secret if her mother, Holly Bennett, and the Tampa General staff had gotten along. But they clashed to the point that the hospital petitioned the court in 2007 to replace Bennett as guardian in the interests of her daughter’s care.


Circuit Judge Susan Sexton decided that Bennett was incapable of looking after her daughter’s interests and appointed a professional guardianship agency.


Bennett appealed the decision to the Second District Court in Lakeland, where a three-judge panel affirmed the decision without comment in May 2008.


Records from the hearings that took place in 2007 and the report that followed, which had been stored in a court records warehouse, became available Wednesday afternoon.


They portray a hospital staff locked in a power struggle with Bennett, whom her daughter had appointed as her health-care surrogate early in her stay.


Campbell, as an uninsured patient without any money, would ordinarily have been covered under Medicaid. But as TGH’s chief social worker Carolyn Soucy testified, the state program doesn’t pay for patients like Campbell who don’t need hospital-level “acute” care and could be kept comfortable in a skilled nursing facility.


Soucy testified that the staff tried more than 150 referrals to other facilities, but all ultimately refused because of the ventilator. “There are only three facilities in the entire state of Florida that will take long-term ventilator patients,” she testified, and none of them had beds available.


The staff found a placement for Campbell in Ohio, Soucy said, but Bennett refused, not wanting her daughter so far away.


Hospital witnesses said they offered to pay for private-duty nurses if Bennett would accept her daughter’s discharge to her home. She said no.


According to a report by a three-member independent panel and court magistrate, witnesses described Bennett’s behavior as increasingly strange. Nurses and doctors said she accused them of trying to murder her daughter and sometimes screamed at them to leave her daughter’s room.


They said they would set up meetings to discuss the case but Bennett wouldn’t show up. Sometimes months went by between Bennett’s visits, they said.


Bennett sent complaints to the state Agency for Health Care Administration, which investigated and concluded that Campbell was getting good quality of care and found only a couple of minor documentation problems.


Bennett “fired” the pulmonologist and palliative care specialist in charge of Campbell’s case, Dr. Vincent Perron from the University of South Florida. Perron, who is in the U.S. Navy Reserves, said Bennett even wrote a letter to the U.S. Navy, accusing him of trying to harm her daughter.


One letter in the file shows that the hospital warned Bennett that she was “firing” so many doctors and nurses that it was becoming increasingly difficult to find someone to care for her daughter.


After Tampa General succeeded in its petition to remove Bennett as guardian, Campbell remained there for two more years, dying on June 18, 2009. The record is not entirely clear on why Campbell was never transferred, apart from the testimony from two years earlier about the difficulty of finding placement.


Presumably, Medicaid continued to refuse coverage, but that isn’t explicitly stated in the record. A spokeswoman for the Agency for Health Care Administration said she couldn’t discuss the case – even after being told that Campbell’s hospital records are part of the court file – because of federal privacy laws.


Similarly, Tampa General spokesman John Dunn said hospital officials had declined to comment. Such reticence is common when a hospital fears being sued.


On June 9, Bennett filed a notice in Circuit Court that she intends to file a wrongful death suit against the hospital. It appears that she is representing herself.


For more information about a Miami-Dade, Broward and Palm Beach County home health care agency for seniors, Alzheimer's patients, sufferers of dementia and other family members needing home health care services or in-home health aides, contact Brian Gauthier at A Family Member HomeCare (954) 986-5090 or visit www.afamilymemberhomecare.com.

In its Bloomberg business section, the Washington Post focuses on the grim side of hospice:


Death’s Door Opens Slowly as Hospice Bill Hits 
By  Gary Putka and Peter Waldman

July 22, 2011


July 22 (Bloomberg) -- With his mother wheezing and losing consciousness in a California nursing home, Robert Rogers wanted her moved to a hospital. Vitas Healthcare, her hospice provider, said that wasn’t in the plan.


“Our job is not to prepare them to live,” a Vitas nurse told Rogers on the phone, according to a deposition he gave in April. “Our job is to prepare them to die.”


Rogers called 911. At the hospital, an emergency-room doctor removed 11 maggots from an open wound on his mother’s big toe. Five days later, in September 2008, 91-year-old Thelma Covington died of a sepsis infection brought on by gangrene in her toe and poor circulation, her death certificate said.


Rogers is suing Vitas, a unit of Cincinnati-based Chemed Corp., in a California court for alleged elder abuse and wrongful death. Vitas, the biggest company in hospice care, has denied negligence and said that Covington and Rogers knew the risk involved in entering hospice. Ninety-five percent of Vitas care gets positive family ratings in surveys, said Kal Mistry, a company spokeswoman.


As hospice care has evolved from its charitable roots into a $14 billion business run mostly for profit, patients like Covington and their families have paid a steep price, according to lawsuits and federal investigations. Providers have been accused of boosting their revenues with patients who aren’t near death and not eligible for hospice -- people healthy enough to live a long time with traditional medical care. In hospices, patients give up their rights to “curative” measures because they are presumed to be futile.


Widespread Neglect


“By admitting these folks to hospice, they are denied access to routine medical and rehabilitative care that they need to extend and improve their lives,” said Cristen Krebs, executive director of Catholic Hospice of Pittsburgh, a non- profit. “A vulnerable and voiceless population is preyed upon for money.”


At the same time, patients are being neglected, according to the claims in the lawsuits, government court filings and interviews with more than 30 people who have worked in the industry or had relatives in hospice. In 2009, a Medicare oversight report found nearly a third of hospice patients were not getting services in care plans that describe the treatment and visits providers promise to give them.


More than four in 10 Americans now meet their end in hospice care, drawn by its promise of palliation and pain alleviation instead of extreme measures in their waning days. Medicare’s hospice rolls doubled to 1.1 million patients from 2000 to 2009, the last year of available data.


‘So Caring’


The expansion “has been excellent for patients,” improving care for a large underserved population, said J. Donald Schumacher, president of the National Hospice & Palliative Care Organization, an Alexandria, Virginia-based trade group. Studies by Brown University researchers and others have found families whose relatives died in hospice are more satisfied with care than those whose loved ones passed away under conventional care.


William Susdorf of Rancho Mirage, California, suffered from inoperable intestinal cancer and received home hospice care from Vitas for six months before he died in May, said his wife Dorothy. Susdorf, 85, a retired auto-leasing executive, developed a strong bond with his nurses and his Vitas chaplain, whom he asked to deliver his funeral eulogy, his widow said. Vitas “couldn’t have been nicer to us; they were just so caring,” she said.


Whistleblower Suits


The government is investigating whether Vitas “engaged in an extensive scheme” to “defraud the Medicare and Medicaid programs of potentially hundreds of millions of dollars” by falsifying records and hospice certifications, and billing for services it didn’t deliver, the U.S. Attorney in Dallas said in a federal court filing that drew little attention last November. The company, which expects $1 billion in revenue this year, is following Medicare and Medicaid rules, according to its regulatory filings.


New federal hospice investigations rose 50 percent between 2008 and 2010, according to Gerald Roy, deputy inspector general at the U.S. Department of Health and Human Services, which oversees Medicare spending. More than 30 cases were opened last year on the heels of whistleblower suits by former hospice workers and others alleging Medicare fraud, according to federal officials who asked not to be named because many of the cases are sealed.


Facing Investigations


An executive of a hospice owned by Harden Healthcare LLC emailed managers in 2008 urging them to “stop all these live discharges” of patients to keep enrollments high, according to a civil fraud complaint by the Justice Department in federal court in Kansas City, Kansas. Company spokeswoman Meg Meo said the alleged events occurred before Austin, Texas-based Harden owned the hospice.


A whistleblower lawsuit brought by a former social worker for hospices run by Atlanta-based Gentiva Health Services Inc. said her job was to talk people who weren’t dying into believing that they were. The allegations predated Gentiva’s ownership of the chain, spokesman Scott Cianciulli said.


Gentiva’s Odyssey hospice unit faces investigations by HHS’s Office of Inspector General and the state of Georgia, according to regulatory filings. The company, which is the second-largest hospice provider, is cooperating with investigators, Cianciulli said.


Unconditional Resistance


Hospice got its start in the 1960s as a social movement. Volunteers, often meeting in schools and church basements, organized care so patients could die at home with loved ones, instead of at the hospital laced with tubes. Dame Cicely Saunders, the pioneering English physician who opened St. Christopher’s Hospice in London in 1967, fought traditional methods of unconditional resistance to death, and brought the concept to U.S. shores.


The government’s suspicions about providers have been fueled by rising costs and lengthier patient stays. During the 2000-2009 period when Medicare patients doubled, the government’s bill quadrupled to $12 billion.


The average for-profit patient costs the government $12,609, 29 percent more than a non-profit patient, because the for-profits find people who live longer, frequently at nursing homes, the OIG reported on Tuesday. Of the hospices with two- thirds or more of their patients in nursing homes, 72 percent are for-profits. A majority of patients receive their hospice care at home.


Longer Stays


Two-thirds of patients in hospices run for profit have general diagnoses like “failure to thrive” and “debility” compared to half in non-profits, which cater more to faster- killing conditions like cancer, a Harvard University study found earlier this year. Patients stay an average of 98 days in for- profit hospices versus 68 days at non-profits, which have a 0.2 percent profit margin, according to Medicare. The margin at for- profits is 50 times higher at 10 percent.


“Long stays on hospice subvert the intent of the program and suggest a pattern of behavior that needs to be investigated,” said Robert Berenson, a fellow at the Urban Institute in Washington and vice chairman of the Medicare Payment Advisory Commission, or Medpac, which advises Congress on health care policy.


Robert Stone, assistant medical director at Indiana University’s Bloomington Hospital Hospice, sees an “inherent conflict” between the profit motive and providing the best hospice services.


“Hospice is undergoing a radical change in its soul to a for-profit business,” he said.


Bonuses, Kickbacks


To be eligible for Medicare hospice coverage, a person must have a prognosis of six months or less to live, certified by two doctors. Yet 20 percent of hospice patients live beyond that term, with their providers receiving government checks via recertifications that can go on indefinitely.


Enrolling patients, retaining them as long as possible, and controlling costs are the top priorities at for-profit hospices, according to former and current employees interviewed by Bloomberg News. To increase revenues, hospices tie employee bonuses to enrollment, pay kickbacks to patients and referral sources, and use false diagnoses to admit ineligible patients, according to whistleblower, or qui tam, suits against three chains filed under the False Claims Act, which allows plaintiffs to share in any financial recovery for the government.


One of the suits was filed by Misty Wall, a former social worker at Gentiva’s VistaCare hospice unit who said she was fired in 2005. Wall was assigned to convince people who weren’t dying that they were, she said in an interview.


‘Selling Feature’


Wall, now an assistant professor of social work at Boise State University in Idaho, said one woman broke down in tears when Wall suggested her father was dying from renal failure. The man’s own doctor had declined to recommend hospice, prescribing dialysis instead. Wall said VistaCare sent her to the daughter to change the family’s mind.


“I gave her this huge emotional blow, then sat there and soothed her,” Wall said. “Of course she signed.”


Wall’s lawyer, Loren Jacobson, said, “It wasn’t her idea. She did it because that was what was expected of her as part of her job, and when she refused to do it anymore and complained, she was fired.” Jacobsen called her client “an extremely good soul stuck in a bad situation.”


Wall’s lawsuit, filed in federal court in Dallas, accuses VistaCare of paying illegal kickbacks to patients and nursing- home employees who referred residents to hospice. It also accuses VistaCare of doctor shopping to get patients certified.


As part of its sales pitch, the hospice told prospects, “The VistaCare Foundation is here to make all your dreams come true,” Wall said. “We used it as a selling feature.”


‘Lay Opinion’


VistaCare gave hospice patients cash and gift cards for groceries, household bills and a wheelchair ramp, the suit alleges. Wall said she sent patients on gambling and beach holidays with VistaCare funds, and paid for a furloughed prison inmate to visit his mother in hospice care.


Weight gain by patients with diagnoses like “debility” and “failure to thrive” is a red flag to Medicare auditors checking eligibility for hospice, she said, so VistaCare would reduce visits to these patients by staffers who fed them “to see if the weight would come back off to keep them on hospice.”


Federal law leaves hospice certification “solely to the discretion” of doctors, so Wall’s “lay opinion” that admitted patients were ineligible is irrelevant, VistaCare said in a motion to dismiss her claims in March. The motion said there was nothing wrong with giving hospice patients money or goods.


Roto-Rooter


The judge allowed Wall’s kickback claim to go forward, dismissed 11 other claims and allowed three of them, including the ineligibility and undelivered care accusations, to be resubmitted in an amended complaint, which the company is also seeking to dismiss.


VistaCare is a unit of Odyssey Healthcare, which runs hospices in 30 states and was bought by Gentiva last year for $1.09 billion. Gentiva, the second-largest hospice provider, had net income of $52.7 million on revenue of $1.45 billion in 2010. Vitas’s average patient stay is 79 days; Gentiva’s is 92 days.


Kevin J. McNamara, the CEO of Chemed, told analysts in January the key to making money in hospice is minimizing labor costs and increasing back-office efficiency. Vitas expects to boost profitability without affecting “the care we provide at the bedside,” he said.


Vitas’s arc to the top of the industry began when its purchase by Chemed was completed in 2004. The prospects in hospice quickly overshadowed the company’s other operating unit -- the Roto-Rooter drain-cleaning and plumbing chain. With Chemed in command, Vitas acquired hospices in Atlanta, Pittsburgh, the Philadelphia area and Birmingham, and opened new branches in 11 states.


No Overtime


Chemed earned $81.8 million last year on $1.28 billion in revenue, with Vitas and its 58,000 patients responsible for 98 percent of profits. The company’s 5.5 weekly visits to patients tops the industry average by 20 percent, according to Mistry.


Vitas’s efforts to save money on labor has hurt patients, former employees and patients’ relatives said. In 2006, the company paid $19 million to settle a class-action suit filed by nurses, home-health aides and social workers in Southern California. They claimed Vitas refused to pay overtime for the hours needed to visit scheduled patients and didn’t allow lunch or rest breaks. After the settlement, in which the company admitted no wrongdoing, Vitas started new policies for employees to document hours worked, according to Mistry.


‘Terminal Agitation’


Employees still can’t meet care obligations because of overtime restrictions, said Mark Wasley, a former Vitas nurse in Palm Springs, California. Wasley, in an interview, gave an account of events on a late shift in 2010 when Vitas dispatched him to a patient in “terminal agitation,” a state of restlessness that grips some people just before death.


After driving 75 minutes across the desert, he found the woman ripping off her nightclothes and her husband and son arguing about what to do. He settled her with morphine. At 3:30 a.m., his shift nearly over, Wasley said he asked for permission to stay until the woman died.


Vitas ordered him home and turned down his request for a chaplain or social worker to replace him at the bedside, Wasley said, because the company didn’t want to pay him the overtime rate of $76 an hour. Wasley said Vitas also nixed his offer to stay for free. He said he learned the patient died an hour or two later.


“They talk about one-on-one care, but they don’t really want it,” according to Wasley, who said he quit last year, upset with the company’s practices.


Left Alone


Vitas immediately addresses “unsafe, unfair or unprofessional” situations identified by employees internally, said Mistry, the Vitas spokeswoman. She declined to address the specifics of Wasley’s account.


The night before his father died last year in hospice care, Barry Burdick said a nurse told him his dad, who had prostate cancer, was comfortable, so Burdick went home. The next morning he learned his father had died while his mother, who has Parkinson’s disease, was lying beside him calling her husband’s name, Burdick said.


Vitas, which was providing hospice care for the couple, had left her alone with the body, Burdick said he was told by nursing home employees.


Sharon Hill, a former Vitas team manager, said she remembers the angry call from the nursing home asking why no one from Vitas had attended the death, listed among the standards of care of the industry trade group. At the time, one Vitas nurse was on vacation and another was out sick while a substitute had eight patients to see, Hill said.


Seeking Help


“It was a horrific situation because hospice promises it will be there at a time of death,” said Hill, now working for another hospice in Palm Springs.


Mistry said Burdick’s account was inaccurate and declined to elaborate.


Burdick, a fifth-grade teacher in Delhi, California, said he revoked Vitas’s care for his mother and moved her to another facility without hospice, where she has gained 12 pounds in the past 14 months and is thriving.


In 2009, Vitas settled a lawsuit brought by survivors of Frank Todd, a retired banker who stayed at the Sunrise at Canyon Crest assisted-living home in Riverside, California. Vitas admitted him without consent and caused his death by giving him an inappropriate drug, according to the plaintiffs, including Todd’s stepdaughter Susan Freeman.


Vitas saleswoman Lori Scott said she heard about Todd from a Sunrise official who told her Freeman, Todd’s designee for making his medical decisions, was seeking more help for her dad. Scott said in a deposition she visited Todd’s doctor and obtained a prescription for a hospice evaluation.


Scopolamine Patch


Within 48 hours, he was enrolled in hospice care with a diagnosis of terminal “cerebral degeneration,” the plaintiffs said. Freeman said she never gave her consent, and Scott’s deposition acknowledged she didn’t notify Freeman of the admission. Vitas’s legal responses said a nurse obtained oral consent from Freeman.


On Todd’s first day in hospice, a Vitas nurse gave him a Scopolamine patch to treat his drooling. Three days later, he was hospitalized after several falls “with an altered level of consciousness,” Vitas court filings said. The label for Scopolamine, used often to control nausea, warns that elderly patients may suffer neurological side effects that can cause psychosis, confusion, agitation and delusions.


Crossword Puzzles


Freeman withdrew her stepfather from Vitas’s care and said the company had behaved like a “used car salesman,” according to an internal Vitas memo submitted to the court. Todd’s health spiraled downward and he died three weeks later.


Vitas’s court filings denied Scopolamine caused his demise and said the drug is commonly given to hospice patients to keep them from choking on their saliva.


Vitas admitted Thelma Covington to hospice in November 2007, taking over her medical care at Willow Pass Healthcare Center in Concord, California. Her son, Robert Rogers, who had Covington’s power of attorney, said a Vitas salesperson called him and offered help so he wouldn’t have to be there so much.


Rogers said he didn’t know he was giving up rights to curative care when he signed his mother up for hospice, and wouldn’t have done so if he did. He said he “didn’t read the fine print” and gave his consent because he was told there would be more people looking after her, taking a load off him.


He described her as alert on his visits, doing crossword puzzles, discussing movies and enjoying the Kentucky Fried Chicken he brought her.


Ointment Treatment


The Vitas admission assessment for Covington said she was terminally ill with “debility, unspecified” and had various other conditions, including dementia, congestive heart failure and diabetes. Two doctors certified that she had less than six months to live.


“She didn’t have no dementia,” Rogers said.


No one said anything about his mother’s life expectancy, according to Rogers, 75, a retired longshoreman and Covington’s only child. For 10 months, Medicare paid Vitas $199 a day to provide palliative care for her at Willow Pass, bills show.


On July 9, 2008, two months before her death, a Vitas doctor ordered a two-week cleansing and ointment treatment for an open wound on Covington’s toe, medical records show. The treatment was never carried out because the plan wasn’t placed in the “treatment administrative record” that the nursing home used to implement orders, according to a deposition by Jennifer Bernal, one of Covington’s Willow Pass nurses. She called it “a serious nursing error.”


In Agony


Nevertheless, Vitas “discontinued” the toe treatment on July 28, according to notes written by one of its nurses, who added “course complete.”


Two days later, Covington was in agony from the wound; a Vitas nurse assessed her pain at level 10 on a 10-point severity index, records show. She was given morphine and a sedative.


On Aug. 25, a nursing home employee noted in a “skin condition report” that the toe was scabrous, swollen, contained pus and had developed black “eschar” -- dead tissue that’s a sign of gangrene. “Hospice notified,” the report said.


Vitas’s notes on the toe for Aug. 25 and Aug. 27 again said “interventions effective, continue plan.” On Sept. 5, a Vitas nurse described “soft black eschar” on the toe. By then, Covington was in such pain from the wound that she lay moaning, “Lo[r]d have mercy,” a Vitas nurse noted.


On the morning of Sept. 7, a Vitas nurse discovered the gangrene and maggots, conferred with a Vitas doctor, washed the toe and wrapped it in plastic, according to nursing notes.


‘Comfort Care’


Rogers said in his deposition that he learned of the maggots later that day from the emergency-room doctor.


When Covington regained consciousness, “I told her, ‘When you get better, I’m taking you home with me,” Rogers testified. She died two days later.


In its court filings, Vitas has yet to address all of Rogers’s neglect allegations.


“The purpose of hospice care is not curative care. It is comfort care,” it argued in an unsuccessful effort to dismiss some of his claims in March. “Accordingly, the fact that [Covington] had conditions which were not ‘cured’ or in fact worsened and she died is not unexpected or unanticipated in a hospice situation. It is not reckless elder abuse.”


--Editors: Gary Putka, Anne Reifenberg





For more information about a Miami-Dade, Broward and Palm Beach County home health care agency for seniors and other family members, contact Brian Gauthier at A Family Member HomeCare (954) 986-5090 or www.afamilymemberhomecare.com. Serving Coconut Creek Cooper City Coral Springs Dania Beach Davie Deerfield Beach Fort Lauderdale Hallandale Beach, Hillsboro Beach Hollywood Lauderdale Lakes Lauderdale-by-the-Sea Lauderhill Lazy Lake Lighthouse Point Margate Miramar North Lauderdale Oakland Park Parkland Pembroke Park Pembroke Pines Plantation Pompano Beach Sea Ranch Lakes Southwest Ranches Sunrise Tamarac Weston Wilton Manors Aventura Sunny Isles Beach Hialeah Miami Lakes Boca Raton Delray Beach Home health care agencies home health care agency home health care services in home health care senior home health care home health care providers health care agency home health care jobs at home health care home health care agencies in florida home health care florida medicare home health care health care agencies home health care elderly home health agency home health care service home care agencies home health care companies home health care agency florida private home health care home health agencies elderly home health care home care agency what is home health care home health care agencies in broward county home health services home health care cost accessible home health care florida home health care home health aide agencies in home health care services home health care business home health aide home health care nursing home health care provider home health care employment in home health care jobs home health aide jobs home health aides home health care medicare in home health care agencies home health care seniors. We work with all South Florida hospitals and rehabilitation clinics to ensure safe transitions to in-home health care and provide attendants, caregivers, certified nursing assistants (CNA), companions, HHAs, homemakers. Providing homecare in Miami-Dade County, Broward County and Palm Beach County Member of Society of Certified Senior Advisors, National Association for HomeCare and Hospice; Home Care Association of Florida; American College of HealthCare Executives, Volunteer Broward, Hospice by the Sea, Rotary Club of Fort Lauderdale, Joseph Meyerhoff Senior Center, HomeHealthCompare, home health advance beneficiary notice, Florida Agency for Health Care Administration

July 20, 2011

The New York Times

A Fair Wage for Home Care Workers

By PAULA SPAN


Let’s say a home care agency employee comes to your parent’s residence, changes the sheets and does the laundry, helps him bathe and dress and makes his lunch before moving on to her next client. Should that employee receive minimum wage and, if she works longer than 40 hours in a week, overtime pay?

If that aide performed the same tasks in an assisted living facility or a nursing home, she would be covered under the federal Fair Labor Standards Act, like a vast majority of American workers, and would be guaranteed the minimum wage.

But in 1974, when Congress added domestic employees to the act, it exempted those providing “companionship services.” “The idea was to carve out the teenager down the street,” said Catherine Ruckelshaus, legal co-director at the National Employment Law Project. “Companions were more like elder-sitters.”

No longer the neighbor who occasionally spends an afternoon with the old woman next door, home care workers have been battling for years to get rid of that exemption. “To exclude this huge set of 1.8 million home care workers, who are trained professionals, often paid by Medicaid — it’s an enormous unintended consequence,” Ms. Ruckelshaus said.

When lawmakers introduced the exemption, she added, “they weren’t thinking of this industry. It barely existed then.”

But now that industry does exist. Home Instead, for example, employs more than 65,000 caregivers in all 50 states. And the industry wants to keep the exemption right where it is. Compel such agencies to pay workers more, executives warn, and they’ll have to raise prices for consumers. “There’s only so much a senior and a family can afford to pay,” Paul Hogan, chairman of Home Instead, told me in an interview.



If you think this discussion sounds vaguely familiar, you’re right. In its waning days, the Clinton administration proposed revising the Fair Labor Standards Act to include home care workers. The arriving Bush administration reversed course. In 2007, a lawsuit by Evelyn Coke — who was retired and ailing, and who’d never gotten overtime in her many years as a home care aide on Long Island — reached the Supreme Court. The justices unanimously ruled against her.

Now, here we are again. The Labor Department has announced that it intends to re-examine the companionship exemption. If the department decides to change the regulations, a comment period will follow during which all interested parties can weigh in, pro or con. It’s a slow process, with no final decision likely for many months, perhaps even a year or longer.

At the same time, the Direct Care Alliance, which represents the women (primarily) who provide hands-on care in facilities and in private homes, is pushing a legislative solution. Bills introduced in both the Senate and the House would extend the requirements of the Fair Labor Standards Act to home care workers and provide state grants to improve their training. “Given the hard-fought battles in the past, we thought we needed a law,” said Leonila Vega, director of the alliance.

Unsurprisingly, the industry paints a bleak picture of what might happen if the bill passes and agencies raise the rates for home care. “Clients will have no choice but to choose nursing homes,” Leann Reynolds, president of Homewatch CareGivers, which has franchises in 36 states, said in an e-mail statement.

Or perhaps, as Mr. Hogan predicted, clients will turn to independent caregivers who don’t work for agencies, the so-called gray market. This may not always be a perilous choice when consumers have a way to check employees’ backgrounds and experience, but it does give families all the responsibilities of employers. Not everyone wants to shoulder them.

As it happens, 21 states already mandate the minimum wage for home care workers, and another 15 require overtime payment (the bigger issue for employers). The sky doesn’t appear to have fallen.

Nevertheless, Home Instead, the nation’s largest provider of nonmedical home care, is seeking a Congressional sponsor for another bill that would not only leave the companionship exemption intact but also prevent any future administration from changing the rules. “We’re asking that the decision-making be removed from the Department of Labor,” Mr. Hogan said.

“Two economic forces keep butting heads,” he added.

Families already struggle with the high cost of agency home care, which averages $19 an hour nationally for a homemaker and $21 for a more skilled home health aide, according to the latest MetLife Market Survey.

But home care workers struggle, too. Theirs is among the fastest-growing and lowest-paid jobs in America. They have high injury rates, often from lifting and repositioning their clients, yet often lack health insurance. Small wonder that turnover is high.

“These need to be middle-class jobs,” Ms. Vega said. “We save a lot of money by keeping people out of nursing homes and hospitals.”

The Labor Department has set two “listening sessions” next week, and it would be a pity if lobbyists were the only folks the regulators got to hear from. You can call in, too, and say what you think about paying these home care workers minimum wage and overtime.

The first session is Monday, July 25, from 4 p.m. to 5 p.m. Eastern time; the second is from 4 p.m. to 5 p.m. Eastern on Wednesday, July 27. At those times, call (888) 730-9140 and use this passcode: 34478.


Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”



Note from A Family Member HomeCare

A Family Member HomeCare assigns only certified Home Health Aides, Certified Nurse Assistants, RNs, LPNs and Companions. All A Family Member HomeCare certified Caregivers must have the appropriate experience to match Client needs. Our proprietary screening processes go far beyond the State of Florida requirements and include:

• Liability coverage to $1,000,000 and theft coverage to $100,000
• Worker’s Compensation Protection
• Nationwide Background Screening
• Social Security Number Trace
• Motor Vehicle Report
• Drug Screening
• Written and Clinical Skills Test by RN
• Credentials Check
• Physical Health Screening
• Reference Verification

In her July 19, 2011 Miami Herald column, Cindy Krisher Goodman tackles the issue of dividing up how to care for aging parents among siblings:


Caring for elders a challenge for families
By Cindy Krischer Goodmanbalancegal@gmail.com


Kirk Lyttle / MCT
The phone call came when Robin D’Angelo was at work. Her father had fallen and was headed to the hospital in an ambulance — again. “I had to drop everything and rush to the scene.” D’Angelo felt her temper rising. She recently had argued with her brothers who live hundreds of miles away over whether to spend money to hire a full-time caregiver. “I feel like it’s all on me. I think the money would be well spent.”

For siblings, taking care of an aging parent can be fraught with decisions and dissention. As parents grow dependent on their adult children, arguments can erupt over whose work schedule is most flexible, whether mom or dad should move to a nursing home or who has control over financial decisions. The desire to cling to old familial roles or continue a festering rivalry can surface at the precise time when siblings most need cohesiveness.

“Even if siblings didn’t get along before, it’s possible to bond over the care of a parent,” says Rona Bartelstone, senior vice president of care management at SeniorBridge, a provider of elder care at home. “Focus on the common goal. It is all about your parent.”

Parent care promises to be an increasingly big concern for adult children. About 43 million Americans look after someone 50 or older, according to the National Alliance for Caregiving. Compared with five years ago, a smaller percentage — 41 percent vs. 46 percent — are hiring professional help. And more — 70 percent vs. 59 percent — are reaching out to unpaid help such as family and friends. Care giving is projected to cost those who look after their parents an estimated $3 trillion in lost wages, pensions, retirement funds and benefits, according to The MetLife Mature Market Institute.

Avoiding sibling struggles over parent care requires the ability to disagree without judgment, show each other mutual respect and communicate early and often. Experts say it’s possible to work together even if not everyone can participate in the same way and it’s possible to achieve consensus even in the most dysfunctional family. Warns Bartelstone: “There is no magic formula because every family is unique.”

• Call a family meeting.

Experts say calling a family meeting becomes critical as parents become frail or suffer health problems. Often, that means starting fresh, letting go of a past grievance and giving a sibling a second chance.

“Let everyone speak and be respectful just like in business setting,” says Joy Loverde, author of The Complete Eldercare Planner: Where to Start, Questions to Ask, How to Find Help. “Leave all emotional issues out of the room and focus on what would mom want.”

Elder care specialist Alene Feinstein, director of admissions for The Palace Group, suggests the family make a list of the pressing concerns — eating habits, medication, hygiene, health issues. “Everyone talks over the list, prioritizes what’s most important, discusses options and taps into resources available.”

For there to be harmony, everyone is going to have to agree that some difference of opinion is OK and find a way to compromise.

“It is not always a democracy,” Feinstein says. “A brother who doesn’t participate in daily care and just waltzes in is entitled to an opinion, but not a vote.”

In some situations, a family may need to bring in a professional, an elder care mediator, to smooth over differences and develop a plan. With more than 80 percent of elder care (an average 71 hours a week) provided by family members, an emerging field of geriatric experts known as professional care managers have sprung up to help.

• Divvy it up.
Experts suggest the next step is finding ways for every sibling to feel involved to the extent they can and want to be. Sometimes a family member’s greatest contribution can be letting another sibling take the reins.

When caring for their 90-year-old father, Janet Carter of Coral Springs and her two siblings still cling to the labels that defined them in the past. Carter, the oldest and the only local sibling, does most of the hands-on work, overseeing the decisions about dad’s care after a major cardiac event. The family recently moved dad to an assisted living facility. Carter’s sister, hundreds of miles away, acts as a sounding board and helps with research, looking into what organizations can provide support. Her brother, three hours away by car, provides emotional support and helps with the logistics of moving dad from one location to another. “I’ve always been junior mom,” Carter says. “They respect me and accept what I delegate. I know for other families, that’s not always the case.”

Yet, for those adult children like Carter who take the lead in parent care, stress can be significant. Currently unemployed, she balances care-giving responsibilities with her job hunt.

Experts say a sibling carrying more of the burden may need to ask for help rather than become resentful. “Don’t hint. Don’t whine. Don’t blame. Don’t bring up past issues. Be very specific about what you need, when you need it, why you need it, why your loved one needs it,” suggests Gary Barg, editor-in-chief of The Fearless Caregiver.

• C ommunicate often; communicate change.

Miscommunication or assuming can create tension. There’s nothing like actual human conversation with siblings to work through challenges.

Almost weekly, Brian Weiss of Miami convenes conference calls with his three siblings in three different states to discuss his 90-year old mom. Although he lives nearby, the family hired a full-time caregiver, who along with doctors, reports to Weiss. During the calls, the siblings will talk over a suggestion from her doctor or a new care plan. When necessary, they’ll put a decision to a vote. “Sometimes if we can’t come to a consensus, I say let’s try it and we can re-evaluate in a few months.” Weiss is convinced his mother’s health has benefited from the siblings’ teamwork. “When it comes to reminding her to take her medicine or to exercise, we’re united, and on the same page.”

Cindy Krischer Goodman is CEO of BalanceGal, a provider of news and advice on work/life balance. Visit www.worklifebalancingact.com or email her at balancegal@gmail.com.


Read more: http://www.miamiherald.com/2011/07/19/v-print/2321664/caring-for-elders-a-challenge.html#ixzz1ThAg8bex




For more information about a Miami-Dade, Broward and Palm Beach County home health care agency for seniors and other family members, contact Brian Gauthier at A Family Member HomeCare (954) 986-5090 or www.afamilymemberhomecare.com. Serving Coconut Creek Cooper City Coral Springs Dania Beach Davie Deerfield Beach Fort Lauderdale Hallandale Beach, Hillsboro Beach Hollywood Lauderdale Lakes Lauderdale-by-the-Sea Lauderhill Lazy Lake Lighthouse Point Margate Miramar North Lauderdale Oakland Park Parkland Pembroke Park Pembroke Pines Plantation Pompano Beach Sea Ranch Lakes Southwest Ranches Sunrise Tamarac Weston Wilton Manors Aventura Sunny Isles Beach Hialeah Miami Lakes Boca Raton Delray Beach Home health care agencies home health care agency home health care services in home health care senior home health care home health care providers health care agency home health care jobs at home health care home health care agencies in florida home health care florida medicare home health care health care agencies home health care elderly home health agency home health care service home care agencies home health care companies home health care agency florida private home health care home health agencies elderly home health care home care agency what is home health care home health care agencies in broward county home health services home health care cost accessible home health care florida home health care home health aide agencies in home health care services home health care business home health aide home health care nursing home health care provider home health care employment in home health care jobs home health aide jobs home health aides home health care medicare in home health care agencies home health care seniors. We work with all South Florida hospitals and rehabilitation clinics to ensure safe transitions to in-home health care and provide attendants, caregivers, certified nursing assistants (CNA), companions, HHAs, homemakers. Providing homecare in Miami-Dade County, Broward County and Palm Beach County Member of Society of Certified Senior Advisors, National Association for HomeCare and Hospice; Home Care Association of Florida; American College of HealthCare Executives, Volunteer Broward, Hospice by the Sea, Rotary Club of Fort Lauderdale, Joseph Meyerhoff Senior Center, HomeHealthCompare, home health advance beneficiary notice, Florida Agency for Health Care Administration

For the U.S. Government's official Medicare guide on to how to select a legitimate home health care agency, click here.  A Family Member HomeCare of Hollywood, Florida is accredited by the Joint Commission, as well as licensed by the Florida Agency for Health Care Administration and has full credentials with quality caregivers who are bonded and insured. 


Miami-Dade couple indicted on charges of conspiring to commit health care Medicare fraud, money laundering


By Jay Weaver, The Miami Herald
9:42 PM EDT, July 27, 2011
There is life after prison — in the Medicare rackets.

Consider Luis Alejandro Sanz, who served five years for cocaine smuggling and money laundering in the 1990s. He reinvented himself by opening a Miami-Dade home health-care agency that authorities say billed Medicare more than $11 million to treat purported diabetics who, it turned out, didn't really have the disease or need nurses to inject their insulin.

Medicare paid his home care agency more than $7 million. To cover up his management role, prosecutors say, Sanz made his wife, Elizabeth Acosta Sanz, the sole corporate officer of Ideal Home Health.

On Tuesday, the 57-year-old Sanz and 44-year-old wife were indicted on charges of conspiring to commit health care fraud, money laundering and paying kickbacks to recruiters who prosecutors say supplied Medicare patients to the couple's agency between 2006 and 2009. The Sanzes are scheduled to be arraigned Friday.

Sanz's reinvention as a Medicare entrepreneur is nothing new for freed felons. The federal program claims it regularly conducts criminal background checks on Medicare operators and has disqualified felons as a result, but many have slipped through the system.

"Medicare contractors are supposed to be responsible for enrollment and screening applicants, but the process is broken and ineffective," said Ryan Stumphauzer, a former federal prosecutor who ran the health care fraud section in the Miami U.S. attorney's office and now heads his own firm.

"Felons and crooks can get as many provider numbers as they want by recruiting nominees or family members to sign documents," he said. "The nominees know absolutely nothing about Medicare, have no experience in healthcare, and couldn't pass the simplest blush test. They are never even interviewed or screened in a meaningful way."

In recent months, the taxpayer-funded Medicare program adopted new measures designed to combat the failed "pay and chase" model of doling out dollars for claims, then pursuing the schemers after they have run off with the money. As part of the new Affordable Care Act, Medicare received $350 million to develop stricter screening of healthcare providers and more sophisticated software for detecting fraudulent claims.

Among the improvements: Providers who historically have posed a higher risk of fraud, such as medical equipment suppliers and home care services, must now undergo more comprehensive screenings, including FBI criminal background checks and fingerprinting.

Also, if Medicare contractors receive a "credible" allegation of fraud from a patient, payments to a provider can temporarily be suspended while an investigation is done. New enrollment can also be temporarily halted in a healthcare area suspected of fraud.

The Sanzes' alleged Medicare scheme was deemed so serious that U.S. Magistrate Judge Patrick White denied their bids for bond Tuesday while they await trial, saying they are a risk of flight.

Assistant U.S. Attorney Dan Bernstein argued that the couple's home care agency issued Luis Sanz checks totaling $1.5 million, and another $1.5 million to DASA Investments, of which he was president. Sanz's wife received an additional $1.65 million, he said. She is being detained before trial, too.

Bernstein said the couple and their agency, Ideal, "had 40 separate bank accounts, and at the present time the government has not been able to trace all of the monies that this defendant and the co-defendant received," according to Luis Sanz's detention order.

Their attorney, Jay Moskowitz, said they were arrested by the FBI a month ago and knew the indictment was imminent. "We are dealing with the case," he said, declining to comment further.

Sanz was convicted in 1996 as part of a 20-member cocaine trafficking ring.




For more information about a Miami-Dade, Broward and Palm Beach County home health care agency for seniors and other family members, contact Brian Gauthier at A Family Member HomeCare (954) 986-5090 or www.afamilymemberhomecare.com. Serving Coconut Creek Cooper City Coral Springs Dania Beach Davie Deerfield Beach Fort Lauderdale Hallandale Beach, Hillsboro Beach Hollywood Lauderdale Lakes Lauderdale-by-the-Sea Lauderhill Lazy Lake Lighthouse Point Margate Miramar North Lauderdale Oakland Park Parkland Pembroke Park Pembroke Pines Plantation Pompano Beach Sea Ranch Lakes Southwest Ranches Sunrise Tamarac Weston Wilton Manors Aventura Sunny Isles Beach Hialeah Miami Lakes Boca Raton Delray Beach Home health care agencies home health care agency home health care services in home health care senior home health care home health care providers health care agency home health care jobs at home health care home health care agencies in florida home health care florida medicare home health care health care agencies home health care elderly home health agency home health care service home care agencies home health care companies home health care agency florida private home health care home health agencies elderly home health care home care agency what is home health care home health care agencies in broward county home health services home health care cost accessible home health care florida home health care home health aide agencies in home health care services home health care business home health aide home health care nursing home health care provider home health care employment in home health care jobs home health aide jobs home health aides home health care medicare in home health care agencies home health care seniors. We work with all South Florida hospitals and rehabilitation clinics to ensure safe transitions to in-home health care and provide attendants, caregivers, certified nursing assistants (CNA), companions, HHAs, homemakers. Providing homecare in Miami-Dade County, Broward County and Palm Beach County Member of Society of Certified Senior Advisors, National Association for HomeCare and Hospice; Home Care Association of Florida; American College of HealthCare Executives, Volunteer Broward, Hospice by the Sea, Rotary Club of Fort Lauderdale, Joseph Meyerhoff Senior Center, HomeHealthCompare, home health advance beneficiary notice, Florida Agency for Health Care Administration

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For more information about a Miami-Dade, Broward and Palm Beach County home health care agency for seniors and other family members, contact Brian Gauthier at A Family Member HomeCare (954) 986-5090 or www.afamilymemberhomecare.com. Serving Coconut Creek Cooper City Coral Springs Dania Beach Davie Deerfield Beach Fort Lauderdale Hallandale Beach, Hillsboro Beach Hollywood Lauderdale Lakes Lauderdale-by-the-Sea Lauderhill Lazy Lake Lighthouse Point Margate Miramar North Lauderdale Oakland Park Parkland Pembroke Park Pembroke Pines Plantation Pompano Beach Sea Ranch Lakes Southwest Ranches Sunrise Tamarac Weston Wilton Manors Aventura Sunny Isles Beach Hialeah Miami Lakes Boca Raton Delray Beach Home health care agencies home health care agency home health care services in home health care senior home health care home health care providers health care agency home health care jobs at home health care home health care agencies in florida home health care florida medicare home health care health care agencies home health care elderly home health agency home health care service home care agencies home health care companies home health care agency florida private home health care home health agencies elderly home health care home care agency what is home health care home health care agencies in broward county home health services home health care cost accessible home health care florida home health care home health aide agencies in home health care services home health care business home health aide home health care nursing home health care provider home health care employment in home health care jobs home health aide jobs home health aides home health care medicare in home health care agencies home health care seniors. We work with all South Florida hospitals and rehabilitation clinics to ensure safe transitions to in-home health care and provide attendants, caregivers, certified nursing assistants (CNA), companions, HHAs, homemakers. Providing homecare in Miami-Dade County, Broward County and Palm Beach County Member of Society of Certified Senior Advisors, National Association for HomeCare and Hospice; Home Care Association of Florida; American College of HealthCare Executives, Volunteer Broward, Hospice by the Sea, Rotary Club of Fort Lauderdale, Joseph Meyerhoff Senior Center, HomeHealthCompare, home health advance beneficiary notice, Florida Agency for Health Care Administration