Editor’s
note: This article is the second in a three-part series examining how
and why New York’s nursing homes too often fail to keep their residents
safe. Read the first part here.
Robert Negron, 60, has been shuttled
between more nursing homes than he can remember – at least six and
perhaps as many as 20 – before landing in his current bed at Beth
Abraham Health Services in the Bronx. The instability has been wearing
on Negron, a Crohn’s disease patient who uses a wheelchair and needs
regular attention for an unhealed wound on his foot and chronic skin
ulcers – but it’s still better than being in a homeless shelter, he
would say.
“In the shelters it's dirty, it’s nasty. You could
not get enough medical attention and lose a limb,” Negron said,
explaining how the unsanitary conditions at the men’s shelters on Ward’s
Island, over the 10 years he occasionally stayed there,put
him at risk. Although he visited a clinic for care and did the best he
could to change his own bandages, “There were times when my foot was
really bad,” he said. A New York City Human Resources Administration
spokesman said that since Negron’s stay, “substantial improvements” have
been made at that shelter.
Yet nursing homes, Negron said, have forced him into
city homeless shelters three times. While there, the only thing that
concerned him more than the lack of medical care were the people around
him.
“They victimize you,” Negron said. “The criminals and
the undesirables, they prey on the homeless disabled.” Once, he said,
another man assaulted him in the shelter when he refused to hold drugs
for him.
Negron’s case is an extreme one, advocates for the
disabled say, but he is not alone. His experience is illustrative of a
long-standing practice of nursing homes placing residents into New York
City’s Department of Homeless Services shelter system. These vulnerable
New Yorkers often have chronic medical conditions that have improved
little, advocates say, but are moved to shelters that are poorly
equipped for ailing individualsand are rife with violence.
Long-term care advocates are alarmed by a sudden
spike in the number of older adults who report being forced out after
having received nursing home care for many months or years. Although the
city keeps no official statistics on transfers from nursing homes to
shelters, advocates say there is evidence that the figures are rising.
In March, Gov. Andrew Cuomo called the city’s
homeless shelter system “deplorable” and “dangerous,” citing recent news
reports that show high numbers of assaults. The city has taken steps to
try to address these issues, most recently opting to retrain shelter
security staff in order to manage the violence.
“We are in the throes of a homelessness crisis in New
York City … and we are watching people being poured into the shelters
from nursing facilities,” said Susan Dooha, executive director of Center
for Independence of the Disabled, New York. These often frail
individuals, she said, “cannot be cared for in the shelters,” where
there is no skilled nursing care and part-time clinics offer what is
often the only medical aid available.
Nursing homes are required by state law to ensure all
transfers are made to a safe place. For that reason, Dooha said she
“cannot fathom” how nursing homes could send their residents to the
city’s homeless shelters. Beyond that, Dooha said, federal protections
were also being trampled.
When reached for comment, an HRA spokesman said “no
one” should have been transferred from a nursing home to a shelter “if
the needed medical treatment is not available at that shelter.”
“Their civil rights are being violated, in my
opinion,” Dooha said, citing protections under the Americans with
Disabilities Act that ensure safety and accessibility for the disabled.
"I recently brought this up with people in the governor's office because
I'm so concerned,” Dooha said, adding that she had also alerted the New
York State Department of Health and the New York State Office for the
Aging.
“People are not furniture,” Dooha said.
Nevertheless, nursing home administrators responsible
for what they call “involuntary transfers” of their residents into
homeless shelters tell watchdogs that there’s little they can do. If
someone no longer requires a “nursing home level of care,” the logic
goes, that person needs to leave. And for those with nowhere else to go,
that means they go to a shelter.
“What I've heard directly from the people who were
responsible for the discharge is, ‘Yes, it's unfortunate. We wish we had
another option. Our hands are tied. They gotta go,’” explained Richard
Danford, director of the New York City Long Term Care Ombudsman Program,
a federally mandated and largely volunteer group advocating for nursing
home residents.
In the past, Danford said, “You could count the
number of shelter discharge complaints the ombudsman program got in a
year on one hand.”
In the last four months, however, complaints are coming in at eight times the normal rate.
Since last November, the program fielded calls from
16 nursing home residents in New York City complaining that they were
being transferred to homeless shelters. And while that number may appear
low, Danford said, those complaints represent only a small fraction of
what’s happening in the city’s nursing homes. It is likely that there
are many others being sent into homeless shelters who did not call to
complain, Danford said.
“These are the people who have it together enough to
be able to read their notice, realize they can call us, and realize they
can appeal the discharge,” Danford said.
And those calls did not originate from a single
nursing home or even a few nursing homes. The calls came from 16
residents in 15 different homes, in four out of the five boroughs in New
York City. In other words, Danford said, there are indications that the
transfers are not only increasing in number, they’re becoming more
widespread.
“We're really worried that that's the tip of an
iceberg,” Danford said. “It's clearly becoming a practice. … There’s no
question about it. Our biggest fear is that the number is substantially
higher” than the call logs show.
After City & State requested statistics on the
number of nursing home residents discharged into city homeless shelters,
a spokesman for the Human Resources Administration responded that “DHS
has not been systematically tracking entries from nursing homes but will
be doing so in the future.”
The spokesman added, “As part of the 90 day review,
we will be enhancing DHS procedures to make sure that clients are not
discharged from nursing homes to DHS shelters when that is not
appropriate.”
Daniel Ross, a lawyer with MFY Legal
Services, which provides pro-bono civil representation for vulnerable
New Yorkers, has counseled several nursing home residents threatened
with a transfer into a homeless shelter.
“Most shelters are inaccessible (to the disabled) and
they're unsafe,” Ross said, citing news reports describing shelter
conditions. “And those two things are particularly concerning for
nursing home residents who are particularly vulnerable to those
conditions.”
“I don't think a homeless shelter can be an
‘appropriate discharge plan’ for long-term nursing home residents,” Ross
said, referencing the plans that nursing homes must develop before
removing someone from their care.
Nursing home residents can be discharged against
their will for a few reasons, according to state regulations, including a
determination that “the transfer or discharge is appropriate because
the resident’s health has improved sufficiently.” Advocates say that
this is the most common reason nursing home residents are given when
they are told they are being transferred to a shelter.
Nursing homes are required to provide residents
written notice 30 days before transferring them. The notice should
include a care plan that shows the facility has arranged for relocation
to a specific destination that is safe. Guidelines even suggest an
advance visit to the destination.
But actual notices reviewed by the ombudsmen cast doubt on how – or if – nursing homes are meeting these requirements.
One recent notice, dated March 4, appeared not to
give the resident 30 days notice. It noted an “Effective/Anticipated
Date of Discharge” of just one week later, on March 11. It also didn’t
specify where exactly the resident was going. The transfer destination,
scrawled in looping handwriting, read simply: “Department of Homeless
Services.”
Looking at the form, Danford wryly noted, “That’s it.
Just any shelter (they) can drive him to.” In summary, he said, the
notice “is not in compliance with the legal requirements.”
But on the face of it, the reason for the transfer
was valid: “As per interdisciplinary team, resident has completed health
goals and no longer requires skilled nursing care.”
Since nursing home medical staff can make that
determination themselves, advocates believe that many residents feel
helpless in the face of a transfer, so they do not challenge it.
Residents have the right to appeal to the state
Department of Health, but advocates worry that few are even aware of
that, because they have found that nursing homes do not always give
residents that information, as required.
Ross, at MFY Legal Services, has represented residents who wanted to challenge their transfer.
In one case, a client had lived in the nursing home
for years, receiving care for an array of problems.
The man, an amputee,
had an ill-fitting prosthesis that left him reliant on his wheelchair
to move around. Nevertheless, his nursing home wanted to send him to a
shelter.
He appealed the decision to the Health Department,
which regulates nursing homes and acts as arbitrator in transfer
disputes. An administrative law judge from Albany came down to New York
City to preside over a hearing in a conference room at the nursing home.
Gathered around the table, each side presented their
case. The nursing home’s physical therapist argued the man did not need
to be a resident any longer. Ross argued the man needed further care.
The judge ruled in the nursing home’s favor and
approved the man’s transfer into a homeless shelter. Ross said he has
not heard from his client since then and did not know where he was.
“If a nursing home wants to do this,” Ross said, “it's not that challenging.”
Ross explained that a core problem is that the Health
Department has decided that homeless shelters can be an “appropriate”
place for long-term nursing home residents. “I think we just disagree
with the Department of Health about what ‘appropriate’ is,” Ross said.
The Department of Health’s in-house administrative
law judges have approved discharges to shelters “in certain instances,” a
spokesman acknowledged, “particularly where an individual was homeless
prior to being admitted to a nursing home for short-term skilled nursing
care and have no other housing options.” The department did not respond
to requests for statistics on how often these hearings occur.
The department spokesman also stressed the
responsibility of nursing homes to “establish that the discharge is safe
and appropriate for the person’s clinical needs.”
Michael Balboni, executive director of the Greater
New York Health Care Facilities Association, which represents for-profit
nursing homes in the New York City area, agreed with the Health
Department on that point, stressing the need for nursing homes to follow
state regulations.
But Balboni said there are pressures from
state-implemented federal programs, aimed at reducing health care costs,
that incentivize nursing homes to push out patients who don’t require
skilled nursing care – particularly the Delivery System Reform Incentive Payment Program and managed care.
Richard Herrick, president and CEO of the New York
State Health Facilities Association, which represents a variety of
long-term care facilities, echoed that sentiment, agreeing that nursing
homes were under pressure to discharge patients. The state Health
Department, he said, is “always very strict about warning us about the
inappropriate placement of patients in nursing homes – ‘inappropriate’ means that they don't meet skilled (nursing) needs.”
A spokesperson for LeadingAge New York, an
organization that represents the state’s nonprofit nursing homes,
further explained that discharging a nursing home resident to a shelter
may allow that person to access public assistance benefits they would be
unable to receive while living in nursing home care.
That reasoning sounds familiar to Negron.
He recalled a social worker telling him before he was
transferred into shelter, “All we can do is send you to a shelter, but
you won't be there long. They'll help you get out.”
“But that's a crock, man,” Negron said. “They don't
give anyone with a wheelchair housing. All you're doing is waiting to be
shipped off to another nursing home.”
“Between the shelter and the nursing home, there is a revolving door,” Negron said of his experience. “It’s a vicious game.”
Whatever the rationale, advocates say long-term
nursing home residents like Negron should not be placed in the city’s
shelter system.
The ombudsman’s office has a catalog of stories about
such long-term patients that it believes should never have been removed
from nursing care. In one such instance last summer, a man who had been
transferred out of a nursing home into a homeless shelter immediately
walked himself to the nearest hospital emergency room and was admitted
for inpatient medical care.
As the number of complaints go up, Danford’s office expects to have more stories to tell.
“There’s definitely been an increase, there’s no
doubt about it,” Danford said. “Something’s going on and someone needs
to figure out what it is.”
Balboni agrees.
“The Department of Health, the state Senate, the
state Assembly should hold joint hearings on this. They should find out
what's going on,” Balboni said. “But more importantly: How do you stop
it?”
For now, Negron holds out hope that the current care
he’s receiving at Beth Abraham will allow him to recuperate enough to
find his own place someday. And perhaps, he said, sharing his story will
help others, too.
“Maybe if there's enough exposure,” he said. “Maybe someone will say we need to do more for those people.”
You can view an example of a nursing home discharge/transfer notice below.
Nursing Home Notice of Discharge or Transfer
Full Article & Source:
NYC nursing homes forcing residents into homeless shelters
