Pelé is reportedly responding well to treatment for a respiratory infection, his hospital says. Photograph: Lucas Jackson/Reuters
The Brazilian football great Pelé posted on
Instagram on Saturday evening to say that he is feeling “strong” and
“with hope”, after an outpouring of concern online in response to
unconfirmed reports that he had been moved to palliative care.
“I want to keep everyone calm and positive,” Pelé wrote, sharing the latest medical report from São Paulo’s Albert Einstein hospital that says he remains in stable condition. “I follow my treatment as usual.”
Pelé, 82, who helped the Brazilian national team win three World Cups, ended his message by calling on fans to watch the seleção play in this year’s tournament. Brazilwill face South Korea in Doha on Monday.
Earlier, the hospital said Pelé remained in a
stable condition after being hospitalised this week as he battles colon
cancer. He has also responded well to treatment for a respiratory
infection and his condition has not worsened in the last 24 hours, the
medical staff said. He was admitted to hospital on Tuesday to
re-evaluate his cancer treatment.
On Saturday
morning the Brazilian newspaper Folha de S.Paulo reported that Pelé is
receiving palliative care after he stopped responding to chemotherapy
treatment for the cancer.
According to the
newspaper, the chemotherapy has now been suspended and Pelé is receiving
end-of-life care, being treated only for symptoms such as pain and
shortness of breath.
The Albert Einstein hospital in São Paulo declined to confirm reports
that the football legend known as The King is under palliative care and
said it would only communicate through official bulletins. A medical
report released on Friday said Pelé was being treated with antibiotics
for a respiratory infection. His condition was “stable, with a general
improvement in his health status”, the report said.
Football stars past and present, including French
striker Kylian Mbappé, wished Pelé well on social media following the
reports that he is receiving palliative care. “Pray for The King,”
Mbappé tweeted.
Pelé had sought to reassure
fans in an Instagram post on Thursday, saying that he was making his
“monthly visit” to hospital. He posted a picture of a Qatar building lit
up with a message wishing him a prompt recovery and thanked the World
Cup-hosting nation for “the tribute”.
His
daughter, Kely Nascimento, who is in Qatar for the tournament, also
sought to assuage concerns surrounding the football legend’s health.
“The media is freaking out again,” she said on social media on Thursday,
adding that her siblings were with their father and that Pelé’s health
did not require her to jump on a plane back to Brazil.
Born
Edson Arantes do Nascimento, Pelé is considered one of the greatest
footballers of all time. He rose to international fame aged just 17 when
he scored six goals for Brazil in the 1958 World Cup, including two in
the final in which Brazil beat the hosts, Sweden, to win their first
world title.
Pelé, who retired from football in
1977, has been suffering from health problems in recent years. He was
diagnosed with colon cancer in September 2021 and spent two weeks in
hospital last December.
George Pappas and his daughter, Mary Hilliard, in a photo taken in the 1950s and preserved in a family photo album. Maria Sterlini/Special to the Record-Eagle
BAD AXE — It was June 2021 and by the way she describes it, every
bone in Maria Sterlini’s body told her the solution to a family
emergency seemed obvious.
Five years earlier, a Huron County
probate court judge deemed Sterlini’s cousin, Mary Hilliard, 68,
incapacitated because of a mental health diagnosis. In 2016, the judge
appointed Hilliard’s elderly mother, Rita Sniecikowski, as guardian.
But then last summer Sniecikowski, 83, was hospitalized, throwing
Hilliard’s life into disarray. Hilliard’s family lost control of her
care — and have since felt isolated from her.
Sterlini said she
wanted to keep her family together, yet at times it seemed to her as if
those in positions of authority did just the opposite.
A public
guardian and staff with Adult Protective Services supported Hilliard’s
emergency placement in an adult foster care home, while Sterlini and
another close relative said they thought Hilliard should live with
family.
This case came to light last August when Record-Eagle
reporters began examining probate court records in 10 Michigan counties,
as part of an ongoing probe of the state’s guardianship system.
Reporters
learned, among other findings, problems can arise when family members, a
judge, and social service agency staff all contend they are acting in
the best interests of a vulnerable person, but disagree on what those
best interests are.
Hilliard became a resident of Lauren
Osantoski’s AFC in Bad Axe on June 9, 2021, and has had scant contact
with some members of her family since.
“This doesn’t make sense to
me,” Sterlini said. “I don’t understand why the family wasn’t included
in this decision. We never wanted her in a foster care home.”
Sterlini
said she and Hilliard’s father, George Pappas, of Harbor Springs, can
count on one hand the number of times they’ve spoken with Hilliard in
the past year.
The public guardian contends the frequency of
communication is what Hilliard wants, while Sterlini and Pappas
expressed concern the AFC’s phone policy, trauma experienced by Hilliard
when her mother was hospitalized or stonewalling by caretakers could be
responsible.
Calls to the foster care home by a reporter seeking
to speak with Hilliard went to voicemail and were not returned.
Osantoski, owner of the AFC home, did not return calls seeking comment.
County officials confirmed the facility does not allow individual
cellphones, providing instead access to a house phone.
Ashley
Kidd, a case worker with Huron County’s Public Guardian office, which
now oversees Hilliard’s case, said limited contact is what Hilliard has
so far preferred.
“Mary does have all of their phone numbers and
she is allowed to call if she wants to,” Kidd said. “She doesn’t always
want that communication, at least not right at the moment.”
Pappas,
96, who owns a car and drives short distances but cannot make the
460-mile trip from Harbor Springs to Bad Axe and back, said he last
spoke with his daughter in mid-April.
Sterlini and Pappas said
they tried to make a conference call to Hilliard on April 24, Greek
Easter, a holiday of special significance for the family, who are
members of the Greek Orthodox Church. The call went to voicemail and
wasn’t returned, Sterlini said.
Pappas is himself no stranger to
the control a third-party court-appointment can exert over a person’s
life. In 2021, an Emmet County Probate Court judge appointed him a
conservator, the decision went awry and continues to be the subject of extensive reporting by the Record-Eagle.
“I
feel like Mary has been stolen from us by all these people,” Pappas
said, of staff with social service agencies and the probate court. “I
can’t even get with her anymore on the telephone.”
Worth saving
Maria
“Dolly” Sterlini, 74, lives 130 miles south of Bad Axe in Canton. When
Hilliard’s mother was hospitalized, Sterlini, who lives alone, said
she’d hoped Hilliard could come live with her.
Sterlini and
Hilliard have always been close, Sterlini said, growing up as they did
just blocks from one another in a Detroit suburb. Hilliard is
artistically talented, Sterlini said, recalling summer afternoons the
two spent together, painting and drawing.
“Mary is the most
beautiful, heartfelt person you ever want to know,” Sterlini said.
“There’s never been a cross word between us. She’s like my little
sister. And she’s worth saving.”
Hilliard is one of more than
130,000 adults in Michigan who a probate judge has determined requires
help managing their medical, housing or financial affairs and as a
result have a court-ordered guardian, conservator or both.
When
Huron County Probate Court Judge David Clabeusch appointed Hilliard’s
mother as her guardian, he also appointed the county’s Public Guardian,
Stephen Allen, as her co-guardian and later, her conservator. Jacilyn
Geiger took over in the role when Allen retired in 2020.
Guardians
make medical and housing decisions, conservators handle finances, which
in Hilliard’s case included $643 in monthly social security disability
benefits, records show, and $76 a month from Veterans Affairs.
A
court-appointed attorney met with Hilliard on July 6, 2016, court
records show, and reported back to the court that Hilliard did not
drive, cook or grocery shop, but had easily recited her age, birthday
and address.
The attorney said in her report that Hilliard questioned whether her mental health diagnosis was still accurate.
Sterlini
said she also has questions about Hilliard’s diagnosis and treatment;
annual guardian reports filed in 2017 and 2018 by Sniecikowski state
Hilliard saw a psychiatrist twice annually for treatment and
prescription medication refills.
Doubly Victimized
Pappas
said he feels like his family has been doubly victimized by a system
that has long failed to care for the state’s most vulnerable residents.
Decades
of reform attempts by governors, attorneys general and legislators have
so far failed to alter the Michigan judiciary, which controls
guardianship and conservatorship in the state’s probate courts.
But
it is family members and other “persons of interest” — and not the
court — who bear the responsibility of making sure appointed guardians
and conservators protect the people they are assigned to serve.
Pappas
and Sterlini are listed as “persons of interest” in Hilliard’s case,
records show, and after APS placed Hilliard in the AFC home, Sterlini
fought Hilliard’s guardianship in court.
On Aug. 6, 2021, Sterlini
filed a petition in Huron County Probate Court, seeking to have herself
appointed Hilliard’s guardian. The court appointed a guardian ad litem
who met with Hilliard and reported back to the court, but never met with
or mentioned Sterlini, records show, even though Sterlini was the
petitioner.
Hilliard attended the Aug. 10, 2021 petition hearing,
where Judge Clabuesch asked her where she preferred to live, at the
Osantoski home or with Sterlini — who the family knows as “Dolly.”
In
hundreds of pages of documents the Record-Eagle reviewed for this
story, the transcript of this hearing is the only time Hilliard’s voice
was evident.
“The Osantoski home is a — what’s, what is it?” Hilliard asked the judge.
“Right there, where you are,” the judge said.
“Oh, oh, oh, oh. Lauren’s,” Hilliard said.
“Lauren’s,” the judge confirmed. “Do you —”
“I, I, I think I’ll go with Dolly,” Hilliard said.
The
judge asked again whether Hilliard wanted to live with Dolly and the
transcript shows Hilliard said living with Dolly would alleviate
pressure on her mother.
When the judge responded that he didn’t
want to know about Hilliard’s mother, he wanted to know which place was
best for her, Hilliard said she couldn’t make up her mind.
“All right. That’s fine,” the judge said. “That’s a sign of somebody being incapacitated.”
Sterlini’s
petition was denied, court records show, the public guardian retained
its appointment as co-guardian and conservator and Hilliard stayed at
the AFC home.
Sniecikowski, after being hospitalized, did not
return to the apartment she shared with her daughter and, records show,
now lives in a nursing home. In October the court removed her as
Hilliard’s co-guardian.
A Difficult Spot
In Michigan there
are a handful of counties, like Huron, in the state’s thumb, which fund
public guardian offices and employ staff to accept probate court
appointments. Their jobs are difficult and, records show, frequently
underfunded.
A county public guardian is different from a public
administrator, which most counties in Michigan have. Public
administrators are attorneys who handle estates when there are no heirs
on record. The state also has an overall public administrator, Katharyn
Barron, who acts as “person of interest” for vulnerable people who’ve
been appointed a guardian or conservator, and have no family of record.
“As
a county-funded office, we don’t turn down any cases,” Kidd, employed
by the county’s public guardian office since 2017, explained. “We are
having a growing number of people who are on our caseload and now live
outside the county as there’s a lack of appropriate housing available in
our area.”
Vulnerable adults the public guardian office is
appointed to serve all once lived in Huron County, Kidd said, and many
still do, though others are placed in facilities as far away as Rose
City (117 miles), Grand Rapids (204 miles), Berrien County (260 miles)
and Detroit (113 miles).
A fact Sterlini said makes placement of
Hilliard into a sought-after spot in the county, instead of with family,
all the more inexplicable.
The county’s public guardian office
has a full-time staff of four, Kidd said, who are responsible for the
well-being of about 270 people. Kidd confirmed she and others in the
office have had repeated communications with Sterlini and Pappas.
“Dolly
does have the right to petition the court if she feels there is a more
appropriate placement or a guardianship alternative of her being the
guardian,” Kidd said, of Hilliard’s case. “I get where Dolly is coming
from. We empathize that she wants her family close to her.
Unfortunately, it just hasn’t ever gone that way due to Mary’s wishes.”
Kidd
said the staff all know Hilliard and see her frequently. Osantoski’s
AFC is near the public guardian’s office and Kidd said a dozen other
people the office serves as guardian or conservator also live there.
Osantoski’s
AFC is one of the only facilities in the area that accepts emergency
placements like Hilliard’s, whose situation was first investigated by
Adult Protective Services after Sniecikowski expressed concern for her
daughter to a hospital social worker.
That doesn’t explain why
Sterlini and Pappas weren’t informed, or why faulty information stating
Hilliard was in danger of becoming homeless, was included in an APS log
documenting the complaint.
Records show Sterlini began
communicating with the public guardian’s office in 2019, asking to be
kept informed about Hilliard’s care. Pappas said he wasn’t initially
informed his daughter was placed in an AFC home, either.
Instead, when Pappas learned his ex-wife was hospitalized and he couldn’t reach his daughter, he called police.
Records
show officers from Bad Axe Police Department visited Osantoski’s AFC
for a welfare check and found Hilliard safe, happy and in good health.
The involvement of law enforcement, however, prompted another alarming
entry in the APS complaint log.
This entry, dated June 23, 2021, referenced a call to APS from Osantoski.
“Lauren
stated Mary’s dad called her on Friday night,” the entry states. “No
one knew she had a father. He called police and had them come out to
check on Mary ‘cause Lauren would not release any information.”
If Pappas wanted to speak with his daughter, the APS log states, he had to go through the public guardian.
Kidd
said the public guardian’s office is in a difficult spot – Sterlini and
Pappas would like Hilliard to live with family, while by law public
guardian staff must respect Hilliard’s wishes and according to Kidd,
that means staying at Osantoski’s.
“She would do OK in a home
setting with family or whatnot, if that was something she desired,” Kidd
said, of Hilliard. “She’s been very happy where she’s at. She has not
expressed wanting to go anywhere else.”
Pappas previously
expressed concern about the care Hilliard is receiving there, and while
state records with the Bureau of Licensing and Regulatory Affairs show
the facility is in compliance, there have also been regulatory
violations.
Since October of 2019 the facility has been the
subject of six special investigations by LARA licensing consultants –
none have substantiated allegations or recommended the facility’s
license be reviewed.
“The residents are going to be afraid to tell
you the truth for fear of what will happen to them when you leave,”
stated one complainant, whose name LARA redacted.
Adult foster
care homes in Michigan are required to be licensed by LARA, and many of
these facilities draw all or a large portion of their residents from
placements by social service organizations, like APS or community mental
health.
Previous reporting by the Record-Eagle has found it is
common for residents of AFC homes to be appointed guardians,
conservators or both. AFC home residents are often elderly,
developmentally disabled, mentally ill or struggle with memory issues.
Pappas
said last year he was unable to speak with his daughter on Father’s
Day, and is hopeful when he calls on June 19, the result will be
different.
Pappas kept a tally of his attempts to talk with his
daughter, jotting down on a yellow legal pad repeated denials and
excuses, including, “we’re eating lunch,” or “It’s Sunday.”
Phone
calls are the only way Pappas can communicate with his daughter, he
said, since he is unable to drive to the AFC home and, while he sends
cards and letters, she doesn’t write back.
“That is something that
we have addressed with the home,” Kidd said, reiterating Hilliard has
phone numbers of family members and can make outgoing calls if she
wants.
Sterlini has continued to communicate with the public
guardian’s office. For example, in October she emailed the office to ask
whether Hilliard received the hot pink hat, scarf and gloves Sterlini
sent to her for the winter.
Last year, during one of several
visits a Record-Eagle reporter made to Pappas’ apartment in Harbor
Springs, Pappas put the handset for his landline on speakerphone, called
Osantoski’s AFC, gave his name and asked to speak with his daughter.
The staff member who answered the phone said Pappas had to call Hilliard’s guardian.
When Pappas asked for the name of the guardian and their phone number, the call was disconnected.
SUTTONS BAY – The story begins at Martha Rothaug’s upright Yamaha.
It
was June 2016. Martha, a former concert pianist, was becoming
increasingly forgetful, struggling to play songs she once knew by heart.
A doctor told Martha’s daughter, Jen Rodgers, the misplayed keys could
be an early sign of dementia.
For Martha — “Marty” to family and friends — at stake was not only
her health and where she would live in the final years of her life, but
control of her $1.8 million estate.
The family’s accumulated
wealth was far above average, yet their problem will sound familiar to
many — an aging parent who wants to live independently; adult children
who disagree about their parent’s care.
Particularly alarming in
this case, however, is that Marty, 78, had planned for such an
eventuality, consulting with an attorney on a 40-page estate plan she
signed more than a decade before a doctor flagged the memory issues.
Jen
was the person Marty trusted to handle her end-of-life care and
decision-making. In 2007 and again in 2014, Marty put those wishes in
writing.
“I nominate Jennifer A. Rodgers to serve as Guardian over
my person and Conservator over my estate if a protective order over my
person or estate is commenced after the execution of this power of
attorney,” a document Marty signed and notarized Sept. 26, 2014 states.
But
in March 2017, a state worker cited unsubstantiated complaints about
Jen in a court petition. A Leelanau County Probate Court judge responded
by appointing Jill Case, a woman neither Jen nor Marty had ever met, to
be Marty’s guardian and conservator.
This decision by Judge Larry
Nelson gave Case control over where Marty lived, how her money was
spent and who could visit her. It also sparked a legal battle that would
fester for years, occupy two northern Michigan probate courts,
temporarily separate a mother from her daughter and rack up thousands in
attorneys fees.
Jen, who previously shared part of this story with the Northern Express, said she tries not to dwell on the past, but that’s not easy.
“I still don’t understand why we couldn’t have worked together as a family,” she said.
A family divided
Marty has a son, Simeon Rodgers, Jen’s older brother who lives in Ohio.
Court
documents show in the mid-2000s, Marty and Simeon became estranged
after the family’s once successful metal fabrication company fell on
hard times.
A resulting bankruptcy forced the sale of Marty’s Lake
Leelanau home and in 2007, she sued Simeon in the Common Pleas Court of
Montgomery County, Ohio, for breach of contract. Simeon counter-sued
for defamation and infliction of emotional distress, court records show,
and several months later, Marty wrote her son out of her will.
Simeon
says Jen manipulated their mother into changing her will, that his
lawsuit was a standard response and not intended to be punitive.
“My
sister engineered all that,” Simeon said, of being removed from his
mother’s will. “When you are sued, do you know the law well enough to
know you always file a countersuit? You always do.”
Jen disputes
Simeon’s characterization of her. In 2015, records show Simeon and Marty
did begin to try to repair their relationship.
By then Marty had moved to Suttons Bay and soon after loaned Jen money so she could purchase her own home nearby.
Jen
worked as a traveling surgical technician and she recalled that for the
next several years, the two women’s lives adhered to a predictable
schedule.
Jen would go to Florida in the winter for work, Martha
would visit for a few weeks and then Jen would return to Michigan every
spring. During the rest of the year, mother and daughter saw each other
several times a week, going out to dinner, sharing home decorating ideas
and visiting each other’s homes to watch HGTV.
This changed abruptly in March 2017.
While Jen was in Florida, Simeon’s adult son, Spencer Rodgers, paid Martha a visit.
The APS complaint
“No
one lives with Martha. No one has been assigned to care for her. She
has rotting food in her fridge. Jennifer has had no regular physical
contact for 4 years with Martha.”
These words anchor a March 3,
2017 investigation report by Adult Protective Services, filed after
staff at the state agency received a complaint from Spencer.
After that, things happened fast.
An
APS worker, Michelle Hagerman, interviewed Simeon about what Spencer
said he found in Marty’s refrigerator. In her investigative report,
Hagerman made broad conclusions about Marty and Jen’s relationship, many
of which court officials found later to be false or unsubstantiated.
The
report stated Marty wasn’t taking her medications, and suggested Jen
was not only neglecting Marty but was preying on her financially —
observations which Simeon continues to contend were true.
The APS
report stated Jen borrowed money from Marty and wasn’t paying it back,
and that Jen “might” have taken out a $150,000 loan against Marty’s
house in Marty’s name.
It’s unclear how Jen could have done this
while also not having any regular physical contact with her mother in
four years — a non sequitur in the report Hagerman didn’t explain.
Instead,
Hagerman filed an emergency petition in Leelanau County’s probate
court, seeking to have a judge appoint a temporary guardian for Marty.
Emergency
guardianship petitions are designed to protect vulnerable adults who
are in immediate danger. When a probate court register receives such a
petition, he or she often schedules a hearing within a few days.
Emergency petitions filed “ex parte,” as it was in Marty’s case, means
an opposing party — in this case, Jen — doesn’t have to be notified.
“At
this point, I’m a perpetrator,” Jen said, of how she believed the court
and the state viewed her. “I was panicking. I should have caught a
plane. But I didn’t know the magnitude of what was getting ready to
happen.”
If Jen had booked a flight home, she said she could have shown Nelson a folder of documents proving the APS complaint was false.
There
were notes from Marty’s doctor stating Jen should do what she could to
help her mother maintain her independence. Paperwork from a service Jen
arranged to assess Marty’s driving ability, as well as cost estimates
from a home health care agency — tasks Jen completed before leaving for
Florida.
Finally, Jen could have explained how the $60,000 real estate loan was so she could live near her mother.
Hagerman
spoke with Simeon and Spencer, but didn’t interview Jen. Consequently,
none of the above information was in Hagerman’s investigation report.
Four
days after the emergency petition was filed, Nelson signed it. And
appointed Case — who Hagerman suggested — as Marty’s temporary guardian.
Losing Control
In family disputes, it’s not unusual for a judge to see an unrelated third party as an objective solution.
It
is unusual, however, for a judge to override signed durable power of
attorney and patient advocate documents, which the law says must be
followed unless a judge decides there are extenuating circumstances.
“If
I have trust documents or a durable power of attorney before me, it’s
very, very rare that I will override them,” said Melanie Stanton, who
served as Grand Traverse County’s probate court judge from 2013 to 2021.
Judges
do have the power to override these documents when they suspect abuse
or neglect. A transcript of the emergency hearing shows Nelson appeared
to be under the impression that Jen was angling for her mother’s money.
That
suspicion was amplified by Hagerman, who testified — without evidence,
the transcript shows — that Marty’s dementia may have affected earlier
decision-making.
Judges often defer to recommendations from APS
investigators. They also rely heavily on a type of court-appointed
attorney called a “guardian ad litem,” assigned to meet with a
vulnerable person like Marty and report their findings to the court.
The
guardian ad litem in Marty’s case was Traverse City attorney Mattias
Johnson. The court asked Johnson to review documents, meet with Marty
and offer an opinion on whether the order granting temporary
guardianship should be made permanent.
Johnson in his April 4,
2017 report described Marty as charming and well-dressed, and her home
as beautiful and tidy. He acknowledged Simeon’s removal from Marty’s
will and the legal documents naming Jen as her mother’s choice of
decision-maker and beneficiary.
Johnson spoke with Marty’s
financial manager, John Schubert who confirmed Marty’s substantial
investments and stated Jen was helpful to Marty in financial matters and
nothing she did struck him as untoward.
Johnson then recommended continuation of the outside guardian.
“While
it is of yet unclear whether there has been any actual impropriety, GAL
believes that the appearance of impropriety lends itself to continuing
with a third party management of Martha’s finances and health
decisions,” Johnson wrote in his report to the court.
Nelson, who
declined comment for this story, entered an order May 17, 2017, making
Case’s role as Marty’s guardian and conservator a permanent appointment.
Background Checks
Case
appeared to have the right credentials to make decisions about the
health, housing and financial needs of an elderly person showing signs
of vulnerability.
She worked for Grand Traverse County’s
Commission on Aging and her county personnel records show she passed
FBI, Michigan State Police and state Department of Health and Human
Services criminal background checks.
Probate courts differ from one county to the next on whether to
conduct background checks on people they appoint. Emmet County, for
example, asks the sheriff’s office to do it, Oakland County requires a
background check and a credit check to be on its approved guardianship
list and Grand Traverse County doesn’t conduct any background checks at
all.
Judges and staff don’t have the time or the resources,
Stanton said, and even if they did, they can’t access LEIN, the
nationwide law enforcement intelligence network’s database that contains
records of criminal offenses.
There’s no record of a criminal
background check on Case by the Leelanau Probate Court, though if there
had been a check, it’s not likely it would have noted civil infractions —
records show Case’s paycheck years before was garnished by a debt
collector.
Case had also been cited at her Commission on Aging job
by COA Director Georgia Durga for unprofessional and inappropriate
conduct, bullying and violating the county’s violence in the workplace
policy.
“It is my expectation you will cease using bullying
tactics as detailed above,” Durga wrote to Case in a 2010 corrective
action form. “From this day forward I do not expect to receive any
additional complaints from other employees/departments regarding your
behavior. When you meet with me, I want you to bring solutions on how to
coach employees to make them successful, not ways to remove them from
their positions.”
Five years later, in 2015, Durga suspended Case
for behavior which she said made another employee feel threatened; the
five-day suspension was later vacated by a county administrator who
labeled it a she-said, she-said accusation.
Following her
appointment as Marty’s guardian and conservator, court records show Case
communicated frequently with Simeon’s family, and positioned herself as
a gatekeeper between Jen and Marty.
Records show Case told
Spencer to unplug Marty’s home phone, then allowed Jen 15-minute phone
calls with her mother and short, twice-weekly supervised visits. Jen
could come to Marty’s home as long as she didn’t go anywhere but the
kitchen, living room or dining room.
When Jen took her mother outside in July and to a nearby orchard, Case reported it to the judge.
“(H)er
visits were to be supervised and that an aide needed to be with her mom
at all times,” Case wrote, in a July 13, 2017 report to Judge Nelson.
“She was not to take her mom outside without an aide.”
Case soon
paid thousands for Marty’s care, hiring two women — Monica Bradford and
Kathy Bower — to stay with Marty around the clock, either in her home or
theirs. Canceled checks show, in April and May of 2017, Case paid
Bradford and another woman, Anne Cole, $22,780 from Martha’s estate.
Case
also moved Marty’s investment portfolio away from Schubert, Marty’s
longtime financial adviser, to someone new, locking Jen out of
monitoring transactions on her mother’s accounts.
This concerned
Schubert enough, a guardian ad litem report shows, for a colleague of
Schubert to file a suspicious activity report. Schubert did not return
calls seeking comment, regarding the result of that SAR.
“Ms. Case
was withdrawing large (in the mid-five-digit range) sums of money,
something Marty had never done,” a GAL report filed with the court
states. “When the advisor and his business partner questioned the
Conservator about this, she moved the account to another investment
firm.”
Near the end of summer in 2017, Case moved Marty out of her
home and into an assisted living facility, the Highlands, in Northport.
Court documents show Case didn’t tell Jen about the move. When Jen
learned of it, these same records show Case refused to tell Jen where
her mother was.
The move infuriated Jen, but according to court records, it also upset Marty.
“Martha
asked why I was doing this to her,” Case wrote, in her report to Judge
Nelson. “I reminded her that she has a disease and that the doctor said
she needed 24/7 care. I told her that it was my job to make these
decisions to look out for what is her best interest in where she lives.”
Case
appeared to view a Mother’s Day gift to Marty from Jen — fleece-lined
Crocs the color of Pepto Bismol that Jen mailed to her mother — as
something nefarious.
Shortly after Mother’s Day in May 2017, Case
filled out the paperwork for a personal protective order against Jen,
stating in the application that recent mail and other communication from
Jen was upsetting Marty.
PPOs are court documents mandating
separation between alleged victims and their suspected abusers. They are
signed by a judge and violators can be arrested.
“It cemented her control,” Jen said. “If I didn’t contest it, I would have never seen my mother again.”
Fighting Back
Jen
said she tried to fight back against the court actions involving her
mother, from the emergency guardianship petition by APS, to Johnson’s
guardian ad litem report, to the PPO, but was unable to stop what she
later referred to as a runaway guardianship train.
Jen said she
remembers feeling angry and powerless until she hired her own lawyer,
Andrew Shotwell of Smith & Johnson Attorneys P.C., a Traverse City
firm. Records show Martha’s sister-in-law Lynne Hackenberger also had
concerns about Marty’s guardianship and hired Traverse City attorney,
Adam Lett, to contest Case’s appointment.
In December 2017, Case
moved Marty from the Highlands in Northport to French Manor, an assisted
living facility in Grand Traverse County. By changing the county Marty
lived in, Case also changed probate court jurisdictions. Stanton, not
Nelson, presided over Grand Traverse County’s probate court.
Stanton
responded to petitions by Shotwell and Lett by revoking the PPO and
assigning a new guardian ad litem, Traverse City attorney Janet Mistele,
whose lengthy reports to the judge read like a spy novel.
“Despite
Marty’s extensive estate planning, when APS received a referral from
Simeon’s son alleging financial exploitation and physical neglect of
Marty, rather than doing a proper fact-based investigation and
attempting to confirm or dispel information from and about Marty’s
daughter, APS accepted as true hearsay and other unverified information
provided by members of Marty’s previously estranged family,” Mistele
said.
Simeon maintains the accusations investigated by APS were
legitimate and only a change of venue kept Jen from being investigated
by law enforcement, a characterization Mistele in her report found no
evidence of and Jen vehemently denies.
“It should be noted,”
Mistele said, “that as to the allegation of financial exploitation, two
separate prosecutors (Leelanau and Grand Traverse) have apparently
reviewed the case and declined criminal charges based upon prior
informal business dealings between mother and daughter.”
Mistele
in her report also said she was “very disturbed” by photos posted on
social media of Case, Hagerman, Bradford and Bower socializing and
recommended Case be removed or allowed to resign as Marty’s guardian and
conservator.
Lett flagged concerns about improper communications
between Case, Matthias Johnson and Judge Nelson. Johnson on June 8, 2017
sent a private note to Nelson, copying Hagerman and Case, about Jen’s
efforts to terminate the PPO. Communications outside of court with the
judge that don’t include all parties are banned under the Judicial Code
of Conduct.
Lett also lambasted Case’s relocation of Marty.
“Hiding
the ward from family and friends is not among the powers of a
Guardian,” Lett wrote in a court filing. “This woman believes she does
not answer to anybody. That cannot be true.”
Case’s reputation
with the court began to fall apart. She missed multiple filing deadlines
and no-showed court hearings, not only in Marty’s case, but for seven
other guardianships to which she’d been appointed.
Case was not
criminally charged, though Judge Stanton took an unusual step and issued
bench warrants for Case’s arrest. No arrest was made and Case’s
accountings were later submitted and accepted by the court.
APS
filed petitions to remove Case from all eight guardianship cases, which
Stanton signed. Discipline came for Case at her COA job, when a
subsequent COA director, Cindy Kienlen, ordered her suspension, as well
as an apology to Judge Stanton.
Case refused, then filed retirement paperwork.
Case
declined repeated requests for comment, stating she felt previous media
accounts of Marty’s guardianship did not portray her fairly.
A note in her COA personnel file, from an interview Kienlen conducted with Case, provides some insight into Case’s actions.
“You
stated that after taking over the first guardianship you quickly became
overwhelmed by the amount of work required in the Guardianship and
Conservatorship process,” Kienlen wrote, in a Sept. 18, 2018 letter to
Case. “You denied receiving the mailings of bench warrants and subpoenas
for your appearance at court. This is highly suspect that all mail and
communication were not received by you, especially since Amanda (Probate
Court Register Amanda Flowers) reported that none of the letters mailed
to you were returned to the court.”
On Dec. 6, 2018, records show
Jen filed a complaint with Michigan’s Attorney Grievance Commission
against Johnson for his ex parte communications with the judge.
The
Grievance Commission investigated, records show, though did not take
further action. Johnson did not return a request for comment, though
records show he responded to the complaint with an explanation and an
apology.
Nearly everyone involved in the case sent ex parte
communications to Judge Nelson, Johnson said, and this was his
first-ever guardian ad litem assignment.
“I understand the
seriousness of this offense and the repercussions that it could have had
and that was not my intention,” Johnson’s Feb. 14, 2019 response
states. “I would like to apologize to Ms. Rodgers for this error, to the
Court for in any way placing them in a difficult situation, and to the
commission for this action.”
Michelle Hagerman, the APS worker who
triggered Marty’s guardianship and recommended Case, was “reassigned”
to another state department more “suitable” for her, a court filing
states.
Stanton appointed a different professional guardian to
take over Marty’s case. Jen said this new guardian was expensive — she
charged $70 an hour – but it was worth it.
Case, according to court documents, was providing her services at no cost.
Unanswered questions
Marty Rothaug died Oct. 14, 2020 and Jen says she believes stress from the guardianship proceedings hastened her death.
“It
killed my mother,” Jen said, adding she agreed to share her story
publicly, in hopes it might educate other families about guardianship
and conservatorship and prevent them from experiencing similar grief.
Unanswered questions still keep her up at night, she said, even today more than five years later.
How
did a key to Marty’s safety deposit box end up in the parking lot of
Huntington Bank, where it was found by a staff member? Jen said her
mother’s most valuable pieces of jewelry were later accounted for,
though she’d like to know what happened to her father’s watches.
How
could caregivers hired by Case burn through $125,000 of Marty’s life
savings in only eight months? Who is supposed to vet those expenses?
And finally, how is it that Case, with her garnishments and COA disciplinary record, was appointed at all?
“They felt Jill Case was a better person to take care of her than her own daughter,” Rodgers said. “That’s the courts.”
Ellie Craig Goldstein holds a pouch
containing sentimental items from her brother, Peter Craig. Three years
after Peter’s death, his sisters Ellie and Joyce Craig are haunted by
the memory of his final hours.
(Francine Orr / Los Angeles Times)
By Kim Christensen, Ben Poston
Martin Huff was 67 when he fell off his bicycle, banged up his knee
and spent a couple of hours in a Riverside County emergency room before
walking out under his own power.
Ten days later he was in hospice
care, diagnosed as terminally ill by a small Covina provider of
end-of-life services that said he was weak and wasting away, with six
months or less to live.
Five years after that grim prognosis,
however, Huff was still very much alive. He testified in federal court
that no one from California Hospice Care had ever given him a medical
exam before claiming he was dying.
“I really never knew exactly what the deal was on the hospice,” he said.
Huff
is among a legion of mostly older Americans targeted for audacious,
widespread fraud in an industry meant to provide comforting care in
their final days, a Los Angeles Times investigation found.
Like
Huff, many are unwitting recruits by unscrupulous providers who bill
Medicare for hospice services and equipment for “terminally ill”
patients who aren’t dying.
Intense competition for new patients —
who generate $154 to $1,432 a day each in Medicare payments — has
spawned a cottage industry of illegal practices, including kickbacks to
crooked doctors and recruiters who zero in on prospective patients at
retirement homes and other venues, The Times found.
The exponential boom in providers has
transformed end-of-life care that was once the realm of charities and
religious groups into a multibillion-dollar business dominated by
profit-driven operators.
Nowhere has that growth been more explosive, and its harmful side effects more evident, than in Los Angeles County.
The
county’s hospices have multiplied sixfold in the last decade and now
account for more than half of the state’s roughly 1,200
Medicare-certified providers, according to a Times analysis of federal
healthcare data.
Scores of providers have sprung up along a
corridor stretching west from the San Gabriel Valley, where California
Hospice Care was located, through the San Fernando Valley, which now has
the highest concentration of hospices in the nation.
“There are too many providers in L.A. County, and too many providers
who are in it for the wrong reasons,” said Edo Banach, who heads the National Hospice and Palliative Care Organization, the largest U.S. trade group for hospices. “Folks who go into this for the wrong reason generally do not do a good job.”
Much more than money is at stake.
Some patients who unknowingly enrolled in hospice later discovered
they had signed away their rights to lifesaving emergency medical
treatment, state inspection records show. Others endured excruciating
pain in their final days when providers failed to deliver the comforting
care they desperately needed.
Still others suffered the consequences of neglected, festering sores that developed maggots or resulted in hospitalizations.
Privacy
laws and government reports that keep the names of patients, doctors
and hospice administrators confidential make it difficult to quantify
and humanize many of the cases.
But The Times found that since
2008, regulators have cited hospices in California more often than
anywhere else in the country for the most serious types of violations,
four times as many as states such as Texas and Georgia, which also have
large numbers of providers.
Despite those citations, California and federal regulators
have rarely fined, suspended or shut down deficient hospices, state
reports show. Oversight has been weakened further during the COVID-19
pandemic, as regulators suspended requirements for most hospice
inspections and limited the types of complaints they investigate.
California,
which has among the lowest barriers to setting up a new hospice, also
leads the nation in violations for enrolling patients without medical
proof they were terminally ill.
The Times’ analysis revealed that
Los Angeles County hospices discharged patients 80% more often than
providers nationwide, highlighting a rate that federal authorities say
is a red flag for Medicare fraud.
California Hospice Care claimed
that Jesse Staten suffered from terminal heart failure when it signed
him up for end-of-life treatment. His predicted six months to live
expired in 2012, but he didn’t: When The Times contacted him eight years
later, he was still going strong.
“I’m hanging in,” said Staten, 75. “I’ve got a lot of issues in my blood and I have other issues, but I can’t complain.”
Federal
prosecutors accused California Hospice Care of bilking taxpayers of
$7.5 million in illegal payments in connection with Staten, Huff and
scores of other ineligible Medicare recipients. The hospice owner and
two doctors were sentenced to prison, and several others were convicted
or pleaded guilty in the scheme.
Many of the hospice’s patients were addicts lured by the promise of free narcotic painkillers, prosecutors said.
Some were enlisted by a doctor who collected a bounty from the hospice on each, according to his indictment.
One was a 47-year-old woman who lost her place on a waiting list for a
liver transplant when she signed up for hospice, which prohibits
curative care. It took her months to get reinstated, and she died not
long after finally receiving a new organ.
“That’s the last hope,
and having that person removed from the liver donor list by placing them
in the program is conduct that is hard to understand,” U.S. District
Judge S. James Otero said when sentencing a hospice nurse to 18 months
in prison. “That’s callous.”
::
Conceived
as an end-of-life option for terminally ill patients, hospice care
properly delivered has been a godsend for millions of dying Americans
and their families. It provides palliative care and prescription drugs,
nursing services, medical equipment, supplies and spiritual counseling
for those given a prognosis of six months or less to live.
The
U.S. hospice industry took root in the mid-1970s but flourished only
after Medicare began covering its services in 1983. For-profit providers
sprang up to meet a growing need that outstripped the capabilities of
charities and religious institutions that pioneered end-of-life care.
In the last 20 years, the number of U.S. providers has roughly
doubled, while Medicare spending on hospice has grown sixfold, to $19.2
billion a year. More than 1.5 million Medicare beneficiaries now receive
care from some 5,000 hospices, nearly a quarter of them in California.
“Virtually
all of the growth is of for-profit providers, which appear to be
crowding out the local nonprofits that established the hospice model and
had a desire to maintain its integrity,” said Michael Connors, a
long-term care advocate with California Advocates for Nursing Home Reform.
For-profit operators now make up 70% of all hospices certified by the Centers for Medicare and Medicaid Services and 91% of those in California. In Los Angeles County, they account for 97%.
Many provide excellent care.
Satisfaction surveys reported by hospices nationwide show that more
than 80% of respondents rate their hospice as a 9 or 10 out of 10, but
in L.A. County that figure drops to 74%. Respondents in L.A. also were less likely to report that hospices always gave them the help they needed.
Most
hospice care is provided in patients’ homes, but services also are
rendered at stand-alone facilities, nursing homes and assisted-living
centers. Regulatory inspections and financial audits are infrequent,
making the system a soft target for scammers.
Complaints about shady operators began lighting up the California Senior Medicare Patrol
hotline in mid-2017 and have not let up, said Sandy Morales, who
oversees the federally funded statewide hotline whose mission is to help
Medicare beneficiaries prevent, detect and report fraud.
“It’s
all over Southern California: Riverside County, Hemet, Indio, Long
Beach, Los Angeles, Bakersfield,” she said. “Right now, it’s huge.”
Since January 2019, her agency has forwarded more than 100 cases of
suspected hospice fraud to federal investigators, Morales said. One
doctor’s office in Los Angeles County recently reported that 10 patients
appeared to have been fraudulently enrolled by a hospice.
Fraudsters
stick to a familiar script, enticing or duping Medicare recipients into
signing up for services they don’t need, she said. They send recruiters
door to door and to churches, food banks, senior centers and apartment
complexes, often misrepresenting hospice as an “extra” Medicare benefit
that pays for nursing visits, hospital beds or other needs.
‘It makes no sense. I can’t imagine there
are 60 hospices in Burbank that are doing it the right way. There can’t
be enough people for 60 hospices there.’
Jan Jones, recently retired CEO of the California Hospice Network
The pandemic has spun off new schemes, she said, with
unscrupulous recruiters now enticing prospects with hand sanitizer,
gloves and promises of other COVID-19 “freebies.”
Many who sign up don’t even realize they are in hospice care.
“They’ll say, ‘No, I’m not dying. I wanted help with housekeeping and cooking, and that’s what I signed up for,’” Morales said.
In
May 2017, the daughter of an Alzheimer’s patient told a state
investigator that a marketer for All Seasons Hospice in Paramount signed
up her mother with a promise of 24-hour nursing care. When no one
showed up, she called the hospice and was told the only 24-hour service
was by phone.
The hospice administrator acknowledged the bogus sales pitch but mostly shrugged it off.
“It is a dog-eat-dog situation out there, very competitive,” the administrator told inspectors, according to a state report
that did not name the employee. “I have no control over what these
marketers say or do. They do what they want and promise anything to get
the patient.”
The Centers for Medicare and Medicaid Services did
not respond to specific questions about the extent of hospice fraud but
said in a statement that the agency aggressively seeks to ferret it out.
“CMS
identifies fraud, waste and abuse in hospice services utilizing
cutting-edge data analytics, medical review and program integrity
investigations,” it said. “In instances of potential fraud, CMS refers
those providers to law enforcement for further criminal investigation
and for appropriate administrative actions.”
The U.S. Department of Health and Human Services’ Office of Inspector General reported in July 2018 that inappropriate billing and fraud by hospice providers cost taxpayers “hundreds of millions of dollars,” but the full extent is unknown.
The watchdog agency declined to comment on the scope of hospice fraud
and said it could not provide a count of cases it has investigated. The
Department of Justice did not respond to repeated requests for its
prosecution numbers.
But according to interviews with hospice
providers and industry experts, and a review of law enforcement releases
on individual cases, state licensing reports, lawsuits and federal
data, fraud is widespread.
“Hospice fraud remains absolutely
rampant in the United States,” said Mark Schlein, an attorney with the
Los Angeles firm Baum Hedlund who specializes in hospice whistleblower
lawsuits. He links the fraud in large part to the industry’s unfettered
growth.
“That translates into much more money being paid to
hospice companies by federal healthcare programs,” he said. “When Willie
Sutton was asked, ‘Why do you rob banks?’ he said, ‘Because that’s
where the money is.’”
::
More than two
dozen hospices pepper a mile-long stretch of Victory Boulevard, an
east-west artery in the San Fernando Valley. One well-worn office
building in the 13600 block in Van Nuys is home to 15 providers.
“Hospices
have been growing like mushrooms around here,” said one of the other
tenants, who declined to give his name for fear of alienating his
neighbors in the complex, where monthly rents start at an enticingly low
$399.
Scores of others are in neighboring Valley communities, all
part of a sprawling regional hotbed of for-profit hospices. Many are
small operations, some purchased as investments by people with little or
no healthcare experience.
Since 2010, the number of providers in Los Angeles County has skyrocketed from 100 to 618, federal data show.
North Hollywood is home to 35 hospices, while Glendale has 60, Burbank has 61 and Van Nuys 63.
By comparison, New York state and Florida both have fewer than 50.
With
a population of 103,000, Burbank has a per capita rate of hospices that
is nearly 40 times the national average, according to The Times’
analysis.
“It makes no sense,” said Jan Jones, recently retired chief executive officer of the California Hospice Network,
a coalition of nonprofit providers. “I can’t imagine there are 60
hospices in Burbank that are doing it the right way. There can’t be
enough people for 60 hospices there.”
New York, Florida and dozens
of other states require prospective hospice owners to obtain a
“certificate of need” to justify the demand for additional providers
before they can get licensed.
California providers must be free
of felony convictions, but there are few other qualifications for
starting or operating a hospice beyond getting licensed by the state and
certified by Medicare, a process that costs only a few thousand
dollars.
“There is not a high-cost entry point to start a hospice
program, unlike a hospital or a nursing home,” Jones said. “I think a
lot of people think it is an easy business, which frankly I think is
wrong. It is very complicated and complex, and very important to the
people we serve.”
::
With the explosive growth have come serious quality-of-care issues.
The
Times’ review of more than 800 state licensing and inspection reports
revealed instance after instance in which patients were deprived of
comforting care because of the actions — or inaction — of hospice
providers.
Mismanaged pain medications, neglected infections,
missed nursing visits, incompetent or dishonest home health aides — all
were cited among hundreds of violations that required hospices to draw
up plans to correct the problems but resulted in little or no
disciplinary action.
Ellie Craig Goldstein holds a photo of
her brother, Peter Craig, and sister, Joyce Craig. The sisters say they
were traumatized when no one from hospice came during his final hours.
(Francine Orr / Los Angeles Times)
Patients suffered for lack of pain medication or had maggots crawling
out of festering foot sores and head wounds, state inspection records
show. Others died alone or without the help they neededbecause no one from the hospice showed up in their final hours.
“We
will never heal from that devastation,” Joyce Craig said of the final
moments of her brother, Peter Craig, 74, a partner in a Los Angeles
accounting firm who died of cancer in 2017.
The California
Department of Public Health licenses and regulates hospices to ensure
they meet state and federal standards but has limited ability to punish
offenders. The only fines it can impose are for breaches of patient
confidentiality.
To qualify for hospice, patients must be
certified as terminally ill by their attending physicians, if they have
them, and by a hospice doctor. The certification process is ripe for
fraud.
The Times’ analysis of federal data showed that California hospices
led the nation in violations for enrolling nonterminal patients, logging
57 such deficiencies since 2008, nearly three-fourths of them in L.A.
County.
The next closest states were Georgia and Louisiana with 22
each. But the actual numbers in California and elsewhere are probably
much higher because of variations in how improper terminal diagnoses are
coded and categorized by state inspectors.
At Eleos Hospice in Van Nuys, state officials who sampled five
patients’ records in December 2016 discovered no evidence that any were
terminally ill. The agency was “claiming or attempting to claim
reimbursement for patients who did not need hospice care and services,” a
licensing report noted.
All five were promptly discharged, but records show no action was
taken against the doctor or hospice. The hospice has changed hands twice
since then, according to a new owner who took over in August and said
he was unaware of those deficiencies.
Inspectors found a similar
scenario when they examined the records of two patients of Orion Hospice
Care Services in Valley Village in November 2018.
The hospice’s
medical director, in recertifying a patient as terminally ill, wrote
that she was experiencing a steady decline in health and appetite and
was losing weight. But that’s not what the patient told a state
investigator.
“I did not have pain and my appetite is OK,” she said, “and I did not lose any weight.”
In fact, records kept at the board-and-care home where the woman
lived showed she had gained 7 pounds over the preceding three months.
The
hospice administrator declined to comment when asked by inspectors to
explain, and the medical director admitted he’d never put the woman on a
scale, describing a method akin to a guess-your-weight booth at a
county fair.
“I assessed her weight by my own clinical measurement
and judgment, not by any actual documented measurement,” the doctor
said, according to a state inspection report.
State inspectors found no records to support either terminal diagnosis, nor do inspection reports reflect any disciplinary action against the doctor or hospice beyond requiring a corrective action plan.
For a patient at Guiding Light Hospice in Sun Valley, the assessment could not have been bleaker.
The
woman was easily fatigued; needed help with feeding, dressing, bathing,
toileting, walking, handling money and taking medications; and could
speak “less than six intelligible words per day,” a state inspection record noted. She also was incontinent, had a history of falls and was forgetful, disoriented and confused, “with imminence of death.”
When
interviewed by state inspectors, however, the woman, identified in a
state licensing report only as Patient 1, said her only infirmity was
some back pain from arthritis.
“Patient 1 stated she knew she was
not ready to die, and laughed while denying she had a terminal
diagnosis, and a life expectancy of six months or less,” according to
the report.
The nurse who made the dire, detailed assessments insisted they were
accurate, despite all evidence to the contrary. No disciplinary action
was taken, but when inspectors returned for a follow-up 16 months later,
Guiding Light had closed its office.
::
This office building in the San Fernando
Valley is home to several hospice providers. Since 2010, the number of
providers in Los Angeles County has skyrocketed from 100 to 618,
Medicare data show.
(Francine Orr / Los Angeles Times)
Karen Alvarez at first gave little thought to the visitors from Ace
of Hearts Hospice who showed up at Lancaster’s Sierra Retirement Village
with armloads of fast food. After all, the apartment manager said, many
of her low-income tenants were grateful for a complimentary meal.
But Alvarez was soon struck by the aggressive tactics of the Ace of
Hearts personnel, who took over the lobby every Wednesday and trailed
residents back to their units to pitch them on “free” hospice care,
hospital beds and motorized scooters, all billable to taxpayers.
“You
know, hospice people are gentle and talk to you nice. They are
understanding and kind,” she said. “They don’t come in swarming like
bees, like these people did.”
Few hospices better epitomize the
most serious problems that afflict the industry — or underscore the
failure of regulators to address them — than Ace of Hearts.
More
than a dozen patients were not terminally ill and should never have been
enrolled, according to a felony criminal complaint and state reports
that detail a litany of deficiencies.
Based in a small office on Foothill Boulevard in Tujunga, the hospice
racked up at least 115 regulatory violations from 2014 to 2016, second
most among the 1,200 California providers over the last decade, federal
records show.
Details of the violations fill nearly 200 pages of state inspection reports chronicling mishandled medications, neglected sores and repeated missed visits by nurses and home health aides.
In one patient’s case, aides failed to show up for 18 straight visits over a span of several months.
“It
must have been a computer glitch,” was how the Ace of Hearts
administrator explained it to state inspectors, who found dozens of
other missed patient visits.
Ace of Hearts owner Rozanna Avetyan, 42, who signed the inspection
reports as the administrator, did not respond to requests for interviews
left with a person at her Stevenson Ranch home and with a woman who
answered her cellphone but would not identify herself.
Her attorney, Donald Marks, did not respond to repeated phone and email messages.
In 2016, the government paid the hospice about $450,000 for 29
patients, nearly two-thirds of whom were discharged alive, Medicare data
show. Although hospice patients may be recertified to receive care for
more than six months, federal officials say that very long stays and
high “live discharge” rates are potential indicators of fraud.
Ace of Hearts’ 62% live discharge rate in 2016 was nearly six times
the national rate that year, according to The Times’ analysis of
Medicare data.
That October, state inspectors could find no
evidence of terminal illness for three of 11 patients sampled. Some had
been admitted by the hospice medical director, who signed certifications
electronically, state inspection records show.
The unidentified
doctor, whose office was in Palm Springs, more than 100 miles from
Tujunga, told state officials he did not recall some of the patients and
didn’t know how his signature wound up on their certifications.
“I
do not like computers so I do not use them,” he said, according to a
state licensing report. “I did not sign anything electronically.”
The improper certifications had serious ramifications: Some
nonterminal patients who signed up were stunned to learn they had
forfeited their existing medical coverage in the process, the report
states.
At least two lost their HMO coverage when they were
enrolled in hospice without being told they could refuse. One was signed
up while in an assisted-living facility, the state licensing records
show, and the other while residing in a board-and-care home.
“The
HMO won’t even see him in the emergency room, and he does not understand
it,” the board-and-care owner told state investigators, according to a
state report.
When pressed for an explanation, the report said,
the Ace of Hearts administrator blamed the board-and-care owner for
referring the man, who developed serious bed sores while in hospice
care.
“I had nothing but trouble with the board-and-care owner,” the
administrator said. “Now the patient has multiple wounds. I told [his]
caregiver that we don’t do wounds here.”
Poor wound care was
nowhere more evident than in the case of one patient treated by an Ace
of Hearts nurse who lacked enough clean gauze to dress a serious foot
sore.
“She picked up the dirty discarded Kerlix dressing that was
removed from the wounds that was soiled with a few spots of old red
colored discharge and she re-used the old dressing on top of the clean
dressing,” wrote a state inspector who witnessed the violation of
infection-control protocols.
It was but one of a long list of serious deficiencies over the years.
“The cumulative effect of these systemic practices resulted in the
failure of the hospice agency to ensure the provision of quality
healthcare in a safe environment,” a 2016 inspection report said.
Despite
that finding, however, Ace of Hearts continued to operate for three
years. It eventually was undone not by state regulators but by its own
weekly free-breakfast sales-pitch visits to Sierra Retirement Village
and the nearby Aurora Village Retirement Center.
Alvarez, the
Sierra complex manager, told The Times that two federal agents dropped
by one day to grill her about the visits and kickback offers of up to
$300 per patient by Avetyan, who also owned Team Hospice in Lancaster.
“I
wasn’t interested in that at all,” Alvarez, who was not accused of
wrongdoing, said of the kickbacks. “I said, ‘No, I have a job, I don’t
need that.’”
Authorities had been tipped off by a county social worker who was
surprised that a resident she was visiting had been given a “hospice
bed” when she was not ill, Alvarez said.
In 2018, the California
attorney general’s office filed fraud charges against Avetyan and four
others, alleging that her hospices had billed Medicare and Medi-Cal for
$1.2 million for ineligible patients.
Avetyan had paid more than
$180,000 in kickbacks for illegal referrals, some of them by a woman who
worked in a doctor’s office and gleaned names from the patient roster,
prosecutors alleged in a criminal complaint.
A different
physician, Dr. Blanca Galapon, now 80, was accused of falsely certifying
a dozen patients as terminally ill in exchange for unspecified payments
from Avetyan, according to the complaint.
Avetyan pleaded guilty in April 2019 to one count of conspiracy to
pay and accept insurance kickbacks and was given a suspended six-month
jail sentence and placed on four years’ probation.
Galapon and other defendants cut plea deals for deferred prosecution or probation.
In
January, Avetyan was barred from all federal healthcare programs,
including Medicare and Medicaid, for at least five years. By early this
spring, both Ace of Hearts and Team Hospice had closed their offices.
But court documents and other public records indicate that Avetyan sought continued involvement in the hospice industry.
At least five hospices based at one Van Nuys office building appear
to have been spun off directly from Ace of Hearts or have significant
links to it, The Times found. Online biographies that list two young
women as chief executives of the five hospices describe both as former
Ace of Hearts employees.
One of them, Arpine Melikyan, is a 2019 graduate of Cal State L.A.
who was an Ace of Hearts accountant and now heads up two other
providers, Life Hospice and High Care Hospice.
In a 2019 lawsuit,
Avetyan alleged that she agreed to pay Melikyan $5,000 a month and
provide staffing and other resources in exchange for a 30% stake in the
two hospices. Melikyan declined to comment on the lawsuit, which accuses
her of reneging on the deal.
Avetyan is due back in court Dec. 16, accused of violating her probation.
Prosecutors
would not provide details but said in an email to The Times that she
continued to bill Medi-Cal for hospice services after being barred from
the program.
One of the clear trends emerging from U.S. health reform is the
transition from a provider and procedure focused system to one that puts
the patient at the center of care. “Patient-centered care” is defined as “providing care that is respectful of, and responsive to, individual patient preferences, needs and values.”
While most physicians build patient partnerships guided by individual
patient needs and values, at the system level, we are just now
beginning to embrace patient-centered care. As the health system fully
considers the comprehensive needs of each patient, we are starting to
recognize the critical role that family caregivers play in patient
satisfaction and health outcomes. This is especially true for elderly
patients that want to age-in-place at home, and depend on support from family members and loved-ones to manage their care. Common sense and an emerging body of evidence tell us that the integration of informal caregivers into the U.S. health system holds tremendous promise for improving thewell being of patients while having the potential to reduce costs associated with hospital readmissions and nursing home care.
As individuals age, their need for both medical and nonmedical
services and supports increases. Millions of aging Americans receive
help with their activities of daily living (ADLs) — such as getting
dressed, bathing, and getting around the house. The number of Americans
who need help with ADLs and other activities such as paying bills or
taking medications (collectively called “long-term services and supports” or “LTSS”) is expected to rise from 12 million today to over 27 million in 2050. According to the Congressional Budget Office (CBO), 20 percent of individuals over age 65 and 41 percent of individuals over age 85 need assistance with at least one ADL.
We recently published a report at the University of Pittsburgh, Addressing the Needs of Caregivers at Risk: The Policy Landscape.
In it we review current policies addressing the needs of family
caregivers, evaluate emerging evidence on the effectiveness of these
policies, and suggest some potential new policy approaches, which we
will discuss in the following blog post.
The Cost of Long-Term Care
Daily help with LTSS can come from paid, formal sources, such as a
nursing home or home care agency, or unpaid informal sources, such as
family members or friends. According to the Institute of Medicine,
there are somewhere between 29 and 52 million unpaid caregivers
nationally. Long-term care is costly, and assistance from family
caregivers helps to alleviate the financial burden for those in need of
care.
However, family caregiving can take a large financial, emotional, and physical toll on the caregiver. According to the AARP, the value of informal caregiving provided to adults was approximately $470 billion in 2013. Additionally, close to one out of 10 Americans over the age of 40 are both providing LTSS assistance to a family member and supporting a child. The emotional, social, physical, and financial burden on this “sandwich generation,” is significant.
Few Americans consider their need for LTSS when planning for their financial future. According to recent survey data, only 53 percent
of Americans over age 40 believe that they will eventually need some
form of ongoing living assistance. A very small portion of the
population—only about 5 to 7 percent over age 45—carries long-term care insurance.
Though most Americans prefer to remain at home as they age, the cost of long-term care is high, and can quickly exceed the retirement savings of the average American. The estimated annual cost of nursing home care is $91,250 for a private room and $45,760 for a home health aide. According to a recent study
based on data from the Federal Reserve Survey of Consumer Finances,
among working age households with individuals aged 55 to 64, the average
savings balance was $104,000 in 2013.
The same study found that 45
percent of American households have no retirement savings.
While Medicare provides health care coverage to seniors, many
Americans don’t realize that Medicare coverage of long-term care is
extremely limited. Medicare only covers a short duration of “medically
necessary” home or nursing facility care following an episode of acute
illness — it won’t pay for ongoing nursing home care or home health aide
services. Given these limitations, many Americans either pay out of
pocket for LTSS services, or turn to their family members for
assistance. About 20 percent of LTSS spending in the US is out of pocket
spending.
In contrast, the Medicaid program, which covers about 70 million
children and adults annually, pays for long-term care services in both
the home and institutional settings for the low-income elderly and
disabled. Medicaid is the largest payer for LTSS
in the United States, encompassing over half of total spending. As the
population ages, Medicaid will also fund LTSS for individuals who “spend
down” into the program. Because so many Americans do not have a plan in
place to meet future long-term care needs, those with income that
currently exceeds Medicaid qualification may “spend down” into poverty
and enter the Medicaid program when they can no longer afford to pay for
a nursing home or other LTSS out of pocket.
Because of the potential for spend down, Medicaid serves as a safety
net for the entire population. The Congressional Budget Office (CBO)
estimates that spending on LTSS as a percent of the GDP could more than
double by 2050. Medicaid is a huge line item in state budgets, and
increased Medicaid spending can crowd out other priorities at the state
level, such as education and economic development.
For many individuals, the alternative to spending down into poverty
is to increase their reliance on family caregivers. This strain does not
show up in state or federal budget tables, but does impact the
caregiver — depleting personal financial resources, interfering with
employment, and exacting an emotional and psychological toll. Creating a
comprehensive strategy to support family caregivers could help
alleviate the burden felt on all sides — both stabilizing the increasing
enrollment in Medicaid, and ensuring that family caregivers and those
they care for are able to lead healthy and productive lives.
The Impact of CARE
At both the state and federal level, we are beginning to see
encouraging signs that caregiving is becoming more central to
post-Affordable Care Act health policymaking in the U.S. With the recent
passage of the CARE (Caregiver Advise, Record, Enable) Act in
Pennsylvania, Michigan, and Virginia, 25 states now require providers to
identify and train caregivers during the hospital discharge planning
process.
A recently proposed change to the Medicare conditions of
participation for hospitals would require that nearly all caregivers
receive specific discharge instructions,
such as a list of all medications and warning signs to watch out for
relevant to the patient’s condition. Under the proposed discharge
planning rule, hospitals must consider the availability of family
caregivers, their capacity to provide care, and community supports
available to the patient. Ensuring that a family caregiver is
well-informed and trained to provide appropriate post-discharge care can
help avoid re-hospitalizations as well as prevent a decline in the
health and functional status of the patient.
Last year, the National Academy of Medicine formed a committee of the
nation’s leading experts to conduct a consensus study and make
recommendations for public and private sector policies to support family
caregivers. The release of this evidence-based study should be an
important step forward in accelerating caregiver policy and practice
development. Much like we have begun to do with our acute care system, a
comprehensive, all-hands-on deck local, state, and federal strategy is
needed to incorporate caregivers into the U.S. health system.
Policy Options Going Forward
Our recent report, Addressing the Needs of Caregivers at Risk: The Policy Landscape, covers three key areas:
Alleviating Financial Hardships
Several states offer tax benefits to family caregivers, to compensate
for spending on services such as home modifications. However, these tax
credits are small, limited in scope, and many individuals are unaware
of their existence. The federal Dependent Care Tax Credit helps families
with their child care needs, but its application to adult children
caring for aging parents is severely limited. One potential approach to
alleviating the financial hardship faced by family caregivers is to
allow them to claim Social Security benefits in exchange for the time
they spend providing care to loved ones.
Promoting Flexible Employment
The Family and Medical Leave Act (FMLA) allows qualified workers to
claim up to 12 weeks of unpaid leave to care for a sick family member.
The generosity of this benefit varies by state, with a few states
offering paid rather than unpaid leave. Existing research shows that the
impact of family and medical leave is positive, and in most cases, does
not result in any negative effect on the profitability of a business.
Providing Services and Supports
The National Family Caregiver Support Program and Lifespan Respite
Care Act provide funding to states to meet family caregiver needs by
increasing the availability of respite care, providing resources for
education and training, and offering supplemental services such as
support groups, home modifications, and supplies. However, these
programs are significantly underfunded. Many Medicaid home and
community-based service (HCBS) waivers contain a “self-” or
“participant-directed” component which allows the waiver recipient to
select and pay their own caregivers, including family caregivers. The
ability of Medicaid participants to hire and pay a family caregiver
using Medicaid funds varies from state to state.
Early caregiver research indicates that systematically incorporating
family caregivers into the U.S health system, for example, into discharge planning,
could improve the psychological and physical health outcomes of
patients, while reducing readmissions and total health expenditures
(Rodakowski, et al., Integrating Caregivers of Older Adult Patients into
Discharge Planning: A Systematic Review, in press).
The time has come for practitioners, providers, insurers, employers,
and policymakers to consider this emerging body of evidence and develop
strategies that fully embrace the critical role caregivers can and will
play in our health care system.
