The May 2006 Edition of Street Spirit

A publication of the American Friends Service Committee

 
 

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In this issue:

Oakland Tenants Face Eviction

UC Attacks the Berkeley Freebox

Berkeley Freebox Poetry Contest

Reform Profit-Making Nursing Homes

A Berkeley Fair for Street Youth

Ultimate Gift of a Homeless Veteran

Tax Cuts for Rich Harm U.S.

Many Children Left Behind

S.F. Bayview: History Lesson in Urban Removal

Let Their Chains Fall Off

Poor Leonard's Almanack: On Poets and Poetry

May Poetry of the Streets


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Reforming For-Profit Nursing Homes

The drive for nursing home profits ensures poor care and continuing horror stories

by Christopher Cherney

Art by Tiffany Sankary

Why do the horror stories in nursing homes never end? Simply put, the U.S. nursing home system subordinates human values to the profit motive. The profit motive controls every aspect of nursing homes: staffing levels, wages, the quality of food, the number of wheelchairs, the availability of clean linens -- everything.

In December 2004, at a Sacramento nursing home, a resident died after getting stuck between the mattress and the bed frame. She was wedged in so tightly that it took four people to extract her from the bed.

In November 2003, a Petaluma nursing home was cited by the State Department of Health for a resident burning to death on October 12, 2001, from her cigarette.

On November 23, 2002, a resident in another Sacramento nursing home died after being given the wrong medication 13 times in the previous two weeks, despite her repeated objections, her noted medication allergy, and noted severe symptoms of an allergic reaction.(1)

These three incidents are common occurrences in California nursing homes. Equally common are stories about nursing home residents developing infected pressure ulcers, becoming severely malnourished, or becoming dehydrated to the point of dying.(2)

The modern U.S. nursing home developed in the late 1960s, in the wake of the creation of Medicare and Medicaid. Since the 1970s, a litany of reports and testimonies by government investigators, advocates, academics, journalists, and, significantly, nursing home residents themselves, has confirmed that U.S. nursing homes provide poor care.

In 2003, the General Accounting Office concluded, "the proportion of nursing homes with serious quality problems remains unacceptably high."(3) California nursing homes have been singled out by the federal government, most recently in 1998, for providing especially poor care.(4)

Why does poor nursing home care continue? Why do the horror stories never end?

Simply put, the U.S. nursing home system subordinates human values to the profit motive. The profit motive controls every aspect of the U.S. nursing home system: staffing levels, worker wages, the quality of food, the number of wheelchairs, the availability of clean linens -- everything.

In California, almost nine in ten nursing homes are for-profit businesses.(5) By definition, these businesses strive to maximize revenue and minimize expense. From a business perspective, minimizing nursing staff, providing lower cost food, and delaying the purchase of new linens are rational acts.

But minimizing nursing home expenditures cannot lead to optimal quality -- ever. When profit is the driving motive of the nursing home system as a whole, quality must suffer -- and has suffered -- because every dollar of profit literally is one less dollar for care, one less dollar for quality. The drive for nursing home profit ensures poor care and guarantees continuing horror stories.

Economically and politically, the nation's $100-billion-per-year, for-profit nursing home system is formidable. For 30 years, on multiple fronts, advocates for quality nursing home care have skirmished with the for-profit system and its omnipresent lobbies. While many advocates yearn to eliminate the profit motive, on-the-ground political realities have dictated a less sweeping approach.

Recently, California advocates have been focusing their reform efforts in three keys arenas: direct care staffing accountability, labor union advocacy, and elder abuse litigation. While none of these reform efforts of itself can bring down the for-profit nursing home behemoth, each effort in its own way is nibbling at the heels of a sinister system.

Inadequate staffing levels

In 2000, California State Assembly Bill 1107, signed by then-Governor Gray Davis, mandated that California nursing homes provide for each patient, every 24 hours, no less than 3.2 hours of direct care staff. On its face, the bill was revolutionary. For the first time, the State mandated a specific number of staff -- without exception -- and politically ratified the research that correlates nursing home quality with direct care staffing levels.

The leading academics have concluded that, in fact, it takes at least 4.1 hours of direct care per patient per day (PPD) to provide minimal quality nursing home care to residents who are not especially frail, demented, or sick.(6)

Getting California nursing homes to provide even 3.2 hours PPD has remained an elusive goal. In 2002, almost 40 percent of California nursing homes self-reported staffing levels below the 3.2 hours PPD standard.(7) A Ventura County nursing home has verified under penalty of perjury that, in 2002, staffing levels were below the 3.2 hours PPD standard for 24 out of 26 pay periods -- that is, all but four weeks of the year.(8)

The California Department of Health Services (DHS) occasionally cites and fines facilities for failing to meet the 3.2 hour per patient per day minimum. For example, on December 22, 2004, a Chico, California, facility was cited and fined for not staffing at 3.2 on 11 of 15 days.(9)

Staffing citations are the exception. Despite the radical nature of Assembly Bill 1107 as policy, California's DHS never implemented a uniform, statewide system for calculating nursing home staffing levels.

An underfunded and overworked DHS relies primarily on nursing home residents (and their families) to call in staffing complaints, which subsequently are investigated, although not uniformly, or even expeditiously. Sporadically, DHS requests that facilities report staffing levels. More often than not, there is no staffing reporting at all. Even more depressing is the fact that, for most nursing home providers, 3.2 has become a maximum staffing level, not a minimum.

Because the Department of Health has had no reliable mechanism for calculating actual staffing levels, California nursing homes have not been held accountable to the minimum staffing standard. Stalwart advocates for nursing home reform at present are trying to mandate a uniform system for computing nursing home staffing levels in California.

Senate Bill 526, introduced in 2005 by Senator Elaine Alquist, D-Santa Clara, stipulates an objective, uniform staffing accountability mechanism. The bill requires nursing homes to electronically transmit to DHS direct care staff payroll data, so that actual staffing levels can be computed. The bill also establishes a financial penalty for nursing homes not reaching the minimum 3.2 standard.

Pat McGinniss, for 22 years the executive director of San Francisco-based California Advocates for Nursing Home Reform (CANHR), a bill sponsor, says of SB526, "It's the first time there has been a bill toward ensuring some kind of accountability. And staffing is one of the few ways to ensure accountability."(10)

Nationally, nursing home operators resist any demand to provide more, or even adequate, staff because direct care staffing is every nursing home operator's highest expense -- the typical nursing home spends two-thirds of its budget on staff-related expense. For-profit nursing home executives -- whose practices influence the small number of nonprofit executives -- universally are expected to realize shareholder value by maximizing revenues and minimizing expenditures.

Labor expenditures are managed on multiple fronts. Worker pensions are uncommon. Whenever possible, hourly wage rates are minimized. According to the Bureau of Labor Statistics, in 2002 the national average hourly wage of nursing aides, who provide 70 to 90 percent of nursing home direct care hours, was $9.27 per hour, or $19,282 per year.(11) This wage rate was exactly $0.57 per hour above the 2002 federal poverty level for a family of four.(12)

In October 2003, after being subjected to years of intense political pressure from the for-profit nursing home industry, the federal government issued new rules that allow untrained staff to provide feeding assistance to nursing home residents. These so-called "single-task workers" now are working in 15 states, and most earn the minimum wage, therefore exerting a downward pull on already-low nursing aide wage rates. A pending federal lawsuit filed in July 2004, in Seattle, has challenged the legality of the new rules.(13) In the meantime, the impact of single-task workers on nursing home profits is real.

Nursing home executives further manage labor expense by strictly monitoring overtime. A 1998 Department of Labor study found that 30 percent of U.S. nursing homes violated the Fair Labor Standards Act, including provisions for minimum wage, use of volunteers, and overtime pay.(14)

It is extremely common for nursing home staff, especially licensed nurses, to clock out after their regular shift, and keep on working, sometimes for hours, without pay, so as to complete their assigned duties without incurring management's wrath. This behavior invariably leads, subjectively, to burnout or staff resentment. Objectively, it leads to lower labor expenses, and poor care for the residents.

Nursing home managers exert their greatest control over labor expenses by strictly monitoring daily staffing levels. The primary tactic for limiting direct care staff is the widespread industry practice of not replacing nursing staff who call in sick. Because nursing staff call in sick almost every day, but especially on weekends and holidays, a practice of "no replace" guarantees lower-than-optimal staffing.

Senate Bill 526 takes dead aim at this practice. If SB 526 is passed, then nursing homes will be held financially accountable for not replacing nurses who call in sick.

Labor union bashing

As a result of stringent management efforts to maximize profits by managing labor expense, never has there been a shortage of acrimony between, on the one hand, nursing home workers and their unions, and, on the other, nursing home management. While strikes are uncommon, the bad blood is perpetual and omnipresent. The combativeness is emotionally draining, and poisons the care environment.

Nationwide, where union density rates range from zero (widespread) to almost 80 percent (in New York City),(15) management distaste for nursing home unions is visceral, and practically universal. In the Bay Area, where almost half the nursing homes are unionized, anti-union rhetoric is particularly vitriolic; it is a permanent part of the fabric of nursing home culture.

California's primary nursing home union, Oakland-based United Healthcare Workers (UHW), part of the Service Employees International Union (SEIU), has a long history of confronting hostile, for-profit nursing home operators.

For example, since 2003, UHW has been engaged in an ongoing, sometimes nasty campaign against the Ensign Group, Inc., a for-profit chain of 43 nursing homes in the Western United States. In an October 2004 lawsuit against Ensign, the union alleged "rampant understaffing" in multiple Ensign facilities.(16)

The company, for its part, notes on its website that it specializes in taking over, and then returning to profitability, "broken nursing homes," and that the union mischaracterizes Ensign facilities by focusing on the regulatory records of pre-takeover operators.(17) The union has launched a sophisticated website called EnsignWatch, and on its own website, Ensign categorically rebuts the union's claims. It's a high-tech food fight.

UHW's Charlie Ridgell, for 12 years (1989-2001) the disarmingly witty, tough-as-nails UHW Nursing Home Division Director, notes with an understanding borne of experience, "It's the nature of labor and management to be in conflict. That conflict adds a level of stress. On one level, the union gives workers a tool of hope. But at the same time, it does mean that you need to fight. There is that stress of the struggle."(18)

Nursing home union-bashing is a national pastime. Arkansas-based Beverly Enterprises, Inc. (now known as BEI), has for decades been one of the nation's largest for-profit nursing home chains. In 1997, during a town hall meeting in Pittsburgh, Cornell University Professor Kate Bronfenbrenner testified, at the invitation of several members of Congress, that Beverly Enterprises was "one of the nation's most notorious labor law violators."

Almost immediately, Beverly filed a defamation lawsuit against Bronfenbrenner, and sought through discovery to obtain access to her confidential research data on union organizing. About a year later, in May 1998, the suit was dismissed in federal court.(19) In February 2000, Beverly paid a $175 million fine to the federal government for defrauding Medicare. The settlement included a $5 million criminal fine.(20)

In Connecticut, in March 2001, a four-week strike by 4,500 unionized nursing home workers against 39 nursing homes was thwarted by Governor John Rowland, who used $20 million of taxpayer dollars to help nursing home operators pay replacement workers, many of whom were escorted to work, at Rowland's direction, by National Guard troops.(21)

The union sued the governor in federal court, and, in September 2002, the court ruled in part that the governor had interfered with the workers' federally protected right to strike.(22) On June 21, 2004, Gov. Rowland resigned amidst allegations of graft and a drive to impeach him.(23) On April 1, 2005, he reported to federal prison in Pennsylvania to begin serving a one year and one day sentence for corruption.(24)

Elder Abuse Litigation

As real as the labor wars are the litigation wars. In 1990, the California Legislature enacted the Elder Abuse and Dependent Adult Civil Protection Act (EADACPA). A 1991 amendment allowed for punitive damages and attorney's fees, and encouraged the use of civil enforcement through private lawsuits. EADACPA twice has been bolstered by California Supreme Court rulings, most recently in a 7-0 ruling in 2004 (Covenant Care, Inc. vs. Superior Court).

Fearful of trial, most California nursing home operators settle elder abuse cases -- for hundreds of thousands, if not millions of dollars. Or, alternately, they sell off their California facilities. Within the past five years, Sun Healthcare and Beverly, for-profit national chains, have been divesting themselves of California facilities.(25)

Cases that go to trial risk incurring the wrath of juries. Already the nursing home industry has a poor public image. A 1997 poll noted that 30 percent of Americans would rather die than be admitted to a nursing home.(26)

In 1998, elder abuse attorney Michael Thamer of rural Callahan, California, won for his client $94 million in punitive damages against Beverly Enterprises; at the time, it was the largest-ever award levied against a nursing home operator. While the punitive damages award later was reduced to $3.1 million, defense attorneys statewide seem to more frequently cite the higher figure.(27) Perhaps that is because Thamer's movie-star good looks and fiendishly disarming charm set them to imagining his impact on a jury called to adjudge an allegation of elder abuse against a for-profit nursing home.

Russell Balisok, of Glendale, who successfully argued the Covenant Care case before the California Supreme Court, and who literally wrote the book on pleading elder abuse cases,(28) gets about 15 case referrals every month. Reverently called The Professor by colleagues, Balisok has managed some 60 elder abuse cases; he has lost fewer than five.

Balisok observes that, "Until nursing homes truly are at risk of financial disaster" due to poor care, he and his plaintiff's bar colleagues will continue to get case referrals for horrific nursing home outcomes. "For now," he notes matter-of-factly, "their liability insurance rates go up, and they don't even care."

In a current case, Balisok is arguing that liability under California's elder abuse statute is uninsurable. If his argument prevails, a statewide crisis may ensue. Were elder abuse uninsurable in California, overnight the industry would be at serious financial risk. In Balisok's view, only this real financial risk will force the industry to improve care delivery. Until then, Balisok likely will continue to win huge settlements paid out by insurance companies.(29)

Clearly, the litigators have become the de facto nursing home enforcement system. Unlike the state or federal governments, plaintiff attorneys are conducting thorough, timely investigations, getting facilities to pay huge, timely fines (through settlements or heightened insurance premiums), and frequently are forcing facilities to implement truly actionable quality improvement plans, including increases in the number of caregivers.

Pat McGinniss, of California Advocates for Nursing Home Reform, notes, "Overall, we have highly ineffective governmental enforcement of California nursing homes."(30) Amazingly, state fines against nursing home operators for staffing violations are far less than the savings gleaned from understaffing.

Consumer complaints to state or federal regulators can take months or years to resolve, sometimes significantly compromising investigative findings, and sometimes possibly even compromising resident outcomes. A California man in January 2005 was at his mother's funeral the day the Department of Health started to investigate his earlier complaint that she had suffered a life-threatening injury caused by her nursing home's neglect.(31)

Profit by other names

Lawsuit settlement payments and increased liability insurance premiums reduce nursing home profits. But, even without these impacts to operating cash flow, operators for decades have pleaded poverty, incessantly. In 2002, half of California nursing homes claimed no profit, or a net loss.(32) Today, the for-profit industry association insists that facilities nationwide are shortchanged by Medicaid to the tune of $4.5 billion per year.(33)

Perhaps from constant overuse, these pleas over the past four decades have gained credence. Nursing home insiders have come to believe that the sky is falling; that poverty plagues the U.S. nursing home industry.

And yet, many nursing homes, while pleading poverty with the right hand, with the left hand enrich themselves with a host of payments that are booked as operating expenses. These payments can include monthly management fees -- averaging about seven percent of gross revenues -- paid to usually cash-rich for-profit holding companies. Or rent, which can eat up about eight to ten percent of gross revenues. Frequently, for-profit nursing home chain operators pay inflated rents to affiliated real estate subsidiaries, even as those subsidiaries accrue equity, and enjoy hefty tax writeoffs.

Other internal transfers may include payments to a closely held pharmacy for drugs used by a nursing home's own residents, payments to a subsidiary rehab corporation for rehab services provided to in-house residents, and payments to equipment company affiliates for medical equipment used by residents. These payments, fees, and transfers to related parties are in effect hidden profits, and can be substantial -- in some cases these payments exceed 30 percent of gross.(34)

Emblematic of these super-profits, Sun Healthcare erected in Albuquerque, New Mexico, a $47 million headquarters building, with 262 parking spaces.(35) There are plenty of nursing home millionaires.

But there are not as many nursing home millionaires as there are indigent nursing home residents receiving Medicaid. About 60 percent of the nation's nursing home residents -- that is, more than 1 million people -- are Medicaid recipients. To receive Medicaid, applicants must prove net liquid assets of less than $2,000.

These indigents are the residents to whom we as a nation too often provide substandard care. It is on behalf of these poor people that federal and state revenues conservatively approximating $50 billion per year flow to the corporations that own and operate the nation's 17,000 nursing homes.(36)

Clearly, there is a cynical perspective about the flow of $50 billion in taxes directly to mostly for-profit corporations that, among other things, pay themselves hidden profits while, at the same time, they bust unions and pay non-living (if not poverty-level) wages to employees caring for the indigent elderly and other dependent adults. Without question, for too long the U.S. nursing home system simply hasn't worked for large swaths of residents and workers.

Creating real reform

So what are the essential ingredients for better nursing home care? Motive and money; in that order.

First, we need to re-orient the motive for operating a nursing home in the United States. It must be starkly stated: profit cannot be the primary motive. It is impossible to turn a profit (by whatever name) and at the same time provide optimal care to our nation's most dependent citizens.

If we desire quality care, then we will need to enact legislation that objectively supports this goal, including laws that bar profit-making by any nursing home operator. These statutes must address limits to related-party expense, another name for hidden profits. Of note, New York State for years has forbidden out-of-state for-profit nursing home chains from operating nursing homes within its borders.(37)

We cannot legislatively mandate quality nonprofit nursing home care. The processes and ideologies of for-profit U.S. healthcare, and our nation's collectively ingrained fears about poverty, disability, and death, are so deeply woven into the cultural psyche that passing laws cannot, of itself, transform U.S. nursing homes into institutions of selfless caring.

But, as some of our nation's recent history demonstrates -- none more clearly than the stunning achievements of the civil rights movement -- laws can and do change behaviors to such an extent that, in time, hearts soften, and we find we have lived ourselves into a deeper humanity.

This, then, is a starting point for transforming the U.S. nursing home. By mandating a not-for-profit care delivery model with limits on payments to related parties, we can begin to free nursing homes to become more humane institutions.

Some nursing home pioneers are taking steps toward manifesting heart-centered, nonprofit care. Some, like Providence Mount Saint Vincent, in Seattle, are succeeding with innovative models of care delivery.38 However, even these facilities are constrained by the financial limitations of the current, broken system.

After we have eliminated the profit motive, we must address the second key ingredient of quality nursing home care: more money. To obtain optimal results, nursing homes need significantly more money. Mother Teresa would have had a hard time operating a successful nursing home today on $130.50 per day, the average Medicaid rate, nationwide.(39) And while citizens might eagerly give more public money for improving a nursing home operated by Mother Teresa, citizens nationwide rightly understand that there is something not quite right about giving more money to a for-profit nursing home system whose first priority is increasing shareholder value.

By reorienting the nursing home system to not-for-profit care, it becomes monumentally easier to mold political will in support of increased funding for nursing homes. Realist Charlie Ridgell of UHW reminds us, at the same time, that, "The real changes that would really benefit residents and workers will of course be very, very hard to realize, given the for-profit nature of the nursing home industry, and the limited government funding."(40)

Within the context of a national, nonprofit nursing home system, increased funding will mean more and better-paid staff, as well as a proliferation of innovative care delivery models. In turn, care will improve -- both in the technical and non-technical sense.

As we envision a future with widespread, quality nursing home care, here is the real-world financing, which, frankly, is not unreasonable. Nationwide, we would need to spend about two to two-and-a-half times the current average Medicaid rate to provide: 1) living wages and full benefits to all nursing home staff; and 2) average direct care staffing levels of 4.1 hours per patient per day, which, the academics tell us, would provide for minimally acceptable care.
In sum, we would need to spend another $50 to $75 billion a year, depending on how much quality we want. Either figure is an amount less than what we have been spending each year, for three years running, on the wars in Iraq and Afghanistan.

Clearly, the money is there to pay for quality nursing home care. The deeper question is: Do we really want it? Without cynicism or despair, we can pose the question: Do we as a nation want -- among other human service imperatives -- loving, nonprofit nursing home care, or do we prefer a perpetual war economy, and consistent tax breaks for the wealthiest ten percent of the population?

The joy of giving ourselves

At the deepest heart level, all of us individually and collectively yearn for love, for service to others. Most nursing home staff - most parents, for that matter -- know from experience the inner joy that springs from giving of ourselves to those who utterly depend on us. It is conscious awareness of this joy, I am sure, that explains why so many nursing home caregivers keep going back to work, day after day, in facilities that can be, on their best days, depressing, draining, and harsh.

Paradoxically, there is a power that springs from giving to those who, like so many nursing home residents, or like any newborn infant, are powerless. Quite simply, this power is love in action. Ultimately, it is this power that will undergird a transformed U.S. nursing home system.

Of itself, the paradoxical power of love is not sufficient to transform the system. Other, more prosaic, sociopolitical issues, including the elimination of nursing home profits, and the shift of billions of dollars into nursing homes nationwide, are crucial antecedents. But when the monies have been shifted, the loving can flourish.

May we all yearn for the day when the nation celebrates its nonprofit nursing home miracle, and recalls only with disbelief its for-profit nursing home tragedy.

The author has been a licensed and practicing nursing home administrator since 1997. He can be reached at ccherney@earthlink.net.

CITATIONS

1. All citations are noted in the California Advocates for Nursing Home Reform (CANHR) Citation Watch Consumer Report, Spring 2005.
2. See CANHR Citation Watch Consumer Report, 2005, 2004, 2003, 2002, 2001, 2000.
3. Prevalence of Serious Problems, While Declining, Reinforces Importance of Enhanced Oversight, GAO Report GAO-03-561, July 2003, www.gao.gov.
4. GAO report number GAO/HHS-98-202, California Nursing Homes: Care Problems Persist Despite Federal and State Oversight, July 1998.
5. California's Nursing Homes: A System in Trouble, California Healthcare Foundation, July 2003, p. 3, notes that 86% of California nursing homes in 2001 were for-profit.
6. See Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes: Phase II Final Report, December 2001, www.cms.hhs.gov/medicaid/reports
7. Nursing Homes: A System in Crisis, California Healthcare Foundation, 2004. Data, University of California School of Nursing, Annual Report for California Nursing Home Search, San Francisco, CA, 2003.
8. Source: Plaintiff's attorney Jody Moore, (805) 604-7130, who sued the referenced facility.
9. Citation Watch Consumer Report, Spring 2005, California Advocates for Nursing Home Reform, San Francisco, CA, p. 5. The facility is Riverside Convalescent Hospital, Chico, California. The citation #23154601116, was issued as a Class B citation, and $950 fine.
10. Telephone interview, May 17, 2005.
11. Bureau of Labor Statistics, www.bls.gov, click on "Nursing, Psychiatric, and Home Health Aides."
12. U.S. Department of Health and Human Services, http://aspe.hhs.gov/poverty/02poverty
13. "Nursing home residents challenge 'feeding assistant' regulations that lower standards of care." www.medicareadvocacy.org
14. "Feds: Labor violations rampant in LTC," McKnight's Long-Term Care News, July 1998, p. 8.
15. Source: www.1199SEIU.org. SEIU1199 represents nursing home workers throughout the Northeast United States.
16. See www.Ensignwatch.com, and "Nursing Home Firm is Sued Over Staffing," by David Haldane, The Los Angeles Times (Orange County Edition), October 16, 2004.
17. See www.EnsignGroup.net.
18. Telephone interviews with Charlie Ridgell, May 17, 2005 and May 25, 2005.
19. "Defamation lawsuit against Cornell labor researcher is dismissed." See www.news.cornell.edu/releases/May98/case_dismissed.dg.html. See also, "Cornell Professor Fights a Slander Suit," by Steven Greenhouse, The New York Times, April 1, 1998.
20. "Huge fine to nursing home firm for fraud," by Josh Richman, The Oakland Tribune, February 4, 2000, NEWS-2.
21. See "Nursing Homes Are Locking Strikers Out in Connecticut," by Paul Zielbauer, The New York Times, March 22, 2001. See also, "An Expensive Strike," by Steven Greenhouse, The New York Times, May 29, 2001, p. A17.
22. See www.ltcombudsman/org/uploads
23. "Embattled Conn. Governor resigns," www.msnbm.com, June 21, 2004.
24. www.cbs4.com/topstories
25. Regarding Sun divestiture, see "State inspections find pattern of dangerous short-staffing at Sunbridge. The financial reports show a company on the ropes," by Arno Holschuh, Northcoast Journal, November 9, 2000, www.northcoast.com. For Beverly, see www.mindbranch.com/products which notes: "Beverly is currently implementing a corporate strategy of divesting facilities that account for a disproportionately high share of its patient-liability costs. During 2003, Beverly divested or closed a total of 81 nursing facilities and seven assisted living centers."
26. "A Nursing Home? Or Death?" by Susan Gilbert, The New York Times, August 6, 1997.
27. From www.trinityinstitute.com/gregory
28. Actually, a chapter in the book. "Actions Against Skilled Nursing Facilities," in California Elder Law, An Advocate’s Guide, Continuing Education of the Bar, 1993. Balisok revised the chapter annually.
29. Telephone interview of May 25, 2005. Balisok is contesting the insurability of liability under the elder abuse statute in the case Pitluck vs. Beverly Enterprises et. al.
30. Telephone interview, May 17, 2005.
31. Source: Mike Connors, CANHR analyst; mike@canhr.org
32. Nursing Homes: A System in Crisis, California Healthcare Foundation, 2004. Data: UCSF School of Nursing, Annual Report for California Nursing Home Search, San Francisco, CA, 2003.
33. "SNF Medicaid Gap Grows Wider," by Lisa Gelhaus, Provider, May 2005, p. 12.
34. US News & World Report, "The New Math of Old Age," by Christopher Schmitt, September 30, 2003, p 67.
35. "Northrop Moving into Sun Building," by Diane Velasco, www.ABQJournal.com, March 7, 2003.
36. Center for Medicare and Medicaid Services. See www.cms.hhs.gov
37. Source: www.medicareadvocacy.org/ ArchivedPages/SNF_NrsgHomeBankruptices.htm
38. "Seattle's Elderly Find a Home for Living, Not Dying," by Sara Rimer, The New York Times, November 22, 1998, front page.
39. From "Liability Costs Taking Deeper Bite," by Lisa Gelhaus, Provider, May 2005, p. 10.
40. Telephone interview with Charlie Ridgell, May 17, 2005.


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