Keep a close eye on your loved one’s care in a nursing home

It almost goes without saying that if your loved one is admitted to a health care facility, somebody outside of the institution needs to immerse themselves in the treatment & care planning process, read the chart on an ongoing basis, know what’s being prescribed, speak with the care providers or treatment team frequently, and demand answers to reasonable questions about What is being planned, Why it’s being recommended, How it will affect the patient, Where the follow-up care will be, and Who needs to be available to implement a safe follow-up plan. If the family member who is known as the “first responder” is having trouble gaining access to this information, the patient or his/her agent under power of attorney can sign a HIPAA authorization.  Somebody has got to keep an eye on what’s going on: there can be a lag time between the time a request is made and when the physician or nurse can act on it; the addition of a new medication can create new symptoms and imbalance for the patient; if the resident exhibits dramatic changes in demeanor such as lethargy, falling, stupor, or increased confusion, the family needs to be able to address it right away. And of course, often, a decision by the family is being demanded in a big rush.

Another reason somebody has got to keep watch over the patient is that there are times when inappropriate or unnecessary treatment is being provided. CNN did a disturbing expose recently about the off-label over-prescribing of a medication called Nuedexta to nursing home residents who have Alzheimers’ disease and other dementias, but also have symptoms of depression. The article says:

The pill, called Nuedexta, is approved to treat a disorder marked by sudden and uncontrollable laughing or crying — known as pseudobulbar affect, or PBA. This condition afflicts less than 1% of all Americans, based on a calculation using the drugmaker’s own figures, and it is most commonly associated with people who have multiple sclerosis (MS) or ALS, also known as Lou Gehrig’s disease. … Since 2012, more than half of all Nuedexta pills have gone to long-term care facilities. The number of pills rose to roughly 14 million in 2016, a jump of nearly 400% in just four years, according to data obtained from QuintilesIMS, which tracks pharmaceutical sales. … Nuedexta is approved by the Food and Drug Administration (FDA) to treat anyone with PBA, including those with a variety of neurological conditions such as dementia. But geriatric physicians, dementia researchers and other medical experts told CNN that PBA is extremely rare in dementia patients; several said it affects 5% or less.

The report goes on to discuss, among other things, severe adverse consequences experienced by many patients who are receiving the drugs inappropriately.

The main point is not that I’m expressing a position on the bona fides of any particular practitioner’s prescribing patterns. It is, rather, to emphasize the extreme importance for every patient and every nursing home resident to have an attentive advocate watching over what is happening.

Call us for advice about elder care, nursing home placement and long term planning .. 732-382-6070


Eliminating the Medical Expense Deduction Will Harm People Who Are Chronically Ill

House and Senate Republicans have approved their plans to reform the tax code and are currently in a conference committee. The House legislation calls for ending the medical expense deduction (MED). This proposed change will cause major disruption to individuals and families trying to privately pay for the catastrophic costs of long-term services and supports (LTSS).

The MED has been in the tax code in one form or another since 1942, at  26 U.S. Code § 213  .  

Elder law attorneys are intimately familiar with it because they have a front-row seat to their elderly clients’ chronic illnesses and long-term care expenditures as well as the special medical and remedial care expenses of individuals with disabilities. In my work as an elder law attorney, I deal with this tax deduction every single day, usually to reassure my clients that they will probably be able to offset the taxable income from, say, their IRAs or 401Ks,  with their substantial deductible nursing home expenses and minimize the tax consequences of paying for long-term care (LTC) themselves.

Right now, the MED is used for a variety of expenditures and situations. Taxpayers can deduct medical expenses in excess of 10 percent of their Adjusted Gross Income for the 2017 tax year. The Senate tax bill actually lowers this threshold back to 7.5%.  The MED can be used when people are:

  • Trying to afford their health insurance premiums, co-pays, and deductibles
  • Paying for the cost of childbirth and post-natal care
  • Paying for their own LTC or the LTC of a dependent child, parent, or other relative
  • Paying for assisted living
  • Paying a Medicaid cost share to a facility
  • Using pre-tax accounts for catastrophic medical expenses when they have no insurance or insufficient insurance coverage
  • Paying for home accessibility for disabling conditions
  • Paying for dental work, which is critical to long-term health
  • Paying for toxic lead or mold remediation
  • Paying for drug abuse rehabilitation for their dependent relative
  • Paying for additional ABA for a child on the autism spectrum

Our current long-term care system is driven by Medicaid, a means-tested program, and it sometimes acts as a disincentive for the middle and working class to save. Perversely, many middle- and working-class individuals who develop a chronic illness would have been better off had they not saved at all, thereby allowing them to qualify immediately for Medicaid. Clients express this frustration to us all the time. The MED acts as a key counterweight to that disincentive by substantially expanding the length of time someone could pay privately before needing government assistance.

The House Republican Tax Reform plan takes this important tax incentive away without any appropriate justification. Elder and special needs law attorneys are leading the way in educating and persuading stakeholders and the larger public  to fight back against removing the MED.

Read more about the Medical Expense Deduction for the Chronically Ill.

This post first appeared on the mailing list of the National Association of Elder Law Attorneys (NAELA): View the original online here.

Call us for advice about long-term care planning, nursing home care and elder law . 732-382-6070

Upcoming Live Seminar: Protecting Assets While Qualifying for Medicaid


Lauren Marinaro will present at an upcoming National Business Institute live seminar: Protecting Assets While Qualifying for Medicaid

Date: Tuesday, August 15, 2017

Time: 9:00 AM – 4:30 PM

Molly Pitcher Inn
88 Riverside Ave
Red Bank, NJ 07701

For more information or to register, please visit:

New SEC rule could protect vulnerable adults from exploitation

There is a fine line to tread when a concerned person observes what appears to be financial exploitation of a person with cognitive impairment. Under the law, an adult is presumed to be “competent” unless and until a Court has entered an Order declaring him or her to be incapacitated. As dementia develops, there can be a long distance between the onset of impaired judgment with impaired resistance to suggestion, and the point of actual incapacity.

Third parties who interact with the customer — such as people working in banks and brokerages,  insurance agents etc. — may observe disturbing behavior. They may observe that their customer is now accompanied by somebody who seems to be telling them what to do or is doing the speaking for the customer. There may be a sudden new pattern of  changing the title or beneficiary of assets. These observations can put the financial professional in a tricky position. Reporting is optional, not mandatory, for such professionals under the New Jersey Adult Protective Services Act, N.J.S.A. 52:27D-409. ” 4.a.(1) A health care professional, law enforcement officer, firefighter, paramedic or emergency medical technician who has reasonable cause to believe that a vulnerable adult is the subject of abuse, neglect or exploitation shall report the information to the county adult protective services provider.      (2) Any other person who has reasonable cause to believe that a vulnerable adult is the subject of abuse, neglect or exploitation may report the information to the county adult protective services provider.”

Recently, the SEC adopted new FINRA rules (Financial Industry Regulatory Authority) designed to give some tools to financial professionals who are seriously concerned about these kinds of problems. The rules will become effective February 5, 2018. FINRA Rule 2165 is called Financial Exploitation of Specified Adults. It allows members to place temporary holds on disbursements of funds or securities from the accounts of specified customers where there is a reasonable belief that financial exploitation of these customers is going on. In addition, two amendments to FINRA Rule 4512 (Customer Account Information) now require members to make reasonable efforts to obtain the name of and contact information for a trusted contact person for a customer’s account. Many readers may have received such notices from your investment managers.

We have been involved in cases over the years where the first person to realize that something suspicious was going on was a banker or investment manager. Those alerts let to the placement of court-ordered protective arrangements which safeguarded the assets and protected the individual against further exploitation. The new rules should prove to be a helpful “arrow in the quiver” towards preventing financial exploitation of aged and infirm people in our communities.

Call us to discuss elder care planning and litigation …….. 732-382-6070