[Senate Hearing 110-308]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 110-308

                          ABUSE OF OUR ELDERS:
                           HOW WE CAN STOP IT

=======================================================================

                                HEARING

                               before the

                       SPECIAL COMMITTEE ON AGING
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                             WASHINGTON, DC

                               __________

                             JULY 18, 2007

                               __________

                           Serial No. 110-12

         Printed for the use of the Special Committee on Aging



  Available via the World Wide Web: http://www.gpoaccess.gov/congress/
                               index.html


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                       SPECIAL COMMITTEE ON AGING

                     HERB KOHL, Wisconsin, Chairman
RON WYDEN, Oregon                    GORDON H. SMITH, Oregon
BLANCHE L. LINCOLN, Arkansas         RICHARD SHELBY, Alabama
EVAN BAYH, Indiana                   SUSAN COLLINS, Maine
THOMAS R. CARPER, Delaware           MEL MARTINEZ, Florida
BILL NELSON, Florida                 LARRY E. CRAIG, Idaho
HILLARY RODHAM CLINTON, New York     ELIZABETH DOLE, North Carolina
KEN SALAZAR, Colorado                NORM COLEMAN, Minnesota
ROBERT P. CASEY, Jr., Pennsylvania   DAVID VITTER, Louisiana
CLAIRE McCASKILL, Missouri           BOB CORKER, Tennessee
SHELDON WHITEHOUSE, Rhode Island     ARLEN SPECTER, Pennsylvania
                     Debra Whitman, Staff Director
            Catherine Finley, Ranking Member Staff Director

                                  (ii)






















                            C O N T E N T S

                              ----------                              
                                                                   Page
Opening Statement of Senator Herb Kohl...........................     1

                                Panel I

Jennifer Coldren, Rome, NY.......................................     3

                                Panel II

Daniel Fridman, senior counsel to the Deputy Attorney General, 
  U.S. Department of Justice, Washington, DC; accompanied by 
  Marie-Therese Connolly.........................................     8
Gregory Demske, assistant inspector for Legal Affairs, Office of 
  Inspector General, U.S. Department of Health and Human 
  Services, Washington, DC.......................................    30

                               Panel III

Beverly Laubert, Ohio Long-Term Care Ombudsman and President, 
  National Association of State Long-Term Care Ombudsman 
  Programs, Washington, DC.......................................    47
Paul Greenwood, deputy district attorney, Office of the District 
  Attorney, San Diego, CA........................................    60
Robert Blancato, national coordinator, The Elder Justice 
  Coalition, Washington, DC......................................    65
Daniel Reingold, president and CEO, The Hebrew Home for the Aged, 
  Riverdale, NY; accompanied by Joy Solomon......................    73

                                APPENDIX

Prepared Statement of Senator Gordon Smith.......................    91
Prepared Statement of Senator Hillary Clinton....................    91
Prepared Statement of Senator Robert P. Casey, Jr................    93
Response to Senator Smith's Questions from Gregory Demske........    94
Response to Senator Smith's Questions from Daniel Reingold.......    96
Testimony of Dr. Eric Whitaker MD., M.P.H., director Illinois 
  Department of Public Health....................................    98
Statement submitted by the National Association of Medicaid Fraud 
  Control Units..................................................   103
Letter and Statement from Bruce Yarwood, president and CEO, 
  American Health Care Association (AHCA)........................   118
Articles submitted by Dr. Laura Mosqueda.........................   122

                                 (iii)




























 
                ABUSE OF OUR ELDERS: HOW WE CAN STOP IT

                              ----------                              --



                        WEDNESDAY, JULY 18, 2007

                                       U.S. Senate,
                                Special Committee on Aging,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 12:30 p.m., in 
room SD-628, Dirksen Senate Office Building, Hon. Herb Kohl 
(chairman of the committee) presiding.
    Present: Senator Kohl.

             OPENING STATEMENT OF SENATOR HERB KOHL

    The Chairman. All right. Well, we thank you all not only 
for being here today but for bearing with us as a result of 
activities on the floor. I think we were scheduled to start 
here at 10:30; now it is 12:30. So you are pretty sensational 
to wait for as long as you have.
    The hearing itself is going to be conducted in a somewhat 
different way, because they put a hold on formal hearings as a 
result of activities on the floor. That is something that 
Senators, under unusual situations and conditions, are allowed 
to do.
    So instead of a formal hearing, we will have an informal 
hearing, which will give all of those who are here to testify 
an opportunity to express yourselves and be heard. I will be 
somewhat more constrained in asking questions, but certainly we 
will get to hear everything you have to say. We are looking 
forward to it.
    I would like to welcome our witnesses and everyone who is 
here, of course, and those who will be watching on television.
    Today we are going to be talking about a really important 
subject: elder abuse in our society and what we can do to 
prevent it.
    Naturally, we want to not just talk about it but we want to 
talk about solutions. We want to challenge ourselves here in 
Washington to do something more to combat elder abuse and to 
propose some concrete things for action.
    I believe we need to enact a common-sense bill, a bill 
which is called the ``Patient Safety and Abuse Prevention 
Act,'' which I introduced with my friend from New Mexico, Pete 
Domenici. This bill, if we can get it passed, will protect our 
most vulnerable Americans who need long-term care by making 
sure that people who care in these facilities and care for them 
do not have any criminal background in their record.
    We need to keep predators out of our system, not just 
prosecute them after they have ruined people's lives. What we 
intend to do is set up a national registry of people who have 
criminal backgrounds, and so that, when they apply for 
employment in any kind of a facility across the country, they 
will be immediately identified and denied employment.
    I am pleased to say that several members of our Committee 
are cosponsors of this bill, including Senators Clinton, 
Lincoln, Collins, Senator Whitehouse and also Senator Casey. So 
I thank all of them very much for their support.
    Also today, I am happy to say that this bill is going to be 
introduced in the House of Representatives by Congressman Tim 
Mahoney, who also understands how important this issue is to 
our Nation's seniors.
    This bill is going to be modeled on a pilot program that 
has been occurring in seven States across our Nation over the 
last few years. The program, in its pilot aspects, has been 
very successful. Over the last 3 years, more than 5,000 
individuals in these seven States who had a criminal background 
have been identified and denied employment in long-term-care 
facilities.
    In Michigan, which is the State that had the most 
comprehensive pilot program, fully 5 percent of applicants for 
long-term-care jobs were excluded because their background 
check uncovered a serious criminal history. You can imagine the 
mayhem that they might have caused had they been able to become 
employed.
    The bottom line is that, in every State where the pilot 
programs have been established, that they have worked. I 
believe that is very important, and that is a victory for our 
elders.
    So we are going to be hearing from people about elder 
abuse, the ``Elder Abuse Act,'' as well as this criminal 
background check registry, which is going to hopefully be part 
of the ``Elder Abuse Justice Act,'' which is making its way 
through Congress.
    My colleague, Senator Blanche Lincoln, introduced this 
bill, the ``Elder Justice Act,'' and I am an original 
cosponsor. Both Senator Lincoln's bill and mine, as I said, 
protect seniors and save lives, and we need to pass those bills 
this Congress.
    So we are going to start this hearing today with a story 
from a brave young woman who has traveled all the way from New 
York to talk to us today about what happened to her grandmother 
one day when a predator who never should have been allowed to 
work in a medical facility became employed and found her 
grandmother alone.
    We will then have testimony from two Federal agencies about 
the Federal Government's attempts to address elder abuse.
    Finally, we will hear in our third panel from four of the 
leading experts in the United States who are working at the 
front lines of advocacy, of law enforcement and of service 
delivery to stop the scourge of elder abuse.
    We welcome you all here today.
    I would like to introduce our first witness.
    We are very happy to have you here, Jennifer.
    Jennifer Coldren is here from New York, the community of 
Rome, NY. Ms. Coldren is here to testify about the needless 
suffering that her grandmother encountered while recuperating 
in a long-term-care facility. The horrific crime was 
perpetrated by a criminal who never should have been employed 
but slipped through because of the patchwork system of 
background checks.
    So, Jennifer, thank you so much for coming. We are 
delighted to listen to whatever you have to say.

            STATEMENT OF JENNIFER COLDREN, ROME, NY

    Ms. Coldren. Chairman Kohl and distinguished members of the 
Committee, thank you for inviting me to testify this morning. 
The place I had hoped one day to be being able to share and 
have the opportunity to tell what happened to my beloved 
grandmother and my family, hoping that by having this chance to 
tell her story somehow will make a difference and help change 
the laws governing all facilities that take care of our elderly 
so something this horrifying doesn't happen to anyone else.
    My name is Jennifer Coldren. I live in Rome, NY, in the 
vicinity of Syracuse.
    The nightmare for my family began last year when my 
grandmother, who was 90 years old at the time, who had never 
had one act of violence done against her, was raped and 
assaulted by an employee of the residential facility she was 
in.
    He was 45. The man had a criminal record, and it was only 
the third time he had worked on the floor. He worked on the 
floor as needed, and his permanent job had been working on the 
surgical unit of the hospital.
    Had there been an effective background check performed, he 
would not have had the opportunity to harm my grandmother.
    Mr. Turtora's office prosecuted this criminal this spring, 
and this criminal received up to 25 years in prison for what he 
did to her. Her abuser showed no remorse for what he had done, 
and the judge called him a sick man and said what he did was 
second to murder.
    Before we lived this, our family believed that, with 
society the way it is today, that safeguards were already in 
place to protect our elderly from abuse. Unfortunately, we had 
to learn a tragic lesson that they weren't.
    I respectfully ask you to do something to prevent other 
similar crimes and further abuse of the elderly from happening 
in assisted care and medical facilities, for we were outraged 
that policies and laws were not in place to prevent something 
like this from happening.
    In this situation, a background check could take 30 to 120 
days to come back. A lot of damage can be done in that time. My 
grandmother's story is an example of what that timeframe can 
do.
    This is what happened to my grandmother. First, to give you 
an idea what this did to her family, I would like to start by 
summing up our feelings into words, what we felt living this 
nightmare: disbelief, fear, numbness, pain, anger, bitterness, 
shock, outrage, and our hearts broken. We also shed a thousand 
tears for her.
    But we also were proud, for my grandmother was not only a 
victim but a hero. She prevented him from hurting her again and 
from hurting anyone else on the floor that night. If she hadn't 
told anyone what happened, it made us wonder how long the abuse 
would have gone on before he had been caught and stopped and 
just how many more elderly people he would have harmed. See, my 
grandmother had dementia at the time, and we knew just how 
lucky we were she got her story out, and terrified of what it 
could have been if she hadn't.
    Before this took place, my grandmother had a smile for 
everyone. After this happened, she no longer smiled, cried all 
the time and had told us numerous times she wanted nothing more 
but to be an angel and for God to take her. She kept her 
feelings bottled up inside, did not discuss what happened with 
us or psychiatrists.
    Through her depression, her mind and body weakened. About 5 
weeks after, she had a stroke. She could no longer put full 
sentences together anymore and her words became mumbles. She 
had given up on life.
    My family had made the decision to bring her home. See, I 
couldn't live with myself leaving her there. I didn't trust 
anyone for her care anymore and was scared that something else 
bad could happen to her. The day we took her out of the 
facility, she smiled ear to ear--the first time since this 
happened to her.
    Our decision also came from when we found out that her 
abuser had also worked in another long-term-care facility and 
also in a State facility prior to this that works primarily 
with the elderly and severely handicapped people. He had also 
had numerous complaints of a sexual nature, inappropriate 
touching complaints, and they were all unfounded. He slipped 
through so many cracks. We felt we had no choice but to take 
her out of there.
    My grandmother has lived with me and my husband now for the 
past 5 months. It hasn't been an easy road, for she has 
Alzheimer's dementia, which presents new struggles and 
challenges every day, but she is beginning to be happy again. 
For us, our family, we have peace of mind, knowing she is safe 
and sound and happy. We made the right decision.
    The way things are, this tragedy can happen again in any 
nursing home, hospital, home care setting, and anywhere our 
vulnerable elderly are being taken care of by someone hired to 
take care of them.
    I ask the Committee for a moment to put yourself in our 
shoes. How would you feel if this happened to your mother, 
grandmother or someone else you love?
    We need to protect our aging loved ones who can't protect 
themselves, because if we don't, who will? Someday we will be 
old too.
    For my family, we will never forget what happened, and I am 
reminded every time I look into my grandmother's eyes what 
happened to her. I will never forget for the rest of my life.
    Our hope is something good will come out of this nightmare 
for us and that together we can come up with a solution for a 
growing problem so this never happens to another elderly person 
and their families again.
    In closing, we cannot change the past or what happened to 
my grandmother, but we can change things for the future 
generations so no one will ever know the fear and pain my 
grandmother and family has endured through all this. This is 
our hope, to be a part of that by being here today.
    Thank you for letting me speak and share her story today.
    The Chairman. Jennifer, that is really a moving story and 
so, so very well told by you. We know how difficult it is for 
you to stand up and--or sit down, come here and speak today. 
This has not been an easy experience for you but maybe somewhat 
cathartic, and certainly it does result in putting into place a 
system that will prevent, as you point out, prevent it from 
happening again. Certainly, I know you will feel that the time 
you spent here today was more than worthwhile.
    Because I am sure that is your number-one goal to see 
happen and occur, is that a system is put in place. Is that 
right?
    Ms. Coldren. Yes.
    The Chairman. How many years ago was that, Jennifer?
    Ms. Coldren. It was last year.
    The Chairman. One year ago?
    Ms. Coldren. It was in May of last year that this happened.
    The Chairman. Oh, just over a year.
    Ms. Coldren. Yes.
    The Chairman. Your grandmother is now living with you?
    Ms. Coldren. Yes, 5 months now.
    The Chairman. How is she doing?
    Ms. Coldren. She has her good days and her bad, but she is 
a lot happier now----
    The Chairman. Happier with you?
    Ms. Coldren [continuing]. That she is with us--yes--than 
she was in the nursing home.
    The Chairman. She does have dementia?
    Ms. Coldren. Yes.
    The Chairman. Progressive dementia?
    Ms. Coldren. Yes. Some days she is her old self, and then 
other days she has really bad days. That is hard to watch.
    The Chairman. She is in her 90's, did you say?
    Ms. Coldren. She had her 91st birthday this past April. We 
had a big party for her.
    The Chairman. That is wonderful. She is pretty lucky to 
have you.
    Thank you so much for coming.
    Ms. Coldren. Thank you.
    The Chairman. You have done a real public service.
    Ms. Coldren. Thanks.
    [The prepared statement of Ms. Coldren follows:]
    
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    The Chairman. At this time, we will turn to our second 
panel.
    Our first witness on our second panel will be Dr. Daniel 
Fridman, who is senior counsel to the deputy attorney general 
in the Department of Justice. In this capacity, Mr. Fridman 
advises the deputy attorney general on national criminal policy 
issues, including health-care fraud, child exploitation, 
immigration enforcement, as well as bankruptcy fraud. Mr. 
Fridman was an assistant U.S. attorney from the Southern 
District of Florida, where he had served as a trial attorney 
prosecuting violent crimes and other offenses. Currently, Mr. 
Fridman is on detail in Washington.
    Accompanying Mr. Fridman is Marie-Therese Connolly, a 
senior trial counsel in the civil division. Ms. Connolly is 
charged with coordinating the Elder Justice and Nursing Home 
Initiative at DOJ.
    Our second witness is Gregory Demske, who is the assistant 
inspector for legal affairs in the office of the Health and 
Human Services inspector general. Mr. Demske is responsible for 
administrative health-care fraud actions on behalf of the HHS 
OIG. He has worked in the OIG's counsels office for the past 15 
years. He has also served as a special assistant U.S. attorney 
in the District of Columbia.
    So we thank you both for being here.
    Mr. Fridman, we will take your testimony.

   STATEMENT OF DANIEL FRIDMAN, SENIOR COUNSEL TO THE DEPUTY 
 ATTORNEY GENERAL, U.S. DEPARTMENT OF JUSTICE, WASHINGTON, DC; 
             ACCOMPANIED BY MARIE-THERESE CONNOLLY

    Mr. Fridman. Thank you, Mr. Chairman. Thank you for 
inviting the Department of Justice to discuss its work fighting 
elder abuse.
    Appalling stories of abuse, like the one that Ms. Coldren 
had the courage to come here today and describe, remind us that 
there is still much work to be done.
    We also want to commend and recognize the work of Mr. 
Turtora, the New York State prosecutor who works with the 
Medicaid fraud control unit there, who brought Ms. Coldren's 
grandmother's abuser to justice.
    The MFCUs--the Medicaid fraud control units--State 
attorneys general offices, and local D.A.s, like Paul 
Greenwood, who is here today, bring most of the prosecutions 
against individuals who abuse and neglect elders.
    The elder-abuse cases that the Department of Justice 
pursues primarily involve systemic wrongdoings in facilities. 
We pursue those Federal cases under civil and criminal 
statutes, such as health-care fraud and other legal theories, 
working closely with our colleagues at the HHS Office of 
Inspector General.
    We also pursue financial crimes targeting elders, such as 
our identity-theft cases, our telemarketing cases, some Part D 
cases, which are described in my written testimony.
    I know I speak for the thousands of dedicated prosecutors, 
litigators, agents and grant-makers in the Department when I 
say that these are the kinds of cases that really make our 
blood boil. These cases that involve egregious human harm and 
suffering really motivate us to work to find a way to find 
justice for the victims.
    I am an assistant U.S. attorney from Miami on detail to 
Main Justice, where I advise the deputy attorney general on 
health-care fraud enforcement policy. In that capacity, I have 
a bird's eye view of what the Department's many components are 
doing to fight elder abuse and to hold their abusers 
accountable.
    Within DOJ, this effort involves each of our 93 U.S. 
Attorneys Offices; the Criminal, Civil and Civil Rights 
Divisions; the Office of Justice Programs; the Office on 
Violence Against Women; and the FBI.
    Let me give you some snapshots of some of the Department's 
most recent work.
    In the Borne case in Louisiana, the owner of a small 
nursing home diverted millions of Federal health-care dollars 
to buy his $1.2-million residence and his opulent estate called 
Annedelle Gardens, which had 150 acres, man-made streams and 
waterfalls and ponds that were stocked with exotic black swans 
that cost $5,000 apiece.
    At the same time, his nursing homes were chronically 
understaffed and rundown, lacking vital basics: soap, linens, 
sheets, wound-care supplies, and disinfectants. The relatives 
of one resident even brought in a truckload of turnip greens 
one evening so that everyone could be fed.
    Many residents in Borne's facilities suffered terribly, 
including from bed sores and malnutrition. Borne was 
prosecuted, sentenced to 37 months' imprisonment, and forfeited 
his lavish estate and residence.
    A recent St. Louis case, AHM, involved the suffering of 
numerous patients in three facilities. One woman had red ants 
crawling all over her eyes, mouth, ears and genitalia, as she 
lay there dying. Another patient died of a treatable bowel 
obstruction, which she had begged for staff to treat. Another 
was beaten to death by an aide. This case resulted both in a 
Civil False Claims Act settlement of $1.25 million, and the CEO 
of the three facilities pled guilty to felony charges.
    When the facility in question is a publicly run facility, 
that is where our Civil Rights Division can pursue cases under 
the Civil Rights of Institutionalized Persons Act, also known 
as CRIPA, to address conditions that violate Federal statutory 
and constitutional requirements.
    In a recent New Mexico case, a 71-year-old patient with 
life-threatening low blood sugar levels died when the staff 
failed to recognize and treat obvious signs of distress.
    Another patient that was admitted for rehabilitation 
following hip surgery died a week later of aspiration pneumonia 
because staff didn't follow proper procedures in feeding her. 
This case was resolved with a court-enforceable agreement where 
New Mexico will correct the systemic problems in its nursing 
homes.
    The focal point of the Department's elder-abuse efforts has 
been the Elder Justice and Nursing Home Initiative, which is 
spearheaded by my colleague sitting next to me, Marie-Therese 
Connolly. She supports prosecutors' failure-of-care cases, 
coordinates with numerous other entities on a broad scope of 
elder justice activities, and oversees a budget that funds 
grants for elder justice training as well as groundbreaking 
research in the field.
    Let us talk about some of that research.
    There is a consensus that there is a paucity of experts and 
research in the area of elder abuse. Responding to this, the 
Department's research arm, the National Institute of Justice, 
issued one of the first-ever solicitations for research grants 
relating to elder abuse in 2005. NIJ now has several research 
projects under way, and we have results from at least one of 
them already.
    This project related to bruising in elders, and the 
conclusions were as follows: No. 1, contrary to conventional 
wisdom, you cannot date a bruise simply by looking at its 
color. No. 2, 90 percent of accidental bruises in the elders 
studied appeared on limbs and 10 percent on the torso. Well, 
why is this important? Well, now practitioners know that if an 
elder has a bruise in another location, someone should be 
asking more questions about where that bruise came from.
    One of the most important sources of funding the Department 
relies on for this work are the funds provided by the Health 
Care Fraud and Abuse Control Account, which was established by 
HIPAA in 1996. Since 1997, these funds have helped the 
Department maintain dedicated prosecutors, litigators and FBI 
investigators who focus on health-care fraud cases. Our Elder 
Justice Initiative is funded out of these same funds.
    But since 2003, those funds remained constant without 
inflationary adjustment under a statutory cap until this year, 
when Congress passed and the President signed an inflationary 
cap adjustment to the funds each year until 2010.
    The President's 2008 budget requests an additional $17.5 
million to supplement the Department of Justice's HCFAC 
allocation, and we would appreciate your support for full 
funding of the President's request so that we can continue 
growing in these important efforts.
    I will conclude by saying that the cost of elder abuse, 
both human and economic, is high. The Department is committed 
to expanding the fight against this problem as America ages.
    [The prepared statement of Mr. Fridman follows:]

    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    
    The Chairman. Thank you for your testimony, Mr. Fridman. We 
will get back to you and Ms. Connolly in just a moment.
    Now we have as our second witness, as I said, Mr. Demske, 
who has particularly made an effort to be here today, because, 
as we understand, your wife is having a baby as we speak or 
something like that. Is that correct?
    Mr. Demske. Well, in a few hours, yes. [Laughter.]
    The Chairman. Congratulations.
    Mr. Demske. Thank you, sir.
    The Chairman. Go ahead.

 STATEMENT OF GREGORY DEMSKE, ASSISTANT INSPECTOR GENERAL FOR 
LEGAL AFFAIRS, OFFICE OF INSPECTOR GENERAL, U.S. DEPARTMENT OF 
           HEALTH AND HUMAN SERVICES, WASHINGTON, DC

    Mr. Demske. Good morning, Chairman Kohl. I appreciate the 
opportunity to join you here this morning.
    Stopping elder abuse requires a multifaceted commitment 
from Federal and State agencies, providers and other 
stakeholders, many of whom are represented here today.
    The Office of Inspector General at HHS advances this 
important goal of preventing elder abuse in three ways: We do 
oversight, enforcement and guidance.
    First, in our oversight role, we evaluate the programs and 
systems involved in regulating quality of care and make 
recommendations to the Centers for Medicare and Medicaid 
Services. OIG reviews have examined the effectiveness of 
oversight and enforcement by CMS and the States, screening of 
long-term-care employees, and the effect of reimbursement 
systems on access to care and the quality of that care.
    As an example, in testimony before this Committee in 1998, 
we recommended enhanced efforts to require criminal background 
checks and development of a national-abuse registry for long-
term-care employees.
    The second broad area of our work is enforcement. Although 
most cases of elder abuse are investigated and prosecuted by 
States, the Office of Inspector General works with the 
Department of Justice to investigate cases of systemic 
substandard care.
    You have heard some examples of those types of cases. Among 
the types of things that we have seen in nursing homes in cases 
we have investigated are patients suffering from dehydration, 
malnutrition, untreated broken bones, avoidable amputations, 
drug overdoses and deaths.
    In order to better team with States to address these 
issues, OIG has, over the past year, initiated extensive joint 
training programs and enhanced coordination with MFCUs, with a 
particular emphasis on jointly developing failure-of-care 
cases.
    With respect to administrative enforcement, OIG has 
excluded many individuals from participation in Federal health-
care programs. Last fiscal year, we excluded over 2,000 
individuals who either had been convicted of patient abuse or 
neglect or had lost their license to perform health care for 
reasons bearing on their professional performance or 
competence.
    In cases involving failure of care in which we do not 
require exclusion, we require the organization to enter into a 
corporate integrity agreement with our office. These corporate 
integrity agreements require the organization to hire an 
independent quality monitor selected by the OIG. These monitors 
have access to the providers' facilities, staff, programs and 
records. Using that access, they make recommendations to the 
providers about how to make systemic changes to protect the 
safety and well-being of the patients.
    The third major component of our quality-related work is 
our guidance to the health-care provider community. For 
example, in 2000, we issued the ``Compliance Program Guidance 
for Nursing Facilities.'' As part of that document, we provided 
guidance to facilities about what they should include in 
voluntary compliance programs, including steps to safeguard the 
safety and security of patients.
    OIG is also increasingly focusing on the role of boards of 
directors in safeguarding quality of care. We believe it is 
essential for board members to focus at least as much attention 
on the quality of care furnished by a provider as they do on 
the financial performance of the provider. Just last month, we 
issued a guidance document for members of boards of health-care 
providers to outline steps they could take to fulfill their 
oversight responsibilities with respect to quality of care.
    In conclusion, elder abuse in our health-care system can 
only be stopped through a concerted, multidimensional effort by 
many parties. OIG is committed to advancing this goal through 
review of CMS and State oversight, vigorous investigation and 
enforcement of wrongdoers, and guidance to leaders at health-
care providers about how they can enhance quality of care.
    Thank you.
    [The prepared statement of Mr. Demske follows:]

    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    
    The Chairman. Thank you, Mr. Demske.
    I would like to ask all three of you--maybe we will start 
with you, Ms. Connolly, because you haven't had a chance yet to 
express yourself--how vital, how important, how urgent is it 
that we put in place a background check system that can be 
accessed and used by facilities all across the country?
    Ms. Connolly. Senator, first, thank you very much for 
holding this hearing.
    I believe that the Department of Justice believes firmly 
that elders should be protected from convicted criminals. We 
have the legislation that you have introduced under review by 
our various components at this time.
    Mr. Fridman. Yes, Senator, the Department does agree that 
all people who come into contact with elders in a nursing home 
or long-term-care facility should have Federal background 
checks. We should be making sure that the background checks are 
complete and cover all the bases.
    As you know, the FBI has been participating in the pilot 
project, the $25-million pilot project, that was started by the 
MMA. It is available in seven states right now. The FBI tells 
me that, as of March 2007, they have run 165,000 background 
checks and they have identified 1,100 individuals for 
disqualification from the checks. The pilot concludes in 
September, and the results of the pilot will then be analyzed.
    The FBI tells me that they are working on getting some of 
the technology aspects that are called for in the bill, like 
the wrap-around technology that will, if a person passes with a 
clean check, gets employed by a nursing home, and then 
subsequently commits a crime, the system will then alert the 
State and the nursing home that the person has had an arrest or 
conviction.
    They are working on the technology. They have seen the 
legislation, and they have some concerns about timing and 
logistics that we could certainly discuss with your staff. But 
the Department is available to work with you and your staff to 
address any issues.
    The Chairman. That is very good.
    Mr. Demske.
    Mr. Demske. The OIG believes that criminal background 
checks are one of several mechanisms that can be helpful in 
screening out potentially abusive caregivers at facilities.
    We have been, as I mentioned in my testimony, on the record 
since 1998 as advocating criminal background checks as well as 
exploring ways to establish a national registry of employees at 
long-term-care facilities. With a national long-term care 
employee registry we can avoid some of the issues that arise 
from having a patchwork system in various States. In some of 
our reports, we have identified systemic problems of facilities 
in one State checking the registry in that State but not 
checking registries where the person may have worked before. As 
a consequence, people who are listed on one State registry for 
abuse can become employed in another State by a different 
facility.
    The Chairman. Very good.
    Well, we thank you, all three of you for coming here today.
    We are talking, naturally, about physical but also 
financial abuse and emotional abuse, abuse of all kinds, on the 
elderly. That is what we are focusing on with the ``Elder 
Justice Act,'' as well as the background check system contained 
within the act.
    We really do hope that, with the help that you are 
providing, we can get that act passed, and passed this year. I 
think, if we can, we will all feel as though we made jointly a 
real contribution to the elderly population and their security.
    So we thank you so much.
    Again, we wish you well with your impending arrival. If you 
would let me know, I would like to send your wife some flowers. 
[Laughter.]
    So let me know what hospital she is in. Will you do that?
    Mr. Demske. I sure will. Thank you very much.
    The Chairman. Thank you.
    Thank you all for coming.
    All right, well, we will get on to the organizations. Mr. 
Blancato is the recipient of many honors, including one in 1999 
from the American Society of Aging for his contributions to the 
field of aging.
    We do have a fourth witness, who is Daniel Reingold, 
president and CEO of The Hebrew Home for the Aged in Riverdale, 
NY. The Hebrew Home offers more than 3,000 older people a range 
of residential and long-term-care services.
    Most importantly for our discussion today, The Hebrew Home 
for the Aged also created our country's first comprehensive 
elder-abuse center, known as the Weinberg Center, with the Pace 
Women's Justice Center. Accompanying Mr. Reingold here today is 
Joy Solomon, who is of the Justice Center.
    So we will start now, and maybe we will go from my left to 
right.
    Ms. Laubert, would you like to make your comments?

STATEMENT OF BEVERLY LAUBERT, OHIO LONG-TERM-CARE OMBUDSMAN AND 
    PRESIDENT, NATIONAL ASSOCIATION OF STATE LONG-TERM-CARE 
               OMBUDSMAN PROGRAMS, WASHINGTON, DC

    Ms. Laubert. I certainly will. Thank you so much.
    Thank you for the opportunity to talk with you today about 
the problem of abuse and neglect in long-term-care facilities. 
Calling abuse and neglect a problem sounds trivial; it is 
better identified as a horrific problem, a tragedy or a crisis 
that is an embarrassment to our country.
    Every day of my 20 years as a long-term-care ombudsman, I 
have been touched by the bravery of residents and family 
members, like your first witness, who entrust their care to 
strangers.
    Chairman Kohl, NASOP appreciates your many years of support 
for our important work advocating for residents who are often 
otherwise without a voice. Your leadership and the leadership 
of George Potaracke, the Wisconsin State ombudsman, give us 
hope.
    Our network of 1,300 staff and 9,200 volunteer ombudsmen 
seek resolution of problems and advocate for the rights of 
residents of long-term-care facilities.
    Tens of thousands of long-term-care professionals and 
paraprofessionals provide loving, compassionate and competent 
care to our Nation's older and disabled citizens. But today I 
want to tell you about conditions that we have seen that can 
and must be changed.
    Someday, with your help, perhaps we can say with confidence 
that all of our Nation's older citizens are receiving the care 
they deserve where they choose to receive it. However, in a few 
minutes I will introduce you to Anna's story, which provides 
evidence that we aren't there yet.
    In 2005, ombudsmen received over 20,000 complaints of 
abuse, neglect and exploitation. Those are just the complaints 
in which someone used the words ``abuse'' or ``neglect.'' We 
collect data on complaints that are not called abuse but result 
from abusive or neglectful behavior. Nationwide, we received 
92,000 complaints related to resident care, such as improper 
handling and pressure sores.
    I applaud the introduction of the ``Patient Safety and 
Abuse Prevention Act.'' It would buildupon the work of States 
that have developed systems to check criminal records of 
caregivers. I have found that although most States do some type 
of screening at the time of employment, the methods are 
inconsistent.
    Mr. Chairman, we thank you for your steadfast pursuit of 
this critical area for ensuring quality care. The pilot program 
that you helped to secure has led us to this important juncture 
where Congress should now step forward and ensure a national, 
consistent approach to doing background checks.
    We are hopeful Congress will also address broader elder-
abuse issues this year with the ``Elder Justice Act,'' which is 
another stride along the critical path of justice for this 
Nation's older adults. The bill would establish a national, 
coordinated approach to elder justice and research, as well as 
support for building a well-trained long-term-care workforce.
    Every provision in the groundbreaking ``Elder Justice 
Act,'' including training for surveyors, improving ombudsman 
capacity and training, and funding Adult Protective Services in 
every State, must be passed as soon as possible.
    Ohio's criminal background check law has been in place 
since 1997, and my written testimony provides details of what 
that law does. There are several areas of inconsistency among 
the States, so an older adult cannot rely on a blanket of 
safety wherever he or she resides.
    My written testimony details examples of the variations: 
differences in whether fingerprints are used and whether they 
are obtained using ink cards or electronic equipment; 
differences in the timing of background checks; differences in 
the use of FBI searches; and differences in the data bases 
used.
    It is time to establish a nationwide system to improve the 
effectiveness of screening. As written, the proposed Federal 
law would address the problem of caregivers moving from State 
to State, thereby avoiding effective scrutiny. Unsupervised 
volunteers having similar duties as direct-care staff involving 
one-on-one contact with residents would be included in 
screening requirements. A wrap-back provision would identify 
caregivers who committed crimes after employment.
    To personalize the issue of abuse and neglect, as you have 
seen today, is heart-wrenching. I keep a folder in my office 
labeled ``Reminders,'' and every now and then, I open that 
folder and bolster my resolve to help residents and to be their 
voice to people like you who have the power to truly make a 
difference.
    I encourage you to read about Anna's story at the end of my 
testimony. Her family wrote to Governor Strickland in Ohio and 
sent pictures that are included in my written testimony of Anna 
and the problems that she had in a long-term-care facility. As 
my ``Reminders'' folder bolsters my resolve as an advocate, I 
hope Anna's story encourages and supports your efforts to make 
life better for America's older adults receiving long-term 
care.
    My time is getting close to expiring, so I will stop now, 
but I welcome the opportunity to share additional examples and 
answer your questions.
    Thank you.
    [The prepared statement of Ms. Laubert follows:]

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    The Chairman. That was very good, Ms. Laubert.
    Ms. Laubert. Thank you.
    The Chairman. Mr. Greenwood.

 STATEMENT OF PAUL GREENWOOD, DEPUTY DISTRICT ATTORNEY, OFFICE 
            OF THE DISTRICT ATTORNEY, SAN DIEGO, CA

    Mr. Greenwood. Good afternoon, Chairman Kohl. Thank you for 
allowing us this opportunity. I am honored to speak not just on 
behalf of my office, the San Diego D.A.'s office, but on behalf 
of a growing list, fortunately, of dedicated local prosecutors 
around the country who are seeing elder abuse as a significant 
major problem in our society today.
    Over the 11 years that you have indicated I have been able 
to prosecute these cases, I have become a true believer in the 
collaborative system. I believe the reason that our unit has 
prospered is because we have seized the opportunity to work 
with agencies such as Adult Protective Services and law 
enforcement and medical personnel.
    If I can just briefly mention five areas that we feel that 
we have made an indent in the road: First, we have created an 
elder-death review team, which has been very significant.
    Second, my office arranges, every 3 to 4 weeks, brown-bag 
lunches in the community, all around the county, where we 
invite members of the public and other agencies to come and 
address issues of elder abuse. That has been tremendously 
helpful to all of us.
    Third, we have been very involved with training banks, 
credit unions and other institutions, first responders such as 
paramedics and law enforcement, in what to look for in terms of 
red flags of elder abuse.
    Fourth, Adult Protective Services have created a tremendous 
awareness campaign called ``Silence is not Golden,'' and we 
have put our weight behind that too, to ensure that the public 
know who to call if they suspect that elder abuse is occurring 
in their community.
    Finally, I am proud of a project that has been funded by 
Archstone, a nonprofit organization, that allowed my office to 
have wrap-around services for elderly victims of crime through 
the Family Justice Center.
    Senator, I believe one of the major important steps as a 
prosecutor is to try to educate prosecutors around the country 
and to destroy the misconceptions that seem to stay with elder-
abuse prosecutions.
    For example, there is a myth that elderly witnesses are 
going to make poor witnesses. In my 11 years, to the contrary: 
They make the most compelling, fascinating and believable 
witnesses in the courtroom.
    Second, there is a myth that financial elder-abuse cases 
are difficult to prosecute because of cognitive issues of the 
victims. But we are learning new ways to overcome that.
    Third, that even though victims of physical abuse, who may 
have been assaulted by their own loved ones or by a nurse in a 
nursing home, will be reluctant to testify, nevertheless there 
are ways that we can learn how to prosecute those cases, 
because we can learn from the tremendous example given to us by 
domestic violence prosecutions.
    Fourth, there is this myth that, for example, home repair 
fraud, which is rampant amongst elderly homeowners in your 
State and every other State in this country, that those cases 
are somehow civil in nature. They are not. These are insidious 
criminal cases, and we should aggressively prosecute them.
    Senator, I have thought long and hard about this, but I 
have outlined seven areas which I think are crucial for us to 
move forward in this country with regard to prosecuting elder-
abuse cases.
    First, absolutely we need the passage of the ``Elder 
Justice'' bill this year. Thank you for your lead in trying to 
make sure that this is happening. This will create such 
encouragement amongst the rank and file of prosecutors, law 
enforcement, Adult Protective Services, so many dedicated 
agencies who see this bill as being absolutely pivotal in 
helping them do their job.
    With that, we urge the passage of the ``Patient Safety and 
Abuse Prevention Act.'' For those people who will say that this 
act would be too expensive, let me tell them that if we can 
prevent folks like this gentleman that we have heard about 
today in New York from working amongst elders, how much will we 
save from having to prosecute those people? Over the past 11 
years, I have prosecuted countless numbers of prior-convicted 
felons who have abused elders.
    Second, we need to improve State laws and make sure that 
every State has laws that reflect the severity of the crime, so 
that they should be felonies and not misdemeanors.
    Third, to create or expand the list of mandated reporters 
in each State, so that there are classes of groups of people 
who are mandated by law to report elder abuse.
    Fourth, to make the courts more accessible to elderly 
victims and witnesses and for us to take a leaf out of the book 
of Judge Julie Conger from Alameda County, who has made her 
court so elder- and user-friendly.
    Fifth, that every urban area in this country should have a 
dedicated police unit that has investigators just primarily 
focusing on investigating elder-abuse cases. I am very blessed 
that in San Diego we have such a unit.
    Sixth, for district attorneys around the country to develop 
these multidisciplinary teams and to realize that collaboration 
is the way to go. We cannot prosecute these cases on our own; 
we have so much to learn from everyone else.
    Finally, for everyone to invest in awareness campaigns so 
the public can feel confident that if they suspect elder abuse 
in a nursing home or in a private setting that there is a 
number that they can call and that they have the confidence 
that their call will not go unanswered.
    So I want to take this opportunity to thank you, Senator, 
for your listening. It has been a difficult day for you. But 
thank you for the priority you place on this terribly important 
issue.
    [The prepared statement of Mr. Greenwood follows:]

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    The Chairman. That was great testimony. Thank you so much.
    Mr. Blancato.

 STATEMENT OF ROBERT BLANCATO, NATIONAL COORDINATOR, THE ELDER 
               JUSTICE COALITION, WASHINGTON, DC

    Mr. Blancato. On behalf of the nonpartisan, 545-member 
Elder Justice Coalition, I am pleased to participate in today's 
hearing.
    We applaud the bipartisan leadership of this Committee and 
its work over several Congresses to promote elder justice. 
Today is another important contribution.
    Mr. Chairman, we commend your steadfast efforts to fight 
elder abuse and promote a national criminal background check 
system for those working in long-term care. Our coalition 
supports your bill, S. 1577. We hope for its consideration 
either as a stand-alone bill, part of the ``Elder Justice 
Act,'' or in some other legislation. We also appreciate your 
cosponsorship of S. 1070, the ``Elder Justice Act.''
    But with all due respect to all this work, the Nation has 
waited long enough. We have good bills before the House and the 
Senate, the product of much work, negotiation and concession by 
major stakeholder groups. It is time for Congress to finish the 
job.
    Mr. Chairman, your ``Patient Safety and Abuse Prevention 
Act'' is critical to the effort to help stop elder abuse. The 
2003 legislation instituted the seven-State, 3-year pilot 
projects to determine ways States can implement systems to 
cost-effectively screen applicants for employment in long-term 
care. Data provided by pilot States show that each program has 
successfully excluded individuals with histories of 
substantiated abuse and criminal backgrounds.
    However, as pointed out, these pilots expire in September. 
How do we go beyond the pilots, take their successes, and move 
to a more national system?
    Your bill has one approach: Expand the pilot framework into 
all States between 2008 and 2010, and in 2011 institute a 
permanent prohibition for providers who knowingly employ an 
individual with a history of substantiated elder abuse or a 
criminal conviction for a relevant crime.
    The issue of national criminal background checks needs to 
be addressed by this Congress. Elder abuse is increasing. A 
2004 report points to a 19.7 percent increase in reported elder 
and vulnerable adult abuse cases just since 2000. Adult 
Protective Service agencies received 566,000 reports of 
suspected elder and vulnerable adult abuse. We also know of at 
least 20,000 cases of abuse in nursing homes from just one 
reporting source, the 2003 report of State Long-Term-Care 
Ombudsmen.
    Far more elder abuse goes unreported. A 2000 Consumers 
Digest article says that only one in 25 cases of financial 
exploitation is reported. Consumer Action estimates that while 
adults 60 and over make up less than 15 percent of the 
population, they make up 30 percent of fraud victims. This 
Committee has made estimates of up to 5 million overall victims 
of elder abuse, neglect and exploitation.
    Elder abuse is also current news. Three headlines just in 
this past week: Arizona Daily, ``A nurse in a Flagstaff nursing 
home was arrested after allegedly punching a 93-year-old 
patient in the face.'' ABC-2 News in Baltimore, ``A Westminster 
woman, hired to clean and run errands for an elderly woman, has 
pleaded guilty to embezzling nearly $250,000 from the woman's 
estate.'' Ann Arbor, MI, ``The daughter of a Salem Township 
woman who froze to death in March has been charged with 
vulnerable adult abuse for leaving her mother, who had 
Alzheimer's, alone for 26 hours. The mother was found dead in a 
ditch five miles from home, and she was not wearing a coat.'' 
The current Federal response to elder abuse is piecemeal and 
minimal. Less than 2 percent of all Federal funds spent on 
abuse prevention goes to prevent elder abuse.
    As our population ages, so this problem grows. Today, the 
most common victim is an older woman, 75 years or older, living 
alone. Today, half of women 75 and over live alone. As 
financial abuse increases more quickly than other abuse, more 
and more wealth is being controlled by people 50 and over.
    The ``Elder Justice Act'' offers a comprehensive response. 
It provides dedicated funding for Adult Protective Services, 
grants to improve ombudsmen's capacity, create a national 
training institute for surveyors of long-term-care facilities, 
grants for stationary and mobile forensics centers, and require 
the immediate reporting to law enforcement of crimes in long-
term-care facilities.
    Our focus needs to be directed, as this Committee has 
always indicated, to first helping victims of elder abuse; 
second, preventing new victimization; and third, helping those 
who are working with victims and on prevention.
    It will be 30 years next year when Congress first addressed 
elder abuse in hearings of the old House Select Committee on 
Aging. This is the fourth consecutive Congress with an elder 
justice act and criminal background legislation that is waiting 
to pass. It is, frankly, incomprehensible, but not impossible 
to remedy.
    As advocates, we say, let us work together--Administration 
and Congress, Senate and House, Democrats and Republicans, 
national, State and grassroots groups--to achieve the final 
passage of elder justice legislation so we can genuinely help 
some of the most vulnerable people in our society: victims of 
elder abuse.
    Thank you, Mr. Chairman.
    [The prepared statement of Mr. Blancato follows:]

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    The Chairman. That was very good. Thank you so much.
    Mr. Reingold.

  STATEMENT OF DANIEL REINGOLD, PRESIDENT AND CEO, THE HEBREW 
  HOME FOR THE AGED, RIVERDALE, NY; ACCOMPANIED BY JOY SOLOMON

    Mr. Reingold. Thank you, Mr. Chairman.
    I am pleased to testify today on behalf of The Hebrew Home 
at Riverdale and the American Association of Homes and Services 
for the Aging. We strongly support ``Patient Safety and Abuse 
Prevention Act'' and the ``Elder Justice Act.''
    The Hebrew Home is a nonprofit organization in New York, 
founded 90 years ago. We are a long-term-care provider, and we 
are very much in favor of a national registry. It will make our 
lives easier and the care of our residents better.
    AAHSA represents 5,700 nonprofit, mission-based 
organizations who are providing services to over 2 million 
people a year, and all of our members have been protecting 
elders for all of their history.
    The Hebrew Home provides nursing care, housing, home care 
and daycare, and today I will describe the Nation's first 
comprehensive elder-abuse shelter.
    In our written testimony, we detailed the numerous 
activities of AAHSA, but today I want to focus on the shelter 
as a template and prototype for our Nation. So today, what I am 
presenting to you and to the Committee is the role of a 
nonprofit long-term-care facility stepping in to provide 
shelter and resources for victims of elder abuse in the 
community.
    Elder abuse is often invisible. Unlike children, elders are 
isolated, they are shut in, they don't have public places where 
their abuse may be observed.
    As difficult as it is for women, as well, to escape an 
abusive relationship and find a safe haven, it can be even more 
difficult for the elderly. Victims we have seen in the shelter 
suffer from cognitive and physical frailties, and they are 
frequently lacking in financial resources. So domestic violence 
shelters that exist can not serve the elderly. Many of the 
victims are men, who are not appropriate for the typical 
shelter that exists.
    So victims are frequently brought to emergency rooms, 
homeless shelters, or, worse, they are returned to the abusive 
situation. We observed that, and we decided that we needed to 
step in and make a change. We came up with the model which 
allows The Hebrew Home and the Weinberg Center to provide 
shelter for these victims.
    It exists in a nonprofit, mission-based long-term-care 
facility. We provide short-term emergency housing. We provide 
legal assistance and support services, with the goal of 
returning victims to their home. This is a short-term emergency 
shelter.
    It is a prototype, and we are seeking, through our 
partnership with AAHSA to replicate this model in every 
community, because every community has a nonprofit nursing home 
that can be used as an emergency shelter.
    We have the expertise. We have the facilities. We are 
elder-friendly. We operate 24-7. It is in keeping with our 
faith-based mission and our tax-exempt privilege.
    Joy Solomon, who is the director and managing attorney of 
the Weinberg Center, is joining me today and will describe some 
of our partnerships and the unique training initiatives, some 
of which Mr. Greenwood alluded to, which we are implementing in 
New York City.
    Ms. Solomon. Thank you for allowing me to testify, Senator 
Kohl.
    One of the most significant features of the Weinberg Center 
is its partnerships with law enforcement and community 
agencies. We successfully collaborate with area district 
attorneys' offices, Adult Protective Services, area offices on 
aging, and hospitals to prevent duplication but to assure that 
all the victims' needs are met.
    We train judges, law enforcement professionals, EMTs, 
social service personnel and other people who may come in 
contact with victims who are shut in.
    The beauty of our model is that it can be adapted by any 
community. In New York City, doormen know everything. In a 
unique partnership with their union, we are training New York 
City doormen to identify abuse and contact us. In a rural 
community, on the other hand, this model could reach letter 
carriers, clergy, or other eyes and ears.
    The center also has an extensive outreach program, visiting 
senior centers, retirement communities and shopping centers to 
disseminate information. Awareness, as Mr. Greenwood said, is 
critically important.
    The Hebrew Home Research Division also tracks and documents 
our cases to identify the prevalence and incidents of elder 
abuse. Our work will be even more effective with the creation 
of forensic centers, as called for in the act, with your 
support.
    Mr. Reingold. Senator, I wish to stress, in closing, three 
major points.
    First, as mission-driven organizations, nonprofit providers 
have a moral obligation to assist elder-abuse victims, and we 
have the knowledge and ability to do so. There are nonprofit 
homes in every community. We can provide the physical shelter. 
Through our existing or newly created network, we can provide 
medical care, social work and legal assistance.
    Second, protecting elders requires education and 
collaboration. We are training these people in the community to 
recognize and respond to elder abuse, and we collaborate with 
the police, prosecutors, hospitals, domestic violence shelters 
and seniors directly. This is not about doing it alone. It 
involves all of us in the community who come into contact with 
elders and who can provide assistance.
    Third, we see the Weinberg Center as a way to raise 
awareness about elder abuse and to help Federal and State 
policy. For example, we would hope to convince the Center for 
Medicare Services to make elder abuse a diagnosis for which 
Medicare or Medicaid reimbursement can be issued. Right now, we 
accept people without regard to pay and without regard to the 
possibility of payment.
    As with child abuse and domestic violence, the problem is 
multidimensional and multidisciplinary. Our model can be 
replicated throughout the United States, and we commend you for 
including in the act grants for creating new and innovative 
programs.
    In closing, Senator, creating the elder-abuse shelter has 
been an extraordinarily rewarding experience for our staff, our 
board of directors and our community. An elder-abuse shelter 
housed in nonprofit facilities throughout America is a goal 
that The Hebrew Home, in partnership with the American 
Association of Homes and Services for the Aging, is 
aggressively pursuing.
    We appreciate the opportunity to discuss these issues with 
you today. On behalf of AAHSA and The Hebrew Home, we 
congratulate you on your efforts and your leadership. We look 
forward to working with you in protecting our Nation's most 
vulnerable citizens.
    Thank you.
    [The prepared statement of Mr. Reingold follows:]

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    The Chairman. We thank you.
    We thank you.
    Your testimony was really good.
    Mr. Greenwood and Ms. Laubert, to what extent are crimes 
against the elderly going underreported? Why is that so in our 
society?
    Mr. Greenwood. Senator, yes, it is going unreported by the 
victims themselves for several reasons.
    Obviously, some of our victims don't have the mental 
cognitive ability to know how to report or to be able to 
articulate what happened to them.
    Second, many of our victims, particularly victims of 
financial elder abuse, are ashamed and embarrassed to report to 
the police. In fact, I have sat down with many elderly victims, 
and we found out about these crimes from other sources. When I 
sit with them and gently ask them, ``Why didn't you want to 
tell anybody this happened to you? '', the answer I keep 
getting is, ``Mr. Greenwood, I would rather lose $50,000 to the 
crook than run the risk of losing my independence.'' Because, 
unfortunately, there is a misconception in the elderly 
population that, if you are a victim, that we are all going to 
gather around and take away their independence. We are not in 
that business. We want to take away the independence of the 
perpetrator and not the victim.
    The Chairman. That is very good.
    Ms. Laubert.
    Ms. Laubert. Mr. Greenwood makes very good points.
    The experiences that we have seen with people who are 
receiving home-care services--I remember one woman in 
particular who said that the home health aide, or the 
homemaker, who went grocery shopping for her would come back 
and wouldn't give her change or would have lost the receipt. So 
when we said, ``Well, let us do something about that,'' she 
said, ``Well, Jackie has been taking care of me so well for so 
long, and she had to have her car repaired last year, so she 
really needs the money, and I will be OK.''
    What we see in home care is that the relationships that are 
formed between the client, who is vulnerable and feeling alone 
in their home, and the caregiver are very strong, and they 
don't want to make waves.
    I think about my own personal experiences with my parents 
having medical issues and being hospitalized for long periods 
of time. ``Well, Mom, what do you mean they kept you awake all 
night cleaning the carpet? Let us do something about that.'' 
``Oh, it is OK. I don't want to make waves.'' I think that that 
is a part of that generation. My generation is not going to 
accept those things. So, I think we need to be ready.
    I want to also tell you something very quickly, to give 
Congress a deadline. In 1998, my office received a call from a 
man named Daniel Broadman, who wanted to complain about a nurse 
in a nursing home where he worked who had not responded to a 
resident who was in distress and the resident died. The 
ombudsman got involved, investigated. The State survey agency 
got involved.
    About four years later, Daniel Broadman was in jail for 
passing bad checks. He confessed that he was the one who had 
killed that resident 4 years earlier. So he had three or four 
years, moving from one long-term-care facility to another.
    He is due to get out of prison for involuntary manslaughter 
in 2009 in Ohio. I know he won't be able to work in long-term 
care in Ohio again, but without a comprehensive Federal law, he 
may be able to go to a neighboring State and work in long-term 
care.
    The Chairman. That is very----
    Ms. Laubert. So there is a deadline.
    The Chairman [continuing]. Very good.
    So we take it that, in many ways, you are much like your 
mother, but, however, you are much more assertive than your 
mother.
    Ms. Laubert. Right. [Laughter.]
    The Chairman. Good for you.
    OK. Mr. Blancato, you talked about the importance of 
getting that national registry included as part of the ``Elder 
Justice Act,'' which, as you know, is one of our priorities. 
Would you like to make any other comment on that, as we move 
forward?
    Mr. Blancato. Well, all I would add is that, as a 
coalition, that we have a wide group of people from the nursing 
home industry, the nursing home rights groups, and we believe 
that the strongest possible elder justice legislation needs to 
emerge in this Congress, and we include that in that. The work 
that you have done, I think, deserves being given serious 
consideration this year.
    I think the issue--and we have watched this advocacy 
movement around elder justice emerge over the past 4 or 5 
years. Senator, I assure you, it has strong grassroots 
components. It has strong interdisciplinary elements to it. I 
think this is the year where, you know, we can see that come to 
fruition with the passage of meaningful legislation. We, again, 
commend you for your leadership in that area.
    The Chairman. Thank you.
    Folks, what can you tell us by way of things we can and 
should be doing to encourage the development of Weinberg 
Centers across the country?
    Mr. Reingold. The act provides for grants for innovative 
programs, and these are very cost-effective programs that we 
are describing. We are currently working with three other 
organizations to replicate the Weinberg Center. The startup 
time to open a shelter and get it running could be as soon as 
30 days.
    There are some innovative ideas that have to be adapted to 
a particular community's needs. But with very little support, 
very minimal financial support, we believe that nonprofit long-
term-care providers can step in, as they have stepped in on so 
many other issues, to provide a very innovative solution that 
is cost-effective, that is appropriate and that is nurturing.
    The Chairman. Ms. Solomon.
    Ms. Solomon. I just wanted to go back to the question that 
you asked before, about the underreporting. What we are seeing 
a lot of is that it is the family member who is abusing their 
parent or grandparent, whether it is financial, physical or 
sexual abuse.
    So, when you ask, ``Why is there underreporting? '', I 
think that the reality is that it takes a lot of incidents to 
occur before a grandmother is willing to report her grandson to 
a prosecutor or to the police. That is one of the reasons that 
things are not being reported.
    But if, as a community, we create these partnerships 
together to provide support, then that grandmother could get 
some support and her grandson could get some support too. It 
wouldn't necessarily mean that he goes to jail, but that they 
get some support in the community to live safely together.
    Because, often, elder-abuse victims want to maintain these 
``loving'' relationships even when they have gotten to a point 
of lack of safety or theft or some of the other things we are 
hearing about.
    So we need to create safety nets for the families and for 
the older people, certainly.
    The Chairman. That is a very important point that you are 
stressing, that elder abuse often occurs within a family.
    Ms. Solomon. Yes.
    The Chairman. That is something that we need to note and 
understand.
    Well, we thank you all for being here today. Your testimony 
has been just great.
    I want to tell you, on behalf of the Committee, that we are 
going to work extremely hard to get the ``Elder Abuse,'' as 
well as the national registry, passed this year. I think we 
have a good chance to get it done. I think you will all feel 
more than recompensed for your efforts in being here today if 
we can get that done. You can be assured we are going to do our 
very best.
    So we thank you for coming, and we thank you all for your 
patience in awaiting this hearing. It has been a great hearing, 
and it gives a lot of inspiration to those of us who are 
listening to you to get the job done. So thank you for coming.
    We thank you all for being here. This hearing is finished.
    [Whereupon, at 1:35 p.m., the Committee was adjourned.]
                            A P P E N D I X

                              ----------                              


             Prepared Statement of Senator Gordon H. Smith

    I want to thank Senator Kohl for holding this important 
hearing today. The issue of nursing home quality and safety has 
long been an issue of particular interest for me and I thank 
the panelists for being here today. The essential work that 
they do--whether monitoring care or advocating for nursing home 
residents--supplies the framework that helps so many of our 
elderly family members age with dignity.
    The past two decades have revealed a true culture shift 
occurring within the world of long-term care, including 
services that put the patient at the center of care, encourage 
inclusion of families in decision-making and giving more 
choices in the location of the care, such as community-based 
and in-home settings. However, with those advances has come the 
need to pay greater attention to the quality of care that is 
provided to seniors in all types of long-term care settings.
    Ensuring patient safety is a responsibility that rests with 
no one party or entity. It is shared by the federal and state 
governments, law enforcement agents, local agencies and 
community advocates. It is a responsibility that I take very 
seriously, as I know my colleagues do. I believe there is a 
need for all stakeholders to work more collaboratively to curb 
the incidence of elder abuse. We owe that to the millions of 
seniors who have placed their trust in our nation's long-term 
care system.
    Apart from improving communication and cooperation of 
enforcement activities, there may need to be new, stronger 
policies in place to ensure that seniors receive the safest 
long-term care possible. I plan to reintroduce the ``Long-Term 
Care Quality and Modernization Act'' with Senator Lincoln. This 
bill will encourage a number of important improvements to 
nursing homes and the long-term care system that aim to enhance 
the quality and safety of care provided to our seniors. I look 
forward to working with many of the advocates, industry 
representatives and regulators here today to ultimately pass 
this legislation.
    I would like to applaud the work Senator Kohl has done in 
this area as well, especially in regard to helping nursing 
homes and other facilities better identify potential bad actors 
in the workforce. It is essential that we find more effective 
ways to help poorly performing facilities operate at a much 
higher level of care, or consider ways that they can be phased 
out of the system. We cannot let the inappropriate actions of a 
few continue to destroy the trust our nation's seniors have 
placed in the long-term care system.
    I am confident that the fine panels of experts Senator Kohl 
has assembled today will be able to provide a fresh insight on 
the work that is being done at the federal, state and local 
levels to reduce elder abuse and provide the safest, highest 
quality care possible.
    Thank you.
                                ------                                


          Prepared Statement of Senator Hillary Rodham Clinton

    I would like to thank Chairman Kohl and Ranking Member 
Smith for convening today's listening session on the growing 
problems of elder abuse in our country and what we can do to 
reduce and prevent incidents of neglect, mistreatment, and 
violence against older Americans.
    I'd also like to thank the panelists--several of whom 
traveled from New York--to share their expertise and personal 
stories on this critical issue.
    I'd like to personally extend a special thank you to Ms. 
Coldren for being here today to share her grandmother's 
harrowing experience in a residential care facility.
    My heart goes out to your grandmother for what she endured 
and to you and the rest of your family for the pain and 
suffering you've experienced. Although it was under horrific 
circumstances that your grandmother came to live with you in 
your home, I am very glad to know that she is in the good care 
of you and your husband and that her happiness is beginning to 
return now that she is in a safe and loving environment.
    I am also relieved to learn that your grandmother's abuser 
has been brought to justice, thanks in large part to the work 
of Mr. Tortora who has accompanied you here today.
    Mr. Tortora and others like him in Medicaid Fraud Control 
Units are on the front lines of looking out for older 
Americans, who constitute one of our nation's most vulnerable 
populations. Older adults with Alzheimer's and other dementias, 
such as Ms. Coldren's grandmother, are especially in need of 
protection.
    As the baby boomers begin to reach retirement, it becomes 
increasingly important to have federal policies that promote 
positive aging and protect the well-being of our nations' 
seniors.
    I am proud to represent a state that has model examples of 
how residential care facilities can incorporate elder abuse 
shelters, such as the Hebrew Home for the Aged in Riverdale, 
NY, which provides support and health care services as well as 
legal advocacy for older adults who have been victimized. I 
welcome Mr. Daniel Reingold, president and CEO of Hebrew Homes, 
and commend you for the work you're doing nationally to expand 
the number of nursing homes that include elder shelters.
    We all know that there are thousands of competent and 
compassionate long-term care professionals that provide care 
for seniors in a loving and respectful manner. We are indebted 
to their professionalism and commitment.
    But the available information on elder abuse is truly 
sobering and staggering. Every year, as many as 5 million older 
Americans are subjected to gross neglect, abuse, or 
exploitation. According to a 2003 report by the National 
Academies, up to two million older Americans over the age of 65 
have suffered abuse or mistreatment by those who were charged 
with their protection and care.
    According to a 2004 Survey of State Adult Protective 
Services, there was nearly a 20 percent increase in reported 
cases of abuse and neglect of older and vulnerable adults 
between 2000 and 2004. A separate investigation in 2001 found 
that there's been a national increase in elder abuse in nursing 
homes, with a three-fold increase in abuse violations between 
1996 and 2000.
    Abusive behavior has serious consequences: according to an 
article published in the Journal of the American Medical 
Association, older Americans who are abused are three times 
more likely to die prematurely than older Americans who have 
lived in safe and healthy environments.
    In less than ten years, the first wave of baby boomers will 
turn 65. In light of the growing longevity of Americans, we 
must consider how we will meet the increasing needs of this 
elder boom including the protection of their mental, emotional, 
and physical wellbeing.
    This is about more than statistics: it's about safeguarding 
the dignity and happiness of older Americans--our grandparents, 
parents, senior members of our communities--and doing all that 
we can to support the countless husbands, wives, sons, 
daughters, loved ones and caretakers who give their time to 
provide support and comfort for their grandparents and parents.
    Safety is particularly important for individuals who suffer 
from Alzheimer's disease or other dementias. All of us here 
realize that as the Baby Boomer generation ages, there will be 
a dramatic increase in the number of Alzheimer's cases. By the 
year 2050, if we do not make headway, up to 16 million 
Americans are expected to suffer from this devastating disease.
    As co-chair of the Senate Task Force on Alzheimer's Disease 
with my colleague Senator Collins, I have worked to address 
issues faced by Alzheimer's patients and their caregivers.
    Diseases such as Alzheimer's can contribute to depression 
and anxiety for both those who suffer from the disease as well 
as their caretakers. Access to mental health services are also 
crucial for older adults who have been mistreated or 
victimized. That is why Senator Collins and I introduced the 
Positive Aging Act of 2007, which will integrate mental health 
services into primary care and community settings, making it 
easier for older Americans to get the support and treatment 
they need.
    But we need to stop cases of abuse and neglect before they 
occur. That's why I am proud to join my colleagues in 
supporting both the Patient Safety and Abuse Prevention Act and 
the Elder Justice Act. As an original cosponsor of the Patient 
Safety and Abuse Prevention Act, I recognize that we need to 
strengthen states' abilities to safeguard against abuse and 
neglect in long-term care facilities.
    This bill would meet these needs, by authorizing and 
funding a nationwide expansion of programs that screen 
applicants for employment in long-term care facilities.
    Among other provisions, this bill will also provide 
protections for long-term care facilities that fire employees 
with troublesome histories while also protecting employees from 
wrongful termination.
    Long-term care workers who pass the background checks would 
have certification of employment that they could take to any 
long-term care employer for two years.
    In order to recruit and maintain a quality long-term care 
workforce, we should not burden prospective employees with the 
financial cost of the background checks--the Patient Safety and 
Abuse Prevention Act would authorize funds to cover these 
costs.
    As a long-time supporter of IT as an important tool to help 
improve health care, I am especially pleased that this bill 
would help states establish IT infrastructures for screening 
job applicants at long-term care facilities.
    Improving our ability to detect physical abuse is crucial 
as well. The Elder Justice Act, of which I am a proud 
cosponsor, would, among other provision, support advances in 
forensics specific to elder abuse.
    Both the Patient Safety and Abuse Prevention Act and the 
Elder Justice Act are important steps towards ensuring that all 
older Americans, wherever they may live, are able to enjoy 
their golden years in safe and nurturing environments.
    Again, I thank Chairman Kohl and Ranking Member Smith for 
convening today's listening session, and for their leadership 
on this issue. I look forward to continuing to working with my 
colleagues to make progress for our seniors and families on 
these important issues.
                                ------                                


           Prepared Statement of Senator Robert P. Casey, Jr.

    I want to thank Chairman Kohl for raising this very 
critical issue and for all the work he has done over the years 
to protect our older citizens from abuse and ensure that they 
are treated with dignity, respect and compassion by the 
individuals who care for them. As a Senator, I have an abiding 
obligation to do all I can to protect those who fought our 
wars, worked in our factories and taught our children--those 
who gave us life and love.
    I want to also add that I am proud to co-sponsor Chairman 
Kohl's bill, The Patient Safety and Abuse Prevention Act 
(S.1577) which he introduced a few weeks ago and which will 
address the issue of background checks for workers who care for 
older citizens. Chairman Kohl, you have been a tireless and 
powerful advocate for our older citizens and I thank you for 
your good work.
    We are here this morning to examine what we can do to stop 
the abuse, neglect and exploitation of our elders. The Bible 
tells us to ``honor thy mother and thy father.'' There are no 
words to truly and adequately convey how very wrong it is that 
our seniors should suffer any kind of neglect or abuse in the 
twilight of their lives. Whenever we have a vulnerable 
population that suffers abuse or neglect--whether it be 
children, those with disabilities, or our older citizens--it is 
heartbreaking.
    Elder abuse is a particular problem because we have neither 
a comprehensive system for collecting data nor a uniform 
reporting system. Even the definition of elder abuse varies 
from state to state. But regardless of how statutes may define 
such abuse, we are talking about emotional, physical and sexual 
abuse as well as exploitation, neglect and abandonment. Sadly, 
shame, vulnerability and the fragility of many older men and 
women often render them unwilling to report crimes against 
them.
    What data we do have suggest strongly that there is a 
largely silent epidemic of elder abuse. Data on elder abuse in 
domestic settings, for example, suggest that only 1 in 14 
incidents, excluding incidents of self-neglect, come to the 
attention of authorities. With respect to financial 
exploitation, current estimates indicate that only 1 in 25 
cases are reported, suggesting that there may be at least 5 
million financial abuse victims each year. A study by the 
National Center on Elder Abuse estimated that for every one 
case of elder abuse, neglect, exploitation, or self neglect 
reported to authorities, about five more go unreported.
    Pennsylvania has the third largest elderly population in 
the country--15 percent of the state population or 1.9 million 
citizens. The numbers of elders will dramatically increase as 
our baby boomer generation continues to age. Nationally, we 
know that approximately 1 in 20 people will experience elder 
abuse during their lifetime. This is an alarming statistic. For 
Pennsylvania, this means that approximately 95,000 older 
citizens will be abused during their lifetimes. This is 
unacceptable to me. I know it is equally unacceptable to the 
members of this committee and to all of you who have come to 
testify today.
    Before being elected to the Senate, I spent 10 years in 
state government, eight of them as Auditor General, the state's 
fiscal watchdog. During that time, I conducted performance 
audits of Pennsylvania's oversight of long-term care, home 
health care and personal care homes and advocated changes in 
legislation and policy that improved the quality of care. Our 
audits exposed that Health Department bureaucrats were letting 
weeks and months elapse before investigating life-threatening 
complaints about nursing home care and that the state was 
licensing personal care homes without verifying that 
administrators and staff were properly qualified or trained. As 
a result of our audit work and our advocacy, nursing home 
residents are safer today and the laws governing home health 
care and personal care homes have improved. I am grateful to 
have the opportunity to continue this critical work in the 
Senate and particularly on this Committee.
    There is no denying this is a very complex issue. We have a 
health care system that has long been geared to address 
symptoms rather than focus on prevention that could provide 
better health and lower costs in the long run. Consequently we 
have growing numbers of seniors who experience multiple and 
chronic conditions that rob them of their independence and 
ability to care for themselves, becoming increasingly dependent 
on others to meet their needs. Institutions are under-staffed 
and have unsafe patient-staff ratios. We also have a workforce 
of direct care workers, many of whom face deplorable working 
conditions and professional stagnation. We must offer these 
dedicated workers decent salaries, professional respect and 
opportunities for training and upward mobility. That is the 
only way we will attract the caliber of workers who will care 
for our older citizens the way we would care for them as a 
family.
    We must do more to stop the abuse and neglect of our older 
citizens. Chairman Kohl's bill is a positive step in that 
direction. I welcome the opportunity this hearing affords us 
and I look forward to the experience, expertise and suggestions 
of the three panels of witnesses from whom we will hear this 
morning. I know you all have very important information and 
stories to share and I thank you for being here.
                                ------                                


       Responses to Senator Smith's Questions from Gregory Demske

    Question 1: The Federal/State Disconnect
    LEAD IN: In the most recent GAO report on nursing home 
enforcement, one of the findings that struck me was the level 
of disconnect between CMS here in Washington and the regional 
offices and state agencies that are tasked with implementing 
the statutes and guidelines regarding the nursing home 
industry.
    Question. From your perspective in the Office of the HHS 
Inspector General, can you comment on this discrepancy and 
offer a few ideas on how this can be remedied so that everyone 
can get on the same page and work towards more uniform 
enforcement and oversight?
    Answer. OIG's extensive work related to the nursing home 
enforcement mechanisms highlights inefficiencies and 
inconsistencies in how enforcement actions are referred and 
implemented. To illustrate, in one report, State Referral of 
Nursing Home Enforcement Cases (OEI-06-03-00400; 12/05. http://
oig.hhs.gov/oei/reports/oei-06-03-00400.pdf, we found that 
States failed to refer about 8 percent of cases to CMS as 
required and that late State referrals caused the delay or 
failure to impose mandatory denials of payment. Failures in the 
referral process were caused by insufficient or incorrect CMS-
regional office guidance, inaccurate enforcement data, and CMS 
not recognizing cases as referrals. Inefficiencies in the 
enforcement tracking systems mean that even when enforcement 
actions are required, they may not be implemented timely or in 
a manner that would motivate a facility to return to 
compliance. CMS has taken a number of actions, including 
implementing both case and incident-tracking systems, that 
should help to ensure that referrals are properly identified 
and communicated by the States and CMS and that enforcement 
actions are implemented more timely.
    OIG, like GAO, has also found inconsistencies in the 
citation of all levels of deficiencies (not just the most 
severe) among States, between Federal and State reviews, and 
even among individual survey reports. In a March 2003 report, 
Nursing Home Deficiency Trends and Survey and Certification 
Process Consistency (OEI-02-01-00600), http://oig.hhs.gov/oei/
reports/oei-02-01-00600.pdf, we found that in 2001, one-third 
of the nursing homes in Virginia were deficiency-free while 
none in Nevada were. In the same report, we also noted 
inconsistencies between Federal and State surveys-Federal 
survey teams normally find a larger number of, and more 
serious, deficiencies than state teams. These inconsistencies 
resulted from variations in survey focus, lack of clarity in 
guidelines, lack of a common review process for draft survey 
reports, and high turnover of surveyor staff. We recommended 
that CMS improve its guidance to State agencies on citing 
deficiencies by providing guidelines that are both clear and 
explicit, and work the States to develop a common review 
process for draft survey reports. CMS has taken steps to 
implement these recommendation and is also currently conducting 
training for state surveyors to promote consistency among 
reviewers regardless of the State. OIG continues to monitor the 
implementation of these recommendations.
    In two other reports, Nursing Home Enforcement: Application 
of Mandatory Remedies (OEI-06-03-00410; 05/06) http://
oig.hhs.gov/oei-06-03-00410.pdf and Nursing Homes Enforcement: 
The Use of Civil Money Penalties (OEI-06-02-00720; 04/05) 
http://oig.hhs.gov/oei/reports/oei-06-02-00720.pdf, OIG found 
that CMS does not apply all mandatory remedies (mandatory 
denial of payment and mandatory termination) against 
noncompliant nursing homes are required by statute, that CMS 
does not collect a large portion of Civil Money Penalties (due 
in part to reduction related to waiver of appeal rights, 
settlements and reductions resulting from appeals), and that 
CMS frequently imposes CMPs at the lower end of the allowed 
ranges. For the majority of cases requiring mandatory 
termination of nursing facilities, CMS did not apply the remedy 
because of both late case referrals by States and reluctance to 
impose this severe remedy. We recommended that CMS provide 
guidance to regional CMS staff and States regarding appropriate 
CMP dollar ranges for the varying types of violations and take 
required collection steps. We also recommended that CMS 
terminate noncompliant facilities' participation in the 
Medicare and Medicaid programs within the required timeframes.
    In summary, States and CMS should properly and consistently 
identify deficiencies and demand corrective actions at the 
earliest possible point. Further, to be effective in promoting 
compliance, civil monetary penalties and other graduated 
sanctions must be implemented fully, and not compromised down 
unless appropriate corrective action has been taken.
    Question 2: Targeting Worst Offenders
    LEAD IN: GAO identified in its 2005 report on nursing home 
enforcement that CMS's efforts have been further hampered by an 
expanded workload due to increased oversight responsibilities 
and initiatives that compete for staff and financial resources. 
The latest GAO report found that we are still not succeeding in 
removing the worst offenders from the system.
    Question. Is there a way to refocus CMS's energy on 
oversight tasks and initiatives that are the real 
underperformers?
    Answer. OIG has identified a number of needed improvements 
to the survey and certification system and enforcement 
mechanism if CMS and States are to properly address the worst 
offenders. First, deficiencies should be properly cited in the 
first place, so that all poor performers can be identified. 
Second, it is important to pinpoint the cause of the deficiency 
so that an appropriate corrective action can be taken. For 
certain facilities, the problems that lead to deficiencies are 
not only at the facility level. OIG has worked with companies 
under quality of care CIAs to address those systemic issues 
that gave rise to substandard care at the facility level. As 
one example, a regional director of a nursing home chain placed 
extraordinary pressure on nursing home administrators to keep 
the census in their nursing home high. As a consequence, one 
facility was accepting dozens of patients each month with 
complicated medical needs; however, the facility did not have 
staff with the specialized skills needed to appropriately meet 
the needs of these residents. The root cause of these issues 
and the appropriate corrective actions to resolve the issues 
cannot always be identified through the current survey process.
    Finally, when deficiencies are noted, appropriate sanctions 
should be applied consistently by CMS and States. Without a 
sense that enforcement remedies will necessarily have an impact 
on a facility, some owners and managers will not be 
sufficiently motivated to maintain compliance. CMS and States 
impose graduated sanctions that become increasingly harsh as 
the provider fails to comply--termination being the most 
severe. If CMS or the State fails to implement these sanctions 
as they are designed, ensuring compliance may become more 
difficult. Both State and CMS enforcement staff have reported 
to OIG that they are reluctant to impose what are perceived to 
be harsh remedies that risk putting a nursing home out of 
business or have a negative impact on a facility's ability to 
care for residents. For example, deficiencies are often related 
to insufficient staffing and monetary penalties can put a 
further strain on facilities' financial stability and risk 
maintaining even the prior level of staffing.
    CMS has implemented several initiatives aimed at targeting 
especially poorly performing nursing facilities. For example, 
in January 1999, CMS implemented a Special Focus Facility 
program that involves enhanced monitoring of two nursing homes 
in each State. In December 2004, CMS expanded the scope of its 
Special Focus Facility program from about 100 homes nationwide 
to about 135 homes. CMS also revised the method for selecting 
nursing homes by reviewing 3 years rather than one year of 
deficiency data to better target homes with a history of 
noncompliance. Additionally, CMS strengthened its enforcement 
regarding Special Focus Facilities by requiring immediate 
sanctions for homes that failed to significantly improve their 
performance from one survey to the next, and by requiring 
termination of homes with no significant improvement after 
three surveys over an 18-month period.
    Question 3: Marginalizing Lesser Harms?
    LEAD IN: Nursing home quality reports have focused most of 
their reporting on CMS's oversight of serious harm to 
residents, those rated at the G level and above. Where this 
focus is addressing the critical and immediate needs of 
residents, I am concerned that the enforcement efforts are 
neglecting the lower level harms that still create dangerous 
environments for residents and result in lower quality of care 
for our loved ones.
    Question. If CMS and the states are already overextended in 
monitoring homes for the worst offenses, what can be done to 
assist victims of the lower level harms who are still deserving 
of better treatment?
    Follow Up: What's to say that a facility will allow harm up 
to that G threshold level, but not beyond, knowing that 
enforcement efforts likely will not occur unless it crosses 
that point? Are we gambling with resident's health and well 
being through this approach?
    Answer.
    It is imperative that all deficiencies, including those 
below a level G, be addressed in a timely and complete manner 
in order to protect facility residents from actual and 
potential harm. CMS and States have a variety of tools to make 
this happen. The survey process, corrective actions plans, and 
graduated sanctions are the simplest tools that can be used to 
address deficiencies to prevent them from becoming serious 
deficiencies that cause actual harm to a resident.
    In earlier OIG work examining trends in nursing home 
deficiencies (see question #1), OIG examined all deficiencies, 
including those below the G level. Although GAO noted that 
serious deficiencies have declined somewhat, our work at that 
time indicated that deficiencies overall had increased. This 
increase could be due to a variety of factors. For example, a 
greater number of deficiencies could result from States 
conducting more thorough surveys, while a smaller number of 
deficiencies could be due to surveyors possibly down-coding 
deficiencies.
    Although OIG has not done work focusing on the compliance 
of facilities with deficiencies below a ``G,'' we do not 
believe there is a high risk that nursing facilities would 
willingly allow harm up to a certain level. By statute, every 
nursing home receiving Medicare or Medicaid payment must 
undergo a standard survey no less than once every 15 months, 
and the statewide average interval for these surveys must not 
exceed 12 months. Even though a facility may not have been 
cited for serious deficiencies in a prior survey, it is still 
subject to regular surveys. Additionally, homes with D-level or 
higher deficiencies are all considered noncompliant. CMS and 
States can demand corrective actions to address the deficiency 
and can use a variety of sanctions to help coerce compliance 
with quality requirements ranging in severity according to the 
scope and severity of the deficiency, a facility's prior 
compliance history, and the desired outcome. Serious 
deficiencies (H or higher, and repeated G-level deficiencies), 
however, are subject to mandatory sanctions. If a facility with 
a D-level or higher deficiency does not become compliant within 
a certain time period, then the sanctions are increasingly 
elevated, with the potential end result of termination of the 
facility.
                                ------                                


      Responses to Senator Smith's Questions from Daniel Reingold

    Question: Dissemination of their innovative program
    LEAD IN: I was intrigued by the groundbreaking work being 
done at the Weinberg Center to prevent the abuse of elders. I 
believe such programs are key to the broader effort in 
improving the type of care we provide our seniors.
    Question. What have you done in helping other communities 
replicate the success of these programs?
    Answer. We, too, believe the Weinberg Center model is 
uniquely effective in the intervention and prevention of elder 
abuse and have made great efforts to encourage replication 
throughout the nation.
    First, we have partnered with AAHSA (American Association 
of Homes and Services to the Aged) to encourage all of its 
members to replicate the Weinberg model. In doing so, we have 
set up a link from the AAHSA web site to the Weinberg Center, 
so that interested affiliates can have access to our model, 
policies and procedures, and easy connections to the Weinberg 
Center team for direct communications. The Weinberg Center team 
has given workshops at numerous AAHSA conferences specifically 
on how to replicate.
    Second, through a grant from the Brookdale Foundation for 
dissemination and replication of the Weinberg Center, we have 
created a how to manual, provided consultations to assist in 
adapting the Weinberg model, and held day long training for 
replication.
    Finally, The Weinberg Center team has given numerous 
presentations to professionals, law enforcement, and others who 
come in contact with older adults on elder abuse and the 
Weinberg Center model. In addition to creating collaborative 
partnerships, the Weinberg Center Team is nationally and 
locally active on numerous elder abuse coalitions and 
partnerships, spreading the word about the Weinberg model.

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