Faith Room Mates

Jeffrey Downey asked:


Assisted living facilities are rapidly becoming the nursing homes of the future. According to the National Center for Assisted Living, there are over 36,000 licensed assisted living facilities nationwide with an estimated 1 million residents.[1] However, because there is no common definition for assisted living facilities, this number may not adequately reflect the prevalence of these facilities. In fact, in 2002 the National Conference of State Legislatures hailed the assisted living market as one of the fastest growing long-term care options for senior citizens; the number of seniors in assisted living facilities receiving Medicaid benefits has grown nearly 50% over the past few years.[2]

These facilities tend to aggressively market and recruit residents, many times promising staffing levels or services that, in reality, are not available.[3] In an attempt to compete with nursing homes, assisted living facilities are accepting patients with higher acuity. Most major chains promote special Alzheimer’s Disease Units, and are accepting patients with significant cognitive impairment. The reality is that many of these facilities have staffing that is inferior to the staffing levels present in nursing homes and simply cannot meet the needs of the higher acuity residents. The end result is that residents throughout the county are suffering from serious injuries due to the neglect and abuse that is taking place in these facilities.

A. Assisted Living v. Nursing Home Care

Assist living abuse and neglect cases and nursing home abuse and neglect cases are similar in some respects, i.e., both involve supervision and care of the elderly, but evaluating the assisted living case involves a greater perception of the differences in the two types of facilities.

1. Standards of Care. The litigation of assisted living abuse and neglect cases, like the litigation of nursing home abuse and neglect cases, can be an effective tool in forcing the industry to comply with proper standards. However, since most states have weak regulations, it often becomes difficult to establish the legal standard of care for a particular facility. Many times a plaintiff may have to fall back on basic community practice nursing standards that will apply when an assisted living facility contracts to provide more than just room and board.

Nursing homes are highly regulated and must comply with the regulations set forth in the Omnibus Budget Reconciliation Act (“OBRA”) of 1987[4] (otherwise known as the federal Nursing Home Reform Act) which set minimum standards of care for long term care facilities that receive federal funding. Unlike nursing homes, assisted living facilities are not regulated by the federal government, and the state regulations that do exist are inconsistent and, for the most part, not aggressively enforced.

When considering the basis for liability, one must consider whether the assisted living facility breached regulatory or community practice standards in admitting the resident whose needs may have been too great to be met by the assisted living facility. Many assisted living facilities, especially those with “Specialized Alzheimer’s Units” are accepting residents with advanced dementia who would normally be admitted to a nursing home, and possibly even a skilled wing of the nursing home. In such cases, it would be advisable to obtain an expert who will evaluate the resident’s condition and the relevant admission criteria. Such an evaluation will likely be beyond the abilities of a lay person, although many admissions decisions in assisted living facilities are being made by non-medical personnel.

Almost all states prescribe some limitation on who can be admitted into an assisted living facility. For example, Virginia regulations prohibit adult care facilities from admitting or retaining patients with a variety of conditions, including ventilator dependency, dermal ulcers stages III and IV, those requiring intravenous therapy or injections directly into the vein, nasogastric tubes, and those who require continuous licensed nursing care. 22 VA. ADMIN. CODE § 40-71-150 (West 2003). Other states contain similar limitations with prohibitions aimed at excluding patients with a demonstrated need for skilled or specialized care.[5] Assisted living facilities do not provide skilled care; consequently, they are uniformly required to screen patients to determine the level of care needed and reject patients whose needs exceed their capacity. State regulation of assisted living facilities is lax and, for the most part, ineffective. Only a few facilities in the Commonwealth of Virginia have been denied a license for regulatory noncompliance. It is the opinion of this author that weak regulatory enforcement is in part due to inadequate regulations that do not adequately specify industry standards.

2. Experts. To litigate a nursing home abuse and neglect case it almost always requires the use of medical experts who will define the standard of care and address breaches in the standards. As assisted living facilities are generally not considered health care providers, one may question whether an expert is necessary. This will obviously depend on the facts of your case. But in almost every case, at the very least, you will require an expert to establish causation and damages. Since many times injuries in assisted living facilities result in the patient requiring long term care in a nursing home, you may also want to consider obtaining a life care plan from a qualified expert.

Once you have obtained records, you should have the case reviewed by a nursing expert you can rely upon. Unlike nursing homes where there DON and Administrators are RNs, many of the nurses who work in the assisted living arena are LPNs and lack the background that you may be looking for in an expert. Finding talented nurse experts who are actively involved in assisted living care is a challenging task. This author has used the ATLA list serve, and random calling of facilities to locate qualified experts.

B. Evaluating the Assisted Living Case

1. Facility Records. The first step in assessing liability against an assisted living facility will be to obtain the records from the facility and the contract that was signed. The contract will likely define the duties undertaken by the facility. Most assisted living facilities have various levels of service. Level one might be the basic service which would include only room, board, meals and activities. Level four, or the highest level of service, might include resident assessment, care or service planning, medication administration, and dementia and nursing care. The standards applied by these facilities could be analogized to standards of care applied by a nursing home that was not providing skilled care.

2. Freedom of Information Act. In addition to obtaining the records, you will need to do a Freedom of Information Act request. This will help you identify the corporate entity that actually owns and operates the facility and may also allow you to see surveys or inspections that were done on this facility. The license should always be available, and may include information about the scope of services that the defendant facility is authorized to provide. Do not expect the surveys or inspection reports to contain the wealth of information that are available for nursing homes. Many times surveys are performed by the local Department of Social Services and do not include assessments of whether or not these facilities are complying with regulatory standards of care.

3. Case Review. The following are some factors to consider early on in deciding whether or not to prosecute an assisted living facility for negligence or abuse:

a. The nature of the resident’s condition upon admission. If she was mentally competent and independent with acts of daily living, you will confront significant problems with contributory negligence and comparative fault defenses.

b. The nature of the contract and duties assumed by the facility. If they only agreed to provide room, board, and meals, the defense will argue their duties are analogous to that of a landlord in an apartment building.

c. The quality of the relationship between the personal representative and the victim. If the victim is deceased, this may take on a greater importance as the nature of that relationship may define your damages under the applicable wrongful death act.

d. Whether the family members make good fact witnesses, appear genuinely outraged by the facility’s conduct, and complained and/or removed their loved one from the facility.

e. Whether the facility had serious staffing shortages or a pattern of neglecting their residents.

f. Did the victim suffer a significant injury in the facility that adversely affected the quality of her life for the future, or caused her death?

g. Do you have strong witnesses and powerful exhibits? Do you have an insider who is willing to blow the whistle on rampant staffing shortages? Do you have color photos of that pressure?

h. Do you have significant economic specials that are not encumbered by a Medicare or Medicaid lien?

i. Is the defendant a charitable organization, religious affiliate, or part of a large assisted living chain?

C. Theories of Liability

With weaker regulation, variety in industry standards, and market competition, it is not surprising that the U.S. General Accounting Administration, in 1999, identified problems in assisted living facilities that included inadequate or insufficient resident care, insufficient trained staff, improper medication administration, and not following admission and discharge policies required by state regulation. A 2000 study by the U.S. Department of Health and Human services found that a high percentage of the staff at assisted living facilities were not knowledgeable about the normal aging process and at least 60% of the staff did not know how to properly manage difficult behavior among assisted living residents.

Liability: Improper Admission. Many times, liability based upon an improper admission results when someone is admitted into a facility that is not locked down or enclosed. Many residents with dementia have a tendency to wander and they should simply not be admitted into facilities that are not locked down or do not have appropriate wander guard systems and/or alarms on the doors.

In Selvin v. DMC Regency Residence, Ltd., 807 So. 2d 676 (Fla. Dist. Ct. App. 4th Dist. 2001) a resident of an assisted living facility wandered off and was found dead in a nearby canal. Plaintiff’s complaint alleged two different theories of liability: the first was a statutory wrongful death action and the second was based on alleged violations of statutes relating to assisted living facilities. Plaintiff alleged that the facility had a common law and statutory duty to supply at least the level of services and care that all licensed assisted living facilities generally furnish elderly patients of the plaintiff’s decedent’s classification and condition. At the time of trial, plaintiff sought to introduce expert testimony about specific safety precautions that were the industry standard and further sought to show that the facility should have built a fence to prevent elders from wandering near the dangerous area of the canal. The trial court precluded this testimony, finding that the facility had no legal duty to fence off the canal to the general public. The Appellate Court reversed, finding that the facility undertook to furnish certain services of care and security which created such a duty of protection. The Appellate Court also held it was an error to exclude testimony regarding industry standards of what could have been done to protect these impaired residents from falling into the canal.

1. Liability: Falls. Another common area of liability in assisted living facilities involves falls. Expert testimony may not be required in such cases. See, Walker v. Southeast Alabama Med. Ctr., 545 So. 2d 769 (Ala. 1989).[6] However, fall assessment and fall prevention planning is usually done by a nurse or other medical provider and it may be advisable to have an expert address this issue. In large part, the need for an expert will be determined by the facts of your particular fall. If the staff simply dropped the resident during a transfer, an expert may not be necessary. However, if the resident came in to the facility with multiple risk factors for falling[7] which were never assessed or care planned and he fell one day while wandering the hallway, you should retain an expert to discuss how the standard of care for fall prevention was breached. To establish causation, she will have to testify that if appropriate standards were followed, it would have, more likely than not, prevented the particular fall which caused injury to plaintiff. As this is an area of first impression in many jurisdictions, it is advisable to educate the court with a trial memorandum addressing experts and other issues prior to trial.

D. Other Theories of Liability

Attorneys who prosecute assisted living facilities have an opportunity to be far more creative in the prosecution of these claims, given the broad range of theories that are available. Below are some typical theories that can be advanced against an assisted living facility.

1. Common Law Negligence. This is probably the most common theory of liability advanced in assisted living cases. Make sure you do not plead breaches in medical or nursing standards of care, or you may face the argument that you have pled a traditional malpractice case. You can plead the breach of regulatory standards and/or industry standards which proximately caused injury to your client. As assisted living facilities are not health care providers, they should not be subject to caps or other discovery limitations (i.e., quality assurance privileges) that apply to traditional health care providers.

2. Violations of the Consumer Protection Act. Make sure to inquire of your client what representations were made as an inducement to enter the facility. Obtain the brochures that were handed out by the marketing representative. Most consumer protection statutes provide relief for misrepresentations which were made as an inducement to enter into the consumer transaction. Case law has allowed such theories to be advanced even against health care providers, so there should be no reason that this theory could not be advanced against an assisted living facility.[8] The advantage is that many states’ consumer statutes allow for the recovery of costs and attorney’s fees.

3. Adult Protection Act. Most states have statutes that have been specifically enacted to protect the rights of elder Americans.[9] Some states, like Tennessee, specifically exempt health care providers from the application of such statutes.[10] As assisted living facilities are not health care providers, these exemptions should not apply.

4. Breach of Contract. Almost all assisted living facilities will make their residents sign a contract as a condition of admission. Scrutinize the contract carefully, as it may contain waivers of liability or waivers of the resident’s right to a jury trial. Such waivers can be asserted irrespective of whether one pleads a separate breach of contract claim. Under the laws of most states, contract damages will be limited to foreseeable economic damages, so it would be disadvantageous to plead this as your only theory of liability. However, the contract may have required that certain services be delivered to the resident (i.e., activities, assistance with acts of daily living, 24 hour supervision) which were not, in fact, provided. The resident may have suffered no physical injury from the failure to deliver such services and the defense will argue that such evidence should be excluded at the time of trial. With the contract theory properly pled, plaintiff can argue that such evidence is admissible to prove contract damages and recover monies for services which were not provided.

Be wary that the defense may argue that since plaintiff failed to quantify the extent of services that were not provided, any award of contract damages would be based on speculation. As such, you should make an attempt to have your client provide a good faith estimate in percentage terms as to what services were not provided. However, if you have a strong negligence claim based on a discreet event (i.e., a fall causing a hip fracture) you may not want to confuse the jury with a lot of collateral facts and issues that may not have a strong bearing on your damages.

5. Negligent Hiring and/or Retention. Consider this claim where you have intentional torts committed by an employee and some evidence that the defendants knew or should have known that this was a troubled employee. Many assisted living facilities don’t adequately screen their employees. This evidence may not be revealed until the discovery process begins and it is essential that you obtain the employee’s personnel file early on in litigation so you can amend your complaint if necessary. Depending on the tolling provisions of your individual claim, the cause of action may still relate back because it arguably arises out of the same set of operative facts. It is also a good idea to sue the employee individually. The same defense firm may represent both the employee and corporation, making it impossible to argue that the employee was not operating within the scope of his employment.

6. Wrongful Death. In any case where there is evidence that the facility’s negligence caused or contributed to the resident’s death, a separate wrongful death claim should be asserted. If there is any good faith basis to conclude that the negligence contributed to plaintiff’s death, you should plead both survivorship and wrongful death claims. Any long term care case has greater value if you can argue that defendant’s neglect caused plaintiff’s death. You may also have separate claims for injury that in no way contributed to the resident’s death. Such claims should be pled with your survivorship claims. Research the law in your jurisdiction to determine what forms of damages are recoverable under a wrongful death statute. If you’re in one of those unfortunate jurisdictions that allow only economic damages, you may not want to plead a wrongful death claim.

7. Punitive Damages. As the nature of economic damages in an assisted living case may not be impressive, and as your client will likely have suffered from several preexisting conditions that may weaken your compensatory damage claim, you should, whenever possible, plead punitive damages. Successfully pleading a punitive damage claim will also provide you with the basis for exploring defendant’s conduct with respect to other residents who were neglected in substantially similar ways to that of your client. Cases from around the country have upheld such punitive damage claims against nursing homes, and there is no reason that such precedent would not apply equally to assisted living facilities. [11]

8. Americans with Disabilities Act/Fair Housing Act. The Fair Housing Amendments Act of 1988 (FAA)[12] prohibits discrimination in virtually all housing and related activities, whether such conduct takes place in the private or public sector. This law is complemented by the Americans with Disabilities Act,[13] which, while it specifically does not include entities covered by the FAA, applies to non-housing functions of a facility, such as common areas, meeting rooms, cafeterias, adult day care, or long term care under Title II (state and local) and Title III (public accommodations) programs.

E. Selected Case Results

A survey of reported cases reveals very few published cases throughout the country. This author has litigated fall cases, negligent admission resulting in pressure sores cases, and one case involving an unfortunate resident who caught fire in the recreation room. The manner in which he was ignited was never explained by the facility.

In one assisted living case taken to verdict in Virginia, plaintiff had fallen during the evening and was placed back in bed (with a hip fracture) by a nurse aid who denied the fall ever happened. Plaintiff was alive at the time the case went to verdict and required ongoing nursing care because of her injuries. The jury rendered a verdict of $1.5 million in compensatory damages.

A brief survey of published assisted living cases results and verdicts across the U.S., reveals the following:

1. **** v. Bixby Knowles Towers; No. NC 021 371, verdict date 04/15/1998. Plaintiff was walking through the dining room when she felt hot coffee spill onto her neck, back and shoulder. She turned away from the coffee and stumbled and fell. One employee acknowledged holding two pots of coffee at the time of injury, but denied spilling coffee on the Plaintiff. Plaintiff suffered a fractured distal femur and first and second degree burns. Verdict was $378,990, with medical expenses totaling $128,000.

2. Wiggins v. St. John’s Terrace Homes, Inc. Docket No. 96-2705-CA; FJVR reference No. 98:7-55 (July 1998) Plaintiff, an assisted living resident, was seated at a dining table when a coffee pot burst open, pouring scalding coffee down Plaintiff’s leg. Verdict of $223,893.

3. Weiland, as Personal Representative of Louise Debenack, v. Alexandra & Co. of Boca Raton, Inc., d/b/a/ The Colonnade at Haverhill, Docket NO. CL 99-00066 AE; FJVR reference No. 01:6-54 Pub.(June 2001). Plaintiff found dead after she developed a UTI that became septic. Upon admission to hospital, plaintiff had a large hematoma which was not explained by the defendant. Settlement for plaintiff for $1 million.

4. Estate of John Doe v. Anonymous Assisted Living Facility. (Reported from the Michigan Trial Reporter, JAS Publication) Settlement of $1,350,000 for an elderly assisted living resident who died from burn injuries sustained while showering. Plaintiff’s theory of negligence alleged that defendant was negligent in not having proper temperature controlling devices for their residents.

5. Davis v. Premium Health Care, Inc. Docket No. 98-20263, Reference No. 01:8-12 (August 2001). Settlement of $300,000 for decedent who developed multiple pressures sores (including a stage IV) while in the facility.

6. Casaletto v. Helen Homes Corp., d/b/a The Palace Gardens, Docket NO.: 01-12468 BA 20; FJVR Ference No. 02:9-44 (Miami, September 2002) Defense verdict involving an 86 year old male who was admitted to an assisted living facility in May and suffered a fall in August of the same year. Plaintiff alleged improper admission and failure to properly supervise. Defendant contended that the decedent was a proper admission and that the level of supervision was appropriate in he ambulated independently. Both parties relied on experts in the area of assisted living administration.

7. Pollock v. CCC Investments I. LLC d/b/a Tiffany House by Marriot, Docket No. 01-16746, Ref. No. 05:3-9 (Florida 2005). Defense verdict involving a resident who was murdered by another resident. Defendant’s argued they had no notice of the other resident’s potential violent conduct. The jury found there was no negligence on the part of defendants that caused plaintiff’s death. They also found there was no violation of the assisted living facility’s resident’s rights under Florida statutory law. Defendant’s highest offer was $750,000 with lowest demand at $9,900,000.

II. Conclusion

As this is a new and evolving area of the law, attorneys who litigate these cases should strive to establish favorable precedents for those who follow. If the recent explosion in nursing home litigation is any indication, assisted living facilities could be the nursing homes of the future. As with nursing home litigation, the civil prosecution of these cases provides an important safeguard in protecting the rights of our elderly and assuring that proper standards are followed in the industry.

[1] Mollica, Robert L. State Assisted Living Policy: 2000. Portland: National Academy for State Health Policy, 2000, Executive Summary.

[2] Issue Brief, Health Policy Tracking Service, National Conference of State Legislatures, October 1, 2002.

[3] Based on a study done by AARP that randomly shopped some 80 assisted living facilities, a pattern of discrepancies was found between what representations were made in the marketing materials versus promises made in the admission’s contract. Two previous surveys that compared marketing materials and assisted living contracts, one by the American Bar Association’s Commission on Legal Problems of the Elderly Consumer Reports, and the other by the U.S. General Accounting Office, revealed similar problems. Adrienne Oleck & Bruce Vignery, Nurture or Neglect? Challenging Deceptive Practices in Assisted Living Facilities, CONSUMER ADVOC., Jan. 2001, 7(1).

[4] See, 42 C.F.R. 483.10 et seq.

[5] Montana law prohibits assisted living facilities from admitting patients who, inter alia, are non-ambulatory, in need of physical/chemical restraints, or unable to self-medicate. MONT. CODE ANN. § 50-5-226 (2002); Florida law prohibits admission of residents who are bedridden, those who have stage III or stage IV pressure sores and those residents who may require 24 hour nursing care. FLA. STAT. Ch. 400.407 (2005).

[6] In Walker, there was evidence that a patient had a history of falls and further that the patient’s doctor had instructed the nurse to leave the bed rails up at all times. A nurse lowered the bed rails and the patient fell. The court held that the plaintiffs were not required to present expert testimony because the breach of care alleged by the plaintiffs, leaving the bed rail down contrary to doctor’s orders, was so apparent as to be understood by a layman.

[7] Risk factors for falling could include dementia, confusion, unstable gait, prior stroke, arthritis, medications usage, history of falls, history of agitated behaviors, vision problems, and weakness or muscle atrophy.

[8] Dorn v. McTigue, 157 F. Supp. 2d 37 (D.D.C. 2001) (holding that District of Columbia Consumer Protection Act applied to the medical profession); Chalfin v. Beverly Enters., Inc., 741 F.Supp. 1162 (E.D. Pa. 1989), reconsideration den., 745 F.Supp. 1117 (E.D. Pa. 1990) (health care services provided by a nursing home were within the scope of “trade or commerce” provisions of Pennsylvania consumer protection laws); Winkler v. Interim Servs., Inc., 36 F. Supp. 2d 1026 (M.D. Tenn. 1999) (Disabled Medicare beneficiaries’ claims against home health care provider for violation of Tennessee Consumer Protection Act were not exempt on the grounds that the provider’s termination of services was regulated by the Medicare Act, given the alleged claims did not arise under the Medicare Act).

[9] According to the National Center of Elder Abuse, www.Elderabusecenter.org/laws, all fifty states and the District of Columbia have enacted legislation authorizing the provision of adult protection services in cases of elder abuse. The statutes vary widely on definitions of abuse, investigation responsibility, and remedies for such abuse.

[10] The Tennessee Adult Protection Act, TENN. CODE ANN. § 71-6-101 et. seq. (2002) does not apply to actions against “health care providers,” as defined in the TENN. CODE ANN. § 63-6-228 et. seq. Alternatively, Tennessee’s Medical Malpractice Act provides the statutory authority to suits against health care providers.

[11] See, Texas Health Enters. V. Geisler, 9 S.W.3d 163 (Tex. App. Fort Worth 1999) (repeated shortages of staffing and other acts of negligence supported punitive damage award against defendant); Estate of McIntyer by & Through Ex’r v. Transitional Health Servs., 1998 U.S. Dist. LEXIS 13965 (M.D.N.C. May 1998) (holding that defendant’s knowledge that it was operating in serious violation of several health codes and that it took very little, if any, action to remedy those violations might reasonably be found to constitute reckless indifference to the rights of their elderly residents with varying medical and non-medical needs); Beverly Enters. – Florida v. Spilman, 661 So. 2d 867 (Fla. Dist. Ct. App. 5th Dist. 1995) (testimony that expert was “outraged” at poor level of care of resident who developed and died from an infected decubitus ulcer supported punitive damage award against corporation and management company). See also, Christopher Vaeth, Allowance of Punitive Damages in Medical Malpractice Action, 35 A.L.R. 5th 145 (1996).

[12] Fair Housing Amendments Act, 42 U.S.C. § 3601 et. seq. (2000).

[13] Americans with Disabilities Act, 42 U.S.C. § 12101 et. seq. (2000).

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jamiehanson asked:


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Seif Sel asked:


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• If you and your family spend lot of time there, you must go for things that can maximize storage.

• Sofa beds that can function as couches are perfect if your guests frequently visit you.

• Coordinate your furniture with the walls and curtains of your living room.

• Your furniture for living room is a beautiful investment. So, allow it to enhance the entire look of your home.

• You may even opt for wood furniture for country look in your living room.

• Cabinets, bureaus and centre tables are the additions that will help in highlighting your living area. They will give it an extraordinary luxurious ambience.

• For a more elegant and graceful combination, theme your living room with modern and rustic pieces of furniture.

• You can even scour antique stores for timeless pieces of furniture.

• Team your furniture for living room with jacquard curtains and drapes.

• Go for furniture pieces that would generally suit most budgets.

To conclude, furnish your living room with vintage pieces and turn it into your beautiful castle

Jill Gilbert asked:


Before individual state governments passed much-needed legislation, many assisted living facilities were only private pay situations. Fortunately, for many older Americans facing housing dilemmas, Medicaid waiver programs have taken up much of the slack that Medicare did not. Providing funds for placement in assisted living facilities as well as a number of other helpful services, Medicaid helps lower-income, elderly individuals receive the care they need.

All states accept funds from Medicaid waiver programs for placement within a nursing home, which are normally more expensive than assisted living facilities. While many states do not recognize funds from Medicaid waiver programs for assisted living, those that do are located throughout the country and offer many options to aging Americans needing assistance with daily living activities. After searching high and low, finding a general overview of states that offer the Medicaid waiver program for assisted living was rather nonexistent, but my research is your gain.

Medicaid Waiver Programs State Line-Up

As of publication, there are no definitive lists that outline states with Medicaid waiver programs for assisted living facilities. At best, the government (via the Centers of Medicare and Medicaid Services) has created an online list of all Medicaid waiver programs (1), meaning visitors have to spend time finding the desired information. Although I’ve outlined the states that do accept Medicaid waiver programs, certain impediments may be in place to securing a Medicaid-covered bed in an assisted living facility. Be aware that some states may offer the program on a trial basis, follow limited participation quotas, or are just introducing the program to state residents. As always, verify eligibility requirements with the Centers for Medicare and Medicaid Services.

i. Arkansas – Aged and disabled program participants are provided with adult residential care, assisted living, and medication assistance and consulting till death.

ii. California – Beginning in 2003, California began offering Medicaid waiver programs to aged individuals.

iii. Delaware – Program participants with Alzheimer’s, dementia, physical disabilities, or needing assistance with activities of daily living (ADLs) are provided with funds for assisted living facilities.

iv. Florida – There are quite a few Medicaid waiver programs for the state of Florida, including a broad waiver for all individuals aged 65 or older; individuals with Alzheimer’s disease and dementia; case management services; assisted living; incontinence supplies to frail, elderly, and disabled individuals aged 60 or older; and a home and community based waiver that offers mental health services to seniors in specific areas of the state.

v. Iowa – Many assisted living facilities across the state accept money from Medicaid waiver programs; however, the number of residents in a facility using these funds is limited.

vi. Indiana – Aged and disabled individuals are provided with case management, transportation, assisted living, medical equipment, congregate care, home delivered meals, nutritional supplements, and much more. The state also offers a targeted assisted living waiver program that focuses on therapeutic social and recreational programming.

vii. Maryland – Program participants are assessed and, if deemed eligible, are offered either services in the home or placement in an assisted living facility.

viii. Mississippi – Medicaid waiver programs for this state cover individuals requiring assisted living services due to disabilities, Alzheimer’s disease, and dementia as well as individuals aged 65 and older needing adult residential care.

ix. Missouri – Program participants aged 65 and older needing assisted living services are eligible.

x. Nebraska – Individuals aged 65 or older who agree to participate in medical and health care evaluations are eligible for home services or can be placed in an assisted living facility (2).

xi. New Jersey – Under the Enhanced Community Options waiver (3), individuals can either remain at home to receive assistive services or be placed in an assisted living facility.

xii. Ohio – The Ohio Department of Aging is responsible for determining applicants’ waiver eligibility, evaluation of disabilities, prognoses, and financial assets for proper placement within assisted living facilities.

xiii. Rhode Island – Aged and disabled individuals are provided with assisted living services, case management, and specialized medical equipment.

xiv. Vermont – Eligible Medicaid recipients are provided with assisted living services under Choices for Care, 1115 Long-Term Care Medicaid Waiver, as well as a number of other care options.

xv. Virginia – This state’s Medicaid waiver programs apply only to individuals with Alzheimer’s disease or dementia who require the services of assisted living facilities. Depending upon the medical circumstances, age limits may be in effect.

xvi. Washington – The waiver program provides for aged and disabled residents at assisted living facilities.

xvii. West Virginia – Aged and disabled program participants are provided with adult residential care and assisted living services.

Additionally, some states offer details on restrictions and eligibility that can be downloaded by navigating to each respective state’s Medicaid waiver informational link.

What to Look for in the Future

State governments determine eligibility based on income, giving lower-income seniors an opportunity to be placed in a facility that will look after their needs and supervise daily activities. With the baby boomers retiring as we speak and well into the coming years, will we see growth in the number of Medicaid-eligible assisted living facilities in other states? Perhaps the thirty-three or so other states will realize the incredible benefits to both seniors and society in general.

Sources

1. http://www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/MWDL/list.asp?intNumPerPage=all&submit=Go

2. http://www.nenaaa.com/finding-care/aged-medicaid/

3. http://www.state.nj.us/health/senior/go.shtml

Transylvania Live – Expert In Transylvania asked:


As everybody can imagine Transylvania is all about stunning scenery and terrific places. Everyone knows and fears Dracula; still everyone wants to travel to Transylvania.  Start packing without any worries. Most of the tours are guaranteed to depart on the dates given, as Transylvania Live do not insist on a minimum number of bookings before departure.

Add turtlenecks, garlic and scarves to the top of the packing list, muster some courage, and summon your sense of adventure. The ultimate adventure awaits in a distant land where a 15th-century ruler terrified all who dared to challenge his ways.

 

   All along the Transylvanian way, the terrifying touring unfolds against a backdrop of some of the oldest forest and unaltered land in all of Europe. Transylvania shrouds itself with thick quilts of old pine, projects the Carpathian mountains’ stark peaks and then soothes its visitors with natural mineral spas.

 

 

A Vampire’s Lineage

   The vampires caricatured for silent films, best-selling novels, cereal boxes and even “Sesame Street” all descended from Vlad III Draculea, a Romanian prince who reigned in the 15th century. The prince earned the nickname “Vlad the Impaler” for the merciless ruler’s gruesome method of doing away with enemies. His given surname, Anglicized as “Dracula,” is derived from the word meaning either “dragon” or “demon” in his native tongue.

   Irish writer Bram Stoker drew inspiration from Vlad the Impaler for his novel “Dracula,” published in 1897. The book’s antagonist, a vicious Romanian count with a thirst for young blood, rises from his coffin bed and masochistically preys upon British newlyweds Jonathan Harker and Mira Murray. Decades later, the iconic vampire gave actors, including Bela Lugosi, Brad Pitt, Tom Cruise and Gary Oldman film roles they could really sink their teeth into.

Retracing Dracula’s Tracks

   If they dare, travelers on the Dracula trail can follow the vampire prince from birth to burial. Vlad Dracula entered this world in the Transylvania town of Sighisoara, noted for one of the region’s few walled fortresses. The house of Dracula’s birth, marked with a modest plaque on the door, now multitasks as a restaurant serving Romanian cuisine and a small museum of medieval weapons used during Vlad’s rule.

   Although Castle Bran is strongly associated with Vlad Dracula, the foreboding edifice actually has the weakest historical ties to the Impaler. Perched at the apex of a narrow, climbing road near the city of Brasov, the massive stone building clearly inspired the cinematographers and animators who worked on just about every “Dracula” film project.

 

 What remains of Vlad Dracula’s real abode can be found about 50 miles northwest of Bucharest near the town of Tirgoviste. The fortress ruins are almost inaccessible, requiring a climb of 1,500 steps up a mountain that overlooks a river basin. The castle served Dracula as a refuge from advancing enemies as well as a place to watch their demise. Among the palace ruins, visitors can make out the overlook tower from which Vlad viewed impalements that took place in the courtyard.

   Vlad the Impaler’s own finale happened by assassination, after which his remains are said to have been entombed in the Snagov monastery just north of Bucharest. The 16th-century monastery, accessible only by boat, is situated on an island in the middle of a lake. Romanians still revere the ruler who defended their nation against the Turks, and continue to honor Dracula with a portrait and vases of fresh flowers near his resting place.

Dracula Tours in Transylvania

Departing from Bucharest from June till September Vampire in Transylvania, the Awarded Dracula Tour offers a 7 days trip back in time, following Jonathan Harker’s footsteps but revealing the genuine historical facts and places. Includes the unique medieval citadel of Sighisoara – Vlad the Impaler’s birth place, the Saxon city of Brasov, Bistrita Citadel, the royal Peles Castle, the mysterious Bran Castle as well as Dracula’s Castle in Borgo Pass. In addition, the special activities prepared, all along the itinerary, bring out the essence of the genuine Transylvanian Folklore.

A 3 day Vampire in Transylvania short break including Killing of the Living Dead magical ritual is also available based on the low cost flights to Transylvania.

The itinerary of the Vampire in Transylvania tour was a major source of inspiration for Travel Channel. Transylvania Live has assisted them on a documentary based on Transylvanian dark legends.

A 12 day Halloween in Transylvania – Dracula Tour is offered in October with departure from Budapest, Hungary. It includes an unforgetable Halloween Party in the citadel of Sighisoara, Vlad Dracul birthplace.

More details on www.visit-transylvania.eu, www.visit-transylvania.co.uk, or www.dracula-tour.com .

 

Steven Coleman asked:


A Cost of Living Allowance (COLA) is a salary supplement paid to employees to cover differences in the cost of living, particularly as a result of an international assignment.

The amount of COLA should enable an expatriate to be able to purchase the same basket of goods and services in the host location as they could in their home country. The basis for calculating a COLA is the Cost of Living Index (COLI) which indexes the costs of the same basket of goods and services in different geographic locations. COLA is a simple accurate method of measuring fluctuating salary purchasing power and ensuring parity.

Cost of Living Index

Our cost of Living Indexes measure the cost of 230 products and services across 13 different basket groups in 276 cities across the globe. The data is gathered by a team of research analysts who survey comparable items that are available internationally. A minimum of 3 prices for the same brand/size/volume of product is used to determine the average price for each item in each location. The items are priced on a quarterly basis and tend to rise and fall with inflation. The 13 different basket categories are as follows:

•Alcohol & Tobacco: Alcoholic beverages and tobacco products

oAlcohol at Bar

oBeer

oCigarettes

oLocally Produced Spirit

oWhiskey

oWine

•Clothing: Clothing and footwear products

oBusiness Suits

oCasual Clothing

oChildren’s Clothing and footwear

oCoats and hats

oEvening Wear

oShoe Repairs

oUnderwear

•Communication

oHome Telephone Rental and Call Charges

oInternet Connection and service provider fees

oMobile / Cellular Phone Contract and Calls

•Education

oCrèche / Pre-School Fees

oHigh School / College Fees

oPrimary School Fees

oTertiary Study Fees

•Furniture & Appliances: Furniture, household equipment and household appliances

oDVD Player

oFridge Freezer

oIron

oKettle, Toaster, Microwave

oLight Bulbs

oTelevision

oVacuum Cleaner

oWashing Machine

•Groceries: Food, non-alcoholic beverages and cleaning material

oBaby Consumables

oBaked Goods

oBaking

oCanned Foods

oCheese

oCleaning Products

oDairy

oFresh Fruits

oFresh Vegetables

oFruit Juices

oFrozen

oMeat

oOil & Vinegars

oPet Food

oPre-Prepared Meals

oSauces

oSeafood

oSnacks

oSoft Drinks

oSpices & Herbs

•Healthcare: General Healthcare, Medical and Medical Insurance

oGeneral Practitioner Consultation rates

oHospital Private Ward Daily Rate

oNon-Prescription Medicine

oPrivate Medical Insurance / Medical Aid Contributions

•Household: Housing, water, electricity, household gas, household fuels, local rates and residential taxes

oHouse / Flat Mortgage

oHouse / Flat Rental

oHousehold Electricity Consumption

oHousehold Gas / Fuel Consumption

oHousehold Water Consumption

oLocal Property Rates / Taxes / Levies

•Miscellaneous: Stationary, Linen and general goods and services

oDomestic Help

oDry Cleaning

oLinen

oOffice Supplies

oNewspapers and Magazines

oPostage Stamps

•Personal Care: Personal Care products and services

oCosmetics

oHaircare

oMoisturiser / Sun Block

oNappies

oPain Relief Tablets

oToilet Paper

oToothpaste

oSoap / Shampoo / Conditioner

•Recreation and Culture

oBooks

oCamera Film

oCinema Ticket

oDVD and CD’s

oSports goods

oTheatre Ticket

•Restaurants, Meals Out and Hotels

oBusiness Dinner

oDinner at Restaurant (non fast food)

oHotel Rates

oTake Away Drinks & Snacks (fast Food)

•Transport: Public Transport, Vehicle Costs, Vehicle Fuel, Vehicle Insurance and Vehicle Maintenance

oHire Purchase / Lease of Vehicle

oPetrol / Diesel

oPublic Transport

oService Maintenance

oTyres

oVehicle Insurance

oVehicle Purchase

Each basket category does not count equally and are weighted in the final calculation based on expatriate spending patterns.

In order to calculate an accurate cost of living index for a specific individual the basket items that are not relevant to the individual should be excluded from the calculation. For example if education and housing is provided by the employer these basket categories would be excluded from the cost of living index calculation. This increases the accuracy of the cost of living index and makes it possible for each individual to have their own customized cost of living index based on their specific arrangements rather than using an overall “generic” index which is likely to contains costs that are not relevant to the individual.

The formula for calculating the specific cost of living index for an international assignment is as follows:

Cost of Living Index = Customized Cost of Living Index for Host City / Customized Cost of Living Index for Home City

When moving to a higher cost of living host city, the index will be greater than 1 (positive). When moving to a lower cost of living host city the index will be less than 1 (negative). Where the index is negative it means that in real terms the cost of living in the host city is lower than the home city. This means that if the negative index where to be applied to the employee’s salary, they would actually be paid proportionately less spendable salary in the host city. It is important to note that the majority of organizations do not apply a negative cost of living index because it makes it difficult to persuade an employee to take up an assignment as they tend to see it as a reduction in salary.

Examples of Cost of Living Index Calculations using our data:

Example 1) An Australian employee moving from Perth to London where healthcare and communication will be provided by the employer

More Expensive in London:

•Alcohol & Tobacco +4.77%

•Clothing +21.85%

•Education +31.53%

•Furniture & Appliances +16.03%

•Groceries +16.35%

•Household +50.72%

•Miscellaneous +137.47%

•Personal Care +11.18%

•Recreation & Culture -6.82%

•Restaurants Meals Out and Hotels +34.99%

•Transport +19.80%

The overall difference in cost of living moving from Perth and London is +28.06%.

In this case the cost of living index is positive and would be applied as it is.

Example 2) A British employee moving from London to Mumbai where the employer will provide housing and education

More Expensive in Mumbai:

Alcohol & Tobacco -37.53%

Clothing -9.58%

Communication -44.92%

Furniture & Appliances -19.31%

Groceries -24.03%

Healthcare -31.24%

Miscellaneous -72.43%

Personal Care -24.94%

Recreation & Culture -35.73%

Restaurants Meals Out and Hotels -33.11%

Transport is -27.99%

The overall difference in cost of living moving from London Mumbai is -30.53%.

In this case the cost of living index is negative and would not be applied.

Net Spendable Salary

Differences in cost of living only impact the portion of the salary that is spendable in the host country. Items in the home country such as retirement funding, medical insurance and other home based costs are not impacted by the cost of living in the host country.

To determine the Net Spendable Salary establish what amount / portion of the current salary (in home currency) is spent in maintaining the employee’s current standard of living / lifestyle. What will the expatriate need to spend their salary on in the host country? For example will accommodation be provided or will the employee pay rent, will healthcare be provided etc. Deduct all items that are either provided in kind or are spendable in the home country. Deduct the hypothetical amount of tax, social contributions and any other statutory deductions applicable in the home country from the Spendable Salary. What is left is the Net Spendable Salary.

Cost of Living Allowance (COLA)

The formula for calculating the cost of living allowance using the above inputs is as follows:

(Net Spendable Salary X Cost of Living Index X Hardship Index X Exchange Rate) less (Net Spendable Salary X Exchange Rate) = COLA

Examples of COLA Calculations using our data

Example 1) An Australian employee with a net spendable salary of AUD$100,000 moving from Perth to London where healthcare and communication will be provided by the employer

($100,000.00 X 1.2806 X 1 X 0.4768) less ($100,000.00 X 0.4768) = COLA of £13,379.44 (GBP)

Based on all the above factors a person would require a Cost of Living Allowance of £13,379.44 (GBP), in addition to their current salary of 100,000.00 Australian Dollar (AUD) to compensate for relocating from Perth to London. This Cost of Living Allowance compensates for the overall cost of living difference of +28.06% and the relative difference in hardship of 0%.

Example 2) A British employee with a net spendable salary of £18,000 moving from London to Mumbai where the employer will provide housing and education

Note: Because the Cost of Living Index is negative it is not applied.

(£18,000.00 X 1 X 1.3 X 67.2852) less (£18,000.00 X67.2852) = COLA of 363,340.32 Indian Rupee

Based on all the above factors a person would require a Cost of Living Allowance of 363,340.32 (INR ), in addition to their current salary of £18,000.00 British Pound (GBP ) to compensate for relocating from London to Mumbai. This Cost of Living Allowance compensates for the overall cost of living difference of [-30.53%] and the relative difference in hardship of 30%.

COLA Payment

The COLA is paid as a salary supplement (i.e. as an additional allowance) net of tax in the host country. If the COLA is a taxable allowance in the host country it should be grossed up in order that the full amount of calculated COLA is paid net of tax given that the basis of the calculation is Net Spendable Salary. The COLA is often accompanied by other allowances and benefits such as flights home, relocation / settling in allowance, and furnishing allowance.

Exchange Rate Fluctuations

Significant changes in the exchange rate can make a considerable difference in the COLA calculation. In 2008 some of the major global exchange rates changed by as much as 30-40%.

The cost of living index reflects the changes caused by inflation and exchange rates. In the short-term there may be disequilibrium between inflation and the exchange rate (the one pushes the other), however over time the cost of living index provides the most accurate view of the cost of living.

It is important to remind expatriates that when the cost of living difference is negative, and the negative value has not been applied, they have higher purchasing power in the host country than they would at home.

Where a negative cost of living index has not been applied (our recommended approach), and a change in the exchange rate indicates an upward adjustment in COLA may be required, it is recommended that the COLA should not be adjusted upward until the cost of living index becomes positive i.e. the cost of living reflects that there is a “real” increase in cost of living between home and host countries. This may mean that their would be no increase in the COLA as a result of exchange rate fluctuations for some considerable time. During this time the employee’s purchasing power decreases. But it is important to remember that until the cost of living difference becomes positive, the individual will still have a higher purchasing power than they do in their home country.

It is advisable to stipulate a currency protection rule, rather than reacting to every fluctuation in the exchange rate. For example the rule may state that COLA will be reviewed if exchange rates or local inflation move by more than +10% during a year. It is important to keep in mind that the prices of goods and services are unlikely to drop in local currency. This would only occur in a period of deflation (negative inflation). Therefore the currency protection rule would normally make provision for upward adjustments in COLA and not downward adjustments during an employee’s assignment. Downward adjustments to an existing COLA due to exchange rate fluctuations without a corresponding drop in the prices of local goods and services puts immense pressure on an employee’s host currency budget commitments and can lead to the employee experiencing financial difficulty.

Using an independent service provider provides an independent, objective basis for determining an employee’s COLA.

We recommend therefore that a COLA is calculated by applying the specific (customized) cost of living index to the net spendable salary at the beginning of the assignment and monitoring exchange rate fluctuations thereafter in addition to the annual salary review.

Arthur Prudent asked:


 Playing in a live dealer casino is now possible because of the new live dealer feature applied in most of the online casinos’ game repertoire.  If you are looking for that once-in-a-lifetime gaming experience, then playing in a live dealer casino is the best deal you will ever make. Although many online casinos would still prefer to use the traditional way of marketing their game lineup, the trend of live dealer casino games are immensely growing. That is why a lot of online casinos are now adapting to the “new trend” by adding the live dealer feature to some of their most popular games.

What is a Live Dealer Casino?

Before a player sign up a casino account to play live dealer casino games, the player must first understand the features of the game. The live dealer feature is actually the best thing that ever happened to the online casino world because live casino is a new and exciting way of playing casino games. Players are not required to download any software in order to play the games with a live dealer. Just keep in mind though that, in order for you to participate in the games, you must create a real player account where money is the only ticket to play.

Many players have been intrigued with this new added feature – the live dealer feature used by some of the popular casino games. Today, online casinos are revolutionizing the gaming experience of many casino fans. Because of this added feature, players can actively participate and win in their favorite games with a live dealer they can communicate with.

A live dealer casino refers to an online casino offering games with live webcams and dealers, and players can definitely have a remarkable experience because they will have a live video streaming of the game, an audio of the dealer’s voice, the sound of the flipping cards, and the noises of the actual casino can be fully heard through the live dealer feature.

Another good thing about live dealer casino is that you can get immediate customer service because players can subscribe to live chat offered by these online casinos.  Players can ask for assistance even if the game is still going on.  Since the live chat goes along with the live dealer feature, players will never need to worry about opening a new window or using new software just to get in touch with the live dealer. Live dealer casinos are definitely the ultimate alternative to land-based casinos and even better.

Why Play in A Live Dealer Casino?

After the launch of this live dealer feature to most of the online casino games, the number of casino players increased, and it has dramatically changed the image of online gaming. The concept of online gaming has been appealing to more and more people, and it has been an advantage not only to casino owners but to players as well.  For casino owners, the idea of adding the live dealer feature and live chat is quite an evolution and a big milestone for online gaming. It has created more traffic to online casinos, and it subsequently helped online casinos gain more profits.

Players, on the other hand, can truly enjoy this idea because of the great ambiance of a real live casino at the comforts of their own homes. Players, especially beginners, will have the opportunity to test and enhance their skills at some of the live dealer games.

Since live casinos aim to break the barriers between the virtual reality of online gaming and the reality of brick-and-mortar casinos, many players come to believe that they’ll play even better and increase their chances of winning the pot.

Today, live dealer casinos helped improve the legality and authenticity of online casinos. Players will definitely have the best gaming experience, and the concept of live dealer casino games will surely go a long way.

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