Required Contributions by Relatives of Medicaid Nursing Home Patients

Published by the Government Accountability Office on 1977-05-26.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                           DOCUMENT RESUME
 02228 - [A1532528] " --   _   O
(Reqgired Contributions by Relatives of Medicaid Nursing Hone
Patients]. HRD-77-90; B-164031(3). May 26, 1977. 11 pp.
Report to Sen. Frank Church, Chairman, Senate Special Committee
on Aging; by Elmer B. Staats, Comptroller GeLeral.
Issue Area: Health Programs: Compliance with Financing Laws and
    Regulations (1207); Consuaer and Worker Protection:
    Consumers Protection from Unfair or Deceptike Trade
    Practices, Advertising, and Warranties (913).
Contact: Human Resources and Development Div.
Budget Function: Health: General Health Financing Assistance
    (555); Health: Nursing Homes (557).
Organization Concerned: Department of Health, Education, and
Congressional Relevance: Senate Spec'al Committee on Aging.
Authority: Social Security Act, as amended (42 U.S.C. 1396 et
    seq ). 45 C.F.R. 250.30(a) (8). H.B. 92 (95th Cong.).
          A sample of nursing homes in Florida, Georgia, Ohio,
and Utah was reviewed to determine  whether nursing homes were
 requiring contributions from the families of Medicaid patients
as a condition of the pat!ients' admittance or continued
residence.   Findings/Conclusions: There were no clear cases of
forced contributions, although rose families had felt
"pressured" into ccntributing. At present, Federal laws or
regulations do not specify what nursing hones may or
in soliciting contributions. The four states allowed may not do
contributions, but only Florida forbade solicitation through
coercion or as a condition for admission or continued residence.
The lack of Federal guidance may harve allowed subtle pressures
to be brought on the patients' families by taking advantage of
guilt feelings they might have over placing relatives in nursing
facilities rather than keeping then at home, and by creating
fear that the home drop out of the Medicaid program, resultinga
in the removal of these patients. Reconmendations: HEW should
issue a policy statement to all states defining its position
soliciting contributions. A standard form should be developed on
be signed by tha parties concerned clearly stating legal issuesto
and rights concerning contributions. Congress should amend
Social Security legislation to prevent possible abuses in this
area. (DJM)
                                                        ;y owbOtffca          lCr#                    rl      oflra             iiatstI

                                          COMPT#4OLLER GENERAL                  MrH-UNITI:D STAr't [
      :   4'.
           I.t                                                   C
                                                     wA5tTO~C-WASr               aN
                                                                                 14                 ..                                     /

                                                                                                 6 AY        6 1377
''if:'    tslor   ,'t lt   t' 1:rlr k Church
C.t   elfft ::t,        :'Pv cil    (otnm:itttee                     on   Anin,
Urnilt:l         S;tttr·        ;enate

Nt-ar Mr . Chtir.nln:
        At tihe rr-qu¢o.t of the Chairman, .ubtcommitt.ee                    on Lonq-T'et:m
                                    Conmnlittee  on Aqcinq,    we     re(viewed   ia :;ample
Care,      r;.e       :.p-ctial
                        fl'nt An Florida, Georqria, Ohio, and Uttii, to doLtl-
of nltr:;in/r ti
in IJr  wi-i.thtr     ntorj:iln     holes were relqu i r innq cont             iol;    fro.n             iibut
 th* fai!ij       -:; o(it    redic  id patient:    as  a   confition
                                                                f           of  the    p,:-
 tienl:t.'     adnittance or continLecd re:idcncet at thle ntr-.irjnq hor,,rs;.

         F'cd,'ra1l Mte!ic       riO;        Iaw -nd r tlli;tiO2:                        ; :::.1e n    11o Fef      Ft            -rle:e

t ,)        I. tit    I(l':;,                        3      :fn      a       ;,ri
                                                                             '    7 4,     }977,                       ]  :t  j
                            ('      r'":    ::) >was          i ntrorhduce-(          ir     th,        i;, w             i.im:  ?,
 (!.*i.. 92, '~'th
woalt'    c,4ir        1 .lk.'        tth       ::oticitatio)n                 ('   V :c' t:trf,               ':,     ,:,, '
                  w, .ondrp,             ltion           tcr      acl.*irti:
                                                                  at:,it                 n  .il-:ijc        j]i                 .nt
to a ou:trl               er,,tt .: ;    !
                                         :'   .detr;c.,norr           o.dt
                                                                      tuld'-r        c(    ion       ] 9Ut'        o:     the
SoC i a 1     r, Ctrt  I. y       'Act

                                  Inwl it!        thret. of thit  four gtittea.   wt: :evit.wrC-i                               lict
                           h.               :;u.ect.      In  th-  lourth,     Florid;., ill]Is.,i                        n
not addr:r;':
                           c¢nt   r   butions       has     r!cently             boon        nr.;f.(i.       Altll   otlah
¢loitlinrl     with
p*llci,';         1n1 ,r)rntritbuitions            varied in tli.                tour :;tatos;, t$ioy 'lei-
eral ly foljswed i-.d3.ra1l Medicare                               erlririt'r     ;,rPnt        pr i-n- i i i
which il- r;1tt     '    th     rl;
                                  L    ;   Ior     (cone.id     r   inq       co
                                                                              <' !       it:ul   il i :: i tl rd:tto -
             ri,:     ,*:l.         1
                              abll -'    )'It !]i: butI t (10   fi                 ,::':     th, '    r)'   cit;,
                                                                                                              i    tO :I
   i.n I tl.
 )f           ('01' tr [ i     lit.i o nli;.

                            , l-t,{ no cq¢.3r-cut                    a.'? of forCe!         (-rl. '    r       iUr
                             n,,vlral ;. iot'  i,:                 l lriI" i'is       in !'lel ii3Ja .nd         (;(o) (i.,
 1t-o.'f vir,
                            t ,-,y      !Je I ixvt.    'h       t n tr,';i nki     h:,:; '-      tI I ex X
                                                                                                         x f r      ;. :tod ::
 trilm     ui
                                     li*t f tii ;t i )    .       3                  o L t al
                                                                          t :,,f i:t,.-          t    t ; f e ] !t 1::      t; -
 t               tw;
 t'       -       c''!:.t     3   :I :#        1i;.Ao      v'1v      -    ii: tth- St      lte      wt     rev 4.'w i,            ',tL

                    W,!     t ev jr.W d        I I           in tlhe? fon r .qt.tI.'s aInd
                                                         t fT.l      t hor.
                                          I , t.fv:; -,i   3 t y ndic                     itt hI' o:',
 iut,'t'.,; . *w'*,dI a                                . ]3!   id i;t        -in'; ;
                                                                                       ()! :t(.        't t
 ;;; .*          ',Ii' V I h.wn,-t:'        rel'i.('t ion a:.-
                                                            u,     at t: vit. I(:
 ,.uIt,     1,':: .. i     i '       ,'l)"l, Iit-utt Of 140;!}t 1i,    I'dtiC.,'t iOfl , ,irn':      iNotI'irc
 {I L;'.} rn .l.ittl           .o covtar ii, uition ,


      We believi        the Secretary of iI,.W :;honult requi r      that
 Modicaii ratients         and their families tbe fully infornmed of
   itht  r iqht .; concenin    o contr lbut i on-... W:WeZal (o reComlilendl
 cfn¢it.-::t o1 ]eqi;,lastioLn simnilar L') th.L poretion of :: .eCtion
 t7 of '!.I:. 92 which would,make        th:o nolicit,,t'ioln o( cOntribt.-
 tionr; .r accenti.ncc ot c;onnti n ; .- s a prttcordition for adr.it-
 tijnq i M_.dicaid ttijernt to . nursinq howtem        more clrearly subjcc.'t
 to pro:-ecution :nder section 1'09 of tlie .Social Sf,,curity Act.


                      Medicaid Irqislation anrd rqlulation:l; 0i0, not slv,.-
 citi'-alI                addrcs'
                              t.1lk1   subject of rlur'silq hoio-,T :oJ)iitinLiq c-ln-
 tributio!.          Title XIX of the: Socia Secturity, Act, ei~ amended
 (.2     ,!.S.C.
               l I' t:iIort >    sr q.),        t       f::'; tlI' M:tiiC,-id P       Z -;1
                                                                                         if i  Lt
  (o:f-; n'. ~,::j ' i ,,l 1 ,1         -
                                       -":   ;s1re th:e .t!%)j(o t ofr   'rt;,; t I t Ai'.n; .

           I i.: t
        Leqa         !  o:'. I{i. 12') nit: od1,_uC 3 ijl LilW' fifti.i                                                               nll    JJIiur -
 atr' 4,   1 977,            ,J .ectiorl i9fj
                   to amrt;,:.i             1ciur Or the ,     :,:,                                                                           i t.y Act
 in lu(t,i ;,i p:rovisior, Is::tcLion 17) to rt,;ill?., .intvi. i                                                                           who

                 * *
                 "'       *      !1iryq;,                      solicit:;,    ;      , tr
                                                                                 aor-      , .,r
                                                                                             (,.'; r* . it
             .:'t'./   l!,lr .,
                           qi ! t;, r,r                         C
                                                                60T3        j, c { i ia l) -V
                                                                                              ;l     rd
             th;? r t-'F; e.;tah]tl ihe                            !y        ti. St;,t, *t r ch-arqlret,
             Solicit:;,        accept
                                 s,       or reCf, lV";      aty q it, t    r
             (die1t     ifrrl, or con:-,i,!er:t ion    ; ;i:   r),.-n',l it Inn otf
             arimJ ttinq .                 pati¢-nt to a loi'-tv.ormi car,                                          t;acilit!

Stch .:ct iorn w , il-d cor;t. itutt                 a
                                                     ,3        it, tt. .:or,,      ; :i.h, t't,' 1      )V .I
Ifine        (lt: I<) r i10   n-t-)
                                  i rvon..:*} t . A:; of
                           i,:,ri;onl:,,,~t.            t tlt*n
                                                              Attiii      4
                                                                          4, 1977,
                                                                          *t    t           tq
                                                                                            !I i:: Il,'11:;-
                                                                                         .t-,i:      f i !;-
Lt' il'tn            -otn
                     tl,: not t t                                                                    :ielc .l

                                         n Clr.t d t        n,*'r
                                                             lae    invl'     h*F ! v, t    t;',i'tr
          I!-';1'', r ''i',]ltionr:          (45. ( .I.'..q      2%C). :O()(2I)) 1 ) r ,-      Iu trr- nir:s-
 I i 1F        ii it.i oI th ,'t .             , .tic i t th- M-.,la edllt o{r                         to-
/Ctc' *Mt      2'},10 t      itt/t..5'f i t!    :it *:d
                                                     n-   ti:,jt.      .,'¢t-r'-i ilt- ! - l I 4'l ,r    , .
         t of','r,'}           .        c'ryVc':; tsorovij,'             l.itr       t         .r,;.llol              fs, t jlt         f       .
! ,r;;..tt        1Otl" tclo not COvor (ont                      !i r          ut Iti :1v t                           l     1 tI''f-1.,'' ,
Over,          :. ! ,            ;  es-t,  It      Mie l<(are 0tl,0                    l tri -,                t.       't t t,           tl t!hf
"M.e              >i(-,:-,- Pr:vidoot         p,-i.mburre:emc-nt M.!,ru'.                   !,"          it)        ae¶. tii:;t,,r tWh
 , lro'v, .:r            r.i:;.    t);r'r'l-nt .c,[ti.)n oI thf, I                                 i'.lI c           ,i     I; 0I-l:,,', ..
    ! t'l        ,*xtv.;. t thtdt ';tite(;                    .t' : II,,          i     l''              ," *,,               f 1. ;{tlr/ ;p 'nT'rit
pr 1         }..         ,; to dot.: ',:l          (,:c the'        Z    r.i:.'~t   (H         ' , ,,                    '),i'"flt%          tOf
nur ;t l *I               ;?- t                       (, t, 1| it        I,        I          i W(II INI    ,t                     * t ,I n5  t      ar C
to be <ci"aicted t rom .7 llowoabit.o CoSt'. in c(',,UJUt                                                            i    ir,   vmtuT.ri-

                      ¢.:-Ilwover , tht,,', do ntt                              :           h, jd,:i  i:'           r           rool1           ti.tin:
conlt t irut ins.


      'n a menmorandum to the reqion IV (Atlanta) Commissioner,
Social and Rehabilltation Service, 1/ an assistcrnt regional
attorney stated1 region IV did not *]jt.t to voluntary con-
tritbutins to nursJnq homes or tt, '_lllcitar.lons by nursinq
homes for voluntary con r ibutlonz.   Ilowevcr, he rcii    the
region did object to tl,, u:nc of coerc ion n      eiklnq contribu-
tions and rccoqnizecd tlIat the subject of free will contribu-
tionI was a vague, ill-defined, and hitqhlly subjective     legal
matter hecause what aopv-ared coorcive to nome did not 1.(
others -

   C RNN I t( CONTlr I ;ti' I O.i.;

      The four States hAd varyinq policies on contributiono:
to nursinq honiror by ftirniilio; of Medicifid patif-tas.  Th'et y all
permit nutrsingi tfhoie' t.o receive contrihutions, but on jy
Florida had leqi:l;tili       ipecificall, add jt sing
                             :o                   '    the        etct:
of ,cont r i hut inon:.

Fl ord   d      !aay:    s       olift i J

       Floridla ulrmits nursinq homrn;es p.rticioati              in Mediicaii
 to sel Icit    and rfeeivt, contr ibut ions 'roen      Lamilie.s of nuircinq
 home patients.      Such   0on1t r ibut ionn   r
                                               are   cons idetirel itav.- lai h;
 income to meet the nutinon          hom:n:' c;o::t:; of carinn for thr.
 natients unle;ss the ccon)tributor suthmit:; a written statemr!,.
.to thre State to s;how thatt the contrihutionl is not itfn(1nd.d
 for any specific pati:l't.

           Under Ifqcli:.;iation wh!ich becaLre of ffoct            ivo    October,' 1        ,   1 97 ,
solicitation            of' contrlhkit ions throu:;h coe:rCion nr asa                         c ondll-
t ion o f admi;siln tor () conti irn i.(. re:;:.'en:ce i,; qr)oimnids for
    -dendi , s
         |        ?;e ,nsn , io   O r ;'.voc; t t1)lh I'f
                                  ¢n,                          I i . ries. f' o ,, y , Iurs,,
inr      ho'iome Ifor   w-hich  tt,. to'lt   r ihut
                                                  .ulOn     vwcrre LI         i
                                                                             itd.     d.    other
 Igisl.ition,     neff'f
                     '1:;o            tive i    IcoIt'    1,   1',7f,,          vrrovivdr s t!lot:

         "Any    pe'r-so( ' * . who know-intqiv hbill                   the r.ciPil-
         tnt   ct           lb': 'I    'r      utch,'i i.tCl*l
                                                           p                   c id      oMei
         hi:i fartmily for          ,an
                                      amnOrtrt in          Xi-'.n:; of .that t   rtvlcvi,.
         for t!:,,, law erm r         1,ilul,
                                          t iorn,        *      or whtl in arIyv,::y
         knnwircl l      recI i;:'iv , a;t- t C(,r.,t      t: rftcCiv',      * , .i di::

i.'Medica'id w,:li tdrminint,.-i':d     at the If'otltral 1ev,'' by the :c ,cial
   and rehhabilit,.tiicn :;. rvlc: until Mirct:h           , 1977, when it w.:s
   abolishe   .cI
                nd adrl.mni:'trtt lye r-!'l it,.nibi     I ity was; transtfrred
   to the r.cw I:;.clth t;ar4t      Financimn; Adi;intr;tttion.

  H-164031 (3)

              andi        .,:.    t    In            !'he- Ie                  ipPt         of       unatuthori zed payment
              *     *     I*     1:; qtJl              :              I        C imf:            *    *      * -

  Til       l.'*'qi:.,  *t j ,J:I ,i                                           1p,:.,
                                                                                a     .i; : f)            r ctr      ii   I n I P
                                                                                                                                p   OS    L.'f!C
                                                                                                                                             t i ortN
 t lilt        L .I. ,1     '    , !i                i.lrirr              )r       l:ny dv , rondinqc
                                                                                        flo                                     on w le '-[er thte
     tII'          o1             ltit!:     illVriV(tIr v'                 is morev tlhiln $72,0  in                           o1ny t     C:l5:Co.:ivo

             Accord ini                    to ani t. tornr.y in Flaorida' - D,pa. rtnment c, f
 Hf         t;h
             I     and 1,Iht t ilitativn               I;  tyivi c. S, the St tte eIlnactd thiH
 Ic nlIat
     is     ion Ir'                        ,:tt;e ')i. ,-)     o speciL ic lcit
                                                               ok                 :lat ::n and
 r !u I ati o n, i t Ir,'oth    the 'Jttea   a!ld Ieoderal levels.         Th" at--
 tor neS   !oJ;l    IIn: tlat.,   al houtio! Floritda now hlar a specific
 :;t tuteI      Oiallin1  with Porit.rJtutions, the State          ner.-ri  tn con-
 centratt       ono nfrcjnrer      it:.

      o:'! r i
      or                ;,t 7 ir' i,.>

             (;~<~i(',; ti   ,,j'i!          ''.t:    ,         Hit f:ul-f :    1';:r t j c
                                                                                         i. ::     :. t:.1I        I rI I   7f; ifl
 t o ::-      ,1 : t. <,-                                  ,.      ,,I         ,
                                                                       ,; 1 '7 IIt I      i l     olitC.  C         or,, i    n'r
 }lui t";'      l.,i::1l                     ::      ': i::
                                                        ,   ilri;Fr:: ! !:'i.c'     '; , jinc:c rior
                                                                                                  t         t .:-.. t l,
    I',:(,I"'zIt-i -!t     ,   ; 'I             :,,/i :ik)n (of ;.t , ,].al t e di .i reu                           at i,..; and
prv'':;i.on; fi(ow                          ti, "f, d ic:,ie ]'t uv . .r Re imlbur.;:,:ornt Matnual"
rf ,n .rdint            l,;tt
               ir-,i ,rt;l,,r                                            }r lnciple.;                  rela.          inq     to contrilutions.

                  ,or qjia ih:!              no I aw,;                    !;ptcif ically                       adr,;ir.             cortr ibul--
tions-, accordilllC to                          , :At.te asji:;t            ant attornely qeneral .             Wle
naid (;oq(            jil'   i law :onrl-eininq Medlicaid nirrely stat(.:;                                that
[F',dlr;il rofqlit                       ·
                                  )I l'      W j 1 , fto lowetd.                    The attorney Su;lqq.st·'d
th~t     * i ,-;r        rr ;tqilt ri           ', ,:2,, lin.l     with thi,,  tr           u.  arei nerfdc (dI aind
th.,1 t thy          "mu:;t       h.o,e.     ., !il init     c     ! tit:tutory, la:o          since l'-deral
law; rltd. r ,'lu          l ,1 i(,i::          o)ll Itldic'id           t(   ne(t      ov0er the r.olicita-
tijr     (l I      7tr I i l'         1f   I . 11
                                      1,h)ut1d                  I
                                                               in     :;.q.
                                                                         e         (.ted thIst tL;;,' law
pro(v !il         f r ,,jl:1,         i rl:tI .:t Iv(       rath(-r tharl cr iminal -procedure.; to
cxI dW    itef th:          f.'i."'     w :,r,,      -'I::;     in h!ndi     li:-,     conltrihutioin pi)o:l).1tmk .

Ohio ec,>I il,:,:

            O(hi,         d,,'
                           f'              rnt        o;,.v- .nis                  law;              ;rcir        -.ic.,lly    .adi r,   .!;inq t.!e
   fu!bi) c t :,f         lItt r     j Iti.o          i': t c i,           rr] ;,,-; mn irnly ori I-i-J-
c.rI       r, qtltl,::'.o :        fOr ,i'        aliC
                                                     ,C'  , *rINTC f:iirt,'* tr, the: a;:.'jt;t:3nt
tizx.t(.,5 . (;',t)            I ;../r trt Ist o0i           bl
                                                              i  i c)I ' el f.r¢,.   !.e
                                                                                     H    .r iIa tdrn Ct . hio
 ''.   ';i t';   Fitlt in' q     trl .!      pIlr t c I pat inq in t::lif Mf dic. it            [Irno r;,i
t o, :;(,        ii c t          nlJ r t'( -i v, f('on r illt                                 i()ns .

            Oh)'o'I: .             t.ot     Meir-i ci t'    palnan incrior pt;.  t,      thie "Medicare
Pr.ovid(J r             Reile
                        k             ne;:r     r;   MalitLI I       r ovSii oln    conccnc rn nq the
treatim.rit               ot       :rontr Il ;i;t i:)n: 'r        r e intr mrremont pur        cseC; and

 3-164031 (3)

the State's       "Medical       Assistance       Proqram     Handbook"         for      lornl-termi
care facilities incorporates the payment-in-full provision of
Federal reqtlations.

       'iTh  section of tfhe State plan dect]inrj  wit. h i.r!c(,rle '"!l]-
siz',!    that, in co iputirnq the amount cf. the St;.te s rfi,.mbur:se-
ment, contributions restricted for tt.e care of a             aurticulir
patient must be deducted from the hce;'s       : cost of caeL(; 1how-
ever,     the income section does not d:scu                       unrestri-ct.d
coritributions--c';tLributionsi not dpsiqnated                      for      a speciftic
pjrpo:;e.    Accorclinq to the a.:sistant director, Onio            ncpart-
ment of Public %Telfare, the State's concrrn is that restricted
cuntributions are pro: erly accounted for .so that it will r.ot
payy :Nor,' ttrin it snoul.l.      Hi0:s.aid th-;at s.ice lnursi-ci homle:;
can urse unrestricted contributions as th-y wi.,i,, the qltate is
conc(.cr.n:e o]r.y th.,t su(h contriitJo(4. ;Jr. volun\iicaty nnd ,.nre
-olicite:(.d on q(enerail jrf,:-ic;:f ratiiir th;ll   or; the qrounds tihait
thb   .state's    medlic aifd    fr-,Jir-t£-
                                    i     rmfernt     ;: ilnfirf.'Cj{,ute.

         LUtah permniitis   nturs;inq        et
                                          hu;:c     iarticiratli:qi ,n     ,
                                                                           1':iic1;-              t.
rc ceive     contribtiuiOns       tromn    rli     o!I Mt iicad
                                              lvtevi,                          it,,-t irnt<;.
Utah':; "Provider Man:ual            for Nurs;i 'q a-cil It,'it,:-_
                                                          ties;"                 t, nt
such con tl ib tion s should be deduct,0d                 f rom    the St.ate '";re.:1ic-
aid reo i;nursement.            According to the direc(tor of                  'iclf .
                                                                              -ed                r. rv-
ice's,    Ut}ah Deipartment r)f         S-cial    Services,       th(ese     arf, con'ni,1re-i
r,;stricted contributi.on.                 He said other       contributi.ion.             ot     .'
q.n.-tal naf'ur-, SUClI .S to te nursin,                     or    it:;elf ra.the-r tlhai
t,- or fOr     a  :;,)ucifi  c ,at    jeocl  ad
                                             O     con:siaderd!     ulnr.;tr ict-i.
'The n,!rsinq hto(rl. rt.Ust       roriort. unr',!str ict(.l    cc(nt ibllt ion,, t.but
 it catll us;(' thetm aS it wis:,::         withbout (-iuc:t iru, tht.! f ror t. h,
   t'ittc'n; ;Medicaid   rlomt.lrsemrcitt.

       Utah':;        Provider !,.l !.1 " i lcor. ror;.t:;         the Fod(;0!- l          r.ir--
Imttnt th1at. nrsinq          thlm:,: alccnft t'hc:;'te'::         H,,l'ic,',i/tl't.        ttlr:,r--
  ,ast      p;,'t).:.fil,nt-l.l-full f! r ttih c-OtS. o!              Lt
                                                                       PIV             I .V'I'
caver (       .i.dlby
              ¥          caid.

           Thte d(lrlctor c. i.<i that hif !'it-l not kncow -, .'f               ,t;It
                                                                                tlte      law
  ;        IiCal ly
         t:i            a(jIr   .';
                                 i.'?  I
                                      the    .SUtj)'t of  C,:)t r il-ut i',  ;.      if,.
   0;aid! tliat Uttail does not nave a Ir-hlJem with cntrlt                 ui t ionr;,
!:t            t
         t h- ,,tl   l   .;1,tion cVv r in;I lnhi.     tj   c t wou li     ;f h,(t        x-
clal :i!          a ptrrvenrcat ive rm.a- 'r
B-16403] (3)

CC .-    1l-'t,!T
    jF: !t,                       S TO NUi .P!N
                                              G II{.":S

      Nursing  hore:;3 in ail four St.tat. s receiveco contr Ji'utions.
Liach or th!e homes we vi.'.itktd in Fl or ida anc; Geozrqt~ -iad s:noi-
ci ied arnd receiveu coltl ibut ions.

         (,!tie four hoIa..ps we viv:/ted in Ohio, only oi"v ;'a c')ll,'c,--
L ,Jlt=d, notnpr)ofit hom:e) had -olicitted ant     rcceiv-Ad 93nef.:l
cont iDutions, and another had received restricted cont- i-t.
tic:.Ls.    In Utah, 1/ althtouqh the StaLte had identifiecd minor
  n-uunLt; ot contrihut'ionc    in other hoies , rinne o! t-,. three
facilitie" we vi.sitcld had solicited or received contributionsi
in recent years.

      From: here on, our comments will. be base6d on our work in
Florida and Gegrqi": s:ince we found no cvidence in Ohji:; or Utah
of a cur rent proble, rcgia-'ing the inap; ::,'-r iate solicit ation
of cOr.,tl; I :l:o S.

             ',h        . we        l(,ul],     nr,.':7 w.,-re nur.?int,1 homo:-,
                                  'ie;:r--cu'. (-cut    t
forccr             I a:Iii1
                     wi       .        of     N:diicu        t
                                       pati. rt'- to conotribute, we dilI
Iinti t htat .some sI   i lie s 'felt"     t liey hid been presf;uroed into
contr ibutitl .       i teen o- 44 coen.t ijbeuorr          we intervi ewed said
taey telt    their contributions were not completely voluntary.
Tt;e; felt   coTmpell eai to contributt t(-e'cal:;e ot infererces thle
nursiigJ r.uroes maud. eithetr ciirLctly or through thefne(ws mcedia.

            T'ih       lour nutr-;inq herr:.;: 'ec revicwid, , three in Gccrgia anJ
cne in             Florida, usetd variouqs mc thodi:;      to q.n-rraco contribi..
 lt(,n:;,          includiln;     lettetr'., c1i:;cu2sions; Witi' rospon.ible paCtr-
tli    .,          zji-: irlol} ho{}o' 'a]l ls..
            In'lct ri,,.,,          8 of 1i corrntriu         tincl       tarmnl ieS   -'e int-rvi(:!w,;
con:;idcIi.d        thii,,r contti iutitr'II                 tu te I,   lv       than vo,;lu-.t-y, bt&ll
the' , ctrrt ijbuteld becaaut.el                 thti:y w,intca th, ir rceJative-s to r,'ma-in
in t!e       ur:Lrs3
                  S            ,hea      andi
                                           n      ('ci"'       ,!,'( d car.r .      One per',n     told
ll:: t.lt t :I             titt r , ibho t .  t' (?ci-t'ii ,    thlji nu:·. inq hoi;-·    r,-qu ire i t;
ito~,.v.:: , :,I,,:. stSor,-;p,:<i cernt.r' .!,ut ir,. at tft th;, ;.,rme s,,nt hot a
l t     r stat;nc 11(         I it :;he Ldid not have to contr i!lte                        .  t;tmbr-r

 ]/    u.:.;ii,        !r,+'f'. rt' of          rp ti,:rtr       it-   on: l, u ir:.inq horTe   irn Uta' h   .!j, d
      thehv        felt ptrfc::ur(e to contrilrutl dur nricq
                                                          1970 tc 1973.
      't:"[rt !,.r; been no) p oblem in                       re, the
                                          the n!r ;inr home sin
      ch.,rt q of qeneral rrnocn(-t s in uctobltr ] 973.

of two other families told ut. they fel t pressur?.' to con-
tritbute.    A mrember oc  one frmniiiy sraid he contributed hbecthlie
-he believed hi:, gqnardrroth-,r would have to t, mrc;ed to another
nursingc   home if hle d('Ijnot.      Molnbers of the oth - famtilv said
they f cit   pres_,urerd to contribute     bec:;use the nur sing home
s*rnt theml precoul;mpletd contributtion foims with tie        amount to
be qiw,,rl .ill.ed out,     'llfy didl not     sign the forms hut did con-
trtIbute after roccivir,,l a final bill v,hich included a $53
contribution. They snid they p!iid the total bill because
the patient had reciJved gqood care and they wanted to settle
all thie individual's debts.

           At the c'iitJIlet ion of. our work in the Florida nursing
borc,,      t'4e pro.,iidi,'zt arl, the adlJninistlrtor told us the Iiolme
no       lonqc7r    billvd          c(ntrirbut.or:;        for   their      donations       anrd did
not       .pr-;,:suie.anyoni- tv contribute.

       In Coe;!oia, 6 (10 10 cu-ntrihut inq families wce interviewced
irlvol-vinfj on-, nur .i,    h,oibr.- to.ld 's that their contr ihr. io;,;
were:  not voluntary.      *)S , toti'      of 23 intervie'w:     ; with con
tributArsq; part.if .-. rfr Ii(      othcr two; nomf.:: in G(;orqcia, we
foutnd oniyv oo: poir son wthoi .<aiid tv'lat their        contri  hti;ton hFad;
not boi(-n volnitil y.

           T'li - adIrj riiitrator              of onr     latisiiq      tlOiPtv   in   o(CrqClia s;iid
he wotki'd onl tkb?iarif     g i:;'   uilt    feelin:i; to obtainr cont:r il-
tinrn.     tie u-ed a cgl)umnn in tho horne's monthly nc-wnln-,ttr to
remln:i pttietis     ti d fanilic:; that contributiions wre neccsr;-
.-;ary since co)nt7 wol." r'xcr,'djir,l the .Stot,'s         Mledic-aid reim-
bursemren.t and that wlthboilt ;ritr(iuateit      contribut ion:- tne horn,,
miqhlt !aive- to drro;p olt.               licaid
                                 of the Mted         pr.gqrarr    r 1 ot r the
oV( raIl I tu.al ity   Otf car:.

       L,,:ite in 1975, :;ori, (C:-.or,!i.l nuri;in  r   ho:'er sta"ted p'b'ilic '
tha.t  thi'y would iivfr to ,fro oiut of th. 'lt-dicaid]              proqrat, if
thle :;tate' ¢Ji-J not inetr-,,',   tl     arnmount:   fl its reiml,-sc     r:en .
Th,      pubhl icity , u'      !;r)nm. fari I -jr;to contrib)utr so ti;o h,,-n,-:
WOUdIt      ntI t hav'o t': drop out o!f tii.r Mcdi ;.id proarara.

              T              'CN;      ,u;(;
                                       ;':'Fi      !   )P'!;I)

        IILW.xeqional         ofl icail       -' in Atlant.t.. r'ic,-qniztd tl-at the
cntr    ibut ion' i' inSue wJ/; a prob!l,'!r.                   !fI'wrv.;,        they had Li:;i tc,!
r.cordr.       )incitninq tti, tirr:i!ol.:n ia (;.n , i                      and F] :r ida.           'ril lr
ij v I      et    h. t'; ', -r-n r;!
                                   m :in         tinl
                                                  , i uqh co r           r.";rn.onde nc     wI th : t.; t.,
offi.cai.;,      with rnl )dl-r
                            ,ct l t n                    t- t at nUt;inq            horr,. ,     H-?i
Climirnl; t.vo   av.- in;sif' ti fnt       ,.:     '-(i:'cl-C;      to ,'tfecc tively          r,,v .- W
t h, crn tt tiiit I n!;         i t iatio:
               '!EW'.'       Ai:dlt Agency and Of:ice of Investigqatio                                  ns in   the
 Atlanta            re¢      ion htad              not reviewed             contributions to nuilsing

            iK':'-;!nevrloic nrLte r s of f icils were awat!re of the cont'ri tu-
 tion.',,':ue           irn Floarida and CGoorq i a    T'he,. disaqreed, however,
 wit:l:    rt t,' attornevw; in Florida and Georgia who claimed that
 ,etior,i, re iulacions were inadeauate.    While atdrmittinq thlt
 the r-.aqul ition:: do, not specifically address the issue, they
 told        e'     that              existing          rersulations were                 adequlate   to deal   with
 the:)roblem.       Tlhev pointed out that thle regulation whlich spe-
 cif i:    tat   pr,vid:rsz
                         d    lmust accept the Medicaid reinhburspee;nt
 as !,ua.e'nt-.in-   tiI   for the cost of care for Medicaid paienrts
 i:; :;tronq onough to 'e inter-preted as the qoverning requat          cCn
 tor ;                 qs;uct:ion
                       uie                   ote forced c ntributions.

           tH.%;' !hf,          J.qirtet;
                                 -<a      *:ff.icia] s told 4ts that         if nursinq hnmrse.
 :ol i      -tI c'.ent' ih::tJon:         oin the ha si. of ijnaecrna;         t Stat'e reim-
lu :'i       ;rrt   tnroit'j       h ri. c1i7 i,(I t. ,h      m:, i U ri ;kinq their      eŽi;:i-
Li2i Lt, t                  1i,:rt
                              ici p;:;e in t:           i rogra:; since ti ,y have alirtec:,_
ar,,-,ls'1 to ,7cr.[rt ,M                        a:.! paymrent-in-ti, l i fI:
                                                 :icail                          Mler'lcai1
p,:l t i l.i t: ,s

             'Th         lr:WSthradquarters off ( ials                             aeareed that HEW shoul.
        , a stft,-nrent to thle rel.,-ns
  ,rovid¢                                     ird   the States    d(:,'cr iin'
its   p.olicy and it;j intc rpretation ot         -he roqulations      as they
apply to( the s;olicitation    of contributions.             However,   a, of
Apr il i19- i, rno ,quidance had been provided.

  ';A'!': nF''I([F AC'T'IVT!TI'_:;                         ('O'.ICI'[NING,

         f'tat.            off i,,     ;:!ct.ivitis         var\y with thte do.gree ci          sioi4fi-
 ner,            tti ,cn    d t:.. the cortr           i;uti:,n;i     .robIoI. 1       In FlFoi.ida,
fo,cJ ,.f'        -c':,t r       i outi,:; se,-:n   rd   t o ,e widi, r vr-adrl amoor,- n 'rsin<q
   O;C'r;e,~ a nd      ,bi,      ?Lt3.1t      h,.:; taclk-i    a tor.cet!l     role      in deisalinq
    with th         lro'!,l:r.
                         ,               Althoiuh Gerq;la offic1i-Ils. id ntot.                      n-
S:ffri      !;:i-'c(,!             r',nt
                                   riout1ion            to :e    ,; problem-,       the Stat{( hawd
 t      np:      ,       to'    i' ita ,' surve. illanco                 vt.r all     cont rl ! t iorn:.

 s.it        -ir: ri         's                  ; i lo t liiatati        lth     ri

         ilr        ilf)'r        ;     ;,i }art:f;,nt               ,ftleHalth   and
                                                                                   S,.rv- 'chhabilitative
 ;c,.-^t ,~r.;: '!:, fir.r:i:t1hI+.':'-;,~:
                                   '          O. tI0h'  \~tdoI to; It- te-ra1 ' ott i c
are ,rt.t,.pt i nl to,> (-cit! uttstr- in:olv in;7 contrl hutilorn; to
n'r': 1:        hot:;.     bu.'tt acti :it       las :;..c'n ct:er'ter.d in tihe    eal th
arin.   It *i.abil   it  iv-
                          v      ;    .rv
                                       c .:; ' internal      au-ilit .ection.


     The internal audit section detLerinred tlhat at least tw,'
of nine nursing homes it investigated in 1976 used some for;,
of coercion to obtain contributions from families of Medicaid

      The dcterminat:ion at one nursinq hoine ws basePd on re-
views of the Inursing hoorne's record:s and on contributor;'
responses to Lluestionriaires.   The responses showtj thIt col-
tribt)cions were not voluntary but were exacted as a condition
of the oatients' admittance or continured residence. Th2 State
plans to take legal action against this nursing hoem? to re-
cover Medicaid payments which the State considers to be over-

      Another nursina hoime did not keep records of contribu-
tions, but fdmilies responding to a oue!.tionnaire us.,d by the
internal audit section indicated that contributions we.re rr-
aqirled either as a condition of admi:;:;ion or corntinut-i r~-i-
denc'.    Still another homrre relus.;.d tir( ;ud.ijtorS ICctC,, to
records necessarv for comn!netin:-. their inv: ;ti nati: .       .A t,
combl.-.tion of cur r vi, w, thf   ;t.tate was 'slarnino to t.,kc 1 qI
action against these two Iriomes.

      The supervisor of the internal audit cection told us
that the State hlad 14 orditional audits underwjy in Novnhiver
1976 and had c)ntracted with 5 ,rccountinq firrf:to audit
72 nursing. homes for the fiscal year endinel June 30, 1977.
All of these auiits    are to include spnp^cific coverase of the
contr ibut ions issue.

Statt, activitics     in Geornia

       State offices in Georgia hd-i not audited or invr-stiqdated
the   ;ol icitat ions of contr ibutiopn,, by rur:.in.I hom;l,.i.

       GCorqia 's main t ttivity wtas; to, (Orer rondl        with W!!:W an!
with twe nur,;inqu P.,-        conc_.,rninq lettr.;r  the- nmrsin;      it;rf;~
were usinrgm       :;olicit crnr.trii)utionr.  f(,, fl:nil i'    ,;f ed.H-;ijd
 -.atient_. ." ,'t- StaJt,';,tid tEW con;idr;l , the h' !ettetr. t'o s;tro:Cr
for so lic'tat o:i 1,ur!->,,:)   ; and ask,:,' the. nro,;lri, hoemT.':, ' -) r-
writ- them.

      Since Au:3ust 1,     ] ,   or'!     !hj- rqm;llrfd*I,r:,ini            ho-e--,
to report montnll.  to the Sta;te any voluntal./ v(cntritltio
the.' rcc lye,.  Of t'.-  333 (.        '- . - lc    ri :              ';-or,1:
61 (14 perienit) re::;,rteri receivir-,    115, j6! tet!win           Janualr,
and June 1976.

                      Th-t              t-    St:.
                                              .;t         t
                                               .- rt: urinq   e     a new for;m that: ercl'
                                                                       pl aris
.onltr           -irit L         IIdV.
                                   a       to     i q n .nd submit:          to tie     .State Lor
                 c c;:ru:  ir
                           I-i:" .    Te'o forI            . s 'Jsiqn .- d to pr ovi de ai
st ' .,-,;:o             li,(:t:;cj of rept           tiJ       Lu
                                                                tr,      fin      rx:tr  IC t i,-d ,nd
     ,           ictcLL .Cont. L Lut c..1S,           to t i, ]        ( Intr.iJluttrs tih3t nurf -
 iC' hm t;s inm;;%t acc              jpt t he 'tediC      i .d    p ilymc:!tnt .- ,. paym. nt- in-f1l
fcor   -,rvico.-         covere!d by tl                    ; id proc4ram , ard to exr lain
to contir i)lutor?;            that nu;rsin¢ hokT.:4 cannot prov ide Inierior
treatri.ent to Daui-ienti                  whosc rcitives              do not contriLutLe.

                  T'er ic:;,       ot contrjbuttjionr              by IledJcaial pat i, .tri.' ltmji I
is           uiff      icuit   t o odtal with bec;u-e                  of tie lack o;f ['(-derrl lawl;
or           r iuatl.-         n..      i iff lxn      w';at rlursing h<o.-ios mray or may not
     o       if!
             i:              ito,  *c;l           .:tiur   a;. ttnt:-i

          ctt,:                                   ..Iv.. r;s                       n'           poli   cies    in tI       t;ir       St. tr.                                                                           w,                vjij.-     ;     c:
6e.',_                                               ,, J t                        ;           , I. i C i i -:       t:iCti;:2,
                                                                                                                            .;                                                                                                                       O~P',
I: ' Of i~:c;,
            D                                   . , r t                                      "_r:tl v a enat'ctIc e d i         :,lat                                                                                   iior
                                                                                                                                                                                                                          -ii                           h;,:h

or           s;(ot !'t.ia                                      rc::litencv                                        inr          a nuIr.lniq                                 hlore:.

                      ·                L1I'
                                       .;.:                       ,,                th;
                                                                                      t                 !t h               I atck o£f                             bf'r     cra I qu ids ln - r;ay lhavo
al¢OWt;cc                              P..iottr               '                rioles                        to            ljti-f;l                suibtle                   Dr essurr:;   or t .'C: ! :,ti-
 II t_; ,                              'i',:s tC                    id             knt ii .. t.* by

                      -- tanini,:                                      d4civantaqc                                        u.' guilt                               fef!linnq                            the fan:li.S
                                                                                                                                                                                                                  if   r, iq;ht
                               hi:vo                           r)aci
                                                              Ifot    ,,j rel,'.iv e.;                                                                                in     nurt               ir"l      I ;Ciliti,:.. ltilmr
                               t       ia,;l              k-oitrl; t !..'T  it !:5."'.

                      ---              r''.ot Jr,                              c        I,    lar                 thiat                 t r-                nur';irn:                       to(c wu(1ld                               .irop (cuut
                                       t1 ti :,                        *                ci;::ic&
                                                                                          l      )ro,"t.
                                                                                                    :  ',                                                   wilt:          l:i w           ,ii           r ',ul           t           n1           t r,.
                               ,'i::; (,vs-j                           ;',i             rl'tlict'l;                                 E;: i-,rlt:.,

           t!.q',:;:'. Ni;A'i'Io;                                          *, ' il

                      ;b,,             t          1(.'1:::
                                                    "                  , i              tt             ...   t :t h                e-;t'- I'I f; t.I                                             t .,               (     t       t         f'        .t      :i    n
                                                                                             I t
1t.,:t                   ur
                      t.nc!i                  ,,k:.
                                              -        '                                                          tJ£.                  i                                      .t,        ?l;            "trir          t l           ,o t,                i-;s*u
a           ,,i.                                 t;,:.rt                   t                   *,
                                                                                             l '.:.                   l        st                   ; c                    a r Iy
                                                                                                                                                                     , howi r:                                          [ ; , h. ,;hei-
tu               1,                    t:.i               :of           It              i .                           ,:it:,        o r t-                           . b;
                                                                                                                                                              .tnritution lfc                                           ll it i . r;-tr-
t <'
   I   i; itq,    In                                                ,i tlt:. i(: .                                          In              t,n , tr,"tlt (,r, i,:.,,        i.                                          htf.: ,   rlt,
tilt /tOA, I I 5,ttr                                                                                     ul; ('itf                              , , 'V  f.;t.tr:(!¢,l ti                                                 w'"t
                                                                                                                                                                                                                          , Iii  thC-

to'         i.      ;iio               i,.,:'.,:-n                              t (if
                                                                                   ;,              t              t                         rl              t?,                       '          r       "     !i             f ly,                on:.             :
      I      .. ilr;               ;   it     r;j;   it   ,        3           ilil:;[!                                                                 ,         t         o.i;Jt.¢t;                       :t .         f!          l      a,            :rSutt
      rl              e ;:at ;nt:
                   t! oi;il                                                     ...                          iS            '        r            ;'t:                 cr.Cnc         :r
                                                                                                                                                                                     rr,ro:                              r il ut ior.;.

            f)A-T 10:,
 RECO:)'.i.,D                                TIO
 H                t -lMMITFI'PEL

                  Since title,           XIX of tihe Soci,.l Securitv Act             oC.eS :olt
spccifically                                        0cit
                                     address tt:e -ol       ation of contrilutiofrl;,            w5,
rtcontrr':;!                    thIt   the Conmmj tt.e initijt-A  act ion    tu aOnrp         it tf o
provide a clear                                ntatutory ba:-:i., for pror'ecuti-)n                                                              in        thl          .:vfrnt
contributions                            are             solicited              by nur,;injq                      ho:lcs           .:- a              prcroniition
for admittance or as a requiremiient                                                                       for continued                          stay.

                  If     [I.R.          92     is used av the basi.;                                            for an amendi;.'.t,                                     th,-
                             that portiori of the bill
Con,,,tittee may wish to del-te                          which
provides penalties for anyone who "* ' * c'.argPs, .;licit';,
accepts, or receives any money, gift, or con.idc;er-ition over
and above the rate:; ectabhlished       by th- State f * *."      Such a
reaui1rCeOment m!ay he toc r{i;trictive    hecal,:,_ it W'oU d lcot ,!li.w
the acccptance of any nood faith donations, such as Chri..tr....
qif tt and voluntary contributions.

              di   - Cu: c'   t}:e clitenltts of t.i             rfpor t wirh Itli:W;                                                                                       ! j j.-
cil         rr.I c-o n.irler.dl the i t ¢io?-,7,?nft' '
              .                                              At tT!;, r; ;t,.::t
                                                                            ..       oi                                                                                     t:..-
Subcr:o.)r,il t t' " ;t:-aif  , we did (   ort o(!t.rti nf .c...(l  (    - frrr .. t' o                                                                                        L      ;
ir,clud'r: ! r oU           r   i f'w.

      As aqr,.,'d                            with fti: ,                     c
                                                                           iiCOimiittetet stai f,                                          vil
                                                                                                                               wr ,ire prcx,
copi-:; ot this                              rerport   to               C_'Ser'tor                      Cllren.

          · his rrttort         ¢c,.,ains.               a C.coilfmentd1.At ion tn th. S.'Crta r'/, * ,
 iEh', which              ;            .,; h on !';iz:1 0.
                                      ilt                                           *'\       '1V lI kl            , :IC. (r 1            ,,
of the .:;i::lat            1v-_      hi,.l l                    :::.tir:n Act             f 1970 ro;ui,                    . t.
ihirt        f ;1a 'l:d,-r.! .ql,.nc,/     n.'l ,'          :*;bt.             . wr it. tn                ;:;,t,-i     , nt
                                                                                                                         n          tri
jct inri;; t-jIf-;~n o l ) r . {ii..!rt                                        2    t1        tei      n'1.-              !:p1    t ,'¢,
oin (;:)vcrn t,rerntnr Oper           ti,:      , ,t            'ti.       L;'it,             C,,.mini,:t                     ;ov . -
ITent jI      A Itair_     :n          i ,,r r':y:;t! :a
                                       iot                         6. ,ftr                                ,( ().,.t, *,             tI lr
r 'e , rt     and t.) 'ti,         [I(, ti.;       .ri.',m
                                                        )   ';,r        t,                 i t '.           ;;' ;        !           }! -
t ion-      with      thle ,-*,"      W..           I il.;t
                                                       lr:         I                    lrl
                                                                                        'ic,.      r                I !i       n ;.,
 l: r,
    'J    thi n fC (;,3': ' . -,     It. '         tt,'     d,i, .'               Itt:'         . r"     .          ..       ' l 1 !,.

 .¢[,i,           : .- ',¢     t }[i;        tI *   )4    r t   t          :.        rlttt            r)    Lb ' /:*. .    r       vt.       i        .t:J       1   1:,?      ~ ,,d[
  _,      t                  w1tri       7     .           1    '.tI   l                     i                ':n.*Lit
                                                                                                                   !                         9    4   ''

                                                                       C::.      ,i ; ri                   ,'              '

                                                                                                                   r           Iir                         '
                                                                                     C,.".tr,:-llgr                    (;,:tt,,ra]

                                                                                     iitst       tI                            ;         -