Editor’s note: This article is the second in a three-part series examining how and why New York’s nursing homes too often fail to keep their residents safe. Read the first part here.
Robert Negron, 60, has been shuttled between more nursing homes than he can remember – at least six and perhaps as many as 20 – before landing in his current bed at Beth Abraham Health Services in the Bronx. The instability has been wearing on Negron, a Crohn’s disease patient who uses a wheelchair and needs regular attention for an unhealed wound on his foot and chronic skin ulcers – but it’s still better than being in a homeless shelter, he would say.
“In the shelters it's dirty, it’s nasty. You could not get enough medical attention and lose a limb,” Negron said, explaining how the unsanitary conditions at the men’s shelters on Ward’s Island, over the 10 years he occasionally stayed there,put him at risk. Although he visited a clinic for care and did the best he could to change his own bandages, “There were times when my foot was really bad,” he said. A New York City Human Resources Administration spokesman said that since Negron’s stay, “substantial improvements” have been made at that shelter.
Yet nursing homes, Negron said, have forced him into city homeless shelters three times. While there, the only thing that concerned him more than the lack of medical care were the people around him.
“They victimize you,” Negron said. “The criminals and the undesirables, they prey on the homeless disabled.” Once, he said, another man assaulted him in the shelter when he refused to hold drugs for him.
Negron’s case is an extreme one, advocates for the disabled say, but he is not alone. His experience is illustrative of a long-standing practice of nursing homes placing residents into New York City’s Department of Homeless Services shelter system. These vulnerable New Yorkers often have chronic medical conditions that have improved little, advocates say, but are moved to shelters that are poorly equipped for ailing individualsand are rife with violence.
Long-term care advocates are alarmed by a sudden spike in the number of older adults who report being forced out after having received nursing home care for many months or years. Although the city keeps no official statistics on transfers from nursing homes to shelters, advocates say there is evidence that the figures are rising.
In March, Gov. Andrew Cuomo called the city’s homeless shelter system “deplorable” and “dangerous,” citing recent news reports that show high numbers of assaults. The city has taken steps to try to address these issues, most recently opting to retrain shelter security staff in order to manage the violence.
“We are in the throes of a homelessness crisis in New York City … and we are watching people being poured into the shelters from nursing facilities,” said Susan Dooha, executive director of Center for Independence of the Disabled, New York. These often frail individuals, she said, “cannot be cared for in the shelters,” where there is no skilled nursing care and part-time clinics offer what is often the only medical aid available.
Nursing homes are required by state law to ensure all transfers are made to a safe place. For that reason, Dooha said she “cannot fathom” how nursing homes could send their residents to the city’s homeless shelters. Beyond that, Dooha said, federal protections were also being trampled.
When reached for comment, an HRA spokesman said “no one” should have been transferred from a nursing home to a shelter “if the needed medical treatment is not available at that shelter.”
“Their civil rights are being violated, in my opinion,” Dooha said, citing protections under the Americans with Disabilities Act that ensure safety and accessibility for the disabled. "I recently brought this up with people in the governor's office because I'm so concerned,” Dooha said, adding that she had also alerted the New York State Department of Health and the New York State Office for the Aging.
“People are not furniture,” Dooha said.
Nevertheless, nursing home administrators responsible for what they call “involuntary transfers” of their residents into homeless shelters tell watchdogs that there’s little they can do. If someone no longer requires a “nursing home level of care,” the logic goes, that person needs to leave. And for those with nowhere else to go, that means they go to a shelter.
“What I've heard directly from the people who were responsible for the discharge is, ‘Yes, it's unfortunate. We wish we had another option. Our hands are tied. They gotta go,’” explained Richard Danford, director of the New York City Long Term Care Ombudsman Program, a federally mandated and largely volunteer group advocating for nursing home residents.
In the past, Danford said, “You could count the number of shelter discharge complaints the ombudsman program got in a year on one hand.”
In the last four months, however, complaints are coming in at eight times the normal rate.
Since last November, the program fielded calls from 16 nursing home residents in New York City complaining that they were being transferred to homeless shelters. And while that number may appear low, Danford said, those complaints represent only a small fraction of what’s happening in the city’s nursing homes. It is likely that there are many others being sent into homeless shelters who did not call to complain, Danford said.
“These are the people who have it together enough to be able to read their notice, realize they can call us, and realize they can appeal the discharge,” Danford said.
And those calls did not originate from a single nursing home or even a few nursing homes. The calls came from 16 residents in 15 different homes, in four out of the five boroughs in New York City. In other words, Danford said, there are indications that the transfers are not only increasing in number, they’re becoming more widespread.
“We're really worried that that's the tip of an iceberg,” Danford said. “It's clearly becoming a practice. … There’s no question about it. Our biggest fear is that the number is substantially higher” than the call logs show.
After City & State requested statistics on the number of nursing home residents discharged into city homeless shelters, a spokesman for the Human Resources Administration responded that “DHS has not been systematically tracking entries from nursing homes but will be doing so in the future.”
The spokesman added, “As part of the 90 day review, we will be enhancing DHS procedures to make sure that clients are not discharged from nursing homes to DHS shelters when that is not appropriate.”
Daniel Ross, a lawyer with MFY Legal Services, which provides pro-bono civil representation for vulnerable New Yorkers, has counseled several nursing home residents threatened with a transfer into a homeless shelter.
“Most shelters are inaccessible (to the disabled) and they're unsafe,” Ross said, citing news reports describing shelter conditions. “And those two things are particularly concerning for nursing home residents who are particularly vulnerable to those conditions.”
“I don't think a homeless shelter can be an ‘appropriate discharge plan’ for long-term nursing home residents,” Ross said, referencing the plans that nursing homes must develop before removing someone from their care.
Nursing home residents can be discharged against their will for a few reasons, according to state regulations, including a determination that “the transfer or discharge is appropriate because the resident’s health has improved sufficiently.” Advocates say that this is the most common reason nursing home residents are given when they are told they are being transferred to a shelter.
Nursing homes are required to provide residents written notice 30 days before transferring them. The notice should include a care plan that shows the facility has arranged for relocation to a specific destination that is safe. Guidelines even suggest an advance visit to the destination.
But actual notices reviewed by the ombudsmen cast doubt on how – or if – nursing homes are meeting these requirements.
One recent notice, dated March 4, appeared not to give the resident 30 days notice. It noted an “Effective/Anticipated Date of Discharge” of just one week later, on March 11. It also didn’t specify where exactly the resident was going. The transfer destination, scrawled in looping handwriting, read simply: “Department of Homeless Services.”
Looking at the form, Danford wryly noted, “That’s it. Just any shelter (they) can drive him to.” In summary, he said, the notice “is not in compliance with the legal requirements.”
But on the face of it, the reason for the transfer was valid: “As per interdisciplinary team, resident has completed health goals and no longer requires skilled nursing care.”
Since nursing home medical staff can make that determination themselves, advocates believe that many residents feel helpless in the face of a transfer, so they do not challenge it.
Residents have the right to appeal to the state Department of Health, but advocates worry that few are even aware of that, because they have found that nursing homes do not always give residents that information, as required.
Ross, at MFY Legal Services, has represented residents who wanted to challenge their transfer.
In one case, a client had lived in the nursing home for years, receiving care for an array of problems. The man, an amputee, had an ill-fitting prosthesis that left him reliant on his wheelchair to move around. Nevertheless, his nursing home wanted to send him to a shelter.
He appealed the decision to the Health Department, which regulates nursing homes and acts as arbitrator in transfer disputes. An administrative law judge from Albany came down to New York City to preside over a hearing in a conference room at the nursing home.
Gathered around the table, each side presented their case. The nursing home’s physical therapist argued the man did not need to be a resident any longer. Ross argued the man needed further care.
The judge ruled in the nursing home’s favor and approved the man’s transfer into a homeless shelter. Ross said he has not heard from his client since then and did not know where he was.
“If a nursing home wants to do this,” Ross said, “it's not that challenging.”
Ross explained that a core problem is that the Health Department has decided that homeless shelters can be an “appropriate” place for long-term nursing home residents. “I think we just disagree with the Department of Health about what ‘appropriate’ is,” Ross said.
The Department of Health’s in-house administrative law judges have approved discharges to shelters “in certain instances,” a spokesman acknowledged, “particularly where an individual was homeless prior to being admitted to a nursing home for short-term skilled nursing care and have no other housing options.” The department did not respond to requests for statistics on how often these hearings occur.
The department spokesman also stressed the responsibility of nursing homes to “establish that the discharge is safe and appropriate for the person’s clinical needs.”
Michael Balboni, executive director of the Greater New York Health Care Facilities Association, which represents for-profit nursing homes in the New York City area, agreed with the Health Department on that point, stressing the need for nursing homes to follow state regulations.
But Balboni said there are pressures from state-implemented federal programs, aimed at reducing health care costs, that incentivize nursing homes to push out patients who don’t require skilled nursing care – particularly the Delivery System Reform Incentive Payment Program and managed care.
Richard Herrick, president and CEO of the New York State Health Facilities Association, which represents a variety of long-term care facilities, echoed that sentiment, agreeing that nursing homes were under pressure to discharge patients. The state Health Department, he said, is “always very strict about warning us about the inappropriate placement of patients in nursing homes – ‘inappropriate’ means that they don't meet skilled (nursing) needs.”
A spokesperson for LeadingAge New York, an organization that represents the state’s nonprofit nursing homes, further explained that discharging a nursing home resident to a shelter may allow that person to access public assistance benefits they would be unable to receive while living in nursing home care.
That reasoning sounds familiar to Negron.
He recalled a social worker telling him before he was transferred into shelter, “All we can do is send you to a shelter, but you won't be there long. They'll help you get out.”
“But that's a crock, man,” Negron said. “They don't give anyone with a wheelchair housing. All you're doing is waiting to be shipped off to another nursing home.”
“Between the shelter and the nursing home, there is a revolving door,” Negron said of his experience. “It’s a vicious game.”
Whatever the rationale, advocates say long-term nursing home residents like Negron should not be placed in the city’s shelter system.
The ombudsman’s office has a catalog of stories about such long-term patients that it believes should never have been removed from nursing care. In one such instance last summer, a man who had been transferred out of a nursing home into a homeless shelter immediately walked himself to the nearest hospital emergency room and was admitted for inpatient medical care.
As the number of complaints go up, Danford’s office expects to have more stories to tell.
“There’s definitely been an increase, there’s no doubt about it,” Danford said. “Something’s going on and someone needs to figure out what it is.”
“The Department of Health, the state Senate, the state Assembly should hold joint hearings on this. They should find out what's going on,” Balboni said. “But more importantly: How do you stop it?”
For now, Negron holds out hope that the current care he’s receiving at Beth Abraham will allow him to recuperate enough to find his own place someday. And perhaps, he said, sharing his story will help others, too.
“Maybe if there's enough exposure,” he said. “Maybe someone will say we need to do more for those people.”
You can view an example of a nursing home discharge/transfer notice below.