How the aged and frail are exploited in Washington's adult family homes
Adult family homes in the state are seen as a national model, and in King County alone, they've become more plentiful than Starbucks stores. But the explosive growth, fueled by profiteers and a lack of careful state regulation, is leaving thousands of people vulnerable to harm.
Seattle Times staff reporter
Report abuse: To report abuse of any vulnerable adult or child, call the 24-hour EndHarm hotline, 866-363-4276. You will speak with a real person who will connect you to a direct, local number to make your report.
Call Complaint Resolution: Call a toll-free hotline at 800-562-6078 if the person you suspect is being abused or neglected is living in a nursing home, boarding home or adult family home.
In an emergency: If the person is in immediate danger, call police.
Checking for violationsCall the DSHS regional office for the violation history of an adult family home. DSHS suggests asking for the field manager or regional administrator.
To check those in King County, call 253-234-6001. In Snohomish County, 360-651-6850. In Pierce County, 253-983-3849.
The location of the home was secret. Only potential buyers with a $500,000 line of credit could learn its Seattle address. The seller insisted on discretion because the price included three frail seniors who lived inside.
A Bothell real-estate listing last year touted five seniors for $120,000, "sold separately" from the home. Bids for five vulnerable adults in Arlington opened at $90,000 — "cash only."
These deals aren't illegal. Washington officials not only know about it, they allow it.
Twenty years ago, the state Department of Social and Health Services began licensing homeowners to provide spare bedrooms and care for the old or frail who might otherwise have to live in nursing homes.
These private residences — called adult family homes — were marketed as opportunities for seniors to live in cozy settings and familiar neighborhoods, close to family and friends, with more freedom and superior care.
The owners were given freedom, as well. To encourage this new industry, the state imposed few regulations — no requirements for a minimum level of employees or even, for many years, liability insurance.
Today, Washington is lauded nationally as a leader in community care options for seniors.
But inside the state's 2,843 adult homes, thousands of vulnerable adults have been exploited by profiteers or harmed by amateur caregivers, an investigation by The Seattle Times has found.
The Times uncovered accounts of elderly victims who were imprisoned in their rooms, roped into their beds at night, strapped to chairs during the day so they wouldn't wander off, drugged into submission or left without proper medical treatment for weeks.
In a Shoreline home, a worker whose previous experience was at McDonald's broke a resident's neck when attempting to move her from her bed. At a Seattle home, a worker handed a lit cigarette to a resident who was connected to an oxygen tank, setting off a fiery explosion.
In scores of cases, owners raked in monthly payments while they pinched pennies and eliminated meals, turned off the heat, or left residents in urine-soiled clothing for days.
"DSHS has pushed so hard and developed these adult family homes so quickly that they have little ability to oversee them. It should scare people," said Gary Weeks, director of the Washington Health Care Association, which represents nursing homes.
About 11,200 people reside in adult family homes across the state. About three out of five residents are private pay. There are about 1,100 homes in King County alone, more than three times the number of Starbucks stores.
The pace of licensing is so furious that, on average, the state issues a new one every day.
Officials at DSHS, which inspects the homes at least every 18 months, say the majority are run by caring, competent providers with good records. Officials say the agency's standards are among the highest of those states that allow similar homes.
However, The Times examined 15 years of inspection reports and found that, time and again, DSHS excused reports of abuse and neglect, even when it knew that violators lied to its investigators, provided falsified medical records, or contributed to preventable deaths.
Overlapping trends exacerbate the problem: Washington's aged population is growing. State budgets are underfunded, resulting in a cost-cutting strategy to move state-subsidized patients from nursing homes into less-expensive neighborhood residences. And in today's battered economy, more people than ever hope to make money from their homes by taking in the elderly.
Even a state-approved instructor, one of nine people allowed to teach new owners how to run an adult family home (AFH), makes a get-rich pitch:
"I see other businesses struggling in these tough economic times — but AFH cash flow keeps coming in!" Jo Lyn Cornelsen, who owns a Brush Prairie, Clark County, adult family home, wrote on her business Web site. "The AFH industry elevates minimum-wage workers to six-figure-income business owners in under a year."
But a Times analysis revealed a bleak reality behind the hype: For every four new homes licensed, three older ones go out of business.
"There's always been this perception that it's easy money, that it's a way to make your mortgage payments," said Carolyn Edmonds of the state Long-Term Care Ombudsman's Office.
"Unfortunately, we see the often-tragic human cost when owners are lured by profits and not a desire to help people."
Massive bruises, both old and new
In 2008, Ann Detlefs faced a tough decision. For several years she had prayed that her husband, Darwin — at 84, eight years her senior — could stay with her in their Everett home.
But the warning signs of memory loss, erratic moods and difficulty expressing himself were diagnosed as Alzheimer's disease, and she couldn't care for him by herself.
A retired manager for IBM, he had loved woodworking, crafting toys and furniture for family members from his garage workshop. Now he couldn't take a shower by himself. He was incontinent and often so confused he would try to wander away.
Her first choice, a Seattle nursing home, had a waiting list. In May 2008, she settled on an adult family home, Hidden Gardens, where her older sister had received good care before moving elsewhere.
Owner Susan Martin charged $3,200 a month to care for Darwin Detlefs, who joined five other seniors at the three-bedroom, 2,430-square-foot ranch home in Enumclaw. Martin and her teenage daughter slept in the garage, which was converted into a bedroom.
Within weeks, Martin complained that Darwin Detlefs was combative — he escaped from the house one evening and it took 20 minutes to get him back inside.
As a result, Martin enacted new financial penalties. Nighttime assistance would cost an extra $600 monthly. Repeated demands to go to the bathroom — she dubbed it "inappropriate toileting behavior" — would bump it up to an additional $1,000 monthly.
Martin would waive penalties if families agreed to use medications to "correct the behavior" — in other words, sedate the residents, according to a copy of the rules provided to The Times.
Before long, Detlefs said, she observed signs that Martin was overwhelmed: The house looked unkempt; cat feces littered a bathtub; soiled laundry sat piled high; meals were skimpy and hastily prepared.
Martin "got terribly stressed out when her only caregiver went on vacation for two and half weeks," Detlefs would later explain.
"It became impossible for her to safely take care of six patients by herself."
In July, Detlefs spotted bruises on her husband's arms and an untreated gash on his left hand. She said Martin explained that Darwin Detlefs had tripped over an empty wheelchair.
Ann Detlefs said she was suspicious and asked her husband if he was safe. In a rare moment of coherence, he said, "At least you don't get yelled at."
Alarmed, Detlefs transferred him to an Everett nursing home on July 31. During an admission exam, a nurse discovered massive bruises, old and fresh, across his shoulders. Nurses took photographs for evidence.
"I was told that the injuries were consistent with abuse," Detlefs said.
She filed a complaint with DSHS. However, its investigation was "unable to verify alleged abuse," records show. There was no acknowledgment of the photos.
After Darwin Detlefs moved out of the Martin home, the agency received complaints about mistreatment of three other residents in the home, DSHS records show. This time, investigators wrote, the evidence of physical and emotional abuse was overwhelming. The agency revoked Martin's license.
Martin declined to be interviewed. The house was sold last month for $220,000.
Ann Detlefs still wrestles with guilt: Should she have routinely undressed her husband? Did she react too slowly? Did he suffer, unable to cry for help?
She said she kept the photos of the yellow and purple bruises on Darwin Detlefs' reed-thin body, but "I can't look at them."
Her husband died from complications of Alzheimer's last April. But in his nursing home he had regained weight and was happy despite the limitations of his disease.
That's the image of him Ann Detlefs said she chooses to remember.
More homes but fewer investigators
Washington's tiny adult-family-home industry got a boost in 1993 when the state, desperate to cut Medicaid expenses, began to relocate or steer patients from nursing homes into private residences, which cost less than half as much.
State officials maintained that nursing homes were glutted with lower-income patients, covered by Medicaid, who didn't require 24-hour care. Essentially, these residents were not infirm enough to justify the costs.
In the first year, DSHS reduced the number of its 17,448 nursing-home patients by 750. The next year, lawmakers approved relocations of 1,400 more.
State officials said the strategy, in 2008, saved $105 million in state Medicaid funds that would otherwise have gone to nursing homes.
By 2012, DSHS plans to relocate another 1,100 nursing-home patients into adult homes or other community-based facilities.
The state may not be able to adequately oversee the growing ranks of government-paid and private-paid residents in adult family homes. DSHS is not able to answer such questions as: Which homes and how many didn't provide enough food? What homes had assaults on residents?
The Times coded and analyzed the past four years of enforcement actions, more than 2,000 records, and built its own database to provide answers unavailable from DSHS.
In 2008, for example, The Times found 576 violations involving caregivers performing unauthorized medical duties; 46 cases of residents unnecessarily restrained; and 1,201 instances in which medication records were missing or incorrect.
In a Bothell home, for example, a caregiver passed out Vicodin, a narcotic pain medication, to control a resident who "talks a lot." The resident, who had no pain, was given the powerful drug at least 10 times in one month, records show.
Few cases are more tragic, or better underscore lax licensing standards, than a five-day lapse inside a Lynden, Whatcom County, adult family home.
In December 2006, owner Tony Nam, 69, was left alone with three residents when his two caregivers went on a short vacation. When the employees returned five days later, they discovered a critically ill female resident who was severely dehydrated and covered in fresh vomit. The caregivers demanded that Nam call for help.
The problem, according to a DSHS investigation, was that Nam "could not speak English well enough to explain the resident's health condition to the physician."
One of the caregivers had to grab the phone and explain the emergency.
The woman, 58, arrived at the hospital in a coma, with pneumonia in both lungs. She died five days later.
Nam's English was so bad that he later struggled to answer questions from DSHS investigators. He did not recognize the woman's symptoms as life-threatening, he told investigators.
The ability to communicate in English is one of the requirements to become an adult-family-home owner. DSHS officials could not explain how Nam passed the English requirement. They later revoked his license.
Nam couldn't be reached for comment.
Kathy Leitch, a deputy director who oversees the DSHS Aging and Disability Services Administration, said a hiring freeze — the result of state budget cuts — has left fewer investigators to monitor more homes.
Many licensing and training standards may be outdated, she said.
"There's this idea that it's a cottage industry, and that the state shouldn't be overly regulatory. Personally, I think that's a bit naive."
Unlicensed home, unnecessary death
In the early 1990s, the state limited owners of adult family homes to one residence. But lawmakers lifted the restriction when owners argued that the benefits of bulk purchasing and hiring a universal staff, to rotate among homes, enhanced quality of care.
Today, 322 people own two or more adult family homes, according to a Times analysis.
Many of the better owners have successfully juggled multiple homes. But one with a particularly rocky history is Bernardita Sarausad, 62, a registered nurse who owns six homes in Seattle, Shoreline and Edmonds. Since 1999, DSHS has halted new admissions to her homes three times after investigations uncovered substandard conditions.
State files reveal dozens of citations involving resident care, including preventable pressure ulcers (bedsores); delay of care; and undertrained staff.
Marcella Sides, of Kent, said she uncovered the same problems in 2007 with the care of her parents.
Her mother, Alice Clayton, 88, had become bedridden after a fall left her partially paralyzed. Her father, George, 87, a retired Navy veteran, could walk and care for himself. More than anything, he wanted be with his wife. Few adult family homes were willing to accommodate them both.
Sarausad told Sides she had a two-bedroom condo near Northgate that would be just right for her parents. It would cost $6,500 a month for 24-hour care for her mother and $1,500 for meals and rent for her father.
The condo, however, was not licensed as an adult family home, according to state records. Its sole caregiver was a woman accused of fraudulently posing as a registered nurse at a Tacoma nursing facility, The Times has learned. Sides knew none of this.
Sides did learn, however, that the caregiver often worked seven days a week without a break and slept on the living-room couch. "It was like slave labor," Sides said.
Unknown to Sides at first, the woman considered the condo's living room to be her space in the evening, and made Alice Clayton stay in her bedroom from 6 p.m. to 10 a.m. "I'm a prisoner in my room," she told her daughter.
Then Sides discovered an inflamed sore on her mother's left shoulder in early 2008. The caregiver and a visiting nurse said there was nothing to worry about, Sides said.
However, the wound worsened, and her mother died in March 2008 at a Seattle hospital; her husband was by her side. The death certificate cited the pressure sore and its subsequent infection as contributing causes of death.
Sides' father now lives in an assisted-living facility near Federal Way.
Sarausad would not respond to interview requests. On her Web site this month, Sarausad wrote that she plans to open three more homes this year, two in Shoreline and one in Edmonds.
Placement agencies: conflicts of interest?
Navigating the labyrinth of adult family homes can be confusing. There is no government clearinghouse to compare the quality of care and services from one home to another.
As a result, this gap has spawned a new kind of profiteer: senior-placement agencies.
These companies offer to match a senior's medical needs to the most appropriate care facility — free of charge. They will generate a list of suggested homes based on the person's medical needs and wishes, such as a private room or recreational activities.
These companies earn hefty commissions paid by owners of adult homes — a potential conflict of interest that is seldom disclosed, The Times has found.
A typical commission is equivalent to a resident's first month of rent, generally from $2,000 to $7,000.
Most of the placement companies are run out of home offices — anyone with a computer and a Web site can set up shop. No licensing, education or training is required. There are dozens in King County.
Are placement agencies steering people to homes that are the best fit — or instead to the ones that pay the highest referral fees? There is no way to know for certain.
But some in the industry are calling for more transparency and state licensing.
"I think patients in many cases are treated like a commodity and I don't like it," said Dotti Snow, 63, of Woodinville, a registered nurse who has operated Aging Safely, a placement service, for 11 years.
She said she has infuriated competitors by charging owners only half a month's rent, and by disclosing to customers that her fees are paid by the adult homes.
To try to get her to refer new residents to them, adult-family-home owners increasingly send gifts and cash to Snow. Currently, adult-home vacancies are at high levels as more financially strapped families delay paying for long-term care.
Snow said she sends back every gift card and gratuity, including, once, a check made out to her for $1,500.
Long hours yield only modest income
So far, two potential buyers have toured the Seattle adult family home on sale for $500,000 with the three residents inside. It is a 2,100-square-foot home on Northeast 133rd Street in Lake City owned by Mihai and Viorica Badet.
They've run the home since 1996 with no major citations, state files show. Mihai Badet, 62, also works full time as an engineer. His wife assists a full-time caregiver in the home. The Badets want out of the business.
Competition is stiff. Dozens of other adult family homes are on the market in Seattle and statewide. Sales pitches sound the easy-money theme: start making money now; guaranteed cash flow; opportunity of a lifetime.
The Badets know better. They care for an elderly man and two women, one of whom is bedridden. Their home grossed $168,000 last year, with monthly rent for each resident averaging $4,700. After expenses but before taxes, they netted $57,000, according to information provided to prospective buyers.
They do not have residents to fill three empty beds, so their long hours bring only a modest income. Comparable homes in their neighborhood have sold for about $400,000.
The Badets believe their home, with three residents under contract, is worth $100,000 more, if a new owner can also qualify for a DSHS license.
"You need to really like this kind of business," Mihai Badet said. "... You're tied to the house 24/7. You can't go anywhere."
He offers this advice: "You can't do this for the money."
Michael J. Berens: firstname.lastname@example.org or 206-464-2288.