REPORT OF THE COMMUNITY TASK FORCE ON THE NEEDS OF THE JEWISH ELDERLY Background   The Jewish Center for the Aged (JCA) has an historic place in the St. Louis Jewish community. Originally founded in 1907 as the Jewish Orthodox Old Folks Home, it was joined some years later by a nursing home sponsored by Reform Jewish groups. For many years, the Home was located at Grand and Blair and was largely supported by donations from the Jewish Community. It moved to its present location in the early 1970s. The historic purpose of the JCA has been to provide services to the Jewish elderly. The original JCA bylaws provided “that all facilities of the Center shall be maintained according to Jewish Orthodox dietary laws and religious traditions.” In recent years, the JCA Board of Directors amended its bylaws and adopted a new mission statement: “to provide the highest quality health care and supportive services, both institutional and outreach, for older adults, within a warm and nurturing environment that respects Jewish values and traditions, and to care for the aged without regard to individual resources, within a framework of fiscal responsibility.” The JCA’s current facility has 276 beds, all of which are certified for Medicaid eligible residents. In June 1999, the JCA filed its application with the Missouri Department of Health seeking approval of a Certificate of Need to replace the existing 276 skilled nursing facility (SNF) beds with 230 SNF beds. That application stated that the JCA also planned to develop a 46-bed residential care facility (which did not require a certificate of need determination and which are not Medicaid eligible). The JCA received its Certificate of Need on August 23, 1999. Of the approved 230 SNF beds, the JCA application stated that 30 of such beds may be dedicated to sub-acute care (not Medicaid eligible) which would reduce the number of Medicaid eligible beds to 200. In early 2003, the JCA applied to the State of Missouri to decertify an additional 98 Medicaid. This would have reduced the number of Medicaid eligible beds to 102. That application was later withdrawn. The application for decertification can be refiled. The JCA began construction of its new facility in February 2001. It anticipates that the facility will be ready for occupancy by late summer. When the current residents are moved, the JCA plans to demolish the existing building. The new complex, called Cedars at the JCA, is described in JCA documents as a $60 million facility, containing an art gallery, a fine-dining restaurant, community meeting areas, banquet areas for private celebrations and retail shops. The JCA has announced that its charges for private pay residents will be $160 per day for double occupancy in the Alzheimer’s unit and $220 per day for single rooms resulting in an annual rate of $80,000. This contrasts with the current average rate of $140 per day or $51,000 annually now being charged by the JCA. In January 2003, the JCA notified Medicaid residents that it could not assure them that there would be a bed available for them in the new complex and suggesting that they should look for another nursing home. In late February 2003, the current Medicaid residents were told that they would be moved to the new complex. Current residents who are likely to become Medicaid eligible in the near future were also informed that there would be space for them. The JCA, however, has declined to state how many beds will be available at the Cedars for new residents requiring a Medicaid bed. Jews United for Justice (JUJ) attempted to work with the JCA to form a joint Task Force to determine how the JCA can best meet its mission and remain financially viable. When agreement could not be reached, JUJ initiated the formation of the Community Task Force on the Needs of the Jewish Elderly. The Community Task Force studied all available relevant materials, heard from experts, and obtained information from Jewish nursing home executives around the country who are successfully merging mission and financial stability. The JCA has not responded to JUJ requests for factual data concerning its current occupancy, its income and expenses or its projections for the new facility. Findings Based on its studies, the Task Force has made the following findings: 1. There is an urgent need for a skilled nursing facility to serve the indigent members of the St. Louis Community in a setting, which is faithful to Jewish traditions and values. 2. Financial restraints on state government make it unlikely that Medicaid payments, at least for the next several years, will cover the full cost for indigent residents at the JCA. 3. There is a need for a skilled nursing facility which will be able to serve persons of moderate or middle income in a setting which is faithful to Jewish traditions and values. 4. The rates presently proposed by the JCA far exceed the rates which persons of moderate or middle income are able to pay. 5. The experience of Jewish nursing homes in other parts of the country should provide a model for the JCA. These include the following elements: a. institutional commitment to the mission of service to persons of low and moderate income; b. institutional commitment to maintaining a truly Jewish environment; c. a board of directors, which is representative of the diversity of the Jewish community; d. maintaining a strong relationship with the Jewish community; e. based on the foregoing, establishing a basis for community funding. 6. A facility faithful to Jewish traditions and values is one which: a. observes the rules of Kashrut so that Jews of all observance levels will feel welcome; b. has a Rabbi on site c. observes and celebrates Shabbat and all Jewish holidays d. a high quality of care and caring consistent with Jewish tradition of care for the elderly. Recommendations of the Community Task Force on the Needs of the Jewish Elderly After careful study of the needs of the Jewish elderly, nursing home standards, and best practices in Jewish nursing homes around the country, the Community Task Force makes the following recommendations to the Board of Directors of the Jewish Center for the Aged and its Task Forces. The recommended principles, practices, and criteria below are essential for the JCA to meet its mission to serve the needs of the Jewish elderly of all incomes and to maintain a Jewish environment consistent with Jewish traditions and values. Care for the Indigent Elderly • Maintain 100% Medicaid eligibility for all skilled nursing home beds. This does not mean that all beds must always be filled by Medicaid residents, but rather that they be certified as such and available for Medicaid residents. • Admissions policies that are explicit about Medicaid eligibility and admissions policies and practices consistent with the JCA mission so that applicants are not rejected solely for financial reasons. Care for Moderate and Middle Income Elderly • The daily patient rate of the JCA needs to be affordable for moderate and middle income elderly who desire a Jewish nursing home. Jewish Character of the JCA • All JCA facilities need to reflect the authentic Jewish character of the JCA. • The JCA needs to maintain careful observance of Jewish traditions, dietary laws, holidays, and Jewish values. • Jewish values to honor our elders need to be integrated into every level of care and respect for the residents. • Marketing and signage of the JCA needs to explicitly use the word Jewish and reflect the commitment to Jewish traditions and values. Communication and Respect • Families need to be considered as partners in the care of the residents. • Family council meetings need to be open, well publicized, conveniently scheduled for family attendance and attended by top administrators. • Clear guidelines for family and resident rights and involvement as well as clear procedures for reporting problems and concerns need to be provided in a resident and family handbook. • Residents and their families need to be treated with dignity and respect in the admission process and after admission. • The admission process needs to provide residents and their families with assistance and support in their transition to nursing home care. This needs to include information regarding the personal transition and available information on payment options including Medicaid. • All administrators and other staff need to be given training in communicating with residents and their families. • All administrators and other staff need to be given training to carry out their responsibilities to maintain all elements of the JCA mission. • The JCA Board needs to inform the Jewish community on JCA finances and financial needs, which it may have in meeting its mission. • The JCA Board needs to regularly communicate with the Jewish community on progress in carrying out these recommendations. Governance • Members of the JCA Board of Directors need to be representative of the various religious, organizational and income groups in the Jewish community. • Family members of JCA residents, as identified by the Family Council, need to be appointed to the Board of Directors. • JCA Board members need to be thoroughly knowledgeable of the JCA commitment to Jewish traditions, values and religious observance as well as its commitment to the indigent elderly. The Jewish value and tradition of providing high quality of care with great respect for our elders needs to be emphasized as the core of this commitment. Orientation sessions on these issues need to be conducted for Board members. • In order to be aware of the needs of residents and their families, the Board of Directors needs to meet regularly in the skilled nursing area of the JCA and make additional periodic visits to the facility. • The decisions and practices of administrators and staff need to clearly reflect the commitment to Jewish traditions, observance and values as well as a commitment to the indigent elderly. • The JCA Board of Directors needs to be fulfill its responsibility to insure that all administrators and staff adhere to the JCA mission. • Selection of administrative personnel, including the Executive Director needs to be based on professional ability to perform their duties and their willingness to authentically carry out the JCA mission. The Community Task Force on the Needs of the Jewish Elderly urges the Board of Directors of the JCA to adopt these recommendations and to regain and maintain its historic purpose to serve the Jewish elderly. The application of these principles and criteria will return the JCA to the original spirit of its mission and open the door for the full support of the Jewish community. COMMUNITY TASK FORCE ON THE NEEDS OF THE JEWISH ELDERLY COMMUNITY COMMENTS - JUNE 29, 2003 TOWN HALL MEETING Please note: The comments below are a summary of the remarks made at the meeting - not a verbatim transcript. Hilda Markowitz I have spoken before, a lot of issues need to be settled and need to be settled as soon as possible. The JCA needs to make life better for residents. Two aides for 30 people is not enough. We need to look into medications and diet to make sure they are right. We need to make sure things are done right. We have to be proud that the community has helped to make things right. The home has to be called the Jewish Center for Aged. Dorothy Goldstein This is the second time the JCA board has upset the community. I was an employee at the JCA for 20 years but I’ve been gone for 10 years. If the JCA is planning an independent living center my suggestion would be to sell off the independent living center. The money could be used to help the middle-income people. We need the JCA as a Jewish institution. Josh Jacobs I have been very concerned about just how Jewish the new Cedars will be. I am glad to hear that we are pushing for a Jewish environment. Without a Jewish environment, it doesn’t matter how many Medicaid beds there are because without the Jewish environment- we could go anywhere. The big danger is that the mission statement speaks of Jewish values and traditions and need to specify what this means. For example does it mean mezuzot on each door and no Christmas trees? People need to know what they are getting into. Michelle Siler I am Anita Friedman’s daughter. My mother died 2 years ago at the JCA. For the last 25 years I have had a family member at JCA until last year when my aunt died. I would love to have had communication with administrators. In the 2.5 years my mother was at the JCA, I never once spoke with Mr. Barsky. I had problems in my mother’s care during one period when there were only 2 staff people on the ward. There were split shifts which made it hard to get to know the staff and for the staff to get to know my mother. In response to my concerns and calls to administration I never heard back from Barsky. Rather than increase staff, they painted her room. Arnold Perel My father was a resident at the JCA until passing away a couple of months ago. First: Quality of care – many of his problems were not diagnosed by JCA staff, but only when he went off-site for physical therapy and other medical visits. The aides were trying to do their best, but they were so understaffed and couldn’t get care done. Second: My father enjoyed trips out of building. The staff kept saying there would be a kosher restaurant in the new building, so they could take father on an “outing” without going so far. Now the restaurant will be treif. We are long past the day when kosher means bad food. Why can’t there be a kosher restaurant at the JCA? They need to respect the wishes of our own people. Third: The financial issue. Many of us fought to get Soviet Jews out of Russia and opened up schools, shuls, and our homes to them. When they go to look for a nursing home they will find the one Jewish home in the community closed to them because they can’t afford it. Rabbi Menachem Greenblatt I am touched by many of the remarks today, as a member of the community and a rabbi in the community. Jewish character is the maintenance of a kosher restaurant. If the JCA is going to reflect Jewish values, it must remain 100% kosher. Jewish character and the quality of health care should not be different items. Honoring our parents is providing the very best health care with an adequate number of aides and working with and listening to the families. That is Jewish character and a Jewish value on par with keeping kosher and having a rabbi on staff. Our parents and grandparents are entitled to the best Jewish facility which means kosher, a rabbi and the very best of health care. Dov Axelbaum As Rabbi Greenblatt and others have noted, the many concerns raised here about the JCA are equal in importance. But unfortunately, they are not equal in solvability. The problem that has been brought up about the intention of the JCA to serve non-kosher food can be solved by deciding not to serve traif food. You decide and the problem is solved. Once the JCA board recognizes that they would benefit from a change in the composition of the board, they make the decision, and it’s done. Once it is agreed that the Jewish nursing home should be a Jewish nursing home in the true sense of the word, you make the decision and it is done. Each one of these concerns can be solved with relative ease, once the decision to solve it has been made. Even when you realize that too many people are complaining about the poor care and the lack of dignity shown to so many of the residents of the JCA – once you decide to change it, solving the problem is pretty straightforward. You fill your top positions with people who are committed to providing the proper care and dignity, and who have proven that they can deliver. Unfortunately, the problem created by the new building cannot be solved so easily. That building needs $220 or more a day to pay its bills. That’s a reality. The majority of Jews in this city can be divided into three groups: those who will have to rely on Medicaid to pay for their care; those who can afford to pay an average, competitive rate for nursing home care; and those that can afford to pay for luxury care. Unfortunately, Medicaid will not pay even half of the cost of that home, and that’s a real problem. You see, The Cedars wasn’t built to provide nursing home care for those Jews. And the reality we must face is that the majority of Jews in St. Louis can’t afford $220 or more a day. So The Cedars wasn’t built to be a nursing home for those Jews either. And even of those people who can afford $220 a day, there are many who don’t want to spend their money on a luxury building. They’d rather give it to their spouse, or their children or to a real charity. They don’t want to spend it on someone else’s idea of luxury accommodations. So the Cedars wasn’t built for those Jews either. And you know what? The unfortunate reality is that The Cedars wasn’t built for the overwhelming majority of us. It wasn’t built to meet the needs of the Jewish community of St. Louis. But it’s already been built. What can be done? There are only so many choices. You can try and turn the private beds into semi-private beds. That would at least being more money in, but you would have to buy additional licenses, there would be major additional costs and it probably would not be financially feasible. And even if you could do it, you would have created a hybrid, trying to figure out how to put a square peg in a round hole. Another alternative is to come up with another 10 or 15 or more million dollars of charitable contributions to pay down the mortgage, and then everyone could live in luxury accommodations at a reasonable price. But is that a reasonable place to put an enormous amount of the community’s resources? Of all the things this community needs, luxury nursing home accommodations for everyone is very low on the list, if it is even on the list. Another possibility would be to create a fund of millions of dollars to subsidize select individuals. But who is going to decide who gets luxury accommodations at half price and who has to pay full price? Why should anyone be forced to pay for luxury accommodations just because they want to live in a Jewish nursing home? Remember that the $220 a day is not buying luxury care, it’s buying luxury accommodations. There is one other solution. It’s radical, but we have a radical problem. Since the building does not serve the needs of the Jewish community, we need to get rid of the building. It’s a radical idea. But that building is already in financial crisis, and it hasn’t even opened. At this point, who cares who got us into this mess, we need to get out of it. It’s a radical idea, because even if the home doesn’t go bankrupt, a lot of the charitable contributions may be lost in a sale. But that is the reality of the situation we’re in, and the problem has got to be solved. One thing is for sure. The Jewish community should not sink one more penny into a building so that a select few can live in luxury accommodations. That much should be obvious. Charitable contributions are for charity - not for subsidizing people that are willing to pay for luxury. Let that home be owned by someone else – someone whose mission is to provide luxury accommodations for the select few. Without that building, the JCA could actually fulfill its mission, and operate a good nursing home for the Jewish community of St. Louis. Dr. Lester Zeffren After listening to Shu and Dov, most of the comments I had have been made. I made these comments to Dennis Barsky and the Board months ago. Luxury accommodation is a non-starter. Changing governance may be the way to bring about changes. I am not impressed with leadership who are unable to compete in the luxury accommodation field. We need to ask the JCA to look carefully when selecting administrators. Jackie Gerson My mom was a resident for 3.5 years. She died in January 2000. During the time she was there I called Mr. Barsky several times to discuss issues and never got a call back. After my mother died, I wrote Barsky a letter. He responded by blaming his secretary for not returning my calls. During the time my mother was at the JCA, my husband was on the board. He was not invited back after I wrote my letter. Every year I sponsor programs at the JCA on my mother’s Yahrzeit. People thought I was crying about my mother but I was crying when I saw how dirty the place was and the poor care people were getting. I have a friend who could afford the new rate but will not go to the JCA because of her concerns about the care. People who care have been kicked off the board and 2 lifetime JCA Board members in the audience today have had their voting rights taken away. As someone who is Orthodox, I am sad to say, I would not send my mother to the JCA if I had to make the decision today. Bobbi Linkemeir The recommendations today were very thoughtful. I want to pose a question. How do you think the board would accept these recommendations when they won’t even collaborate in efforts to review the issues? What is the community task force and town hall meeting going to be able to accomplish? Tobi Huppert This is hard. I toured the Cedars in May by invitation. I visited many facilities in the last 2 years. My husband was at the JCA and then came home. When he needed nursing care again the JCA said a Medicaid bed was not available, so I placed him at Delmar Gardens for 18 months until he died. The design of the Cedars is such that any elderly person with limited abilities would have problems navigating halls etc. – unless there are enough aides. My question is how many aides are there per shift and how much are they paid? How much they are paid will impact the level of care. The state only requires a certain number of aides based on the time of day. As to the Jewish character of the home--I did not see a library at the Cedars. Jewish education and learning are important. We need a library on each level of the building. I am concerned about the level of kosher food. The tour guide said kosher meals would be available upon choice. But there was no information about where the food would be cooked and if it would be frozen. Who designed this building? And why did they design it so the main entrance cannot be seen from highway 40 and seems to be the rear of the building? It is set up as pods and from each pod the residents need to navigate to medical care, meals and social areas. They need 3 times the current staff at much higher pay to get this done. Judy Haber My mother is a resident. I also toured the building. The Shul is at the lowest level and the only way to get there is by stairs or an elevator. There are no ramps and this is a problem on Shabbat. The issue of a kosher facility with Jewish values is big for me. If they go on trips such as for shopping, they always end up at a fast food place that isn’t kosher. So my mother does not go. Why not go to Simon Kohns for meals? Ed Klamen My brother is a resident at the JCA awaiting Medicaid. It is hard to conceptualize that they are not giving the dignity and care that was given to my grandfather at the old home on Grand. Who owns the JCA? How does one get on the board? Hilda Markowitz People have talked to Randy Delkus or Dennis Barsky. I have also tried numerous times and the secretary hangs up on me. I have tried to raise questions about food and nutrition, and I was so upset with all of this one time that they told me I was making a disturbance and called the police on me. . And the police asked me why not go to another home and I said I couldn’t. The police supported me but said there is nothing they can do about it. We need to make sure that the residents are taken care of and advocate for our loved ones to be taken care of with pride and dignity. David Steinberg I have 2 orthodox aunts in their 90s at the JCA and one has been there since 1995. I have more questions than comments. What issues could we not come to agreement with in talking to the JCA and Federation? We all know these problems -why doesn’t the JCA board see this? Dov Axelbaum’s comments are a reality check. Most of the elderly in St. Louis do not fit the marketing profile. The current JCA is being torn down. I’ve been wondering what is the possibility/reality about taking over the existing building? It wouldn’t take $60 million to fix the new building. I’ve been dealing with problems with the JCA for years. We need to do something quickly. My specific question is: there is a facility, it needs repair, but wouldn’t take 60 million to repair – has that been considered? A year and half ago, I asked for list of board of directors) when couldn’t get through to Barsky) and was told they do not give out that information. WRITTEN COMMENTS Please note: The comments below are a transcript of written comments submitted at the meeting. Sarah Nadler How much money is being spent to “sell” the Cedars? Does the JCA own LeChateau or does it pay rent? How much money is spent to entertain with food and drink to “sell” the Cedars? I think the Cedars was a mistake and losses should be taken now. Emphasis should be placed on care of residents where it belongs and on the quality of the caregivers. Dee Wolf Can the current Board of Directors of the JCA be fired? How can a new Board be voted on by caring people so the people who care about the JCA can continue? Please let’s try to get rid of Mr. Barsky. Jerold Axelbaum What is the anticipated cost per day at the new Cedars? Betty C. Tecklin The Needs of the Jewish Elderly and the Situation at the JCA Jewish elderly in the JCA skilled nursing facility need dignity of care, which requires a basic level. Over the last several years, I have frequently witnessed a strangulation of this dignity. Why? I see one CNA covering a 30 to 40-bed unit of maximum care individuals. Adequate care becomes a physical impossibility for the staff and neglect results. This unfortunate neglect is synonymous with abuse. Increased cost of staffing and security is a poor excuse. More staff would show to work if paid in respect for the difficulty of the job. But they won’t show with poor pay and a poor staff-patient ratio. As a result, basic indignity, forced incontinence and infection are what I have observed. The patients that can eat, can’t eat well, or be hygienically clean with low staffing. Thus, the caregiver, if the resident is so fortunate, is constantly at worrisome vigil and is physically and emotionally exhausted from the great effort it takes communicating to achieve some level of satisfaction, or shall we say frustration. The so- called, “bottom line” figure has caused this heartless abuse of those who cannot effectively advocate for themselves. Since the recent patient number has decreased, and the institution is under the magnifying glass, due to the Jews for Justice, outcry, things “appear” satisfactory. But a deep look reveals the less than ideal. Human and Jewish dignity is a requisite and a right, just as Kosher Food, respect for family concerns and prompt positive corrective care action. We must locate the Board to confront. It obviously has its eyes open only to its interpretation of the mission of the complex and what it has done. Top administration, I have to assume, is saved by the Board. It is protected under its umbrella. We must find infractions to stop the fruition of this new facility. This new facility is physically inappropriate and financially unaffordable for mentally or physically incapacitated moderate and low income Jewish elderly. A luxury hotel for the immobile is not part of the mission statement. Should we separate the “marketed” full pay luxury corporation facility from a facility that guarantees Jewish character and the principles upon which the JCA was founded? Should the Jewish Federation and the United Way contribute to the grand entirety that was developed? Many Jews of economic means cannot afford the grand escalation of costs for the skilled nursing facility alone as it presents itself at this point. And Medicaid availability, Jewish tradition and character are threatened and sacrificed at this point. Indeed, the financial burdens of the so- called CEDARS of the “JCA” are the fault of its creators, not the middle and low income Jew. A very painful solution may be to move our loved ones and find Medicaid beds elsewhere, if necessary. The facility can lose revenue and ultimately experience heavy economic problems. We may have to succumb to pressure and may have to sorrowfully suffer greatly to create a separate Jewish facility for the future. The Jewish community will rise to rectify this politically illusive discrimination of the heart and soul of the Jewish community. Members of the Community Task Force on the Needs of the Jewish Elderly Chair David Lander Family Members of JCA Residents Nancy Hirsch Linda Markowitz Jan Wilson Rabbis Rabbi Andrea Goldstein Rabbi Menachem Greenblatt Rabbi Jeffrey Stiffman Rabbi Susan Talve Specialists in Geriatric Care and Nursing Home Administration Dov Axelbaum Niki Nymark Shirley Soule Jews United for Justice Members Jerald Hochsztein Rhona Lyons Shulamith Simon Staff Linda Holtzman SOURCES OF INFORMATION FOR THIS REPORT Resource Persons: John Amman, JD, St. Louis University Law School Dov Axelbaum, Burgin Health Management Pam Clark, Regional Manager of Missouri Health and Senior Services Barbara Gilchrist, JD. PhD, St Louis University Law School Eliot Planels, St. Andrews Nursing Homes Brent Waxman, JD, Elderlaw Attorney Linda Woolf, PhD., Webster University Behavioral and Social Sciences Department Documents: Comparison of the JCA Expenses with Missouri Large Non-Profit Nursing Home Expense Norms: Baird, Kurtz, & Dobson: 2002 Nursing Home Database Jewish Federation of St. Louis, Community Study Summary Report, Dr. Gary A. Tobin, Director, 1995. Medicaid and the Uninsured: Fiscal Challenges to Coverage: The Kaiser Family Commission on Medicaid and the Uninsured, 2002. Missouri Division of Senior Services: Resident Rights. “Your Rights as a Resident of a Long Term Care Facility in Missouri”, 2000. Senior Citizens Handbook, Laws and Programs Affecting Senior Citizens in Missouri. 11th edition, Legal Services of Eastern Missouri, 2000. U.S. Census Phone Interviews Conducted with Directors of Jewish Non-Profit Nursing Homes Milwaukee, Wisconsin Minneapolis, Minnesota Tampa, Florida Tucson, Arizona