Behind Closed Doors: A Closer Look At In-Home Senior Care

Editor’s note: Ashland-based investigative journalist and science writer, Jennifer Margulis, Ph.D., delves into the world of in-home senior care for this feature, made possible by The Fund for Investigative Journalism (FIJ) in Washington D.C., and the Journalists in Aging Fellows Program of New America Media and the Gerontological Society of America. While it is not possible to measure the number of caregivers whose conduct towards seniors is unethical, it is presumed to be a small fraction. But even a small number of unscrupulous caregivers and agencies without proper safeguards can have a wide and lasting negative impact. While Oregon is a state with safeguards in place to keep seniors safe, according to the Office of Adult Abuse Prevention and Investigations, reports of elder abuse are on the rise.

They were so happy to find her. The young woman sent by Home Instead Senior Care made a good impression on the whole family. Not only was she attentive, personable, and experienced, she also seemed strong enough to help Grandpa Joe in and out of his wheelchair, and she was certainly talkative enough to keep him engaged.

Seventy-nine-year-old Joe Guarino was the kind of person who had always done everything for himself. But after his wife died, the disease he was fighting, progressive supranuclear palsy, had taken a turn for the worse. Guarino’s adult children found themselves in crisis, grieving the loss of their mom and trying to figure out how to keep their father safely in his home in Brockton, Massachusetts. It wasn’t until after their mom passed that they realized how much the muscular disorder was affecting Grandpa Joe’s body and his brain. He had his good days and his bad days. He could be lucid and aware, cracking jokes like the man they knew and loved, or disoriented and confused, barely able to move his arms and legs. Joe had always told his four children that he wanted to die at home. Putting him in a nursing home was out of the question.

At first the family set up a schedule for the siblings and their spouses to do the grocery shopping, make sure Guarino was eating, and check up on him, but it was getting to be too much for them to handle alone. They realized they needed to hire help.

Guarino’s son-in-law, Larry Runey, did his homework. He says he called no fewer than twelve different private agencies, based on referrals he got from a non-profit that provides information about services for older adults. The first caregiver sent by Home Instead had been fabulous, and the whole family breathed a sigh of relief. But they found themselves back in crisis mode just a few months later when that in-home aide had to stop working due to a back injury.

Luckily, the new gal seemed just as promising: She gave Guarino a big hug every time she came to work, and confided to the family that her father had also been a veteran and had recently passed. The 29-year-old mother of one was also very pretty. And Grandpa Joe always liked pretty girls.

Debra Blair started working full-time for the family in July, taking Grandpa Joe on outings, helping him on and off the toilet, and reminding him to take his medication. In the evenings and at night Joe, Jr. cared for his dad. The family says Home Instead Senior Care in East Bridgewater charged just over $3,000 a month for the young woman’s help.

The Guarinos and the Runeys were especially glad they could afford hiring an aide through a private agency, because they knew they were getting the highest quality care. Or so they thought.

In the last decade the need for personal care attendants has risen dramatically. The number of Americans age 65 and older was 35 million in 2000. According to U.S. Census Data, it is estimated that there will be more than double that, 80 million Americans will be over 65 by 2030. Many of these aging baby boomers, used to leading independent lives, are keen to grow old in their own homes. So it’s no surprise that along with the increased need for caregivers for older adults, there has been a huge growth in caregiver placement agencies. Indeed, home care aide positions are among the fasting growing jobs in America. In 2000 there were only 13 caregiver placement franchises; that number has more than quadrupled, with over 55 parent companies today. Franchisee information disseminated by Home Instead Senior Care boasts that the Nebraska-based company has over 1,000 licensed franchises in the United States and around the world (including 12 in Oregon and 59 in California) and that these businesses are bringing in over a billion dollars in revenue.

But in all this growth, what has lagged troublingly behind is these private agencies’ ability—or willingness—to thoroughly screen their workers. In a study of 180 for-profit in-home care agencies in the states with the largest populations of older adults (Arizona, California, Colorado, Florida, Illinois, Indiana and Wisconsin), researchers from Northwestern University found that only 55% did any kind of criminal backgroundcheck; only 32% performed drug testing before hiring caregivers; and no agency screened workers on their health knowledge, even when specific duties included accompanying elderly patients to doctors’ appointments and administering medication.

Even more disturbing: not a single agency checked to see if their employees had a criminal background in any other state.

“We have a policy of testing someone for drug abuse if it’s ever questioned,” a patient care coordinator from At Home Senior Solutions in Medford, Oregon told me when I called for information about finding a caregiver. “We don’t do it before hire.”

Why not?

According to experts, the reason is usually cost.

“Doing the background checks and due diligence takes a bite out of the profits,” explains geriatrician Lee Lindquist, M.D., an associate professor of medicine at Northwestern University Feinberg School of Medicine. “With caregivers there’s a lot of turnover in their field. They are very low-paid; many don’t speak English. If they find a better job, they’re going to jump ship.”

Carolyn L. Rosenblatt, a lawyer and registered nurse based in San Rafael, California, who specializes in elder issues, agrees: “The agencies don’t want to spend the money. It cuts into their profit margins. A lot can’t get good workers and they don’t think they’re going to make enough to justify spending the money for a really good background check on every employee.” Although the price of a national background check may be as little as $100 per employee, with the industry’s high employee turn-over, that can add up to thousands of dollars a year.

But it is precisely because families are looking for carefully screened candidates that they go through agencies in the first place instead of finding caregivers on their own via the Internet or word of mouth. And families pay these placement agencies a premium—twice or even three times as much an hour as they would pay directly to a caregiver—to insure they get competent, reliable help to keep their loved ones safe at home.

By paying extra, they think they’re getting extra. Sometimes they are. The problem is that sometimes they’re not. As of now, there’s no easy way to tell.

Not long after Blair started caring for Guarino, the change from $40 his daughter Deborah Runey had given him to pay for turkey sandwiches disappeared. When Runey asked Blair where it was, she said she didn’t know. But the next day Blair announced she found the money in Grandpa Joe’s sock drawer.

“He musta put it there and forgot,” Blair said. Runey’s father was wheelchair-bound and unable to lift his arms. Not only couldn’t he hide the money that way, but his caregiver ought to have known he couldn’t. Doubt flitted through her mind; but she ignored it. She had a helper she needed and wanted to trust, so she gave Blair the benefit of the doubt.

A few days later, some of Joe, Jr.’s new plumbing supplies went missing. The family laughed it off: Joe, Jr. was the scatterbrain. Then one day Joan Guarino, a registered nurse and a medical records reviewer, dropped by the house unexpectedly and noticed her father-in-law’s eyes looked glassy.

“His pupils were pinpoints. He was looking right through me,” she remembers. They don’t have proof but the family believes Blair was giving Grandpa Joe extra pain medication, including morphine, so he would be too doped up to notice she was stealing. While Blair was in the house jewelry and Grandpa Joe’s Korean War medals disappeared. The family also alleges that Blair ran personal errands with Joe in the car, left him unattended for hours, and sometimes didn’t bother showing up for work, though the Home Instead franchise billed them for her hours regardless.

“Mondays are better when you are the boss,” asserts Jack Johnson, Vice President of Franchising of Home Care Assistance, a privately owned senior care franchise based in Palo Alto, California, in an email sent to prospective franchisees. The fortune just waiting to be amassed is highlighted in bright red font. “Whether you are a stay at home Mom, recent college grad, or seasoned executive, there is a place for you to build your future as a Home Care Assistance business owner.” The ad goes on: “And this is not your average business opportunity. The average Home Care Assistance client spends $1,100 per week on services. That means a Home Care Assistance franchisee who has an average client census of 18 clients over the course of 52 weeks (or one year) would have a MILLION DOLLAR BUSINESS.” [emphasis theirs]

But Eric Stites, founder and CEO of Franchise Business Review, a research firm that surveys franchisee satisfaction, cautions that the benefits to owning a senior care franchise are often overstated and these advertising numbers are actually meaningless. As a franchisee, you must pay weekly or monthly royalties (between 5-7%) back to the parent company from your gross revenue, regardless of your actual income after expenses. What may look like a million dollar business may actually be losing money, once expenses are calculated.

“A lot of people come in with false expectations,” Stites tells me, admitting that two thirds of the franchises that his company surveys get such poor marks from franchisees that the feedback is not made available to the public. “The number one problem in franchises is that franchises are oversold.”

Stites cautions interested investors that owning and operating a franchise takes the same amount of energy, experience, and capital as starting a business from scratch. The difference is that you get training from the corporate office and have access to a network of business owners once the business is off the ground. This access, of course, comes at a premium expense.

“It’s human nature to want to ‘get rich quick,’ but the reality is that you’re most likely not going to be that top performer,” Stites says bluntly. “People get attracted to senior care because it’s a very lucrative business and it’s a growing sector, but it’s also a very tough business … It’s one thing if you own a burger stand and someone doesn’t show up for their shift. If an elderly person is waiting and there’s a no-show, it’s a much bigger deal.”

The family called Home Instead several times to complain about the care Guarino was receiving. One evening Joe, Jr. came home from work to find his father all alone on the floor, crawling towards the bathroom. Blair had left early without informing anyone. Larry Runey called Home Instead again and angrily told the office manager that Blair she was no longer welcome. That night they installed a nanny cam in the kitchen. Home Instead sent a different caregiver the next day. Joe, Jr. watched the footage when he returned home from work: the tape captured this new caregiver, a man named Ralph, drinking orange juice straight from the carton and loading his backpack with steaks and frozen dinners from Grandpa Joe’s freezer.

Upset and disgusted, Deborah Runey wrote a letter to the Home Instead Senior Care’s parent company in Omaha, Nebraska, as well as to Old Colony Elder Services, the Home Instead franchise in East Bridgewater, the Massachusetts Attorney General’s Office, the Brockton Visiting Nurses Association, and the Better Business Bureau.

In the letter she wrote: “Hiring a caregiver for a loved one is a difficult decision. I was vehemently assured he would be in good hands, so I contracted with you,” and went on to detail the complaints against Blair, including a list of items that had gone missing. They were then told the franchise would submit an insurance claim to reimburse the family for the missing items, but the owner, Richard Sasso, wrote back denying Blair had stolen money or jewelry.

The Runeys remember sitting down with Grandpa Joe and explaining that he would have to go into a nursing home. It was the most heartbreaking moment of both of their lives. Joe comforted them, saying he understood that they could no longer care for him. Two months later, on February 16, 2011, he died at West Acres Nursing Home. The next day, Larry Runey bought a copy of The Enterprise, brought the newspaper into Santoro’s Pizza & Subs, ordered a cheeseburger, and sat back to read.

The headline he saw made him wallop the counter with his fist in anger: “AIDE ADMITS ELDER THEFTS.”

The aide in question, Debra Blair, also known as Deborah Belcher, admitted to stealing and pawning over $30,000 in silver and other valuables during a three-month period from an elderly couple in Brockton, according to the article.

Runey recognized her mug shot instantly.

Runey assumed Home Instead Senior Care, one of the largest and most successful private non-medical in-home health franchises in the country, had fired Blair after he and his wife had complained.

Instead, they sent her to another family’s home.

A retired pharmacist, 68-year-old Roland Sergio was so careful about his appearance that he mowed the lawn in a starched button-down, slacks, and penny loafers. His mind was still keen but his body was failing—he had heart blockage, a cancerous tumor growing in his lung, and polycystic kidney disease. After open-heart surgery, doctors started radiation to shrink the tumor and dialysis to filter his blood. His wife, Gail, 66, had Alzheimer’s and got confused when their adult daughter came to take Roland to dialysis. Unable to remember where her husband had gone, she would pace the house, crying and wringing her hands. Gail went over to the neighbor’s in tears one day. The family was reassured by Home Instead they had the “perfect caregiver” to stay with Gail: Debbie Blair.

Blair started coming over three times a week for six hours at a time. She seemed competent and likable. It’s true that a few days after she started, Gail told her children she didn’t feel comfortable. But Chris and Julie shrugged it off. Their mom was suffering from cognitive decline. She could have said that about anyone.       

Court documents would later reveal that the day after Blair first sat with Gail, she received $750 from Timeless Antiques, a pawnshop in the heart of Brockton, for a starfish charm. The thefts continued: On January 3, 2011 Blair brought a men’s bracelet, a heart-shaped necklace, and two rings to Timeless Antiques, for which she was given $1,800. In the six weeks that she worked for the Sergios, Blair visited that pawnshop at least thirteen times. She received at least $6,180 from the stolen flatware, watches, rings, necklaces, and gold earrings.

One day in early February Julie was in her parents’ bedroom looking for the Kay Jewelers open-heart pendant she had gifted her mom after her dad survived triple heart bypass surgery. Her own heart started pounding painfully in her chest: the jewelry box was nearly empty. Chris was visiting and she called him into the bedroom. They stared at each other in silent disbelief.

Then they called the police.

Middleborough Detective Simonne Ryder was one of the officers dispatched to Sergios’ home. A specialist in elder affairs, Ryder has been investigating elder abuse for over ten years. It’s a tricky assignment, she says, and not only because of the emotions involved. Often, Ryder explains, families of older adults who have been victimized are reluctant to report the crimes. Sometimes it’s because they’re embarrassed about having allowed a criminal into their parents’ home. Sometimes it’s because they are afraid of negative repercussions. These caregivers, Ryder points out, often have the keys to the house, know the families’ work schedules, and know how vulnerable their loved ones are.

And the eyewitnesses to the crimes—the frail adults needing care— are sometimes unable to speak, so they cannot report what is happening; or they’re suffering from dementia, so their reports are garbled or unreliable. Their families might not believe them. Some older adults who witness bad behavior on the part of aides keep quiet because they don’t want to be placed in a nursing home.

Compounding the problem is that caregivers thought to be abusing the elderly are rarely brought to trial. “You run into issues: is the elderly victim competent to testify at trial? Even if they are, are they physically able to withstand the stress of going into court?” David Yannetti, a Boston-based criminal defense lawyer who spent ten years working as a prosecutor, says. “Only a fraction of elder abuse cases are actually prosecuted.”

On February 15, 2011 three police officers went to Debbie Blair’s apartment in East Bridgewater and placed her under arrest on charges of larceny. After the arrest, Home Instead told local journalists they had no prior knowledge of any wrongdoing and her background checks had come back clean.

When I reach Home Instead Senior Care in Omaha, Nebraska, I am told the company takes safety very seriously.

“The safety and security of seniors is our top priority,” Dan

Wieberg, spokesperson for Home Instead Senior Care, asserts via email. “We have extensive policies and procedures in place to prevent fraudulent activity. Our franchise owners conduct thorough background checks and drug screenings before placing any employee with a client. We also offer information and resources for seniors and their families at www.protectseniorsfromfraud.com.”

But court documents tell a different story: When Blair was hired she was in a methadone treatment program, recovering from a drug addiction. If Home Instead had done a drug screening—either before they hired her or once the Runeys complained—they presumably would have discovered that she was not clean.

Still, in some ways, the families Blair stole from got off easy. In one highly publicized incident when a family complained to A.M.S. Home Care Solutions, a home care agency based in San Diego, that their 98-year-old mother was not being adequately cared for, the director dismissed their concerns. The family installed video cameras and caught footage of two male caregivers sexually molesting their mother, who was paralyzed from a stroke.

In another case that never made the headlines, a frail woman in her 90s who had round-the-clock care from a private agency came to the attention of Stanton Lawson, CFO of Sequoia Senior Solutions, a home caregiver placement agency in northern California. The woman’s financial advisor, worried that something was wrong, asked Lawson to check on her. Her beautiful house on a five-acre estate was almost empty: agency-sent caregivers had stolen all the client’s paintings, furniture, and even her dishes. She had sores all over her body from being confined to her bed.

“The only thing left was the satellite dish, the big screen TV, and the bed,” Lawson remembers. “My guess is they were not supervising their employees. But maybe I’m being naïve. It’s just too hard to believe that someone would actually let employees do that.”

After a year behind bars Debbie Blair got out of jail and spent 18 months on probation. It took me months to track her down. I finally reached her by phone. With her husband—who has a long criminal record and has also done jail time—yelling in the background for her to get the f**k off the phone, Blair insisted she committed the crimes to feed her family, buy gas, and pay the rent on their apartment. She said she wanted to tell her side of the story but wouldn’t permit me to quote her directly.

She was going through a rough spot, she admitted. Her husband was a roofer and fell three stories off the Martha’s Vineyard courthouse. He couldn’t get worker’s comp for four months and the burden of making ends meet fell entirely on her shoulders. She was only making $10 an hour at Home Instead, had to pay for her own gas, and grew desperate after they cut her hours. She also claimed she had no idea anyone had complained. The rumor around the office was that the franchise was going under and that’s why she was given less work.

Blair said her high school ambition was to become a nurse, she loved taking care of people, and she never harmed Guarino or stole anything from his house. It’s wicked hard work, she told me, and the pay is horrible. You can make more money working at Burger King. Four months after her arrest she pleaded guilty in Brockton District Court. She insisted she never hurt anyone. A lot of other caregivers do a lot worse without ever getting caught.

Emad Abdelmessih, the court-appointed criminal defense attorney who first represented Blair, believes it was financial difficulties, drug addiction, the influence of her unscrupulous boyfriend, and the ease with which Blair could take valuables from her elderly clients that made her start stealing. “Her attitude towards her clients was not to abuse them,” Abdelmessih insists. “She had respect for the people she was caring for. You allow somebody to go into your parents’ house, you better keep an eye on them. It’s an unsupervised, unchecked situation. People get weak and start helping themselves.”

After Blair’s arrest, Julie and Chris Sergio moved their parents into an assisted-living facility. Roland Sergio died on May 2, 2012. Gail Sergio, whose Alzheimer’s has worsened over time, currently lives in a locked Alzheimer’s unit of a nursing home. Julie visits her mom several times a week and Chris and his son make the 2-hour drive from New Hampshire as often as they can.

Both the Guarinos and the Sergios were deeply disturbed by what happened. They were angry with Blair for stealing from them but felt even more betrayed by the franchise. Home Instead “sold us a bill of goods,” Chris Sergio told me, “and then put a criminal in our home.”

TO REPORT ELDER ABUSE IN OREGON

TIPS FOR KEEPING OLDER ADULTS SAFER AT HOME

Peg Sandeen, Ph.D., Executive Director of the Portland-based Death with Dignity National Center, says it’s important to prepare for a time when you may not be able to care for yourself. Older adults need to research their options, identify potential caregivers, and talk to family members about their wishes before a crisis hits. “There are so many good caregivers out there, and so many seniors flourishing at home,” Lindquist, the geriatrician at Northwestern, says. “If you do a little planning ahead of time it will help you stay home longer.”

But as you plan for care, Cheri Elson-Sperber, a licensed attorney in California and owner of Gray Matters Consulting, which provides advice and advocacy for older adults in Ashland, Oregon, says it’s important to remember that going through a third party in-home health agency does not necessarily mean the person sent to your home will be carefully vetted.

“Recognize that every owner of the franchise is going to run their business differently,” Elson-Sperber says. “They are separate business owners and there may be one that’s good and one twenty miles away that’s not so good. You still want to do your due diligence.”

Elson-Sperber offers the following tips for finding the best care:

Get Referrals & References Whether you’re finding care through a placement agency or privately, word of mouth is key. Ask your doctor, lawyer, financial advisor, friends, community members, and past clients for recommendations.

Interview The Agency It’s imperative to find an agency with good hiring and supervision practices. Ask them how they recruit, screen, train, and supervise care-givers, how they match caregivers with families, what their policy is on providing substitutes, and what they do if it’s not a good fit.

Trust Your Instincts If a caregiver makes you or a family member feel uneasy, insist on someone else.

Maintain Constant Communication Modern technology makes being in touch from afar easier. Elson-Sperber suggests asking for updates, including photos, by email or text throughout the day. If you are close by, check in verbally at the beginning and end of each aide’s shift for details about the day’s events. If you’re far away, consider installing a nanny cam.

Make Unexpected Visits When you stop by to check on caregivers unexpectedly, you find out exactly what is going on.

Insist On Sobriety Drug problems are common among people who work with older adults. Easy access to clients' medication can make things worse. Require any caregivers to be drug and alcohol free.

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Jennifer Margulis, Ph.D., is an award-winning investigative journalist, Fulbright grantee, and regular contributor to Jefferson Public Radio.www.JenniferMargulis.net.