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OK, right now I'm beginning the Medicaid application process (in NJ, BTW). It's taken me longer than expected to gather together all of Mom's pertinent documents (Mom's always been notorious about not keeping everything in one place) and I'm still waiting on some paperwork re: her pension income.

Right now the current medical advice has her in short-term rehab through the 22nd. She's in the "days 21-60" phase of her Medicare insurance and we're paid up through that date (paid in full through the 11th, agreement to make payments monthly through 2015 to cover the rest).

Unfortunately, rehabilitation has not gone as expected. I genuinely thought she'd make enough progress to come back home eventually, but right now I cannot see that happening, as in some ways she's actually regressed. IMO LT care is going to be a must for Mom. Aside from her SSI, her pension (state, from her late husband) and her house (maybe 100K-125K) she has no assets to speak of.

I guess my main question is: can they "force" me to bring her home after the specified date? I've been advised that maybe I can place her LT "medicaid pending" but what if she isn't accepted? I am currently living in the house as I've been caring for her (PT from roughly 2010-2013, FT since then) and right now I don't have the resources to move anyplace else. If I can place her LT (or even get them to extend her ST stay) I can begin to rebuild my own life and move on, but right now that's just not possible as even having her in a ST rehab is almost a FT job in and of itself.

Anyone else have a similar situation? is there anything I absolutely should or shouldn't do or say? At the moment I am pressing her doctors for some sort of diagnosis, as her faculties are obviously slipping (and IMO very quickly). Does it even matter re: a diagnosis? Thanks in advance for any and all tips, appreciate it.

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Sorry, I don't have an eldercare attny to recommend since I did my in-law's applications myself and they didn't really have any assets.

The POA is going to be tricky if she can't understand it. You should definitely talk to a lawyer about it, once you find one you like. She may or may not be able to pay for this herself with her assets, which you can ask about.

She's definitely over the income limit, so you're going to have to set up a trust in order for her to qualify financially for Medicaid. I found a page that talks about that here: http://www.state.nj.us/humanservices/dmahs/clients/QIT_FAQs.pdf
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Unfortunately the medical records are usually immediately altered to show no neglect, I found this out even though 5 witnesses and this was just confirmed by a friend who is a nurse who is asked to "alter" records all the time-which she refuses but then gets the repercussions. In my case every person with knowledge were all of a sudden "fired" all the same day for some frivolous nonsense that they had gone in together to buy lotto tickets..... as well as other employees who weren't fired! Good Luck....get the documents/witnesses as fast as you can!
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Honestly I would never sue anyone unless I had extremely good cause, as I want nothing to do with lawyers unless absolutely necessary. But I had to ask....
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Speaking only to the issue of a potential lawsuit....

It's been awhile since I've worked in the medmal practice area, so this is based on what the standards were sometime ago.

1. Medmal plaintiff's attorneys in Michigan (and probably elsewhere) have become more focused on the bottom line, which is what the damages are and possible judgments. And the damages need to meet certain criteria.

A friend of a friend's doctor misdiagnosed her with a defective lung, or it might have been lung cancer (this was sometime ago as well and I don't remember all the specifics) and removed the lung. Biopsy was negative - no disease. Bottom line; errors in interpretation or more caused this woman to lose a healthy lung.

I gave her names and numbers of good medmal plaintiff attorneys for whom I had worked, or knew of. Not one would take her case. The damages weren't that significant because she could still breathe and live with one lung. Horrific? Yes, absolutely. Actionable? Maybe, but maybe not - there might have been some nuisance value (see below) but the attorneys I recommended weren't interested, and these were the ones I knew to be successful and prominent attorneys.

Would someone just out of law school and struggling have taken the case? Perhaps. Would he/she have the expertise to handle it properly? Unknown.

2. Treatment rendered or not rendered, and tests not undertaken need to have been outside the "standard of care" existing for that particular medical field/specialty/issue in the geographic area. E.g., if someone breaks an arm, it might be standard for hospitals and ortho surgeons to get a MRI, or maybe it's just standard to do x-rays. If the latter is the standard of care in the area of treatment, someone claiming malpractice because an MRI wasn't done would not be within the standard of care expected.

I say again this may have changed through case law over the years.

3. Medmal attorneys will first order the medical records and generally have them reviewed by specialists in the field to corroborate the existence of malpractice. If they don't have a medical specialist to eventually testify in court, b/c none believe malpractice exists, the attorney has 2 choices: (a) decline to take the case, or (b) take the case and milk it for nuisance and harassment value with the medical malpractice insurance carrier.

4. Another standard is the issue of longevity: how did the alleged failure to treat or mistreatment affect the longevity of the patient?

Actuarial standards used to be applied. I don't know if they still are.

This can make it difficult for older patients since they don't have the longevity or expectations of life and earnings that younger people do.


So, in the long run and even if people often think "I'll sue!", it isn't that easy, practical, or financially justifiable (for the attorney) in the long run.

What can be done though is filing a complaint against specific doctors with the state's medical review board.
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Appeal, ask for a new therapist...I am going through this and one said give up on her put her in a NH....ha! then the next day when I came to watch she got up and walked with a different therapist who was kind, patient and understanding! Some are good, some are bad some don't want to do the paperwork and are working for a check and not because they care!.I could tell you HORROR stories but I won't here.....You should get 100 days on Medicare and I would suggest a 2nd insurance company as well, AARP? They will cover the other 20%. But appeal if you must, I did in the past because she did well with the OT but the PT said she plateaued...hmmm same company they.. sent out a different therapist to evaluate her and guess what she did better again! Many therapists give up, won't be bothered especially if dementia/Alzheimers is involved sounds like maybe your situation? Have you checked into a Memory Care facility with aging in place...meaning they will not send then to a NH but let them age at the Memory Care /ALF facility? I found one that is very reasonable compared to all the awful NH's I looked into and the rate was affordable for her care not $9k-12k a month for a dump that let's them lay in bed all day! Your mom's ssi and pension would cover it! I never knew about this before and was coming out of pocket several thousands every month when I was still working because not one place informed me of this. Try services like Our Home, A Place for Mom they will do all the leg work for you as for as what licenses they have for what kind of care...transfers,wheelchair, costs etc...narrow it down and go view the top 3 maybe and take a look!It is no charge to you. That would be better than the Medicaid mess hoping she qualifies (god forbid she doesn't and you have to pay), selling the house to pay for her care etc....but try to get her 100 days while you work on it.Also you may request the therapist come to the home with you and your mom to make sure your mom can safely navigate the home if not they can't release her!Unfortunately most all of these places are in it for the $$$$$. I even found a huge price difference from different locations run by the same companies since most are now corporate owned...I mean a $5k a month discrepancy no one said well go over to our X location their rates are much lower. Best of luck and message me if I can be of any help! Bless all us caregivers we need to stick together and share our info, I wish I found this site 8 years ago so many great answers from those that have walked the road before us!
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Dman, you can always look at a lawsuit, but your advocacy for your mom now has them doing what they can to correct it. You could do a free consult with a malpractice attorney to see what they say.

You can check the website AVVO, there are attorneys in every sort of practice with client and peer ratings. Maybe a good place to start. Also, since mom is not able to sign you can go through an emergency guardianship proceeding since there is not POA's in place. You may be able to do this yourself. Once or twice a month at our courthouse attorneys volunteer to meet with people on issues such as yours.

Good luck!
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Another brief question: let's say this newest round of tests reveals a problem the hospital missed last time around? Would a lawsuit be out of the question? I certainly don't want to go down that road unless it's warranted, but it is something to consider.
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Thanks for the helpful replies! I don't know if it's allowed here but does anyone know of a good attorney in NJ that you'd be willing to clue me in on via private message? I spoke to one today but she wanted 10k up front, way out of my range. The second one was cheaper but he didn't seem too interested in taking me as a client.

Current problems: I need her to sign the POA forms however right now she isn't capable of understanding them and possibly physically unable to initial them too. I tried to get her to do this years ago (same with signing over the house) but she refused at the time, which I now deeply regret. Just like her own mother, always suspicious of everything.

I've already contacted the Medicaid office however I'm still waiting for the return call. Anyone know how long this normally takes? They just transferred me to a VM box.

Her assets are limited to her house (probably in the 100-120K range) and SSI plus pension totaling around 2700 monthly, plus a couple of small insurance policies. I'm already authorized to access her bank account so getting the records won't be a problem in that regard.

While I'm not expecting the rehab to ID her medical issues, I was expecting the doctor there to assist in ordering more tests. Right now transporting her anywhere is a task and a half, she requires a stretcher and restraints to safely be moved anywhere so getting her to "regular" doctor appointments is impossible. I just spoke to the doctor at the hospital and he expressed concern as her agitation is making it difficult to even examine her.
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I just read your update. Do not expect the rehab to figure out figure out your Mom's medical issues. If you have concerns, make appointments to take her to doctors. You can take her from rehab to doctor's appointments with doctors you choose.

Also, they should've given you statement from Medicare about "discontinuation of care" or something like that. There is a number on it to initiate a "Medicare Dispute of Discharge." Once you get this paper, the clock is ticking. You only have a short window of time to make a dispute with the Medicare QIO agency in NJ. Tell them that there is not an adequate plan of care in place for her transition. They may or may not accept this, so be sure to find out what the rules are for whether she will have to pay herself if they deny her appeal.

In the mean time, tell the nursing home you want to transfer her to long-term care immediately (as soon as her rehab days end). See if they have a bed available. If not, see if there is somewhere else she can be transfered to. You can call your county Medicaid office, and ask them who you have to speak to, to come evaluate her medically for long-term care. Keep communicating with the social worker at the Rehab. There may be a different social worker they have you talk to about ling-term care. Be friendly, but persistent, and ask them what you need to do to make the transition without sending her home. You are not limited to the Nursing Home where she is located, but you will want to choose one that accepts Medicaid, even if she doesn't have it yet. Just don't sign any of their paperwork yourself, because of the reasons I listed in my other reply. Have her sign herself, even if it looks like chicken scratch.
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I've gone throught the Medicaid application process recently for both of my in-laws in NJ. My father-in-law's nursing home allowed him to go straight from Rehab to Long Term Care while his Medicaid application was in process, or "pending." My mother-in-law was already qualified by Medicaid when she moved in to her nursing home, because she went through the process to get Community Medicaid, which allowed her to stay at home with services from the county, like a home health aide, and case management, medical alert, and some other benefits. So, when she needed to switch to nursing home Medicaid, she didn't need to reapply. In NJ, they have Community, Nursing Home, and Assisted Living Medicaid, which are all open to anyone as long as you set things up correctly.

As someone else mentioned, the first thing you need to get is a durable POA. The Medicaid application process involves getting a lot of financial documentation, so you will need that in order to request it. If your Mom has a lot of assets, it might be better to consult an eldercare attorney. If she has little or none, it's possible to do it on your own, but it's not for the faint of heart.

To be eligible for Medicaid, you have to qualify both medically and financially. If you haven't already, tell the social worker at the Rehab that you want to begin the process. They will give you the number for your county Medicaid office. DO NOT WAIT. Call them immediately, and make an appointment. You'll have to go in person, and bring a lot of documentation. They will give you (or you should ask them) for a list of the documentation you need. This will include her identification, like a birth certificate and social security card, proof of income, like the social security statement of benefits and pension statements, and proof of assets, like a deed if she owns a home and any investments and insurance policies and similar.

Then, they are looking to determine 2 things: what her income is, and what her total assets are. There is an income limit in NJ, but recently they "sort of" eliminated it. If she makes over a certain amount, she'll need to start putting any amount OVER this number in a "Miller Trust". Then she will meet the income limit. You'll most likely need a lawyer for this, and you should check the name of the trust, in case I'm wrong.

She will also go through a financial "lookback," which involves getting 5 years worth of statements from any bank, retirement, investment, etc. accounts she has had in the last 5 years. This can take time to collect. They go over the records with a fine tooth comb to make sure she didn't transfer anything to friends, or family, or hide it in an account somewhere else. They will come back to you probably a couoke of times at least looking for additional documentation, like check images and deposit slip images.

Once they determine what her assets are worth, they will come up with a formula that tells you how much of them have to go to pay the nursing home, before Medicaid will start to pay for it. So, and this is VERY IMPORTANT, don't spend any of her money. She will be able to keep a certain amount of her assets (I think it's $2000 and has a certain amount of time when she can spend down and buy things like pre-arranged funeral expenses, and other personal needs. If you think she will have any assets, you should definitly go to a lawyer.

In the mean time, when she switches from Rehab to Long Term Care, they will have another Admissions Agreement and other paperwork to sign. If you are able, have a lawyer review it and DON'T SIGN ANYTHING YOURSELF if she's of sound mind. Even as Power of Attorney, they have tricky language in those things which will make you liable for any balance she has left after she leaves, or passes on. This can be tens or hundreds of thousands of dollars. Have her sign ALL of her paperwork herself, so only she is liable for payment.

Also, the formula for what she will owe the nursing home as her "cost share" each month if she qualifies for Medicaid, is her entire income, minus whatever the amount her Medigap supplemental insuance policy premium is each month, minus $35 she gets to keep for "personal needs." Figure this number out, and start making payments to the nursing home the very first month she is in it in the Long Term Care section. You don't want this to sit and accumulate in her account while you are going through the financial determination process.

They basically give you very little time to get rid of her car if she has one, so start thinking about that. Technically she's allowed to keep it, but you'd have to pay for insurance because she's not allowed to use her assets or income to pay for it. Other assets, like property, have different rules, and you should definitely consult an attorney about them.

If there are any assets, she'll go into a "spend down" period, where she pays for the nursing home until it's all gone, then Medicaid will kick in and she'll only owe her income (minus the deductions I listed before). This all happens while she's already in long-term care.

Try to be as organized as you can, and get going on it right away. The sooner you get it settled, the sooner you won't have to worry about it. Feel free to send me a private message if you have any questions. Best wishes!
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Update: Yesterday the social worker corners me and tells me they're discharging Mom on the 7th, not the 22nd. I demanded to speak to the rehab doctor. She returned my call today and I explained that yes, her (Mom's) original issue has been resolved; however she is CLEARLY in no condition to return home as she is right now. Then I explained that if they force a discharge I will have no choice but to immediately take her to another ER, preferably one out of their system, as she is obviously unwell regardless of what Medicare guidelines have to say about it. An hour and a half later she called again and agreed that my mother needs the further tests I've been asking about for the last three and a half weeks. She's at the hospital right now undergoing those tests so perhaps we will finally get some real answers here.

I spoke to an attorney (way out of our price range) and an advocate as well as the center's ombudsman today and my understanding is that I can absolutely refuse to take her home on Friday regardless of what they have to say about it. I'm telling them tomorrow that until I have a proper diagnosis and a realistic long term care plan in place that I simply can't do it AND that it's their job to help me accomplish those things as opposed to worrying about dollars and cents. IMO they've done a pretty good job regarding daily needs and care but not so good as far as identifying Mom's bigger issues, like why she can't walk, why she's always leaning to one side and how she became so out of it so quickly.
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dmanbro: Be very careful with NH's. When we wanted my mother to go from the rehab section to the long-term care section (because my brother and I lived in different states than her), they told HER (and my brother and I) "maam, you're too well to stay to here, with the PT exiting the room of his "under one minute take on my mother." Less than 48 hours later, she suffered a stroke there and deceased.
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Medicaid in many states will allow the home to be tranferred to you if you have been providing care that is medically necessary to keep her out of a nursing home for a period of two years. How long had you been providing care? I would consider this before opting to have her admitted to a nursing home. Then also consider your family dynamics, if dysfunctional it is a given that at least one sibling would object to the home going to you. This would also happen in families that get along because someone will be worried about what inheritance will be left for them.

You can refuse to bring her home simply stating you are unable to provide the care she needs.
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Don't pay attention to the social worker. Seek help from a Medicaid expert. In this case it will be worth it. Probably an attorney but maybe not!
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Also the elder attorney might be able to help you stay in her house as you have been there for a length of time taking care of her. It's worth checking out.
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Try to do whatever to get mom to do her rehab. They have to be "progressing" to have Medicare pay. Speak with the PT & OT as to where mom is in progress. What motivates her? Work that angle. Medicare allows up to 100 days rehab, try to get the max Medicare benefit. Btw Medicare pays the facility like triple for room & board from what Medicaid would ever pay. Facilities love Medicare whether it's paying rehab or bringing in hospice.

So mom does not have a secondary medi-gap type policy to share the cost of rehab? Bummer....The contract /payment agreement is it just for doing the rehab copay for Medicare 20% match? Review it clearly, you may have signed off to cover full 100% private pay NH rates that would go into effect once she is no longer "progressing" in rehab.

Is all moms legal current? If not, speak with elder law about getting updated if mom is still competent enough to do so. As far as mom being able to divert $, well IMHO once they are at immediate need of a facility those planning options are moot. There is no 5 year window to make this work.

Now mom can use her spend down $ on her care & her property. It does not all have to be paid to facility. Say mom has 30k spend down, so she could private pay 10k a mo to NH for 3 mos. But she could also pay 1k house insurance for a year, months of utilities, yard work for 3k; get a plumber in to do repairs 6k; get roof replaced 10k; and get a fully prepaid funeral & burial policy 10k. Same 30k.
Spend down before applying has this flexibility more easily, comprende?

If the house just has to be sold, you want to get moms SOC diverted to pay for house costs while on market. Can be done but you may have to press on this. Usually for 6 mos and you have to show a MLS listings agreement. having a house on the market is going to have increase costs of utilities, yard care and perhaps a rider or new policy to moms insurance. Who is to pay all this?

Have a reality check on the value of the house. If moms house has decades of delayed maintenance in a neighborhood that has seen lots of renos

If you find in your nancy drew search for paperwork, that mom is over medicaid limits, you should speak with elder lawyer about getting a miller trust done to make her eligible. Use moms $ to do this.
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I'd suggest that you first find out exactly what NJ has as the Medicaid LTC asset & income limits. Assets probably 2k but income varies. Then find moms awards letters - these get sent Nov /Dec that state what the $ will be for the next year and what is being deducted from them (like $100 or so from SS for Medicare). If mom has anything that causes a 1099 to have been issued to her (these get sent between jan & early Feb for tax filings) then there is liklely income from these. An example woukd be interest income from a CD. Now once you have the info is mom within the asset & income limits? If not, she's going to need to spend down and you can forget her getting approved easily for medicaid at this point. Really imho dont apply for meducaid till tiu know they are under $$ limits. More on this in another posting....

You do need to establish if her life insurance policies have any cash value. Whole life usually do, but term usually doesnt. If they do have cash value, they will need to be cashed out - if your DPOA this should be fairly straightforward to do but allow 60 days. For my mom, policy was old school type and not screaming TERM, was like over 30 legal size pages front & back, now medicaid caseworker does not have time or ability to review policy so I got a broker to do a letter stating policy was term & NCV (no cash value) so all ok for life insurance. It's stuff like this that makes you loco & being organized helps your sanity.

Moms house does not enter the asset formula - their home & a car should be an exempt asset for their lifetime for medicaid if they do an "intent to return" statement. If you have been a caregiver for 2 yearsor so and can document that your caregiving kept mom out of the ltc and off of medicaid, You can file for the caregiver exemption to MEdicaids MERP program. Although that sounds just fabulous, what happens is that once on Medicaid or Medicaid pending all their income will be paid to the NH as their required co-pay or SOC ( share of cost) required by Medicaid. They will be allowed a small ($35-105 a mo) personal needs allowance. So everything house will need to be paid by family. Do you have the availability to pay on all on the house from now till mom dies and through probate or property transfer process??

One thing that comes up over & over on this site is the caregiver works for free for parents in parents home, spends their retirement in the process or leaves their paying job. Then years later parents need higher level of care & moves to Nh, caregiver finds themselves impoverished, worn out and unable to pay house items. A frightening crisis for well intentioned caregivers.
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We went through a very similar situation, and here's some things we learned.
1) Medicare is not set up for the transition, nor LT care, only rehab.
2) Even though the SW, PT, OT all agreed that Grams shouldn't be at home alone, it was really up to us to figure out what to do...as she was going to be discharged because she had reached a "plateau".
3) Applying for and going through the appeal process was a great deal of extra work for the rehab staff...and they were not happy they had to do that. It was denied of course due to reason 1 above.
4) We wondered if no one showed up to pick her up, what would happen...and pretty much were told that they would call a cab, put her on a bus and send her on her way. (We opted for the rehab staff to train/show us proper ways to move her from the rehab room to getting her in the car and back out.)
5) You do have the option of keeping her in the rehab facility if they do have room...its just a great deal more expensive than a regular CBRF or ALF. But if you do need a day or two or a week, it is an option. (The spend down would go real quick like then of course)
6) While going through the application process for Medicaid (many ALF's have persons trained in the process, we worked with DOA referrals/staff, or you can fumble through it yourself of course) we temporarily set up her up with FT care back at her home once again.
7) Team Grandma members then toured about 3 CBRF's/ALF's each day for a week until we found one we thought best for her LT care. Worked out a rate for private pay until the Medicaid program we applied for through the county began to cover a good deal of it.
8) The last I heard, the tricky word and statement as far as a diagnosis for one with Dementia/Alzheimer's needs to say "cognitively disabled" since those other terms are tossed around so much I imagine.
Continued best to you!
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Right now we are in the "private pay" phase of nh care for my mom post stroke and broken hip. $15000 per month. She still owns her home which has been empty for yhe two years she's been in care and is being prepped for sale. Funds will pay for an additional 18 months or so after her "real" money runs out at which point we will apply for Medicsid for her. This was all explained to us at the time she was discharged from the hospital from her hip repair. Discharge planner had us fill out a form listing all mom's assets and she walked us through the timeline and told us to confirm with mom's lawyer.
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We are going through a similar situation with rehab. Has she spent down all her assets? My mother will leave rehab, too, but will probably pay for LTC for a year before her funds are exhausted...not including her house. I'm still unsure about the status of her house in terms of assets and nursing home payments.
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Have you consulted a certified eldercare attorney on her behalf? Is her totally monthly income from various sources below the Medicaid threshhold in NJ? I would be working closely with the SW at the facility she's in now to find out if THEY will accept her Medicaid pending or if they are recommending a different facility. I for one do not see a problem with you remaining in her house for the time being. In general, medicaid allows senior to retain their residence subject to recovery afterwards, so it doesnt need to be sold immediately. But consult a lawyer who knows about this stuff.
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I have no answer but want to follow.
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If she needs long term care, they won't release her until you have that in place. There should be a social worker or admin where she has who can assist you in placing her where she can get the care she needs. The diagnosis really isn't critical for that placement to occur. The doctor will determine the type of care she needs. I would seek out that help to get that in order first and then make arrangements to move out of the home lest someone get a bug in their head about you taking advantage of an elderly person. Believe me, it happens more often than you think.
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