His parents came to America and brought their parents from ex-Soviet Ukraine in the refugee migration of the 1990s which brought artists, doctors, lawyers, engineers, professors and accountants to the collective brain power and labor force of America. His parents brought their parents who were also the intelligentsia class, but because of age, the older generation didn’t integrate into the professional American fabric. The oldest generation who came and settled in far out Brooklyn, far north the Bronx, Rego Park and Inwood as part of this mass migration came to work in the job description of grandparents for their first generation American grandchildren. Emigrating in your 60s or 70s isn’t easy and wasn’t necessarily their choice. They became grandparents of Americans because their children offered them the choice, come to America with us or grow old alone in a post-Soviet country.

I briefly took care of Grandson One’s mother’s mother who had been a physician. Then I joined the problem solving team for Grandson One’s father’s mother a year or so later. I already knew how he advocated for grandmothers.

The famously successful letter he wrote is below. I think it is self-explanatory to the situation we found ourselves in for her home care needs. It really doesn’t matter what her medical conditions are. She can’t be alone. She either can’t do for herself or needs to be cued to do the things she is still able to do with oversight. Leaving her alone for any part of a circadian cycle could result in harm to her or even to her neighbors if she caused a kitchen fire. I was given permission to publish the redacted version of this letter so that others could use it as a template because this letter achieved the intended end, his grandmother was approved for split shift care, one home health aide for the day and another who is paid to be awake at night. This arrangement for care is now difficult to get from a Medicaid home care provider because it is more costly for the home care agency and the the Managed Long Term Care insurance company. Spending revenue on the intended recipient leaves less for greedy bastard’s Wall Street range salaries. Grandson One brought the CEO of New York State plan Senior Whole Health owned by Fortune 500 Molina Healthcare Inc. to his knees and quite abruptly. There was no first rebuttal followed by slow capitulation in response to the letter. Mr CEO just appropriately caved. Of note, I was told that Mr CEO threw the nursing and utilization management staff under the bus. Mr CEO said it was all just a big mistake. His underlings were wrong not to approve the request for two 12 hour shifts of a home health aide. No no no, Senior Whole Health doesn’t condone denying Medicaid beneficiaries the home care hours that they need. Don’t be silly, Senior Whole Health doesn’t pay midlevel nurses to perform the daily task of denying members the homecare hours that they need (personal reply: oh yes they do). This whole thing was an aberration, a big boo boo. They don’t have employees trained to look sons and grandsons in the eye and say, “she only needs 12 hours or a family member should sleep in her apartment and take care of her overnight. The fact that you all have to work during the day or don’t live nearby is irrelevant.” (personal reply: oh yes they do). Whoever said that is a rouge nurse-employee. No, its not our corporate culture to $kimp on homecare hour$. “Look over there” said Mr CEO pointing, “that mid level manager under the bus did the wrong thing.” I heard say that Mr CEO told the grandson all of this and as I was hearing it said, I was rolling on the floor laughing because all MLTCs do this so frequently and often that I tell daughters and grandsons to expect it. Mr CEO knows that Grandson One has only his personal experience, but he doesn’t know that grandma’s doctor sees this every day. I know they all try to save state-administered federal revenue to support their own salaries instead of using the tax dollars revenue for the cost of home health aides to help the legitimate beneficiary, his paternal grandmother. And that’s why I am sharing this sharp pointed pen letter which caused Mr CEO to immediately take notice. Its a template what works.

Hello Ryan [CEO] and Holly [COO],

My name is Dr.***** ******** . I am a New York-based physician and the grandson of two longtime Senior Whole Health members, I am contacting you directly due to Senior Whole Health’s ongoing failure to fulfill its medical obligations to my grandparents. Despite multiple attempts, I have been unable to reach anyone other than their recently-reassigned Case Manager, Kelly Pascarella (in copy).

My immediate priority is ensuring appropriate and safe care for my grandmother, ****, following the passing of my grandfather, yesterday. Of note, ****** died after two weeks in home hospice, while waiting for SWH to permit escalation of his care (6 hours per day while fully bedbound and dependent in all ADLs).

Immediate Action Required:

Senior Whole Health must authorize and implement continuous, 24-hour split-shift home care for **** by EOD, Wednesday, July 16. **** is 92 and suffers from advanced dementia and severe medical instability, posing well-documented safety risks, including falls, skin infections, and potential fires due to unattended stove use. Her medical team has extensively documented these risks, underscoring the urgency of immediate intervention. While SWH has taken months to consider, then deny, any increases in her support, SWH reduced her effective support to 5 hours per day with remarkable efficiency (within hours of my grandfather’s passing) and now refuses to provide even interim respite care.

Patient and Family Background:

**** and ******—Holocaust survivors and longstanding SWH members—have consistently received inadequate and unsafe home care. SWH has alternately combined their care hours or individually reduced hours during hospitalizations, resulting in care plans that fail Medicaid and New York State DOH standards. Following ******’s death yesterday—bedridden and without adequate medical support— ****’s home support has been more than halved, compounding her significant safety and health risks. This ongoing administrative neglect has placed extraordinary burdens on my family, with my father providing constant, uncompensated care (while working full-time), and months spent personally navigating SWH’s deliberately obstructive bureaucracy.

Senior Whole Health’s Role:

SWH’s handling of my grandparents’ care clearly violates regulatory and contractual standards under Medicaid, Medicare, and New York State Department of Health guidelines. Specifically:

• Denying care based on inaccurate or incomplete medical assessments breaches SWH’s legal duty for accurate patient evaluation

• Approving demonstrably impractical or insufficient care plans violates regulatory mandates for medically appropriate and safe patient care

• Intentionally delaying essential care through unnecessary appeals (that do not change initial outcomes) contravenes Medicaid guidelines requiring timely provision of medically necessary services

• Defending these callous violations of patients rights and administrative standards by ensuring nil transparency and accountability -- in direct violation of state and federal regulations

• These documented systemic practices, explicitly demonstrated in the care of my grandparents, open SWH to substantial risk of class-action litigation, civil actions, and regulatory action

Broader Context:

As per the Wall Street Journal’s coverage last week, SWH’s parent company clearly faces mounting pressure to manage costs. However, this company will not be doing so at the expense of my only remaining grandparent’s health, safety, or human dignity.

Consequences of Inaction (Deadline: Wednesday, July 16, EOD):

Failure to address this matter immediately will result in:

• Outreach to investigative journalists at major media outlets, including but not limited to: The New York Times (Sarah Kliff), Wall Street Journal (Anna Wilde Mathews), and The Washington Post (Amy Goldstein).

• Engagement of legal counsel to initiate class-action litigation (refer to Bucceri v. Zucker, NY, (2016) and pursue civil legal remedies.

• Contacting state and federal regulators, including the New York State DOH, CMS, and the Office of the Medicaid Inspector General, to formally report SWH’s violations and request investigation into its practices, especially with vulnerable populations.

Ensuring immediate, appropriate care for **** is my sole priority. Please confirm your commitment and detailed action plan by the stated deadline.

I am reachable directly at *** ***-**** .

Regards,

Grandson One, MD, PhD

I want to point out a few important “I see what he did here” aspects of this successful letter.

1. He blocked, bolded and bulleted.

2. His letter is addressed to Ryan and Holly. He addressed the CEO by his first name. This caused me to gasp because even I don’t do that in my call-them-what-they-are letters, but I do think it was brilliant. Respect is earned. I guess Ryan, just some dude on the basketball court or the guy in the aisle seat on the long-distance bus, is not worthy of an honorific. Ryan, now you know, its real people with real articulate grandsons who are on to your bullshit.

3. He succinctly told a very personal story to let them know that grandma is more than her member number. I can not imagine how difficult it was to write this letter the day after his grandfather died. Ryan and Holly are very far removed from the lives of those impacted by their decisions.

4. He background checked publicly available information on the organization. He searched for legal claims against Senior Whole Health which is an insurance company who provides homecare from revenue that is our tax dollars while being a branch of a Fortune 500 company. Senior Whole Health is a government contractor. We all have the right to critique or criticize them for how they spend tax dollars and the quality of the care that results from that spending.

5. He gave them a deadline and concluded with the deadline.

6. He invited them to think how visits from government regulators, letters from lawyers and more publicity would feel.

7. He threatened Senior Whole Health with exposure by journalism. Remember they are a federal-state government contractor. We are owed transparency.

Senior Whole Health is owned by Molina Healthcare, Inc., a Fortune 500 company. It operates as a subsidiary providing government-funded healthcare (Medicare and Medicaid) to seniors in Massachusetts and New York. Notably, Senior Whole Health is transitioning to operate under the Molina Healthcare brand name effective January 1, 2026.

Oops. Maybe The Senior Care Industrial Complex government dollars sector isn’t so good for shareholders. Maybe Molina and Senior Whole Health can only cheat their members so far while buffing their not publicly available salaries. Why is our federal government giving our money to Wall Street to then decide who among the legitimate beneficiaries gets what? How does Wall Street know how best to provide home care?

Oh my I am in a third connection relationship to Mr CEO.

The CEO of Molina Health’s Senior Whole Health MLTC plan in New York State is salesman and that explains why he is no match for Grandson One.

“It ran out.” That was the home health aide’s response to my request to show me the medication cards. My purpose was to confirm she was using the two cards for the two medications correctly which involves following the dates across the calendar-like-package and opening each individually packaged pill on the right day at the right time. Anabel has home care through the state administered federal benefit of Medicaid so her home health aides work for a licensed home care services agency (LHCSA) and they can not remove pills from pharmacy bottles. The pharmacy has a machine which applies a backing label to little plastic trays like a muffin pan with seven columns and four rows after the pharmacist drops a pill in each individual bubble. It is a structural calendar full of pills for each day and dosing time.

Home health aides are not involved with the pharmacy and refills. In New York State, home health aides who work for agencies are not allowed to “give” medication. When we talk about their involvement the terms we use are “assist with” and “remind.” Home health aides who work for agencies can take pills out of plastic weekly boxes and blister packs. They can not open a pharmacy bottle and follow a paper medication list on the kitchen table. Many elders who are dependent on home care workers need help with the instrumental activity of daily living called medication management, but the assistance needed often must involve others beyond home health aides such as nurses, pharmacists and family members. When an elder is receiving home care services under licensed care, the question must be answered, “Who is going to deal with the medications?” because someone besides a home health has to deal with the medication and that person is identified and there responsibility is documented.

Home health aides who work for a LHCSA are not responsible when it comes to prescription and nonprescription medication, but they don’t have no responsibility. The implications of what she said about prescription medication, “They ran out” is no different than if I had asked her to show me the food in the refrigerator and she responded, “It ran out.” What does the logic department in her brain tell her she must do next if she arrives for work and finds no food to feed Anabel? Home health aides aren’t responsible for buying food, but if a person happens to be without food, then a home health aide is least of all an advocate and needs to take an action which is no more complicated than a phone call or two. Nonchalantly letting a vulnerable elder be without medication which comes packaged from pharmacy is like saying I have no role if there is a fire in the home because I’m not the fire department. Its not my job, so I shall do nothing (or rather I shall continue watching television and chatting with my family during work hours.)

If the pills ran out, and definitely before either the food ran out or house was burning, it seems to me that apathy is not an appropriate response for a person whose umbrella job description is that of caregiver subtype home health aide. It is laudable to be proactive even if her job description does not including interacting with the pharmacy; she could have called Anabel’s son or daughter to deliver an FYI message, “There are five pills left and the pharmacy hasn’t delivered new cards.” Just maybe she should perceive her job to including being the eyes and ears of family members who do not live nearby. The only reason anyone knew Anabel was without medication was because I came to make a home visit for some other reason. I just happened to ask to see the pills on the card. The home health aide didn’t report it to me. I happened upon the problem because it is my habit to ask.

When did her pills on the blister pack run out? It’s hard to say. The answer evolved as I attempted to determine how long she had been without levothyroxine, a life sustaining medication. It is a fact that the pills ran out on a specific date. It is a fact that one day someone working as a home health aide pushed the plastic bubble to remove the last pills, leaving the card with 30 broken blisters and then they discarded the remains of the package. Someone gave the third to the last pills and the second to last pills and the last pills at which point it was another fact that “It ran out.” Specifically, there was even a day of the week when this aide, not her colleagues, last assisted Anabel with her pills. Was it this week? Last week? It was hard to say. I asked a clear question starting with “When did YOU last give the pills?” No clear answer followed. I broadened the question, “Did you give her pills this week?” I received an answer unrelated to the question. I gave up trying to risk assess the situation as the vague answers evolved. The fact of when “it ran out” was unknowable because between this home health aide and possibly as many as three others who work the day shift none were paying attention to their job description. Several people in this high risk industry, minimum wage home care workers, who can get a new job if they are fired from this one simply gave up on advocacy and communication.

Home Health Aide Draft Job Description (minimum requirements a work in progress)

Knowledge

1. Possesses the ability to recognize a threshold event for calling the home health care agency supervisor, family member or physician

2. Recognizes that the telephone is a necessary instrument for caregiving

Skills

2. Common sense

3. Ability to communicate verbally

Marketing is making you think the product or services will make something better in your life. I am fully unable to relate to the above images. Neither my father nor my mother, or rather how challenging they were, is represented in these images. Some of these images were clearly photographed to represent nurses not aides. Yes aides strap on blood pressure cuffs, but not a single image shows spoon feeding oatmeal or changing a diaper. Everyone looks very shoulder to shoulder collaborative, instructed by photographer to smile and gaze at each other as if they have a wonderful positive relationship. Lets get real. Homecare is hard. Very few old sick people are easy to take of and almost all homecare workers have complex lives outside of their job. They are immigrants, parents, generally uneducated and live in precarious housing. Its more common than not that the caregiver and care receiver don’t share the same first language. Sometimes they love each other and sometimes the relationship is like a bad marriage.

In none of these photos do I see someone who appears to have dementia (yes, sometimes you can see that in pictures.) They don’t even look sick. The only marker of needing a home health aide is the grey hair, which is neither causative nor correlated.

Here is the search using the term home health ““aide” instead of “agency in the image tab. I don’t see a television or cell phone. The most common complaint about home care workers is that they are always on their phone at work. I know who in the home is watching the TV based on what show is on.

We see smiling handing off pills in the kitchen. Bonus points for two images of proper stand and hand position to assist someone with a walker. I would choose those three women in blue. who are not models but actual aides. They look fierce. Fierce mixed with empathy is the winner trait of a great home health aide. A home health aide helping with bicep curls with weights? Nope, not in their job description. This is some marketer’s idea that a home health aide is going to reverse the muscle loss that comes with aging. If you hire them you can become stronger like Superman. Some of these images are for recruitment into training programs for home care workers and they similarly misrepresent the work day. Fifteen images and only one old person is in bed. Good, but that is statistically farcical. Nobody is wearing a schmatta.* I like that photo on the bottom left, the male aide is genuinely engaged with the man in bed. I would hire him too, except he is a model unlike the women in blue. I love dude-dude homecare relationships. A male caregiver for an older man just works well in my experience. Dudes who do this work tend to have chosen it and are exceptionally good at it. Comparatively, many women who work in homecare often strike me as in the industry because its the only job they can get. Seriously, I meet aides who would be rejected from employment at an Amazon warehouse. I can’t think of a single day in my home visit career when I walked into a home and the patient and aide were smiling at each other like these photos except if there was a birthday party.

When shopping for homecare services look for representation of reality, not smiling fantasy that doesn’t look like your family. Ask about training and supervision. If you are assigned an aide who has worked with that agency for years, that means when they finish one job, the agency wants them for the next job because they don’t get complaints and the do get compliments. Long timers are retained because they are happy to work for the organization and the agency is happy with their work. Bad home health aides go from one employer to the next because the next job will never be the wiser.

If you do marketing for the Senior Care Industrial Complex, give me a call, with a focus group you may better serve reality, the person in need and the home care worker.

* "Schmatta" is a Yiddish word meaning a rag or a tattered, old garment, but it can also be used to describe a general piece of clothing worn around the house.

Hello Doctor,

Marlena has been confused for two days, not recognizing where she is and asking to go home. Last night she spoke in German and could not sleep until 3 a.m. This morning she asked about her “sister.” I am worried about a possible urine infection and I collected a sample for testing.

When I called her, I asked her what happened yesterday. She told me Marlena was confused all day and didn’t go to bed until 3 AM last night because she didn’t know she was at home. I asked her what happened the day before. She told me she woke up and did not recognize she was at home, but then had a normal day. Then she went on to give her “diagnosis” and she told me what she did. I asked why she didn’t call yesterday. She told me she didn’t call because she “needed to find out…” What could she possibly have been finding out? The she told me again what action she took, collecting urine. I told her that her job is to communicate. I told her that it is not her job to find out or decide ANYTHING. I told her its not her job to take ANY action without being told to.

Did I yell? I was walking up Broadway on a lovely day and there are lots of witnesses to my yelling about a job description. Screaming into the phone. Then I yelled in email too.

From: Jomarie Zeleznik
Sent: Thursday, September 11, 2025 10:08 AM
To: T** L***** <********@gmail.com>
Subject: Confused for two days

Do you know why Marlena’s symptoms have gone unreported for TWO DAYS? Because Natia not only had to continue her observation she had to collect urine.

It’s not Natia’s job to gather observational data and then, when she feels she has enough, take an action she was not asked to take. It doesn’t matter if she collects the urine. It only matters that I decide to send a lab order because testing the urine is part of making a diagnosis.

Her job is to communicate not to play doctor, not to omit a phone call until she basically tells me three times “I think this is a urinary tract infection.” It is not her job to think of diagnostic possibilities while she continues to make observations while whatever the cause is goes undiagnosed. In addition the cut off for home lab orders is now 2 pm. The home X-ray company has a cut off time for same day orders. Her ignorance is a form of magically thinking that her “deciding” what the problem is, is the sole consideration.

One day the future, a one day lag time will be the end. Natia is a detriment to Marlena’s health.

You have met 101 year-old Marlena before when she was suffering emotional abuse from a different caregiver. That caregiver was fired. This caregiver is the “good” one. But during the five years that I have been Marlena’s doctor, the good caregiver has failed to call at least a dozen times for health issues that she observed She has been spoken to about omitting communication at least a dozen times by Marlena’s health care agent, her son-in-law, who was married to her deceased daughter. A delay in a call to me is a delay in making a timely diagnosis A timely diagnosis allows the treatment that prevents the trip to the ER. Nobody wants Marlena to go to the ER.

What’s the big deal? What’s the barrier to her completing the simple task of finding my name or Marlena’s son-in-law’s name in her phone and pressing the icon to effectuate the call? Beats me, but since she is an employee, I can do an attitude, knowledge, skills evaluation.

Attitude: She comes from a country which during her life-time gained autonomy from an Empire. I have no doubt that during most of her life she experienced rationing of access to medical care where people has to fend for themselves while waiting for an appointment to sit in a waiting room full of sick people waiting for a rushed appointment. The doctors in her country are probably poorly trained. I presume that because I have never seen a resident physician in the US who came from a medical school in her country. That means their education is not accepted here for entrance into post-graduate training in the US. Based on things she has said about what “we do in my country with old people,” I believe old people in her county probably are the last in line to get a diagnosis therefore they are relegated to bush medicine from caregivers and family members in the absence of diagnosis.

Knowledge: She doesn’t know what she doesn’t know. No smart person doesn’t know where their knowledge ends and the abyss of ignorance begins. No smart person doesn’t understand risk to their self and others from taking action without knowledge. She has no knowledge about the medical diagnoses processes which requires a license to practice medicine. Zero, she has none. The action she took was a monkey-see imitation process. She doesn’t know why I order a blood test, a urine test, an X-ray or no test.

Skills: this home care worker is incapable of making a phone call which is a key skill for her job description.

Magical thinking is a type of fallacious thinking and is a common source of invalid causal inferences

Oh my.

Allstar Homecare Agency has been making donations to NYC Mayor Eric Adams re-election campaign using the names of their home health aide employees as reported by The City, co-printed by Queens Daily Eagle and the World Journal. This is known as a straw donors scheme designed to evade campaign limits and evade the source of the funds.

Allstar Homecare Agency is a for profit home health care agency licensed in the State of New York. In the home care industry we call them a LHCSA pronounced “lick-sah.” Their website has no information on ownership, leadership, or administration. There are no smiling photos on an about us page giving interesting background information about whoever runs the home care agency and how they came to be in the Senior Care Industrial Complex. Commonly that would be something about the founder’s grandmother. They claim they provide skilled nursing (technical term) which is highly unlikely because a nurse doing skilled nursing (technical term) has to work under doctor’s orders. They claim they provide dietician “slash” nutritionist services which means they don’t know that there is a huge difference between a licensed dietician and a nutritionist. Typing a slash between dietician and nutritionist is like apples/broccoli. They also claim they provide social work services, physical therapist services, occupational therapy services, and speech therapy services, all very unlikely as a LHCSA. Services listed includes those of an audiologist. Allstar definitively has no audiologist on staff, nor could they employ one, nor is there any audiologist who is an independent contractor for a LHCSA. I know where to find a home visit audiologist. I bet Allstar does not where to find one. Also listed is respiratory therapist, with a description: “provision of treatment for client (sic) suffering from breathing and cardiopulmonary difficulties.” Laughing out loud loudly. Rolling on the floor laughing loudly. Ha ha ha. Allstar has no mechanism to send a respiratory therapist to the home of their clients. I called to inquire. My call was transferred to a number that rang and rang. I emailed their info@ box stating I was looking for a respiratory therapist for a patient. So far no response. What is on the website is not truth. I know that because I know how state regulations for employment and practice of licensed health care professionals works. The average website reader instead sees that Allstar, a home care agency, seems to be like the clinical at the nearby hospital. Why would that be illogical to the public? To me its laughable because I interface with the operational end of the different types of home care agencies. Home care agencies are not supposed to borrow the names of their employees to make political donations.

A donor who identified herself as a home health aide at Allstar used a credit card to pay for her $2,100 contribution. The billing address of the card was Allstar’s offices in Sunset Park. She also listed that office as her home address in campaign finance filings.

Waiman Liu, Allstar’s administrator, asserted in a brief email that Allstar “and its representatives adhere strictly to all applicable campaign finance laws and regulations. We do not comment on individual donations or internal matters.”

Liu added the agency has “no information on the contributions referenced” and does not “coordinate, encourage or reimburse political donations in any manner that violated legal standards.” Greg B. Smith and Haidee Chu The City 2025 July 24

The last time NYS Department of Health stopped by Allstar Homecare Agency was probably April 2025. They don’t seem to be in much trouble with the Department of Health.

But who owns and operates Allstar Homecare Agency? Dunn & Bradstreet and the NPI registry present that the principle, authorized official is Ting Zhang who also personally donates to Eric Adams.

Probably nobody hearing the term home healthcare agency, envisioning all the home health aides that they train, and send out to the homes of homebound, also envisions these organizations participating in electional politics legally or as in this case, using the names of their unwitting employees to influence who wins an election illegitimately. Most people think of home healthcare agencies as part of the umbrella of the health care industry which for a long time had a reputation of doing good, being there for the sick, the old, those people recovering and permanently unable to care for themselves. That reputation of an industry intrinsically connected to the word “care” and the image of people in need of care being operated by good people is actively dissolving. Allstar Homecare Agency is a LHCSA which means the services are not billed to Medicare. This class of home care in New York State is private pay EXCEPT that they may be contracted by Medicaid Managed Long Term Care (MLTC), the insurer, to provide home health aides to the homebound who qualify for Medicaid. Privately engaging a LHCSA to provide home health aides in New York City can reach $60/hour paid to the agency for the high end agencies and is no less than $35/hour on the other end. How much does Medicaid (federal money passed through to states) via the MLTC plans pay the agencies like Allstar who are willing to take these contracts? I don’t know and I couldn’t find out. It seems that it might be negotiated individually for each MLTC and each agency. The aides must be paid minimum wage but there is a lot more cost to running a home care agency besides salary of the front line workers. The question I can not easily find the answer to is: How lucrative is it to accept MLTC contracts compared to the LHCSAs whose revenue is solely from people who can afford to pay out of pocket for an agency home health aide?

The second puzzle is what is the gain for the risk that Allstar Homecare Agency is taking by making straw donations to the mayor’s race. How does the mayor of New York City interfaces with federal pass through money in the Senior Care Industrial Complex? I don’t see any obvious direct benefit to Allstar or any other agency which accepts federally regulated MLTC contracts from electing one mayor over another. I must be missing something in my industry.

I will survey the owners of mom and pop and franchise homecare agencies and ask what their competitors in the homecare industry might have to benefit from spending time and money trying to influence local election results when undoubtable they could be spending that time on maintaining and improving care delivery.

Marie fits the stereotype of the Haitian people, friendly, trustworthy, joyful, not only hardworking, but hardworking with the purpose of quality of work. How do you measure the quality of work of a home health aide? The person receiving care has the best health they can have given their diseases and disabilities. They are clean, fed, positioned, not alone and smiling. Marie apologized that Rose had a fecal ball in her diaper when I needed to look at the pressure ulcer, but I could tell it had just come out. It wasn’t feces squished and smeared everywhere. No apology was necessary for a natural cycle of excretion. I just happened to arrive as the fecal ball exited Rose’s body. It was completely clear to me that Marie never let Rose sit in feces. I know that based on how diligently she cleaned her.

Marie not only loves old people whose well-being she chose to dedicate a 40-year career to, she is also a proud member of union 1199. I have never met a home health aide who told me they are a union member. It seemed to be another point of pride to belong to a group whose purpose is to ensure that the people like her who work in the health care industry are treated fairly as employees.

Marie and I worked together for half an hour. We swirled around Rose. I asked questions, she answered them. She demonstrated how she does things for Rose. She told me her observations about Rose’s needs. She listened when I explained. We both thanked each other for caring for Rose.

If I was the HR department doing her performance review, I would write the following:

Attitude: Has an intuitive understanding of the need to follow the plan of care. Appreciates that Rose’s needs are unique. She is aware of the importance of communicating and advocating for Rose. Marie sees the mundane and sometimes unpleasant tasks of dealing with diaper content as necessary to achieve the goal of providing best care to a vulnerable elder. She is interested in learning about healthcare. Values communicating and collaborating with colleagues and supervisors. Values the importance of knowing her patient’s birth date.

Knowledge: Has knowledge about how diet texture relates to food intake. Possesses knowledge on the standards for frequency of turning and posting and heel elevation to prevent pressure ulcers. Understands the risk of a hot environment on old people and aware that old people don’t like cold air blowing on them. Marie knows that treatment of pressure ulcers is beyond her job description and requires reporting an observation through her agency to a physician. Aware that she cannot take initiative to diagnose or treat. She knows her patient turned 99 years old two days ago.

Skills: Marie demonstrated the correct technique for positioning legs before turning a bedbound person. She demonstrated the correct technique for replacing a cloth bed chux, rolled new clean one under old dirty one. She demonstrated appropriate communication with a hearing impaired vulnerable elder. She demonstrated professionalism when working with a doctor. After observing a problem, she contacted her agency to report the problem as is required. She provides a joyful presence in the home of a 99-year-old bed bound woman.

Èzili Dantò or Erzulie Dantor is the main loa (or lwa) or senior spirit of the Petro family in Haitian Vodou. Ezili Danto, or Èzili Dantò, is the "manifestation of Erzulie, the divinity of love." It is said that Ezili Danto has a dark complexion and is maternal in nature. The Ezili are feminine spirits in Haitian Vodou that personify womanhood. The Erzulie is a goddess, spirit, or loa of love in Haitian Voudou. Wikipedia

Haiti and the Polish Madonna How the Polish Black Madonna has influenced the cult of Erzulie Dantor in Haiti by Bogdan Kotnis, PhD. 8 May 2021

(a) failure of cultural competency training
(b) lack of common sense
(c) ignorance of the weather advisory
(d) stupidity
(e) elder abuse
(f) all of the above

If the supervising nurse from Special Touch, the licensed home care agency had called and asked if the air conditioner was on, the home health aide’s answer, “Yes” would not technically have been wrong from an electro-engineering standpoint, but I was standing in Rose’s bedroom, and when I personally experienced the temperature not just walking through the front door where there was no air conditioner, but the temperature in her bedroom where the only air conditioner was humming, I estimated the air temperature to be 90 degrees around 99 year old Rose. The digital display was two red eights, and the machine was spitting hot air on me. The other window was open three inches. Yesterday in New York City at the time I was in this Kew Gardens apartment the official measured temperature was 96 degrees with a “real feel” adjustment to 104 degrees for however they calculate the effect on the human body. That’s the evidence I would attest to as a witness for attempted manslaughter. Anybody looking at a computer, phone screen or listening to the news in any language yesterday was being presented with heat alerts and information on cooling centers. Con Edison and NYC have been texting heat advisory alerts to the phones of residents. Answer choice (c) is not excluded because I saw her pick up and look at her phone. Clearly this home health aide was receiving the same messages that I was but wasn’t comprehending the implications of any of it. Answer choice (b) is not excluded either if you speak nice human resources talk because the home health aide was in the room with me and Rose and only one of the three of us knew that it was way too hot and dangerous. Answer choice (d) is just answer choice (b) selected for impact, for instance “It’s the air conditioner stupid.” If you have taken a lot of multiple-choice tests, then you already know the correct answer, but I will prove (a) and (e) anyway.

I made a same-day home visit to Rose because Maia, the supervising nurse at Special Touch, the agency that provides her with Medicaid qualified home care, called to inform me that a home health appropriately called in an observation that Rose “was having trouble swallowing.” That’s it. That’s all I had. I called Rose’s son who got the same message before I did. Neither the nurse nor Rose’s son knew if the observation “trouble swallowing” was new or of gradual onset which would generate a very different differential diagnosis. I was going to this visit equipped with only the diagnostic tool of my wits. It is taught in medical school that 95% of the diagnosis is contained in the history of present illness so I had a guess of what I would find. I had a high pre-test probability of a heat-related health problem, so my second question for Rose’s son was about the air conditioner. I could see him vigorously nodding reassuringly through the phone, “Yes, Yes, the air conditioner set to 70 degrees.”

The life support machine called the home window air conditioner means different things to different people, especially old people who don’t like to be in the direct line of the cold jet of air. But Rose doesn’t make her own decisions. She passively receives care. She is dependent on the knowledge, attitude, skills, kindness and judgment of others for everything. Rose is paraplegic from myelopathy caused by multi-level spinal stenosis. She is a vulnerable Newtonian object at rest which will remain at rest. Rose can neither ask that the air conditioner be turned on or turned off.

Could answer (a) be correct? All disciplines of licensed health care professionals in the US are required to have training in cultural competency because we take care of people from all over the world who hold beliefs and have values for health care decisions which are rooted in a culture which may be different from our own. The converse is not true. People who come from all over the world who work as home health aides, completely unsupervised unskilled workers, in the homes of vulnerable people like Rose are not required to have culture competency about American standards of life. Yesterday would not have been the first time that I met a home health from equatorial Africa who was vaguely aware of the machines called the vacuum cleaner and the air conditioner that most Americans can’t live without. I have seen this so often that I have become proactive in asking about broom cleaning the carpet dust into the air and I do hands-on demonstrations on how to operate an air conditioner. I no longer assume that home health aides born and raised in countries where vacuum cleaners and air conditioners are not universal know how or why to use them.

Special Touch is a good agency. When I call to complain they never make an excuse. Everyone I have ever spoken to there seems genuinely interested in best care for their clients. Despite the cost of sending a nurse to a client’s home more often than the required every six months, they have done it when the aides need corrective action. Supervising nurse Maia is sweet but does not tolerate fools when it comes to vulnerable clients served by Special Touch. She gasped when I called her back to say Rose’s tympanic temperature was 102.3 degrees and the air conditioner was set on “fan” not “cool.” If she had called to confirm that the air conditioner was on, the home health aide’s answer, “Yes” would not have been technically wrong, but Rose would have been dead in a few hours had I not made the medical intervention of switching the air conditioner to “cool” from “fan.” When I felt Rose’s T-shirt it was soaking wet. The aide said, “I changed it three times today.” That would be answers (b), (c) and (d). This was the aide who appropriately called about a swallowing problem, but she didn’t tell anyone that Rose was sweating profusely. This home health aide had to pass a bare minimum English proficiency test to get her job. I had a question-and-answer conversation with her. Her English comprehension is not sufficient to do her job which maybe the root cause of correct answers (a), (b), (c) and (d). Maybe it’s just language stupid.

Rose was in blank stare mode. She does this sometimes even when she isn’t sick. I would fully expect her to not speak to me with a temperature of 102.3 degrees. We were all lucky because despite the lack of communication between Rose and I, she was drinking water from the pink sippy cup when it was handed to her.

And yet again, I wrote “elder abuse” in Rose’s encounter note. I have two friends who say to me, “You call everything elder abuse,” as if I exaggerate. Well, if I was a homicide detective would you also say, “You call everything murder?” Don’t criticize me for just doing my job of preventing manslaughter in this case. Today I could have been looking at the NYS Department of Health website on heat related hospitalization and death where Rose could have been a statistic, but Rose is still here. I did several things the least of which was pushing the button to switch the air conditioner from “fan” to “cool.” Nobody should argue with me that attempted manslaughter is not elder abuse because like racism, elder abuse is not just between two people it is SYSTEMIC, baked into how we fail to select, train and supervise home health aides. The solution is for all of us to select answer choice (f) and insist on improved standards for English fluency, regulations for longer, better, more frequent training for home health aides and actual oversight rather than nurse visits to do paperwork every six months. There are many things which could be changed within the system, but that won’t happen if what happened yesterday is acceptable or a one off or a narrow escape. Someone else besides Rose died yesterday in the same circumstance.

Its (f) all of the above.