Nursing Homes Abuse Blog - By Jonathan Rosenfeld

Sometimes I'm amazed by the number of preventable situations that develop in nursing homes due to a facilities failure to provide basic care.  I mean, doesn't it seem obvious that facilities must provide food, water and a decent environment for their residents?  Am I oversimplifying nursing home care?  Perhaps, but the reality is that an overwhelming majority of nursing home injuries and deaths could be avoided if the facility were to provide this basic level of care.

The Columbus Dispatch reported on this type of preventable situation when it reported on the dehydration death of 61-year-old Peter Southard.  In 2005 Southard was admitted to Whetstone Gardens & Care Center in Columbus, Ohio for short-term nursing care to give his wife a break from her care-giving responsibilities.  Mrs. Southard was the primary caregiver for her husband since he suffered a stroke more than 20 years ago.  The stroke made it physically difficult for Southard to care for himself and realize when he was thirsty.  Unfortunately, the staff at Whetstone Gardens was unable to pick up on his special needs and he died shortly after his 15 day admission to the facility.  The cause of death was dehydration and kidney failure.

Southard's wife brought a wrongful death lawsuit against Whestone due to their failure to provide sufficient liquids to her husband.  Despite claims from the nursing home that the care they provided was sufficient and that Southard died due to dehydration from diarrhea, a jury recognized the facilities failure to provide basic care to this disabled man.  The Franklin County, Ohio jury awarded $500,000 for pain and suffering and $6 million to the wife and family for loss of society.

Dehydration Of Nursing Home Residents

Two out of five nursing home residents suffer from some form of dehydration.  Dehydration in nursing home residents can occur for a variety of reasons, including: diarrhea, the effects of medication, inability to perceive thirst, physical inability to drink or swallow and embarrassment related to incontinence.  Most of the the time, a resident's dehydration is due to inadequate care.  Common situations involving dehydration include:

• Failure of the nursing home to employ adequate staff, which results in the staff's inability to properly feed the residents
• Failure of the staff members to pay adequate attention to those residents needing assistance with eating
• Failure to properly educate the staff on nutrition and feeding methods
• Failure to provide proper supervision over those who provide nutritional services 

In addition to monitoring resident's intake of fluid, staff should be on the lookout for the following signs of dehydration:

• Dark yellow urine
• Sunken eyes
• Ashen skin
• Dry skin
• Bleeding gums
• Urinary tract infection
• Weight loss

Is it really too much to ask that nursing homes provide necessities such as water to their residents.  I guess that is what the Whetstone Gardens and Care Center is asking themselves now.

Related Nursing Homes Abuse Blog Posts

Medical Examiner Rules Tennessee Nursing Home Death A Homicide

Grim Details Emerge Regarding Malnutrition In Kentucky Nursing Home

We All Need Water

The report of a Virginia nursing home worked allegedly stealing the identities of nine residents at two facilities to fraudulently obtain credit cards and merchandise raises the issue of how well nursing homes safeguard personal information.  In this particular case, Karen Priscilla Jones was indicted by a federal grand jury on 32 counts-- including 18 counts of aggravated identity theft.  The alleged crimes took place while Jones worked at The Oaks Assisted Living and Avante Assisted Living Facility.

If convicted, Jones faces up to 386 years in prison and $8.5 million in fines.

The following are some great suggestions for reducing incidence of identity theft--old or young-- compiled by the Legal Counsel For The Elderly.

• Do not give out identifying numbers or financial information on the phone unless you initiate the call and know the person or organization being called. Never underestimate the persuasive skills of these crooks; they can fool the smartest of consumers.
• Shred or tear into small pieces all mail solicitations, bank records or any other discarded documents that may provide information that can be used to identify you.
• Know the due dates for your bills and statements. If a regular bill or statement fails to reach you within a week of the usual time, contact the company to find out why. Thieves often divert mail to themselves to avoid alerting victims.
• Opt out of receiving pre-screened credit card offers. The three major credit bureaus use the same number: 1-888-OPTOUT (1-888-567-8688). (Experian is the only major credit bureau that goes a step further and offers removal from other lists - those used for marketing and promotional purposes.)
• Opt out of MDV lists. Notify the Alabama Department of Motor Vehicles that you do not want information about you provided to marketing and promotional groups. The Alabama law has many loopholes but this may help.
• Register on the Do-Not-Registry by calling 1-888-382-1222, from the number you wish to register; or register online at www.donotcall.gov. Registration is good for five years.
• Opt out of direct mail solicitations and e-mail lists.
  To cut down on unwanted mail, write:
  Direct Marketing Association, Mail Preference Service
  P.O. Box 643
  Carmel, NY 10512
• Give your name (all names you are known by), addresses, previous addresses if you have been there less than five years, and state that you do not wish to receive mail solicitations.
• To remove your name from e-mail lists visit http://www.dmaconsumers.org/offmailinglist.html.
• Do not put your Social Security Number on your driver license and do not carry your SS card in your wallet. Unfortunately, this will provide only limited benefit, since Medicare and other health insurers use the SSN as an identifier. This problem has been called to the attention of the SS Administration and others, but it seems that little is being done to address it.
• Store new and cancelled checks in a safe place, report lost/stolen checks to your bank immediately, and carefully review every statement.
• Periodically request a copy of your credit record. The report will let you know who has asked for information about you recently, which can give an early warning of trouble. To request a copy of your credit report for a very small charge (no charge if you have recently been denied credit), call:

Equifax @ 1-800-685-1111;
Trans-Union @ 1-800-916-8800 or
Experian @ 1-888-EXPERIAN (888-397-3742)

Nursing Homes Responsibility In Identity Theft Cases

If you have become the victim of identity theft in a nursing home setting, the first thing that should be done is to contact the local police.  A police investigation will help determine what information was taken and by who.  If the nursing home failed to safeguard personal information or became aware information was missing- yet failed to act, the facility may be responsible for all damages resulting from identity theft losses.

Nursing homes have a duty to protect their residents from harm inflicted by not just the staff and other residents at the facility--but also keeping residents from harming themselves.  Rivera Healthcare Center, a California nursing home, failed to protect a resident from harming himself and consequently received a $100,000 fine-- the highest fine permissible under California law. 

The fine comes after a California Department of Health investigation related to the burn-related death of a 64-year-old resident.  An investigation into the matter revealed that on December 23rd, a male resident left the facility in his wheelchair to smoke a cigarette.  As he attempted to light the cigarette, the man ignited himself.  

The man sustained third-degree burns to his legs, thighs, groin, buttocks and left hand.  Despite, extensive medical care in a hospital burn unit, the nursing home resident died 18 days after the incident from organ failure and sepsis as a result of the extensive burns.

The report said the nursing home staff failed to monitor the mans whereabouts and failed to respond to the emergency situations.   Apparently, upon seeing the man literally in flames, the staff panicked and failed to use a fire extinguisher and fire blanket just six feet away to douse the flames. 

In addition to this fine and AA citation, Riviera Healthcare Center also had an administrative violation earlier this year in addition to the accident for which the Department issued a $20,000 fine.  Health department records confirm 19 complaints have been filed against the facility since 2005.

Read more about this case involving smoking-related burns here.

Related Nursing Homes Abuse Blog Posts

Resident Who Smoked & Used Oxygen Suspected Of Causing Fire At Assisted Living Facility

Unsupervised Nursing Home Resident Dies From Burns

A Reminder Of What Constitutes Nursing Home Neglect

A recently disclosed Minnesota Department of Public Health report concluded the Good Samaritan Society of Albert Lea was guilty of 'neglect' due to its delay in providing medical treatment to a resident who fell during a transfer from her bed to her wheelchair.  

The episode took place on November 21st when a worker at the facility improperly used a Sabina lift to move a resident with dementia into a wheelchair.  During the transfer, the resident fell and fractured her hip.

A 'care plan' specifically stated that the resident was to wear shoes or gripper socks during transfers. At the time of the incident, the resident was wearing stockings that "enabled her feet to slip from the base of the lift, causing her to fall onto her right hip," according to the state's investigative report.

The resident involved in the incident suffered a stroke prior to her admission and was unable speak and was dependent on the staff for daily living activities.  Despite the resident's disabilities, six staff at the facility were aware of the resident's fall and the possibility of her injury because she was behaving differently after the episode-- yet no medical attention was provide for more than 19 hours after the fall occurred.

The morning following the incident, the resident was transferred to a hospital where and x-ray confirmed the woman's hip was indeed fractured.  The hip fracture required surgery.

Good Samaritan terminated the employee who was operating the lift and the nurse-supervisor following their own investigation into the matter.  According to the nursing home's own investigation, the employee responsible for the lift also failed to provide 'satisfactory' care to two other residents in the days following the lift incident.

Read more about this nursing home injury during a transfer here.

Transfers In Nursing Homes

A 'transfer' in a nursing home setting generally refers to moving a patient from a bed to a wheelchair. Transfers are usually done two ways: using nursing assistants or mechanically (Hoyer / Sabina lift). The type of transfer depends mainly on the patients physical condition.  If a patient is capable of providing some assistance, a staff lift (one or two person transfer) is generally done.  However, if a patient is paralyzed or suffers from physical disability, the use of a mechanized lift may be required to safely transfer the patient.

The choice of how to transfer a patient from a bed to a wheelchair is up to the facility.  A determination of the type of transfer should be part of the evaluation when a person is admitted to the facility and for quarterly reviews of nursing home patient needs.  It is crucial for the staff at the facility to use the properly predetermined transfer technique or the nursing home resident is at risk to injury. 

If you or a relative sustained an injury during a 'transfer' to wheelchair, walker or toilet, there is a strong likelihood the staff responsible for supervising made an error.  We have handled many similar lift-related injury cases.  Put our experience to work for you.  To speak with our team of nursing home attorneys, call (888) 424-5757.

When will cameras become standard issue in nursing homes and assisted living facilities?  Amongst many elderly who are unable to effectively communicate, the only way of 'catching' abusive situations is via surveillance cameras.

A camcorder left in a patients room caught Jason Lynn Pearl abusing two residents at Silver Lake Care Center.  At the time the abuse took place, Pearl was working at the nursing home.  Two co-workers saw the videotaped abuse and reported the situation to authorities. 

Pearl now faces two counts of felony abuse by care taker and is being held by authorities on $100,000 bond.

About Silver Lake Care Center

All residents of Silver Lake Care Center, will be forced to moved from the facility by the time it shuts its doors on June 5th.  The Oklahoma nursing home is owned by Eddie Martin.  Martin owns five other nursing homes and assisted-living facilities in Oklahoma including:

• Pleasant Springs In Colcord
• Cimarron Pointe Care Center in Mannford
• Coweta Manor Nursing Home in Coweta
• Glenpool Health Care Center in Glenpool
• Rolling Hills Care Center in Catoosa
• Sequoyag Pointe Living Center in Owasso
• Shawn Manor Nursing Home in Ponca City

Coincidentally, each facility Martin owns has 32 security cameras mounted in the facilities.  Martin apparently monitors all cameras from his home.  I guess he can't monitor all of the cameras?

Read more about this case of nursing home abuse in an Oklahoma Nursing Home here.

Related Nursing Homes Abuse Blog Posts On Elder Abuse

What Is Elder Abuse?

94-Year-Old Charged With Raping Co-Resident In Oklahoma Nursing Home

Caught On Tape: 90-Year-Old Man Beaten By Home Nurse

Can someone please let me know what drives a person to physically abuse a defenseless elder? Is it empowering?  Is it done out of frustration? Does it just feel good?

Out of Texas, Lufkin Police have arrested a certified nurses aide (CNA) in connection with an episode of abuse witnessed by co-workers.  The incident took place on March 22, 2009 at Castle Pines Health and Rehabilitation Center. Apparently, the CNA took an 80-year-old CNA into her room, closed the door and began striking resident.

Staff at the facility were alerted to a potential problem when the resident activated a call light by the bed.  When staff arrived to check on the situation, they witnessed the CNA striking the resident.  A closer inspection of the situation revealed the resident's blood spattered on her bed.  Bruises were also observed on the resident's arms and legs.

Shortly after she was confronted by co-workers, the CNA admitted to 'popping the victim.'

Currently, the CNA is out and about in the community as she posted the necessary $5,000 bond shortly after she was taken into custody.

About Castle Pines

We make it our top priority to care for seniors with the respect, compassion and dignity they deserve. We understand that caring is what makes a community and without a sense of caring, there can be no sense of community. It's what sets us apart from any other long-term care facility.

Here at Castle Pines Health & Rehabilitation our nursing staff is overly-courteous, respectful and maintains a high level of professionalism at all times. Our primary goal is to get you back in a condition to be independent once again while maintaining a friendly environment and providing nutritionally enhanced meals.

I guess the CNA involved in this incident missed orientation?

McKnight's reported on a new Medicare program intended to reduce the number of people who are re-admitted to hospitals shortly after their discharge --- and ultimately save the agencies money.  Presently, many nursing homes and assisted living facilities are faced with the difficult task of caring for people who may be recovering from a injury or disease that required hospitalization.  In some cases, staff in the new environment are not trained on how to provide proper follow-up treatment.

The lack of staff training can translate to more visits to the hospital.  By CMS's estimates, 20% of hospital patients get readmitted within 30 days of their discharge to a nursing home or assisted living facility.  CMS estimates up to 75% of the re-admissions are preventable with proper treatment in their discharge setting.

The program identified as the 'Care Transitions Project' will be tested in 14 pre-selected communities.  State officials will help facilities create programs to provide necessary care outside of a hospital setting.  The program will begin shortly and will remain in place through the summer of 2011.

I hope this program has sufficient safeguards to ensure the safety of new admissions to nursing homes and assisted living facilities. Many people are at heightened risk for injury and disease shortly after their admission because their medical condition is unstabilized and the facility remains unaccustomed to their medical needs.  Safeguards should be in place to ensure those who really need hospital services receive the care they require.

Lastly, at a time when budgets and services are already stretched thin, do we really want to add more to the list of responsibilities imposed on nursing homes?

Read more about the Care Transitions Project here.

The Chicago Sun Times reports this morning that a 63-year-old resident of a Chicago nursing home died from multiple injuries suffered during an assault.  A spokesman for the Cook County Medical Examiner's office confirmed the man, identified as Thomas Donovan, died on April 1 at South Shore Hospital.  The death has been ruled a homicide and Illinois State Police are conducting an investigation into the matter.

Although the name of the nursing home was not revealed, the Sun Times identifies the facility's location as 14500 S. Manistee Avenue in Burnham. 

Burnham Healthcare's Troubled History

An internet search of the address reveals the facility to be Burnham Healthcare.  Burnham has a history of violence amongst its residents.  In 2004, the Illinois Department of Public Health fined the facility $5,000 for failing to investigate an incident of a resident who was sexually aggressive towards another resident.

The state investigation revealed the resident at issue had a history of sexually aggressive behavior, yet the facility failed to take any action to protect other residents.  On the morning of the reported incident, the staff at Burnham began to take steps to transfer the resident, yet failed to monitor the man while they awaited approval for the transfer.  During the unsupervised wait, the man committed a sexual assault.

Related Nursing Homes Abuse Blog Posts

Update On Nursing Home Rape: Facility Made Errors In Investigation Of Incident

Nursing Home Director Sentenced To 19 Months In Prison For Ignoring Injured Resident

Wrestling Legend Takes Moves To Minnesota Nursing Home

A research study concluded by researchers at Brown University concluded nursing homes with a higher Hispanic populations have higher rates of bed sores (also known as: pressure sores, pressure ulcers, decubitus ulcers) than facilities with less minorities.  The results are detailed in the Journal of the American Medical Association.

The researchers gathered information from the National Repository of the Minimum Data Set, a federally mandated assessment of all nursing home residents and from the Oscar Database System, a survey of all nursing home residents from the Centers for Medicaid and Medicare Services.  Additionally, the Brown study evaluated all nursing home residents over 65 who live in nursing homes in California, New Mexico, Texas, Arizona and Colorado.

The lead researcher of the Brown survey, Vincent Mor, chair of the Department of Community Health, conducted a similar survey in 2007 that concluded African Americans are more likely than whites to live in poor-quality nursing homes.  That study found the disparity of care received in predominately African American nursing homes to be worst in the Midwest.

Read more about the results of this nursing home survey here.

Bed Sores Are A Problem Facing All Nursing Home Residents

A bed sore is an area of skin that breaks down when you stay in one position for too long without shifting your weight. This often happens if you use a wheelchair or you are bedridden-- even for a short period of time (for example, after surgery or an injury). The constant pressure against the skin reduces the blood supply to that area, and the affected tissue dies.

A bed sore starts as reddened skin but gets progressively worse, forming a blister, then an open sore, and finally a crater. The most common places for pressure ulcers are over bony areas like the elbow, heels, hips, ankles, shoulders, back, and the back of the head.

Despite claims from the health care industry, bed sores are preventable with competent medical care.  Staff in nursing homes and hospitals must to an assessment of those individuals who are at heightened risk for development of bed sores and create a plan for their prevention.  Frequently, a care plan will include: frequent rotation to discourage sitting in one area for long periods, pressure relieving air mattresses and special enhanced nutrition diets.

Our Commitment To Minority Communities

One of the reasons there are higher rates of poor nursing home care amongst minorities is due to barriers in communication.  Nursing homes housing individuals should have staff to help communicate both physician orders to the residents and to communicate resident needs to physicians.  When there is a breakdown in communication, resident safety is jeopardized.

At Rosenfeld Injury Lawyers, we pride ourselves on our commitment to all minorities.  For more than 35 years, we have been honored to represent individuals and families of all races and ethnicity's.  We maintain a Spanish speaking staff and frequently work with translators to zealously represent individuals in the Polish, German, Italian, Japanese, Chinese, Korean and Vietnamese communities. 

We believe all people, regardless of their ethnic background, deserve the finest legal representation available.

Nursing Homes Abuse Blog Entries On Bed Sores:

Government Report Confirms Pressure Ulcers Harm All Nursing Home Residents; Regardless Of Race, Sex or Age

Incontinence Amongst The Nursing Home Population

Over 500,000 Adults Suffer From Bed Sores In Hospitals

The Chicago Tribune reported that an 81-year-old resident at the Maryville Manor Nursing Home 'shimmied' through a window to escape the facility and wander from the grounds.  Hours later, the man was found dead along a nearby road.

Authorities at Maryville Manor confirmed that the man suffered from Alzheimer's and had been living at the facility for two weeks. Madison County, Illinois authorities are conducting an investigation into this wandering incident.

An open window?

Nursing homes that house Alzheimer's residents should have necessary safeguards in place to ensure the safety of residents.  One of the biggest threats to Alzheimer's residents is self-inflicted injury due to wandering from the safety of a facility.  In addition to basic precautions such as locking windows and doors, nursing homes should also:

• Use bracelets that track each resident's location
• Assess each resident for their propensity to wander from the facility
• Hire adequate staff to look after residents
• Have contingent plans to locate residents who may wander from the facility

There is no obligation on the part of nursing homes to house every person who seeks out the facility's services.  However, when the nursing home agrees to house a resident who is disoriented or has dementia, the nursing home is implicitly agreeing they are able to properly care for the individual and is responsible for providing proper care.

Related Nursing Homes Abuse Blog Post's

Woman Dies From Hypothermia After Wandering From Assisted Living Facility

Family Sues Florida Nursing Home For Death Of Wandering Resident

What Can Nursing Homes Learn From Jails?

The Des Moines Register reported on a new bill proposed by Senator Tom Coburn (R- Oklahoma) that would end the practice of paying poorly performing nursing homes a bonus.  Under the current system, nursing homes across the country are paid hundreds of millions of dollars in bonuses by taxpayers regardless of their record of health and safety violations at their facilities.

The Register looked at eight programs in seven states where regulatory violations don't disqualify a nursing home from receiving a bonus and determined the eight programs alone cost taxpayers $312 million per year.  "We paid out in excess of $300 million in bonuses to nursing homes that had significant problems in terms of giving the care and meeting Medicare standards," Coburn said. "Why? Why wouldn't we fix that?"

In addition to providing bonuses to nursing homes that fail to meeting government standards, the government also pays bonuses to nursing homes for legally mandated requirements such as installing fire sprinklers or paying employees minimum wages.

The bill was accepted by unanimous consent of the Senate, but the bill remains to be approved.  Read more about this nursing home legislation here.

Related Nursing Homes Abuse Blog Posts

New Bill Would Return Money To Dangerous Nursing Homes After They Correct Problems

New Law Makes Prosecution Of Nursing Home Cases More Difficult

More Support For The Nursing Home Transparency Act

The pending criminal trial of Jill and Julie Barry will have an important impact on Illinois seniors as it will help define what constitutes 'reasonable care' when it comes to the home-care of elders. Currently, prosecutors in Illinois have few parameters when it comes to the definition of 'elder abuse' because Illinois courts have not formally ruled on the issue before. Consequently, the decision as to how to define 'reasonable care' in a criminal neglect context will fall squarely on jurors.

In 2008, Kane County State's Attorney, John Barsanti filed criminal neglect charges against the Barry sisters related to their responsibility to provide care to their elderly mother. Kane County jurors will soon make a determination if the care the sisters provided was 'reasonable'-- or criminal- for their 84-year-old mother.

The criminal charges follow a 2007 Kane County Coroner-ordered investigation.  The coroner ruled Mary Virgina Barry's death was a homicide due to the physical sings of neglect encountered during an autopsy. 

An investigation revealed that prior to her death, Ms. Barry weighed just 70 pounds, had extensive bed sores, and had not seen a doctor for nine months. According to a paramedic report, Ms. Barry was lying in soiled bed sheets and had ants crawling on her when authorities were called to her home.  Barry was immediately taken to a local hospital where she died several days later.

Web Resource:

Elder abuse: Trial to shed light on horrors in home and help home Illinois law, chicagotribune.com, April 2, 2009

Nursing Homes Abuse Blog Related Entries

Southern Illinois Nursing Home Sued For Resident's Decubitus Ulcers

Grim Details Emerge Regarding Malnutrition In Kentucky Nursing Home

Judge Tosses Manslaughter Charges Against Nursing Home Employees In Case Involving Death Of Disabled Resident

Criminal Charges May Be Brought Against Chicago-Area Nursing Home In Connection To Resident's Death

An anticipated decision by the 11th Circuit Court of Appeals may alter the way medical treatment is dispensed for Medicaid recipients.  Under the current system, Medicaid recipients are entitled to receive 'medically necessary' treatment as prescribed by their physician.  In cases of disabled or handicapped people this frequently means home nursing care by a CNA or therapist. 

The case pending before the 11th Circuit involves Anna Moore, a 14-year-old Georgia girl, who suffers from a seizure disorder since birth.  Because of her ongoing risk of stroke and breathing problems, Anna's physician prescribed round-the-clock nursing care. Despite the medical order from Anna's physician (and years of approving the nursing services), officials at Georgia Medicaid decided to arbitrarily reduce the number of weekly hours provided by a home nurse. The reduction occurred despite the fact there was no change in Anna's medical condition.

Anna’s mother initiated a lawsuit against Georgia Medicaid to force the government agency to provide home nursing as prescribed by Anna’s physician.  The decision is now in the hands of the Appellate court after a lower court ruled in favor of the disabled girl.

At issue is the state’s right to overrule medical orders from a treating physician because the state does not agree with the prescribed treatment.  Advocates for Medicaid recipients question the financial motive behind an administrative agencies right to withhold medical treatment.  “[I]f a state budget is pinched, what might have been medically necessary in June won’t be in July…and a medical opinion as to the necessity as to necessity simply isn’t relevant,” said Greg Mellowe a healthcare policy directory at Florida CHAIN.

Lawyers for the state question the medical necessity of some of the treatments prescribed by physicians.  “When left to their own devices, they advocate for their patients and deem all manner of unproved, dangerous, ineffective, cosmetic, unnecessary, bizarre, and controversial treatments as ‘medically necessary,’” according to a court brief filed by the Florida Attorney General.

The 11th Circuit’s decision directly impacts the states in its jurisdiction: Florida, Georgia and Alabama, but the courts ruling will likely set a precedent for all Medicaid recipients in other states.  The court’s ruling will likely be issued in several months.

Read more about this pending court decision here.

Tennessee officials have suspended new the admission of new residents at the Quality Care Health Center in Lebanon, TN.  The suspension comes after state and federal investigators found multiple safety violations during an investigation related to a complaint filed against the nursing home.  Investigators from the Federal Center for Medicare-Medicaid Services found violations in physician services, nursing services and with medical records.

Investigators discovered residents at the Tennessee nursing home were put in 'immediate jeopardy' because nurses did not keep proper charts.  Additionally, nursing home inspectors also documented instances of dramatic weight loss among residents.

Quality Care Health Center was opened in 1978 and has a 290 bed capacity.  The facility has until April 3rd to correct all deficiencies or it will lose federal funding.  Read more about this troubled Tennessee nursing home here.

Watch the video clip regarding Quality Care Health Center from NewsChannel5.com here.

Department of Heath & Human Services Report