Abuse & Neglect of Nursing Home Residents: What are we doing ...
SEXUAL ABUSE IN NURSING HOMES What You Need To Know Wednesday, September 5, 2018 The Consumer Voice The National Consumer Voice for Quality Long-Term Care (Consumer Voice) is a national, non-profit organization in Washington, D.C. that advocates for people receiving care and services at home, in assisted living, or in a nursing home.
Clearinghouse of information and resources for empowering consumers, families, caregivers, advocates and ombudsmen in seeking quality care, no matter where. Provide technical assistance and support for state advocacy regarding long-term care services and supports and have a national action network. Presenters Julie Schoen, J.D., Deputy Director, National Center on Elder
Abuse, Keck School of Medicine (USC) Dr. Pamela Teaster, Director, Center for Gerontology (Virginia Tech) Alisha Lineswala, J.D., Public Policy & Program Specialist, National Consumer Voice for Quality Long-Term Care Amity Overall-Laib, Director, National Ombudsman Resource Center Vicki Elting, Assistant State Long-Term Care Ombudsman, Washington State Long-Term Care Ombudsman Program
Lori Smetanka, J.D., Executive Director, National Consumer Voice for Quality Long-Term Care THE NATIONAL CENTER ON ELDER ABUSE Funded by a grant from the Administration on Community Living and Administration on Aging (ACL/AoA), serving as one of 27 National Resource Centers. The NCEA is a provider of up-to-date, pertinent and valuable resources, education, and information on elder abuse and neglect. As a leader in the elder justice movement, we:
Create valuable educational resources Provide training curricula tailored to a variety of audiences Deliver up-to-date research Build partnerships and make connections Explore innovative models Listen to what the field needs Take advantage of opportunities to advance the field
Communicate our efforts Envision our goals for tomorrow Sexual Abuse in Long-Term Care Settings: Research Findings and Practical Implications Pamela B. Teaster, Ph.D. Professor & Director Center for Gerontology, Virginia Tech National Consumer Voice for Quality Long-Term Care/ National Center on Elder Abuse Webinar, September 5, 2018
Center for Gerontology CDC Elder Sexual Abuse Forced or unwanted sexual interaction (touching & nontouching) of any kind with adult 60+. May include, not limited to, forced or unwanted completed or attempted contact betweenforced or unwanted intentional touching, either directly or through the clothing... These acts also qualify as sexual abuse if they are committed against an incapacitated person who is not competent to give informed approval. Centers for Disease Control and Prevention. (2018). Elder Abuse: Definitions https://www.cdc.gov/violenceprevention/elderabuse/definitions.html
Center for Gerontology Literature Review Prevalence and Correlates of Emotional, Physical, Sexual, and Financial Abuse and Potential Neglect in the United States: The National Elder Mistreatment Study Ron AciernoPhD, Melba A. HernandezMS, Ananda B. AmstadterPhD, Heidi S. Resnick PhD, Kenneth SteveMS, Wendy MuzzyBS, and Dean G. KilpatrickPhD Author affiliations, information, and correspondence details Accepted: May 15, 2009 . Published Online: American Journal of Public Health. September 20, 2011 Sexual Abuse of Older Women Living in Nursing Homes Pamela B. Teaster PhD &Karen A. Roberto PhD. Pages 105-119 | Published online Journal of Gerontological Social Work: 11 Oct 2008. https://doi.org/10.1300/J083v40n04_08
From Behind the Shadows: A Profile of the Sexual Abuse of Older Men Residing in Nursing Homes Pamela B. Teaster PhD,Holly Ramsey-Klawsnik PhD,Marta S. Mendiondo PhD, Erin Abner MPH,Kara Cecil BS &Mary Tooms BS Pages 29-45 | Published online Journal of Elder Abuse and Neglect: 08 Sep 2008 Center for Gerontology Acknowledgements Holly Ramsey-Klawsnik, Ph.D. Director of Research, National Association of Adult Protective Services Erin Abner, Ph.D. Professor, University of Kentucky
Associate Adult Protective Services: Oregon, New Hampshire, Tennessee, Texas, Wisconsin Texas Department of Aging and Disability Services, Wisconsin Elder Abuse, Wisconsin Bureau of Quality Assurance Center for Gerontology Objectives To investigate patterns of the sexual abuse of vulnerable older and younger adults living in longterm care institutions; To test a web-based system for obtaining sensitive
and confidential information on the sexual abuse of vulnerable adults; and To refine an emergent theory of the mistreatment of vulnerable adults. Center for Gerontology Specific Questions
Who are the victims? Who are the offenders? Where are the cases occurring? What factors correlate with sexual abuse in care facilities? How often do these cases reach state attention? How are they investigated? Do professionals have adequate resources to respond effectively? What is our response to victims?
How are perpetrators handled? Can we create a suggested protocol for responding to alleged cases? Center for Gerontology Participating States New Hampshire APS Oregon APS Tennessee APS Texas APS Texas Department of Aging and Disability Services
Wisconsin APS/Elder Abuse Wisconsin Bureau of Quality Assurance Center for Gerontology Data Analysis Goal: to identify factors independently associated with substantiation of sexual abuse allegations Method: unadjusted analysis, adjusted analysis (logistic regression) Center for Gerontology
Unadjusted Results - Victim On average, victims in substantiated cases were: about 10 years older more likely to be female more likely to have dementia more likely to have impaired ADLs less likely to be oriented to person at least some of the time less likely to reside in care facilities with high level supervision See Table 2. Abner et al. Victim, allegation, and investigation characteristics associated with substantiated reports of sexual abuse of adults in residential care settings. J Interpersonal Violence 2016; DOI:10.1177/0886260516672051
Center for Gerontology Center for Gerontology Unadjusted Results - Victim On average, we did not see differences with regard to: Orientation to place or time Ability to communicate Center for Gerontology Unadjusted Results - Allegation On average, sexual abuse allegations were more likely
to be substantiated if: there was also an allegation of neglect the sexual abuse was of a hands-on type rape, attempted rape, molestation, harmful genital practices, oral-genital contact, prostitution of victim, sadistic sexual activity, or sexualized kissing the accused perpetrator was another resident Center for Gerontology Unadjusted Results - Investigation On average, substantiated sexual abuse was more likely if: the victim disclosed abuse
the investigative agency had regulatory authority the time between incident and report was less than 4 days On average, we did not see differences with regard to: Witnesses making the allegation Victims providing a written statement Center for Gerontology Our Adjusted Model We included these predictors: Victim Age, sex, psychiatric illness, dementia, ADL impairments, ambulation,
orientation, ability to communicate, care facility level of supervision Allegation Other abuse allegations, perpetrator relationship to victim, hands-on offense Investigation Victim disclosed abuse, victim written statement, victim injury, agency type Subset analysis: time from incident to report Center for Gerontology
Center for Gerontology Center for Gerontology Conclusions/Determining Risks Based on this analysis, key factors in predicting substantiation of sexual abuse cases in the five states were: Care facility level of supervision Perpetrator relationship to victim Victim injury Victim disclosure Time from incident to report
Center for Gerontology Caveats Results may not be generalizable in other states Other unmeasured factors likely to be important, e.g.: Past experience of the investigator Victim cognitive status Center for Gerontology To Consider
18% of facility sexual abuse investigations substantiated vs. 46% of all allegations (Teaster et. al., 2006) How much of this difference is due to facility cases? How much is due to sexual abuse allegations? Practice question: Are sexual abuse allegations harder to investigate? Harder to substantiate? Center for Gerontology Not Surprising More female than male victims in substantiated cases Alleged physical contact substantiated more
frequently than no physical contact Questions: How do we consider non-touching forms of sexual abuse? Do state and regulation definitions include non-touching sexual offenses? Center for Gerontology Significant Finding Over of alleged perpetrators were facility employees, were residents Yet 63% of substantiated cases involved resident alleged perpetrators
Staff alleged perpetrator sub rate = 19.4% Resident alleged perpetrator substantiation rate vs staff alleged perpetrators= 62.5% (2.5 x) Center for Gerontology Profound Finding Substantiation was more likely when the abuse report was received within 3 days of the alleged incident 4-fold greater odds of substantiation Implications On mandatory reporting & time limits On investigation commencement time
Center for Gerontology Victim Disclosure If the alleged victim disclosed abuse, substantiation was more likely 3-fold greater However, among older women, over who disclosed sexual abuse did not have case substantiated (Teaster, Ramsey-Klawsnik, Abner & Kim, 2015) Implications - those disclosing but not believed Implications for non-verbal victims High need for special communication remedies Center for Gerontology
Injuries Substantiated cases included more visible injuries In fact, 5-fold greater odds of substantiation However, very few victims received forensic exams Center for Gerontology Signs and Indicators of Sexual Abuse Sustaining a pelvic injury Having problems walking or sitting Developing a sexually transmitted disease or STD Torn, bloody, or stained underwear
Bruises of the genitals or inner thigh Bleeding from the anus or genitals Traxler, C. (2018). Sexual abuse of the elderly. https://www.nursinghomeabusecenter.com/elder-abuse/types/sexual-abuse/ Center for Gerontology Signs and Indicators of Sexual Abuse (continued) Panic attacks Signs of Post-Traumatic Stress Disorder (PTSD) Symptoms of agitation Social or emotional withdrawal from others Engaging in inappropriate, unusual or aggressive sexual activities
Suicide attempts Engaging in unusual or inappropriate actions that appear to be from a sex role relationship between the perpetrator of elder sexual abuse and the victim Traxler, C. (2018). Sexual abuse of the elderly. https://www.nursinghomeabusecenter.com/elder-abuse/types/sexual-abuse/ Center for Gerontology Response to Victim LISTEN TO THE VICTIM Act quickly, conduct forensic examination, look for injuries Maintain a high index of suspicion Intervention that protects, not punishes the victim
Consider a spectrum of sexual abuse AND polyvictimization Response to the perpetrator(s), the family, and the affected organization Center for Gerontology Thank you very much! Center for Gerontology FEDERAL REGULATIONS
Freedom from Abuse 483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse.as defined in this subpart. 483.12(a) The facility must (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; Guidelines: Each resident has the right to be free from abuse, neglect and corporal punishment of any type by anyone. Staff (permanent and temporary)
Visitors (including family, friends, and strangers) Even other residents Employment & Reporting 483.12(a) The facility must 483.12(a)(3) Not employ or otherwise engage individuals who Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or Have a disciplinary action in effect against his or her professional
license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. 483.12(a)(4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff Written Policies & Procedures: Prohibition and Prevention of Abuse 483.12(b) The facility must develop and implement
written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (3) Include training as required at paragraph 483.95, Written Policies & Procedures: Investigations of Allegations 483.12(b) The facility must develop and implement written policies and procedures that: (2) Establish policies and procedures to investigate any such
allegations [of abuse] Written Policies & Procedures: Reporting 483.12(b) The facility must develop and implement written policies and procedures that: (5) Ensure reporting of crimes occurring in federally-funded long- term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (i) Annually notifying covered individuals, as defined at section 1150B(a)
(3) of the Act, of that individuals obligation to comply with the following reporting requirements. (ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act. (iii) Prohibiting and preventing retaliation, as defined at section 1150B(d) (1) and (2) of the Act. Facility Response to Alleged Violations 483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse.are reported
immediately, but not later than 2 hours after the allegation is made. Investigation 483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his
or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. ROLE AND RESPONSIBILITIES OF THE OMBUDSMAN PROGRAM IN INVESTIGATING COMPLAINTS INVOLVING ABUSE What is NORC? Funded by the Administration on Aging/Administration for Community Living grant Operated by the National Consumer Voice for Quality Long-Term Care (Consumer
Voice) in cooperation with the National Association of States United for Aging and Disabilities (NASUAD) Provides support, technical assistance, and training for state long-term care ombudsman programs and their program representatives: Information, consultation, and referral for Ombudsman programs Training and resources for state ombudsman programs and program representatives Promotes awareness of the role of the Ombudsman program Works to improve ombudsman skills, knowledge, and effectiveness in both program management and advocacy What is the Long-Term Care Ombudsman Program (LTCOP)?
LTCOP representatives are resident-directed advocates. LTCOPs advocate for quality of care and quality of life of residents in long-term care (nursing homes, board and care/assisted living, other similar adult care facilities). Per the Older Americans Act (OAA) and LTCOP Rule the program: Investigates and resolves complaints. Provides information to residents, families, staff (e.g., residents rights). Advocates for systemic changes to improve residents care and quality of life. Provides technical support for the development of resident and family councils. Represents resident interests before governmental agencies. Advocates for changes to improve residents quality of life and care. Seeks legal, administrative, and other remedies to protect residents. Ensures residents have regular and timely access to the LTCOP.
LTCOP Activity Highlights (2016) Visited 27,822 long-term care facilities at least quarterly Attended 22,205 Resident Council Meetings and 1,974 Family Council Meetings 10,690 community education sessions 4,702 trainings for LTC facility staff 115,708 consultations to LTC facility staff 378,526 information and consultation to individuals (residents, family members, others) National Ombudsman Reporting System (NORS) Data 2016
199,493 complaints in 2016 11,225 nursing home complaints involving abuse, gross neglect, or exploitation 819 complaints involving sexual harassment, sexual coercion, or sexual assault by facility staff, management, or an unknown/outside individual that gained access to a resident due to facility negligence. 2,764 complaints involving willful physical or sexual abuse by a resident against one or more other residents. This Photo by Unknown Author is licensed under CC BY-SA-NC LTCOP Complaint Investigations
Ombudsman program representatives: Investigate individual complaints and address concerns that impact several or all residents in a facility. Can address general concerns they personally observe during a visit (e.g. odors, concerns about the environment, staff not knocking on resident doors before entering). Cannot share information without resident consent. Investigate to gather the facts, but the main goal is to resolve the issue to the residents satisfaction. Call upon others to fulfill their responsibilities to residents. Represent resident needs by working for legislative and regulatory changes (e.g.,
coordinated systems advocacy lead by the State Ombudsman). Resident-Directed Advocacy As resident advocates: The resident guides LTCOP action. The LTCOP needs resident consent prior to taking any action on a complaint or sharing resident information.* The LTCOP seeks to resolve complaints to the residents satisfaction. The LTCOP represents residents interests, both individually and systemically. The LTCOP empowers residents and promotes self-advocacy. *If the resident cannot provide consent, the LTCO will work with the residents legal representative or follow their state procedure if the resident doesnt have a
legal representative. Person-Centered Complaint Processing Ombudsman Program Final Rule 45 CFR 1324.19(b) Person-centered complaint processing approach--the Ombudsman or representative of the Office shall: Support and maximize resident participation; Offer privacy; Discuss the complaint with the resident (and/or residents representative) in order to: Determine the perspective of the resident; Request informed consent in order to investigate the complaint;
Determine the wishes of the resident with respect to resolution of the complaint, including: whether the allegations are to be reported disclosure of information to the facility and/or appropriate agencies. Advise the resident of his/her rights; Work with the resident to develop a plan of action for resolution of the complaint; Investigate to determine whether the complaint can be verified; and Determine whether the complaint is resolved to the residents satisfaction.
Why is resident-directed advocacy important? By providing confidential, conflict free, resident-directed advocacy: Trusted, person-centered problem solver Build rapport Enhanced trust Credible source of information From the residents perspective, if I have a complaint, do I trust the Ombudsman program to investigate and resolve my complaint? Key Distinctions between the Ombudsman Program and Adult Protective Services Mission
LTC Ombudsman Adult Protective Services Resolve complaints to satisfaction of the
resident Improve the quality of care and quality of life of residents Stop abuse, neglect and exploitation; Protect the victim Role of individual self-determination Resident-directed advocate; represents resident interests
Stress victim self-determination, but protects victim even if not consistent with individual wishes Abuse, neglect, exploitation Respond to reports of abuse, neglect, exploitation (and self-neglect in some states) Purpose of investigation
RESOLVE: Not the official finder of fact; do not substantiate abuse Verify to determine whether sufficient information to continue toward resolution Gather information in order to resolve the problem, not for any legal proceeding DETERMINE:
Official finder of fact Determine whether reported allegation occurred Many states use the term substantiate If determined, case often referred to law enforcement for prosecution Systems level advocacy
Required by the Older Americans Act and LTCOP Rule. Not a responsibility (may be prohibited by state law) Respond to any resident-related complaint (ACL provides 119 complaint types) 8% abuse/neglect/exploitation, 2016 To recapthe Ombudsman program Cannot be mandatory reporters
Provides resident-directed advocacy to resolve issues to the residents satisfaction Investigates complaints involving abuse, but is not the official fact finder to substantiate abuse or determine whether a law or regulation has been violated. How to Contact the LTCOP Nursing homes are required to post contact information for the LTCOP and some states require
assisted living facilities/board and care facilities to post information about the LTCOP. Visit the NORC website to locate your local or state LTCO: http://www.ltcombudsman.org/ STATE EXAMPLES The Prevention and Detection of Sexual Assault of
Nursing Home Residents Developed by the Nursing Home Ombudsman Agency of the Bluegrass and the Bluegrass Rape Crisis Center.
This manual and training resource is intended for use by ombudsmen in collaboration with local rape crisis programs. My Body, My Rights brochure http://ltcombudsman.org/omb_s upport/training/materials-create d-by-ombudsman-programs#ab use
Sexuality and Intimacy in Long-Term Care Facilities Examples of facility policies and procedures Consumer education Training for facility-staff by Ombudsman programs http://ltcombudsman.org/issues/sexuality-and-intimacy-in-long-term-care-facilities RESOURCES Abuse, Neglect, Exploitation, and Misappropriation of Property
Based on revised nursing home regulations On-Demand Training Course PowerPoint Fact Sheet http://ltcombudsman.org/issu
es/abuse-neglect-and-exploi tation-in-long-term-care-facili ties#info-for-consumers LTCOP Reference Guide Responding to Allegations of Abuse: Role and Responsibilities of the Ombudsman Program Overview Key Points
AoA Statements What Can An Ombudsman Do? LTCO Advocacy Strategies Resources http://ltcombudsman.org/uplo ads/files/issues/ane-no-conse nt-ref-guide-july_2018.pdf Balancing Privacy & Protection Surveillance Cameras in Nursing Home Residents Rooms
Additional Information Nursing Home Regulations http://ltcombudsman.org/library/fed_laws/federal-nursing-home-regulations Abuse, Neglect, Exploitation Issue Page http://ltcombudsman.org/issues/abuse-neglect-and-exploitation-in-long-term-car e-facilities Ombudsman Program Final Rule http://ltcombudsman.org/library/fed_laws/ltcop-final-rule
ACLs Frequently Asked Questions (FAQs) Question: Does the Rule prohibit an Ombudsman or representatives of the Office from being mandated reporters under state abuse reporting laws? Answer: Yes. Both the Older Americans Act and the Rule prohibit reporting of resident-identifying information without the residents consent. By logical extension, this precludes mandated reporting of suspected abuse which discloses such information. Through the strict disclosure limitations within the Act, Congress has indicated its intent for the Ombudsman program to be a safe, person-centered place for residents to bring their concerns. Residents can be assured that their information will not be disclosed without their consent, the consent of the resident representative, or court order. (OAA Section 712(d)(2)(B)). Despite numerous Congressional reauthorizations of the Act, Congress has never provided an exception for abuse reporting in the Act.
ACLs FAQs Question: Does the Rule prohibit Ombudsman programs from investigating abuse complaints? Answer: No. Both the Older Americans Act and the Rule require the Ombudsman program to identify, investigate, and resolve complaints that relate to action, inaction or decisions that may adversely affect the health, safety, welfare, or rights of the residents. Abuse, neglect and exploitation of residents are among the complaints that fall within this purview. However, Ombudsman programs are not the official entity to substantiate (or, finder of fact) for abuse complaints on behalf of the state or other governmental entity. Ombudsman programs represent the interests of residents, rather than the interests of the state or other governmental entity. (See OAA Section 712(a)(3)(E), (a)(5)(B)(iv); 45 CFR 1324.13(a)(5), 1324.19(a)(4)).
The National Long-Term Care Ombudsman Resource Center (NORC) www.ltcombudsman.org This project was supported, in part, by grant number 90OMRC0001-01-00, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy. A single bracelet does not jingle. -Congolese proverb
The Alliance to End Sexual Violence in Long Term Care Who we are Statewide partnership to provide technical assistance and build capacity and effectiveness together for the advocacy of long term care residents who have experienced sexual violence today, tomorrow, or in the past. Who you are Disability advocates, sexual assault advocates, long-term care ombudsmen, and any individual or organization that cares for or about the lives of residents of long term care.
Who Is Affected By Sexual Violence? Sexual Violence knows no boundaries - it can affect every age, race, class, culture, gender, ability, sexual orientation, gender identity, and sex, but in the end, we are all affected. Residents of long term care facilities are highly vulnerable to sexual violence because of their isolation and dependence on others for their care. Residents are largely silent about sexual violence. Key idea Retaliation is a reality May be for any complaint or problem: residents are encouraged to not cause
or be a problem. May be for forming relationships with other residents May be because one is perceived as difficult Can include: longer waits for assistance, not allowing one to leave the facility, restricting visitors, outings, access to resources, events, and activities, restricting relationships, showers, over or under medicating, cold food or food one cant eat, and the most frightening: the threat of discharge. Advocacy barriers We must be Resident/Survivor driven
Take time, be with the person Role may just be to listen and be present, without resolution Advocate is not the fixer: role is to support and empower Assure confidentiality Question and mirror survivor experience for support
Recognize with trauma, things may not be in chronological order Take time, be with the person Be trauma-informed Advocate role Vision To bring the silence surrounding sexual violence in long term care facilities out of the shadows and into the community for support and healing.
Thank you This project is supported by Grant No. 2012-FW-AX-K003 awarded by the Office on Violence Against Women, U.S. Department of Justice. The opinions, findings, conclusions, and recommendations expressed in this publication/program/exhibition are those of the author(s) and do not necessarily reflect the views of the Department of Justice, Office on Violence Against Women. QUESTIONS? GETTING HELP If You Suspect Sexual Abuse
Getting Help Facilitys administrator, director of nursing, social worker, or other trusted staff-person Law Enforcement Long-Term Care Ombudsman Program State Survey Agency that licenses the facility
Protection and Advocacy or Adult Protective Services Citizen Advocacy Group How to Contact the LTCOP Nursing homes are required to post contact information for the LTCOP and some states require assisted living facilities/board and care facilities to post information about the LTCOP. Visit the National Consumer Voice website to locate your local or state LTCO: http://theconsumervoice.org/get_help RESOURCES
Fact Sheet www.theconsumervoice.org Fact Sheets Guides Assessment and Care Piecing Together Quality Planning Long-Term Care: A Consumers Guide to Basics of Individualized Care
Choices and Advocacy Residents Rights Nursing Homes: Getting Guide to Choosing a Nursing Good Care There Home Abuse and Neglect Emergency Preparedness Restraint Free Care Resident and Family Council information
The National Center on Elder Abuse The goal of the NCEA is to improve the national response to elder abuse, neglect, and exploitation by gathering, housing, disseminating, and stimulating innovative, validated methods of practice, education, research and policy. Find the NCEA Online! ncea.aoa.gov NationalCenteronElderAbuse gero.usc.edu/ cda_blog/
@NCEAatUSC 81 Connect with us online! www.theconsumervoice.org National Consumer Voice for Quality Long-Term Care @ConsumerVoices
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