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Plus
Despite competing clues, a warmer and wetter winter favored for Va.

When it comes to a winter prediction, the honest answer can be the least satisfying one.

There are some general clues about how the upcoming season is trending, but we’ll just have to wait and see for any icy details.

For Virginia, a warmer- and wetter-than-normal winter is modestly favored over the alternatives.

But the odds aren’t especially high, according to the National Oceanic and Atmospheric Administration’s latest outlook. It’s more of a tilt than a cinch. And it’s based on seasonal mean temperatures, so keep the coats handy: Warmer-than-normal doesn’t mean not cold.

We’d all love to know which days will bring snow in our backyards between now and spring, but meteorology doesn’t work that way.

We could skate all the way into a new decade without seeing another snowflake in Richmond, or break a several-year streak of brown-green Christmases.

That first snow of the new decade could be a mere dusting that turns a Monday rush hour into chaos, or a messy mix of rain and snow separated by a matter of miles, or a full-blown whop of the good sledding stuff on a lazy Saturday.

Or our next true winter storm might not even materialize until 2021.

There’s just no way of telling yet.

Contrary to some popular and entertaining methods, there’s no skillful, scientifically proven way to predict specific weather conditions for an entire winter when we’re still in the week of Thanksgiving. Nor did the early debut of snow on Nov. 12 mean that excessively snowy days are sure to come.

The evidence-based indications for this winter are far more general.

On Thursday, NOAA released an updated outlook for temperature and precipitation trends across the United States over these next three months of climatological winter.

After analyzing ocean conditions, air patterns and an array of computer models, their forecasters were left with some contradictory clues about how it’ll all come together and affect weather in our region.

The El Niño-La Niña oscillation, which can often give predictable, alternating flavors to Southeast U.S. winters, is currently in a neutral phase and expected to stay that way.

But forecasters have other fluctuations and anomalies to make sense of.

A patch of warmer-than-normal water in the northern Pacific could build up an atmospheric pattern that results in more Arctic air outbreaks into the central U.S., though there’s no guarantee that it’ll linger all winter or outweigh other factors.

In contrast, the predicted north Atlantic patterns would lead to a preponderance of warmer-than-normal weather over the Southeast U.S., at least through December. Plus, an unusual configuration of storminess in the western Indian Ocean could also end up shaping how the jet stream ripples over the Northern Hemisphere, but with a less clear upshot for our area.

Across the U.S., above-normal winter temperatures are favored for the southern tier, and especially so across the Southwest and Gulf Coast. For the Midwest and Great Plains, it’s a toss-up. No region is explicitly favored to be below-average across all three months.

Regarding precipitation, Virginia is slightly favored to end up with above-normal amounts. But the trend isn’t as strong here as it is elsewhere in the Lower 48.

The seasonal precipitation trends are uncertain across much of the southern tier of the country, except over portions of California and Texas where drier weather is the more likely outcome and drought conditions are expected to expand and worsen.

The best chances for a wet winter extend from the Great Lakes to the Northern Rockies. Across that zone, the colder climate means the extra moisture could translate to more snow than usual. But here, there’s no seasonal snowfall trend to gather from that. As we’ve seen before, all it takes is one well-timed storm or two in an otherwise mild winter to run up some hefty seasonal totals.

NOAA’s 2018-19 winter outlook showed no discernible temperature trend for Virginia, but expected a wetter-than-normal season. It was partially on track: We ended up with above-average outcomes for mean temperature and for precipitation.

And last year was a great example of how a Virginia winter is never all one thing. The weekly moods — frigid, mild, wet and quiet — are driven by short-term swings in the flow of air that can’t be reliably plotted this far out.

An active jet stream can bring a parade of soaking storms. A stalled high over Greenland might repeatedly deflect Arctic air down through the Eastern Seaboard. A tenacious ridge of high pressure over the South could serve up lengthy thaws while drought creeps back in. Perhaps none will prevail, or a little of each, in turn.

If the latest NOAA outlook comes to pass, the Mid-Atlantic winter could be more of a gradual descent from a mild December to another below-normal early spring. Though another wave of unseasonably cold air could breeze through in the first week of December, the month as a whole has fairly high odds to end up on the warmer side.

But when everything from Dec. 1 to Feb. 29, 2020, is added up and averaged, don’t be surprised if the temperature readings and the precipitation totals are a little above normal in our area.

Here’s how that variety can look for us, based on Richmond International Airport observations since 1930:

Coldest low of the season

Typical range: zero to 13 degrees

Last winter: 13

Minimum: 12 below (1939-40)

Maximum: 17 (1931-32 and 2011-12)

Warmest winter high

Typical range: 71 to 79 degrees

Last winter: 75

Minimum: 65 (1930-31 and 1940-41)

Maximum: 83 (1929-30 and 1931-32)

Winter precipitation

Typical range: 6.6 to 12 inches

Last winter: 9.76 inches

Driest: 3.8 inches (1980-81)

Wettest: 16.84 inches (1936-37)

Days with measurable snowfall (December to February)

Typical range: 2 to 8 days

Last winter: 4 days

Least: zero (1952-53)

Most: 14 (1966-67)


Local
VCU program, now in its 10th year, helps students with disabilities take classes and land a job

In a cluttered brick building off Currie Street in Richmond, Robert Doss gets to work.

His employer, Cabinetry and Construction Inc., moved to the new building near Virginia Union University over the summer and needed someone to organize the space. Enter Robert, a Richmond native with autism.

The 25-year-old loves organizing. He enjoys working with his hands, arranging tools and construction materials, and also doing some woodwork himself. The job’s a natural fit.

Since starting with the company at the end of August, Doss has organized the drywall room, the supply room, the painting room, the entrance hallway, the overhead storage — 10 rooms in total. He smiles as he walks from room to room, showcasing his work both organizing — the electric room, for example, took him only 12 days — and with his hands — he’s built shelves to store things.

“I feel more comfortable when I have a job because I feel good about myself,” he said.

Doss got the job through a Virginia Commonwealth University program now in its 10th year.

ACE-IT in College at VCU started in 2010 when the university was one of 27 colleges in the U.S. to receive a federal grant for programs serving students with intellectual disabilities. Students started in the program the next year.

The program gives students one-on-one support both in the classroom and in finding a job.

Each student in the “extremely individualized” program — 37 in the 10 years — takes VCU classes and works part time in various jobs on campus. Students also participate in internships with the goal of landing a job after graduation, when they earn a certificate from the VCU School of Education.

While they don’t get a degree, the classes students take align with their interests. Doss, for example, took biology and art classes. (Students in the program technically audit all but one class, an introduction to VCU course, meaning they do not receive a final grade at the end of the semester.)

“We really try to couple their academics and their employment so we get a sense of what they really want to do,” said Elizabeth Evans Getzel, the director of VCU’s Center on Transition Innovations. “We’re about not just a job, but a career in their area of interest.”

Nine in 10 ACE-IT alumni are now employed, said Jaclyn Camden, an employment specialist for the program. Camden also said that 86% of the students who have gone through the program are in their same job or have moved up in their company since leaving VCU.

“Not only are they getting jobs, but they’re maintaining those jobs and growing in their career,” Camden said. “We all want to be lifelong learners and have good careers and we’re seeing that ACE-IT students are doing that.”

Last year, just 19% of people with disabilities nationally were employed, according to data from the U.S. Bureau of Labor Statistics.

Sitting alongside the ACE-IT students in class are education coaches — trained VCU students who go with them to their classes and meet with them for study sessions.

The paid coaches often become more than just tutors.

Nadia Pablo, a junior kinesiology major from Northern Virginia, was inspired to become a coach after volunteering at the autism center at St. Joseph’s Villa in Henrico County. She’s now in her third semester as a coach.

Pablo coaches in addition to her own course load and hangs out with the ACE-IT students outside of the classroom.

“We build a connection and a friendship,” she said, adding that she invites the other students to Sunday dinners through Catholic Campus Ministry, an organization she’s a part of. “It feels like I’m taking classes with just another friend.”

The program lasts five to seven semesters, with the two extra semesters giving students a bridge to their jobs.

For Doss, who graduated in May, the ACE-IT program still helps him daily with the presence of a career training specialist, Chris Parthemos, at the construction job. The bridge part of the program started this spring.

“We try to open doors where we can,” Getzel said.


Z-no-digital
Unguarded Part 2: Power of Attorney

Shawn Majette stood in the nearly empty courtroom in his signature gray suit and bow tie and made small talk about Disney World with the few people there as they waited for the judge.

“All rise,” the bailiff said as Richmond Circuit Judge W. Reilly Marchant entered the courtroom and took his seat.

“Good morning, Your Honor,” Majette said. “I have the honor of representing Virginia Commonwealth University Health System.”

Majette then asked the court to appoint a lawyer from his firm to serve as guardian of a patient at the hospital, giving the attorney the power to make decisions about the person’s medical care, place of residence and finances. Like most of these guardianship cases, the patient was neither present at the hearing, nor did he have a lawyer to advocate for him. Instead, a guardian ad litem, appointed by the court as a neutral party, was there to represent the patient’s best interests.

Over the past 35 years, Majette has carved out a niche in some of the toughest legal areas involving mental health, competency and guardianship proceedings. He’s become adept at navigating the bureaucracy of Medicaid and creating special trusts for people with disabilities.

His expertise has made him the go-to person in Richmond for guardianship cases. He’s taken on more than 200 such cases in the past five years alone — 10 times the two second-most active guardianship lawyers in the city, who also work for his law firm.

A yearlong Richmond Times- Dispatch investigation that included analyzing more than 250 court case files and interviewing nearly three dozen people raises questions about the oversight of guardianship proceedings and the regulation of private, professional guardians. Court records show that Majette and his colleagues at ThompsonMcMullan law firm are authorized to take control of vulnerable people’s decision-making rights at the request of the health care providers that pay them. Hospitals engage attorneys, who then are appointed as guardians, to have low-income people evicted from expensive acute care beds — in some cases in disagreement with the wishes of the person or family members, according to court documents and interviews with family members.

Once patients are deemed by the court to be incapacitated, they usually end up on Majette’s list of up to 120 wards — six times the number allowed for state-funded public guardians — or are assigned to one of two other lawyers in a department he oversees at ThompsonMcMullan. They’ll ensure a prompt discharge from an expensive hospital bed and have the patients placed, in most of the cases recorded in court documents reviewed by the Richmond Times-Dispatch, in a nursing home that has received poor ratings from the Centers for Medicare and Medicaid Services.

Majette says his law firm performs a community service by taking on guardianship of dozens of low-income people, ensuring that they are admitted to a nursing home and get their bills paid.

“We do more I think for these folks … than anybody I know of — more than other people can do,” he said in an interview last month.

But his work as both a lawyer for the health care provider and as guardian for the people he helps the hospital or nursing home declare incapacitated raises the question: Is he looking out for the best interests of people under his guardianship, or for the interests of the health care providers that pay him?

Ten experts in the fields of guardianship, medical ethics, law and disability rights said the arrangement of having the attorney representing hospitals and nursing homes also serving as guardian raises concerns about how independently he can look after the interests of the people placed under his guardianship.

“It is such blatant conflict of interest,” said Sally Balch Hurme, a Virginia-based elder law attorney and author who has served on the board of directors for the National Guardianship Association and advised on the drafting of the Uniform Law Commission’s model guardianship law, after reviewing The Times-Dispatch’s findings. (Hurme is not related to the reporter.) “It’s the same as an attorney who is drafting a will naming himself as the beneficiary of the will.”

ThompsonMcMullan and two Virginia attorneys said the setup does not violate the Virginia State Bar’s ethics rules to serve as both attorney for the petitioner and guardian because the attorney ceases to represent the health care provider as soon as a judge declares a person incapacitated, moments before he is appointed the guardian.

“I see zero ethics problems. ... We [attorneys] can’t deprive any client of our zealous representation,” said Thomas Spahn, an attorney specializing in ethics with McGuireWoods law firm, who spoke to The Times-Dispatch at the request of ThompsonMcMullan. “They [attorneys] don’t let their judgment be affected. The fact that it might be affected, that can be true in every situation.”

Bernard DiMuro, an attorney and former president of the Virginia State Bar, said in a statement solicited by ThompsonMcMullan after The Times-Dispatch reached out to the law firm, “As the Firm [ThompsonMcMullan] transitions from counsel to the petitioner [health care provider] to guardian for the ward after the court’s determinations, the Firm is not representing two clients whose interests are directly adverse.”

But Hurme said that argument is flawed.

“The hospital is the petitioning attorney’s client who is in an adverse position to the guardian of the individual — of the discharged patient,” she said. “Let’s say there had been some sort of malpractice or improvident discharge. The guardian would be in the position to sue the hospital, but if the attorney appointed as guardian was the attorney for the hospital … they would not be able to adequately defend the interests and the rights of [the patient].”

George Cohen, a University of Virginia law professor, also said there were problems with the arrangement.

“The interests of the hospital and the interests of the guardian could certainly be in conflict,” Cohen said after reviewing The Times-Dispatch’s findings. “Suppose you had someone who had a loan to a bank. Would we say a lawyer for the bank could come and file one of these petitions and become the guardian? That would seem to be very troubling.”

And some family members of the people Majette’s charged with protecting say the change of loyalty is difficult to see in practice.

“The only interest Majette had was getting him the hell out of [VCU Medical Center],” Richelle Richardson-Hayes said of her brother, Richard Richardson, who was one of the dozens of VCU patients put under Majette’s guardianship. “The only thing Majette cared about was his client. ... Shawn Majette is [VCU’s] lawyer first, my brother’s and everyone else’s guardian second.”

Majette asked a judge to either appoint him Richard’s guardian or allow VCU Health System to put Richard, who was paralyzed from the shoulders down, out on the street.

***

Virginia’s public guardianship program, which serves 1,049 people, is held up as a model for the nation because it caps its guardians’ caseloads at 20 people, requires monthly visits and emphasizes planning that encourages autonomy.

But it is overwhelmed.

Lack of funding and inefficient processes have left more than 85 people on a waiting list as of Nov. 13 and an unknown number of vulnerable, low-income people without an advocate, according to Patti Meire, the program’s coordinator.

The result is that some poor people end up under the care of private, professional guardians, who are not subject to the same rules.

And experts say the number of guardianships — currently estimated at 1.5 million nationwide — is likely to rise as the population ages.

Nursing homes have employed Majette’s firm to use guardianship to get bills paid, including, on one occasion, by taking power of attorney and medical decision-making authority away from the son of an elderly resident, Charles Ellis, because the son’s attempts at applying for Medicaid had failed, according to court documents and an interview with the son.

And as long as the lawyers retain guardianship authority, they can apply for Medicaid benefits, pay the person’s nursing home and, in many cases, step into medical treatment and discharge decisions at the hospital or nursing home’s request, even while rarely visiting the people under their guardianship, according to annual guardianship reports filed by ThompsonMcMullan with the court.

ThompsonMcMullan said that because the public guardianship program is so overwhelmed, the people kept under the firm’s guardianship would be helpless without help from its lawyers. The firm said it pays staff members about $176,000 each year for all of the work they do maintaining guardianships that the fees collected from indigent clients don’t cover.

“I wish that we had funding like I understand public guardians do,” Majette said. “They are paid, I think, several thousand dollars per slot. We are paid zero to do that. Nothing.”

A spokeswoman with Commonwealth PR, a local public relations firm that ThompsonMcMullan hired in October after The Times-Dispatch’s third request for an interview, said the firm collects an average monthly fee of $55.57 per indigent ward. Occasionally, the firm will find that the person has additional assets and can charge higher fees in the thousands per year, according to the firm and court documents.

VCU Health System, one of the ThompsonMcMullan’s biggest guardianship clients, has paid the firm $1,158,746.46 since 2007 for guardianship work.

The state funds the public program $4.5 million annually and pays between $5,000 and $7,000 each year per person under public guardianship, according to a program spokesperson.

“The public guardianship program is wonderful,” said Christopher Malone, president of ThompsonMcMullan. “It’s a wonderful idea, but the limited number of slots that are available in the state ... the limited funding for the program, the fact that it could take six months from the beginning of a request for a public guardianship slot until one spot could be made available ... and meanwhile that person is trapped in a hospital.”

Majette said he and his colleagues serve as limited guardians — a role they say is mostly focused on getting the person admitted into a long-term care facility and relieves them of some of the responsibilities of general guardianship, such as visiting with the person.

The powers of the limited guardian are restricted to the areas laid out in the court order, but many of the orders reviewed by The Times-Dispatch grant the firm’s attorneys significant powers over the lives of the patients. This includes the powers to consent to or withdraw any medical treatment, decide what facility patients will live in and how their money is spent.

“They’re making placement decisions and they’re making end-of-life decisions,” said Hurme, the Virginia lawyer who advised on the drafting of the uniform law on guardianship. “That is not a limited guardian.”

Majette and his colleagues rarely visit many of the people under guardianship, according to annual guardianship reports filed with Richmond Circuit Court. Many reports said the guardian had either never visited the person, had visited once while they were at VCU or had visited “several” times, without specifying how many.

“It would make me deliriously happy if we had the resources to become a general guardian and to do what the public guardian is — again — paid fairly substantial amounts [to do],” Majette said. “Do I wish we could do that? Yeah. I’m afraid we cannot do that.”

Public guardians are required by law to visit those under their guardianship at least once a month, and the National Guardianship Association Standards of Practice say that a professional guardian “shall visit the person no less than monthly.”

“As their advocate and decision maker, we need to make sure every person and every provider is providing the best service for this person,” said Edward Richards, the manager for Senior Connections’ public guardianship program that serves up to 40 people in the Richmond area and a guardian himself. “If your family member had to go to one of these places, what would you do? You would comb through whatever they were doing to make sure that they are being taken care of. We do that with our visits … emails and phone calls and day-to-day interactions.”

Majette said he counts on the state’s Department of Health and local departments of social services, which are responsible for licensing long-term care facilities and investigating abuse and neglect complaints, to ensure the safety of his wards. He had 92 as of October.

“I don’t register the visits that I do make because, as far as I’m concerned, I’m going to visit these people to do the best that I can do to make sure that if there’s a concern it’s addressed,” Majette said. “I don’t have a duty to do that because I have asked the court to appoint me as a limited guardian and rely upon one group of people to make sure that if for some reason there’s something going wrong in that nursing home — in the assisted living facility — that that’s being looked at, and that group is the commonwealth of Virginia through the licensing authority.”

David Hutt, an attorney with the National Disability Rights Network, said a facility’s state license doesn’t guarantee that a person living there is treated as they should be.

“Relying on the state, history has shown, is not adequate to make sure the person is being taken care of,” he said. “There have been a number of cases where private attorneys acting as guardians have hundreds of individuals [under their guardianship]. … They can’t be understanding what the needs are for the individuals.”

Most of the nursing homes where Majette and his colleagues placed their low-income wards are poorly rated. They’ve also placed people in nursing homes that they have represented in guardianship petitions.

In 58% of the 122 nursing home placements that were recorded in court documents from 2013 through 2019, the nursing home is currently rated two or fewer stars out of five by the Centers for Medicare and Medicaid Services. In 30% of the cases, the facility does not have a rating, and in 11%, they are rated three stars or higher.

ThompsonMcMullan placed at least eight people in Envoy of Stratford Hills from 2013 to when it lost its Medicare funding in 2015 for failing to comply with CMS’ standards, including by failing to follow sterile procedures with a tracheotomy patient and improperly storing medical supplies. From 2013 to 2018, the firm placed nearly two dozen people in Envoy of Westover Hills, one of the facilities Majette has represented and the only nursing facility in Virginia currently on the CMS Special Focus Facility list. That list includes nursing homes whose performances have been so bad that CMS has threatened to stop their Medicare funding if the facilities don’t improve within two years.

A CMS inspection report of Envoy of Westover Hills documented dozens of violations and said that one resident’s bedsore had a maggot in it. A spokesperson for Envoy of Westover Hills did not respond to requests for comment.

Majette and Malone, the law firm’s president, said there is a shortage of nursing home beds in the state, particularly for low-income people who may have complex health care needs.

But Hurme said guardians should not be excused from ensuring their wards are properly cared for.

“A guardian has more of a responsibility than finding a nursing home and applying for Medicaid,” Hurme said. “I’m a limited [guardian] therefore all I have to do is plop them into a nursing home and forget them?”

On at least 13 occasions, Majette or one of his colleagues suspended their rights and duties as guardian of a person, but retained the ability to step back in if the person ended up in VCU Health System and the hospital requested it.

Cohen, the UVA law professor who reviewed The Times-Dispatch’s findings, said the resignation exception raises the question: “Are [the attorneys] serving the interests of the hospital more than the interests of the ward?”

“In what sense is that being done for the benefit of the person subject to guardianship?” Cohen said. “It has the appearance that this is being done because the lawyer is trying to protect the interests of the hospital. ... [The interests of the ward] are the same regardless of where they’re going to be hospitalized. Why is this automatic process just for this one place and not for others?”

Majette said he resigned in some cases if the person under guardianship was believed to have the ability to live independently, but that he reserved the right to step back in if the person ended up back at VCU Medical Center so that he could have them discharged and admitted to a long-term care facility again.

Asked what would happen if the person were taken to another hospital besides VCU, such as Bon Secours St. Mary’s Hospital in Henrico County, Majette said, “I don’t represent St. Mary’s. I do not represent — I do not know what their discharge planning is. I do not know what their process is.”

Bon Secours Health System pursues guardianship cases for its patients, but does not allow its attorney to be appointed guardian because it is unethical, according to Kelly Stuart, executive director of physician ethics. Instead, the hospital pays for Catholic Charities, which is part of the public guardianship program, to take on the guardianship of the patient after the discharge. Similarly, Sentara Healthcare, which runs several Virginia hospitals, pays Jewish Family Services, another public guardian agency, to take on its patients.

In interviews and court records, some family members of people placed under Majette’s guardianship have complained that he has demonstrated disregard for the well-being and wishes of the wards and their loved ones. In one case, a man under Majette’s guardianship complained that he could not afford to buy himself a coat with the $40 a month that Majette gave him for personal expenses.

The guardian ad litem, the attorney appointed by the court prior to a hearing to investigate the case, said in her report that the man did not want a guardian and that she didn’t think the man was incapacitated.

Still, Majette, who had represented Chippenham Johnston-Willis Medical Center in the guardianship petition, was appointed his guardian. The man was discharged from the hospital to Envoy of Westover Hills and, two years later, asked that his friend become guardian instead of Majette. The guardian ad litem visited him again and said that, although he could take the bus to Walmart, feed himself, bathe himself and get in and out of bed from his wheelchair by himself, there was too much risk of him falling to allow him to live independently. The friend ultimately said she did not want to take on the responsibilities of guardianship and his case was dismissed.

“These are difficult situations where our hospitals manage and serve patients as best as they can on a case-by-case basis,” said Malorie Burkett, spokeswoman for HCA Virginia, which runs Chippenham Johnston-Willis Medical Center, in a statement. “We have a rigorous process in place for when we deem guardianship necessary; it is a last resort when no other options are available. We remain dedicated to providing our community with the highest quality of health care and ensuring the safety and comfort of all our patients.”

In another case, the aunt of a person under Majette’s guardianship hired an attorney and filed a counterpetition for guardianship of her nephew. The petition said Majette had “failed to seek or maintain a relationship with family members,” including the aunt, who had built an extra room onto her home to take in her nephew. It said Majette had “unnecessarily insulted” her and that she had tried to work with VCU Health System before guardianship was pursued, including telling staff about the addition to her home, “but she was treated as someone unworthy of involvement in decision making for his care,” according to court records.

The aunt’s case was dismissed.

VCU Health System declined to comment on specific patient cases, but said that it pursues guardianship of a person with an interested family member only if the medical care team believes it would be unsafe to allow that person to make decisions for the patient.

***

VCU Health System always called Richelle Richardson-Hayes for permission whenever her younger brother, Richard Richardson, needed a procedure, she said. Although Richard was mentally stable, he’d been paralyzed after falling from a balcony on Thanksgiving 2014, when he was 35, and sometimes needed his sister to consent on his behalf. The VCU medical staff had called her when he needed a breathing tube inserted and when they wanted to give him a halo brace to support his neck and head.

That’s why she was shocked when she found out from Richard that the hospital was discharging him to a nursing home in Petersburg without telling her.

Richard, then 38, had been staying at VCU for the past four months, ever since he’d been admitted from his nursing home for a worsening bedsore, complications with his catheter and excessive sweating, according to court records.

Richelle said the hospital staff had been getting impatient with her and Richard’s two other sisters for not finding a place for Richard to go since he was ready to be discharged from the hospital.

According to his medical records, there had been no medical reason for him to stay in the hospital for the past month, but the VCU social workers told Richard that the only place that would accept him was a facility about 45 minutes away in Petersburg. Richard refused to go there. He said he wanted to be closer to his family in Henrico County.

Richard told a VCU psychiatrist that he knew he had to leave the hospital, but he wanted to go somewhere half-decent, unlike the places he’d been shuffled around to for the past three years, according to court records.

Richard’s sister Jennifer, 35, and their mother, Jackie, 60, wanted to get a home where they could bring Richard and take care of him themselves. But it would take some time to get things in order.

One of the social workers said that if they didn’t find a place to send Richard soon, VCU would put him on a stretcher and leave him out on the street, the sisters said.

Ryan Raisig, associate vice president for coordinated care and post acute services for VCU Health System, said the hospital never puts people out on the street.

But when VCU asked Majette to take Richard to court, the petition filed Oct. 20, 2017, requested permission to immediately discharge him, without liability, “to any public street, way or location off the premises” if the court didn’t grant guardianship.

Richard owed the hospital $86,179. The petition said his debt to the hospital was growing at a rate of $3,314 every day.

The court assigned Henrietta Cannon to be Richard’s guardian ad litem. She also had been the guardian ad litem in nearly 90% of all VCU Health System guardianship cases since 2014, usually at Majette’s proposal, and was paid by VCU Health System on its cases.

On Oct. 31, 2017 — 11 days later — the Richmond City Circuit Court held a hearing, and, although both the guardian ad litem and a psychiatrist at VCU found that Richard was mentally competent, the judge granted VCU’s request to have Majette made Richard’s guardian.

Majette said his firm mailed out the hearing notices required by law to Richard’s family members, but family members said they never learned of the hearing until after it was over.

Cannon, who was charged with speaking with family members and loved ones about the hearing in advance of the court date, said in her report to the court that she had called the number she had for Richard’s older sister, Richelle, and had left a message with the person who answered but had not heard back.

Cannon died in May before The Times-Dispatch could reach out to her for this story.

Richelle said she never got the message. Even though she and her sisters took turns visiting Richard in the hospital every day and his medical team had their contact information, the family received no notice of the guardianship proceedings, she said.

Richard was able to address the judge through videoconference during the hearing, but did not have a lawyer.

In handwritten notes, the court order was made temporary, requiring that another hearing be held in 90 days to determine who Richard’s long-term guardian should be.

In the meantime, Majette could have Richard discharged to the Petersburg nursing home against his will.

After Richelle heard from her brother that an attorney had been appointed his guardian, she got Majette’s contact information from the hospital.

“What’s going on?” she said she asked when he answered the phone. “How do I get guardianship of my brother?”

This is my personal number, Richelle said he told her, don’t you ever call me on this number again.

Majette said he didn’t recall the conversation with Richelle, but said he often asks people to call his office number rather than his personal number if the reason for the call is not an emergency.

***

One Friday night this summer, the Senior Connections Public Guardianship Program emergency line rang. Edward Richards, the program manager, answered it and then hurried to the emergency room. Someone under his guardianship had been taken to the hospital because an infection on his finger had made it swell to twice its normal size.

Richards gave the hospital consent to give anesthesia to the man, who has an intellectual disability. He was also there to comfort him. Being in the hospital setting made the man under Richards’ guardianship nervous, and he’d been alarmed and confused by all that was happening around him. Richards put some of his experience with social work to use to help ease the man’s anxiety.

Richards is one of dozens of public guardians charged with advocating for some of the most vulnerable people in the state.

The Virginia Department for Aging and Rehabilitative Services contracts with 13 service providers scattered across the state to serve as guardians for the 1,049 public guardianship slots that the state General Assembly funds. About half of the slots are reserved for people with intellectual or developmental disabilities or a mental illness identified by the state’s Department of Behavioral Health and Developmental Services. Many of these people have previously lived in a state-operated institution, with guardianship used as a way to transition them into a community care setting, such as a group home or nursing facility.

Richards makes a point of changing the timing of his client visits to make sure he’s seeing how they are treated in different settings. He tries to get to know the person so that he can tell when something seems off. And he develops a rapport with the person’s caretakers so he can effectively advocate for his client.

“Obviously, we don’t just visit one time a month, but at minimum one time a month,” Richards said. “When we do these visits, we look to see if there are any signs of abuse or neglect. Does a person have a new bruise we haven’t seen before? Is behavior not what we’re used to seeing before?”

On one recent afternoon, Richards visited one of the people under his guardianship living in a nursing home. He knew to look for the person in their usual hangout spot, watching TV in the dining room. The person eagerly caught Richards up on the latest gossip about the nursing home as he checked the person to make sure they were well-groomed and taken care of by the staff. Before heading off to his next visit of the day, he remembered that the person’s right hand pained them and offered his left hand to shake as he said goodbye.

From Richards’ perspective, having 20 clients under his care is a lot of responsibility to take on, but it’s manageable.

Virginia’s 1-20 ratio is “the envy of the country,” according to Pamela Teaster, a gerontology professor at Virginia Tech who helped create the state’s public guardianship system when she was a doctoral student in 1998. By comparison, Florida’s ratio is 1-to-40.

But private guardians, like Majette, have no cap on how many people they can have under guardianship, nor are they required to visit their wards.

“Some paid professional and public guardians have ratios of one to over 100 protected persons, a ratio far too high to afford an individualized and appropriate level of protection and care,” Teaster wrote in her testimony before the U.S. Senate Special Committee on Aging in April 2018.

Meire, the program’s coordinator, said she’s known of a guardian who woke up at 4 a.m. to go to a dentist appointment with a client who was afraid of getting her teeth pulled, another who brought their family to see the client perform in a theatrical production on a Saturday, and another who made sure the client was placed in the same home as her former foster sister.

“There’s a lot of involvement with the client,” Meire said.

But even so, Meire said the guardianship program should be a last resort, favoring restoring the person’s rights or allowing a family member or friend to take over when possible.

“Guardianship is the nuclear option,” she said.

Before guardianship proceedings are pursued, a volunteer panel of community leaders, including doctors, lawyers, health care administrators and social services representatives, review each case to make sure the person is an appropriate candidate for public guardianship, which is intended for someone who is indigent and “friendless,” meaning there’s no one in their life to help care for them.

The process takes time. A person is generally referred to the public guardianship program by a community services board — a local entity tasked with providing mental health services — someone in the community, or a health care provider. If the panel finds the person to be eligible, they must wait until a slot opens up in the program. Once the slot opens, the petition can be filed.

In many cases, the public guardianship program has struggled to find an entity or attorney willing to bring the case to court. The Attorney General of Virginia has declined to represent DARS as petitioner in guardianship cases unless the state legislature specifically allows his office to because the arrangement would be a conflict of interest, according to the 2018 report on public guardianship to the state General Assembly.

Majette said the state had no issue with his both representing the petitioner and serving as guardian in several cases in 2008 when then-Attorney General Bob McDonnell’s office asked him to represent the Virginia Department of Medical Assistance Services on four guardianship cases when the state closed down a nursing home. A spokesperson for the Office of the Attorney General did not answer questions for this article after several requests.

The lack of a petitioner in public cases can further delay proceedings, although the state’s behavioral health department and DARS will sometimes reimburse attorneys for petitioning to have someone placed under public guardianship, according to Meire.

It takes an average of six months for intellectual disability cases to move through the process. Richards has seen it take anywhere from three months to a year.

The programs also often run near or at capacity. There were 85 people on waiting lists in Virginia as of Nov. 13 just for the state-designated slots. Local programs maintain additional waiting lists for the slots that are not reserved for people leaving state-operated institutions. There are no regulations to address what happens to people while they are on the waiting list, Meire said.

DARS expects the need for public guardianship services to continue to grow, particularly as Virginia’s population ages, with an anticipated 1.8 million people age 65 and older by 2030, and as the state works on moving people with intellectual disabilities out of state hospitals due to a settlement with the Department of Justice.

With the program already at capacity and dozens of people stuck on waiting lists, people can fall through the cracks. Sometimes that means falling under the guardianship of a private professional who isn’t required to follow the same rules as the public program.

Teaster said she wasn’t aware of any guardians maintaining 100 or more wards since a national report was done in 2010. “We don’t see those numbers as high, or they’re not telling anybody,” she said.

But if there were guardians with that caseload, “[the wards] are not getting care and not having their needs met. That would be the antithesis of person-centered care.”

Majette said he could not maintain the people under his guardianship without the help of his firm’s support staff, which includes five people who assist the firm’s attorneys to make sure bills are paid, paperwork and accountings are filed and that quarterly meetings held by nursing facilities where the people reside are attended via teleconference.

Teaster said Virginia’s guardianship monitoring places a higher importance on making sure finances are accounted for than it does ensuring that the person under guardianship is getting the proper care.

***

When Richard Richardson woke up at VCU Medical Center in November 2014 unable to move his arms and legs, he had no idea how he had gotten there.

He couldn’t remember going to his sister’s apartment on Thanksgiving and telling his family that he didn’t think they loved him. He didn’t remember climbing out on the balcony and attempting to go from the second floor to the third floor or the fall onto the ground below. He couldn’t remember his sisters’ screams or the ambulance rushing him to the emergency room.

His sisters would never know what had come over him that day.

Richard and his family were always close. He was an active father and uncle, often bringing his sons over to his sisters’ homes to play with their cousins and taking the kids to the park.

He’d run into some trouble with the law on drug charges in his early 20s, but his sisters said he’d turned his life around since his last charge in 2004.

He treated his bike like his car, riding it from his home in downtown Richmond out to his sister’s place in the suburbs. He worked as a roofer and practiced mixed martial arts in his free time.

Jennifer recalled a time Richard had fixed an elderly man’s roof for free to keep rain from coming into his home.

But the accident changed him. Once his doctor told him he would never walk again, it was like a death sentence. It stole his hope, Jennifer said. Medicaid wouldn’t pay for all the physical therapy he needed, and he was often told his prognosis wasn’t good anyway.

Every now and then, his sisters would see some of his old personality shine through. He would light up with his nieces and nephews. He continued to follow his favorite football team, the Los Angeles Chargers, and watch Ultimate Fighting Championship matches on YouTube.

But they knew he was suffering and depressed. He’d been tossed from one place to another. His most stable living situation was when he lived with Jennifer for a year before he started having seizures. The last nursing home he’d been in landed him in the hospital yet again, this time for a bedsore. And he was afraid of where he might end up next.

Health care providers said he was noncompliant with care, according to court records and emails. His family said he sometimes did not want to be touched or given medication when he was in a bad mood or in pain, but more often his caretakers at the nursing homes offered substandard care, neglecting to turn him to prevent bedsores, giving him his medication late or forcing him to eat hot food before it cooled.

Richard’s sisters had planned to rent a home together where his family could take care of Richard, but he had already been at VCU for months, and their time was up.

Once Majette was granted temporary guardianship and conservatorship of Richard on Halloween 2017, he had him discharged to Petersburg Healthcare Center, a nursing facility that had 13 health citations on its latest inspection report and was rated two out of five stars by the Centers for Medicare and Medicaid Services.

Richard often called Richelle and told her about how he hadn’t been turned to prevent bedsores or that he hadn’t eaten all day. Richelle emailed the nursing home administrators to complain. Eventually, they told the family Richard couldn’t have a phone anymore, she said.

“That place is horrible! Why would you send somebody’s family to a place like that?” said Phyllis Richardson, Richard’s youngest sister. “Man! It’s understaffed. I sat there days, like plenty of days and watched people’s lights just blinking, blinking for 30 minutes. Like, I remember one day I went up to the nurses station and I went, ‘Ma’am, the person across from my brother’s light has been going off for like 45 minutes, is somebody going to check on him?’ ”

“How long did my brother have to sit there and just lay there day after day in that place and [Majette] didn’t even come and see him?” Phyllis said, crying.

Fred Stratmann, a spokesman for Petersburg Healthcare Center, said he couldn’t speak about a specific case because of patient confidentiality but said the center always complies with federal regulations on staffing levels and encourages its administrators and staff to be sensitive to the needs of the residents.

He also said that although CMS gives the center an overall rating of two stars out of five, the center received a five-star rating for short-stay residents on “quality measures” such as hospitalizations, falls with major injury and bedsores. It received a three-star, or average, rating on quality measures for long-stay residents.

“The facility does have its issues and we’re diligently working to correct those issues,” Stratmann said.

Three months after the initial court proceedings, Richelle stood before a judge asking to take back the right to make decisions for her brother. Majette agreed to resign as Richard’s guardian, but told the judge that he didn’t think the family’s plan to care for Richard at home was feasible. Richard’s sister, Jennifer, and his mother, Jackie, were both on disability, so Majette doubted they’d be able to give Richard the care he needed, according to the sisters.

The court order that the judge signed that day made Richelle her brother’s guardian, but with some conditions. Richelle would not be allowed to go against the advice of Richard’s attending physician, whether at the Petersburg nursing home or at any future health care facility where Richard might be treated, according to court documents.

And although Richelle didn’t realize it at the time, Majette could resume his authority, without further court order, at VCU’s request.