An Alaska man developed gangrenous toes. A Philadelphia woman froze to death on the street. An Illinois woman died emaciated, covered in excrement.
These patients suffered as their government-paid caretakers neglected them, collecting paychecks under a Medicaid program that gives elderly and disabled people non-medical assistance at home. In some cases, the caretakers convicted of neglect were the victims' own family members.
The Personal Care Services program, which exceeded $14.5 billion in fiscal year 2014, is rife with financial scams, some of which threaten patient safety, concludes a recent report from the Office of Inspector General at the Department of Health and Human Services.
The OIG has investigated more than 200 cases of fraud and abuse since 2012 in the program, which is paid for by the federal government and administered by each state. These caretakers, often untrained and largely unregulated, are paid an average of $10 an hour to help vulnerable people with such daily tasks as bathing, cleaning, and cooking.
The report exposes vulnerabilities in a system that more people will rely on as baby boomers age. Demand for personal-care assistants is projected to grow by 26 percent over the next 10 years - a rise of about half a million workers - the U.S. Department of Labor projects.
"This type of industry is ripe for fraud," warned Lynne Keilman-Cruz, a program manager at Alaska's Department of Health and Social Services who has investigated widespread fraud. The risks increase because the care takes place out of view in people's homes, and because neglected patients may not advocate for their own care.
The OIG report describes a range of rip-offs, some of which involve caretakers caught up in the nation's opioid epidemic. In one Illinois case, a woman whose nursing license had been suspended for allegedly stealing drugs at work signed up as a caretaker.
She billed Medicaid for $34,000 in caretaking services she didn't provide - including charges made while she was on a Caribbean vacation. In Vermont, a caretaker on probation for drug possession split her paychecks with the patient's wife - in exchange for stealing the patient's prescription painkillers, while he lay in visible discomfort.
In other cases, Medicaid beneficiaries colluded in hoaxes, faking disability so they could hire unneeded help.
In the worst cases, patients got hurt, sometimes fatally.
In Philadelphia, Christina Sankey, a 37-year-old woman with severe autism, froze to death on the street after her caretaker, Hassanatu Wulu, lost her in a crowded Macy's five miles away. Wulu, 32, pleaded guilty to neglect.
In some cases, elderly patients were neglected by their own children, who signed up for caretaker payments.
In Idaho, a woman was hospitalized for severe dehydration and malnourishment after her son and caretaker, Paul J. Draine, neglected her. Investigators found the home they shared littered with drug paraphernalia. Draine pleaded guilty to fraud and abuse or neglect, and was sentenced to a sober home.
Investigators provided no count of how many cases of fraud and abuse involved relatives, but "it's fairly common for family members to be the attendants, and it's fairly common for those same family members to be the ones who are abusing, neglecting, or committing fraud," said David Ceron, an OIG special agent based in Washington.
To detect impropriety, Illinois now requires personal assistants to call in at the beginning and end of each client visit; their phone calls are recorded in an electronic database, according to the Department of Human Services.
Meanwhile, the Centers for Medicare and Medicaid Services is trying to strengthen the program's integrity, spokesman Tony Salters said. In February, CMS started training states to monitor "fraud, waste, and abuse," he said.
But disability groups have pushed back against stricter regulations, arguing that they don't want to limit Medicaid beneficiaries' access to caretakers. So CMS is treading lightly.