Nursing Homes, Assisted Living Residents and Families Cope With Pandemic

There are 71,000 people living in 691 licensed nursing homes in Florida, and thousands more in assisted living residences. Nursing homes and assisted living residences provide comfort, security and help. But these days, they also provide everything the corona virus needs to get a foothold: groups of older, more susceptible people living in close proximity to one another.

A blizzard of new federal and state rules to protect residents' health have been issued over the last few weeks. Those same rules are leaving many residents lonely and isolated, as well as demanding heroic efforts from facility staff. Here is an overview of the key rules under our “new normal”:

You cannot visit, for now

On March 14, the Florida Agency for Health Care Administration banned most visitors to long-term care facilities and assisted living residences. The ban lasts for 30 days, but may be extended. Exceptions may be made for compassionate visitations (end of life visits, for example). Anyone seeking entry to a facility may be given a screening questionnaire and have their temperature taken. Staff members are also checked for fever upon arrival.

Communal dining and other group activities have been curtailed. Residents are also discouraged from leaving the facility except for essential services.

How can you stay in touch with a resident?

By now you’ve probably seen news clips of family members standing outside residents’ windows, blowing kisses and holding up signs. But there are other, simpler ways to stay in touch with your loved one. Phone calls. Old fashioned letters. (Although some are worried about infected paper surfaces, the CDC and WHO say that this is an unlikely means of viral transmission). In some facilities, a staff member goes from room to room to coordinate video chats for families via skype, face time, etc.

How you communicate with your loved one will obviously depend on many factors, including your technical expertise, technology available at your loved one's residence, and your loved one’s cognitive functioning.

You won't necessarily know if the residence has COVID19 cases

As of March 31, 66 long-term care residents at 19 different facilities in Florida had tested positive for the virus. While  families naturally want to know if their loved one's living facility is affected, Florida is withholding the identity of affected facilities. According to the AHCA, releasing the information would violate HIPAA privacy laws. And Florida Governor DeSantis believes the information would cause relatives to worry unnecessarily. Critics counter that HIPAA applies to individuals, not facilities, and that being kept in the dark causes more worry. In any event, Stefan Grow, an attorney for ACHA, says the information will be released only when “…the State Health Officer’s determination that release of the information is necessary for the protection of the public’s health.”

No new admissions

In order to protect residents and staff during the pandemic, long-term care nursing homes are accepting new residents only if they are transferring directly from a hospital stay. Hospitals must follow strict protocols to ensure that discharged patients have tested negative for the virus. 

Assisted living facilities are accepting new residents, but only after careful screening to ensure the applicant is virus-free. 

Here's hoping that we return soon to the OLD normal. Good health to all!

FREE FLORIDA MEDICAID AND ESTATE PLANNING SEMINAR - CHOOSE ONE OF THREE LOCATIONS

FREE SEMINAR!

Hear about how you or a loved one may qualify for Florida Medicaid and veterans "aid and attendance" benefits before losing everything to long-term care costs - even if your loved one is already in a nursing home.  

Find out how good estate planning can protect you, your family and your assets from the many other threats we face as we age.

Attendees are eligible to receive a free, one-hour consultation from one of our attorneys (assuming we can assist you).
No reservations necessary. Light refreshments.

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Thursday, June 27
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  More information at The Karp Law Firm website, or call us at  (561) 625-1100

Skilled Nursing Homes Face Tightened Scrutiny of Staffing Levels

Throughout our many years of experience, we have found the vast majority of nursing home staff to be well-intentioned and hardworking. That said, the Centers for Medicare and Medicaid Services (CMS) have concluded there is room for improvement. 

A new, more rigorous data-gathering system for nursing homes that relies on payroll records - not self-reporting as before - is now being implemented to gather information about staffing levels. The new data has revealed wider deficiencies in staffing than previously believed, particularly with regard to registered nurses. Under federal regulations, a registered nurse must be on site for at least eight hours daily; a licensed practical nurse must be present at all times. According to the payroll records, about a quarter of nursing homes surveyed lacked a registered nurse on site at least one day during each three-month period. Based on payroll data, last year Medicare lowered its ratings for about 1,400 nursing homes.

To remedy the situation, CMS is increasing the frequency of surprise spot checks at skilled nursing homes, particularly on the weekends. However, representatives of the nursing home industry argue that increased spot checks do not solve the real problem skilled nursing homes face: a shortage of workers. Dr. David Gifford, senior vice president of quality and regulatory affairs at the American Health Care Association, writes: “CMS seems to be focusing on a punitive approach that will penalize providers and make it harder to hire staff to meet the shared goal of increasing staffing.” 

To see how a skilled nursing facility rates, check out the  Nursing Home Compare page on the CMS website. The rating scale is based on a scale of one to five stars, with five being the best. Stars are awarded based on staffing, as well as health inspections and several other quality of care measures.

Veterans Benefits Delay Agonizing for Two Proud Marines

V.A. Aid and Attendance (officially known as Improved Pension with Aid and Attendance) is a little-know benefit available to elderly and disabled veterans who served during certain wartime periods and who can meet financial and other eligibility criteria. However, "available" does not mean "easy to get approved for." With the Veterans Administration under so much criticism these days, it is not surprising to learn that the lumbering agency moves slowly -- at times, far too slowly -- for elderly people who apply for benefits. Getting approved for Aid and Attendance benefits requires onerous paperwork and endless persistence. Cynical veterans have morbidly referred to the V.A.'s approach to processing benefits requests as Deny, Delay, And Wait Till They Die. 


This is precisely what happened to Arkansas residents Robert and Mary DeCicco. Their case was reported in a May 24, 2018 Boston Globe article. The elderly spouses, both Marine veterans, had been married over sixty years. Robert was a Korean War vet who had also survived bladder cancer, had a kidney and lung removed, and undergone a triple bypass. Their adult children were caring for them until the summer of 2017, when it became apparent they needed more intensive help than their kids could furnish. It was decided that moving to a nursing home was the best option. The DiCiccos knew it would be expensive, but their son Stephen had researched veterans aid and attendance and knew his parents qualified for benefits that would defray some of the cost. They completed the benefits application. Trusting that the government they had served would come through for them, the couple moved into a nursing home. Stephen gave his parents the initial $3,000 needed to move in. The nursing home agreed to wait on the rest of the money  until the V.A. approval came through.


But the approval did not come through. The bills kept piling up. In January 2018 the DiCiccos had no choice but to sell their modest home, at a loss. Two thirds of the sale proceeds went to cover nursing home bills. Mrs. DiCicco was heartbroken, telling her son, "That money from the house was for you kids."


Ever the proud Marines, neither Mr. or Mrs. DiCicco was about to criticize the Veterans Administration. But Mr. DiCicco was becoming increasingly anxious about the mounting debt. By March 2018, the nursing home bill had climbed to $40,000. Kim Mosley, the facility's director, repeatedly called the V.A. "I told them that these veterans could be homeless if it wasn't for our home taking them in, and that they needed to be approved very soon," she says. She recalls that Mr. DiCicco would listen to these telephone conversations from his wheelchair, disappointed each time there was no resolution - in fact, no updates or any information at all. "They were such a sweet, loving couple that we just had to help them," she said. "They didn't even have hardly any spending money." Their son Stephen also tried contacting the V.A., but encountered long holds on the phone and staff who often could not even locate his parents' files.


Finally, in March, the DiCiccos' benefits were approved. Unfortunately, that was six days too late for Mr. DiCicco. He died on March 2, 2018, at age 85, still worried about the unpaid bills. "What makes me the maddest of all is that he didn't die in peace," his son said. "It's amazing how little anyone knows or is willing to help you."  Mrs. DiCicco said, "He died waiting for it. They do everything over there to get him shot at. He paid a debt to his country, and I feel that they owed him something."


So what in the world happened? Claims for those age 85 and older are supposed to get expedited processing. V.A. officials subsequently explained that the couples' benefits were delayed because pension claims for two married veterans must be processed simultaneously; complications in validating some of Mrs. DiCicco's information had created the hold-up. "Regrettably, our efforts to establish entitlement resulted in delays," the agency said in response to the incident. "Clearly we could have done better for Mr. and Mrs. DiCicco."


The Karp Law Firm has several V.A. - accredited attorneys on staff. When a veteran (or veteran's widow) who might qualify for aid and attendance hires us for Medicaid planning, we will submit the V.A. application as a courtesy. The V.A. prohibits lawyers for charging for help to prepare applications (although accredited attorneys may charge to handle appeals). 


The Veterans Administration needs to do better. We will see what happens now that David Shulkin no longer heads the giant agency. Privatizing services has been floated as a solution, but that idea has its critics. One thing all can agree on is that elderly veterans do not have endless months or a year to wait for their applications to be processed. Like Mr. and Mrs. DiCicco, many are in immediate or near-immediate need and must have a quicker response. 


Learn more about V.A. Improved Pension with Aid and Attendance.

Fines Reduced for Many Nursing Home Violations: What It May Mean For Your Loved One

In keeping with its goal of reducing bureaucracy and eliminating unnecessary regulations, the Trump Administration has scaled back penalties levied on federally funded nursing homes for violations of certain safety and quality standards.  It has also made it more difficult to deny payments to nursing homes for such violations.

Violations are not rare. A 2017 Kaiser Health News report states that since 2013, 4 out of every 10 nursing homes have been found guilty of at least one serious violation. The most common violations include mistreatment, failure to protect residents from avoidable accidents, neglect, and bedsores. 

Predictably, these new policies from the Centers for Medicare and Medicaid Services (CMS) have been met with opposition or approval from different quarters. One thing is certain: It more important than ever to thoroughly research facilities when placing a loved one, and to keep an eye on the care your loved one receives once placed. At the end of this post I will point you to several resources for evaluating nursing homes. But first, let's discuss the new policies.  

New Policies and Fines

• Pre-Arbitration Clause Now Permitted. The Obama Administration introduced a new rule prohibiting pre-arbitration clauses in nursing home admissions contracts. The rule - never implemented due to a court challenge - would have guaranteed residents and families the right to sue nursing homes in court for fraud, abuse, neglect, etc. That rule is now officially rescinded and pre-arbitration clauses continue to be permitted in nursing home admission agreements.

• Daily Fines Not Recommended For Violations Occurring Pre-Inspection. CMS now encourages state authorities to refrain from imposing daily fines for violations that occurred prior to an inspection and instead, levy one-time fines. Industry groups had argued that retroactive daily fines for violations that had already been fixed by the inspection date were pointless. Others argue that the new policy could end up shielding nursing homes from fines for egregious mistakes, above the maximum per-incident fine of  $20,965. The CMS still suggests daily fines for major violations discovered during inspection.

• Fines Discouraged For One-Time Mistakes. CMS' current policy is that while intentional disregard of patient health and safety justifies fines, one-time errors, even for serious violations, are not necessarily appropriate.

• 18-Month Exemption for Drug-Related Safety Rules. In November 2017, nursing homes were granted an 18-month exemption from fines for violations related to several new rules designed to reduce the use of various psychotropic drugs.

Advocates and Critics

Advocates for the nursing home industry applaud the changes. Seema Verma, head of the Centers for Medicare and Medicaid Services, notes that reducing paperwork will increase the quality time staff can spend with residents. The American Health Care Association, the industry's main trade organization, claims that prior rules were more focused on catching wrongdoing than helping nursing homes to improve. “It is critical that we have relief,” Mark Parkinson, the group’s president, wrote in a December 2016 letter to the president-elect. 

On the other hand, patient advocates argue that easing of penalties endangers vulnerable residents. Recently Senators Amy Klobuchar and Richard Blumenthal sent a letter to CMS requesting that it reconsider the changes. They write: “It is abundantly clear that when health or safety is compromised, when errors occur, or in the worst cases, when patients are harmed, there must be a wide range of strong enforcement actions available to ensure that these adverse events are not repeated, precious federal dollars are not wasted, and most importantly, lives are not lost.” A senior attorney at the Center for Medicare Advocacy, Toby Edelman, claims that CMS is “not seeing their responsibility as helping to assure the health and welfare of residents. They’re working to please their customers, the nursing homes.”

 
What You Should Do Now: Research and Monitor!

The relaxed fines make it more important than ever for you to thoroughly research a nursing home in which you are considering placing a loved one, and to continuously monitor your loved one's welfare once he/she is there. 

• Visit. It is imperative to actually visit the facility, especially on weekends and evenings. Ask questions of nursing staff, administrators, residents and residents' family members. Try the food. Ask about use of restraints, psychotropic drugs, staff ratios, staff turnover. Is there special care for those with dementia? How does the place look and smell? Is the facility within a reasonable distance so that family and friends can visit?  

• Check Out Nursing Home Compare. Also check out Medicare Nursing Home Compare. While the 5-star ratings will be "frozen" for 12 months to allow criteria to be updated, serious deficiencies will still be reported on the site. 

• Be Careful About Signing Admissions Agreements. Since pre-arbitration clauses are still legal in admissions contracts, know that signing such a clause means you are giving up your right to sue if your loved one suffers injury or neglect. Make sure you read the paperwork carefully. For guidance on what to look for when you are signing admissions paperwork, see my prior post.

• More Information. Additional detailed guidelines on how to find a good nursing home can be found here:

U.S. News and World Report

Senior Living

New York Times

Nursing Home Abuse and Neglect A Growing Problem: Here's How to Prevent It, Spot It, Report It

This post on nursing home abuse and neglect is contributed by Attorney Michael Brevda of the Senior Justice Law Firm.

If you have a possible case of nursing home abuse and neglect, please call the The Karp Law Firm to discuss your case, at 800-893-9911.

As America’s population lives longer than ever before, nursing homes and assisted living facilities are enjoying record-breaking occupancy rates. Unfortunately, over-packed and understaffed facilities lead to nursing home abuse and neglect injuries. Arming yourself with knowledge is your best weapon in combating this growing trend of elder neglect.

What is Considered ‘Nursing Home Abuse and Neglect’?

For many, nursing home abuse and neglect evokes horrifying images of physical abuse by a caretaker. It’s important to note that physical abuse only accounts for a small percentage of nursing home abuse and neglect cases. 

Nursing home abuse and neglect is defined by The National Center on Elder Abuse (NCEA) as “failures by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm.” This means nursing home abuse includes:

• Bedsore development because staff did not move the patient in bed. 
• Fractures from falls that could have been prevented
• Unexplained broken bones. 
• Medication mistakes by an overworked or undertrained nurse. 
• Dehydration or malnutrition when facility staff ignores a patient’s food/water intake. 
• Wrongful death caused by staff neglect of a resident’s deteriorating condition.

Startling Statistics

An NCEA research brief cites the following startling statistics:

• Only 1 in 14 cases of nursing home neglect gets reported;
• 1 in 3 nursing homes were cited for deficiencies;
• 95% of sampled residents either were neglected themselves or they witnessed another resident suffer abuse/neglect;
• More than half of the nursing home staff sampled admitted to neglecting or abusing residents in the past year.

Stopping Neglect Before an Injury 

If your loved one resides in a nursing home or assisted living facility, take the following steps to prevent them from being neglected:   

• ETA: Unknown (and unexpected!). Visit often and at random times. Do not announce your visits.
• Q and A, every day. Speak with staff and ask questions. Keep a care journal of who you spoke with. Make sure the staff knows you are following up on prior questions and concerns.
• The squeaky wheel gets the grease. If something doesn’t seem right, make sure you express your concerns to the CNAs, the Director of Nursing and the facility doctor. If your family member has not been showered since you saw them last, bring this to the staff’s attention. If they have a new bruise on their leg, make sure that makes it into the chart. Accountability creates action from facility nurses. 
• Bribe them with sugar. Place a bowl of candy in your family members room. This sounds silly, but the nurses will come in and eat the candy throughout their shift. This ensures the staff will check on your family member often while you are not there.

Steps to Take After a Loved One is Injured in a Nursing Home 

The cycle of nursing home abuse can only be stopped by taking action and reporting the incident. If you do not report it, you are allowing it to happen to the next resident. The Administration on Aging recommends the following steps if you suspect your family member was abused or neglected in a nursing home:

• Call 911 if your family member is in immediate danger or has suffered a severe injury. 
• Next, contact your local Adult Protective Services state agency. Here in Florida, you can call 1-800-96-ABUSE to report elder neglect inside a nursing home or ALF.
•  Have your loved one checked out by an outside doctor who has no relationship with the negligent nursing home. 
• Speak with a nursing home abuse attorney who can gather your records and help you get answers on why the incident occurred. 

Long-Term Care Costs Increase Sharply

Genworth Financial has released its 2017 survey of long-term care costs. The picture is not encouraging. Although the cost of care has always been shockingly expensive, and increased annually without fail, the rate of increase seems to be picking up.

Nationally, the median cost of a private room in a long-term care facility is now $97,455, a 5.5% increase over 2016. This is three times the national inflation rate. Compare this to the 1.24% increase from 2015 to 2016. In South Florida, the cost is even higher than the national median: $116,800 annually for a private room.

It’s not just nursing homes that cost more. So do other long-term care services. The national median cost of a home health aide rose even more sharply than nursing home costs, up 6.17% from last year, to $21.50 per hour. Homemaker services rose 4.75%, to $21 per hour. Even adult day care services costs rose, up 2.94% to $70 per day.

Despite these daunting numbers, two thirds of Americans still believe that government programs will cover all or some of their care if they ever need it! Every day my office receives panicked calls from family members who have discovered that assumption isn't so. Unless you are very poor or very wealthy, you are on your own.

With no coherent national policy to address the growing crisis, each of us has to take steps in anticipation that we will need long-term care at some point in our lives. For some, that means securing long-term care insurance. Contact our office and we can put you in touch with someone who can discuss your insurance options. Alternatively, make proactive plans to secure Medicaid benefits for long-term care. Contact a Florida Bar Certified Elder Law Attorney to discuss how you can protect all or some of your assets from the cost of long-term care.

Check out the costs of long-term care services in your state  here.

Nursing Home Residents, Family Can Call On Their Ombudsman for Help

Being a resident in a long-term care facility does not mean giving up your legal rights. In fact, anyone who lives in a nursing facility gains certain rights. You can see a summary of those rights here, and read the full Florida Statutes here.


Of course, problems do arise. Justice in Aging, a nonprofit advocacy organization, has compiled a list of the 20 most common complaints. Among them: disregarding a resident's preferences; improper use of restraints; imposing visiting hours on family and friends; refusal to readmit after a hospital stay; and threatening eviction after refusing medical treatment.

If a resident's legal rights are being violated, or if a resident encounters any other quality-of-life problems with regard to staff, service, food, medication, privacy, etc., the resident, family, or any other interested person should go through staff members, then up the chain of command if necessary. If the problem cannot be resolved, the facility's ombudsman should be contacted. An ombudsman advocates for residents and investigates any issues brought to his/her attention to protect residents' legal rights, safety, health and welfare. The ombudsman is authorized to negotiate with the facility as well as to tap the resources of appropriate state agencies. Complaints are kept confidential, and the ombudsman's services are free of charge. Per the federal Older Americans Act, every facility must have an ombudsman.

Florida has seventeen local ombudsman councils. To identify the council closest to you, check out this clickable map. To locate the ombudsman's office in states other than Florida, click here.

If you'd like to consider being trained to do this important work, check out the Department of Elder Affairs' Frequently Asked Questions.

Six years post diagnosis, Glen Campbell's wife reports on the Rhinestone Cowboy

As I reported in my post in 2013, acclaimed country music singer-songwriter Glen Campbell was diagnosed with Alzheimer's Disease in 2011. This was not entirely a shock to his fans, who had noticed the Rhinestone Cowboy forgetting lyrics during performances. At home, he had begun getting lost while driving well-known routes he'd traveled for years.

Campbell, his wife Kim and children never hid the diagnosis. On the contrary, they leveraged Campbell's high profile to bring attention to the disease.  In 2013 the Grammy Award-winning musician and his daughter testified in front of a U.S. Senate Subcommittee, explaining how the disease was impacting them and urging legislators to support research.

Kim, Cambell's wife of 34 years, cared for her husband at home until she found her strength rapidly decreasing and her worries about his safety increasing. She was always on alert to make sure he didn't fall down the stairs in their home. Eventually, he would no longer allow himself to be bathed. So, in 2014, the family decided that Campbell would be better cared for at long-term care facility in Nashville.

Now, six years after diagnosis, Kim has provided USA Today with an update on both of them. Unsurprisingly, Kim suffers from depression, but tries to remain socially and physically active. She writes a blog that provides information and support for caregivers. She visits Campbell, now 80 years old, nearly every day. He has declined significantly and is in the last phase of the disease. (The average life span after an Alzheimer's diagnosis is 2 to 8 years.) He is no longer able to play the guitar or sing. He is aphasic and can only utter a few words. When his daughter Ashley visits, she plays the guitar and sings for him. "You Are My Sunshine" seems to be one of his favorites. Kim credits her husband's musical mind for holding off the worst of his symptoms for a longer time than is usual, since music "sparks the brain." 

According to the Alzheimer's Association's 2017 report, Alzheimer's is the most expensive disease in America. Our Florida elder law attorneys meet regularly with families struggling to stay afloat financially while shouldering the cost of a loved one's long-term nursing care. According to the Alzheimer's Association, spending on Alzheimer's and other dementias will be $259 billion this year, and $1.1 trillion by 2050 if no cure or treatment is found. Every 66 seconds, someone in America develops the disease. If we had a treatment that could delay the onset by just five years - not cure it, just delay it - Medicare spending could be reduced by almost half in 2050.

The Campbell family's journey is especially timely now, as funding for the research they championed may be in the crosshairs. The National Institutes of Health (NIH), responsible for conducting and coordinating Alzheimer's research with other organizations, is facing a $5.8 billion cut under the White House's proposed budget, America First: A Budget Blueprint to Make America Great Again. While there was bipartisan support for a 2017 congressional appropriations bill to increase funds for Alzheimer's research, there is no guarantee that this area of research will be insulated from the proposed cuts. Any cuts could certainly slow progress toward the goal of having a cure or treatment by 2025, says Bruce Lamb of the Indiana School of Medicine. And the organization USAgainstAlzheimer's notes that starving Alzheimer's research could spell disaster for America's fiscal future. If you support robust funding to find a cure or treatment, be sure to let your representatives and senators know!

If you have a loved one with Alzheimer’s, consult our lawyers about how you may be able to tap into Medicaid and/or VA benefits before you lose everything to a nursing home. Even if you are healthy now, we can help you prepare in case disability strikes in the future.

Let's all keep working toward a world without Alzheimer's!

How NOT to sign a nursing home admissions agreement

A recent Florida Supreme Court ruling underscores the importance of having a valid power of attorney, as well as the importance of being careful when signing a nursing home agreement for a loved one.

Juan Mendez Sr. was admitted to Hampton Court Nursing Center in Miami in 2009. Since he lacked the capacity to sign the admissions agreement, his son, Juan Mendez Jr. signed the agreement. However, the son did not have a power of attorney authorizing him to act on his father’s behalf.

In 2011, the father developed an eye infection that ultimately required removal of the affected eye. In 2012, his son sued the nursing home for negligence. The nursing home sought to block the lawsuit and force the matter to arbitration, per the terms of the admissions contract which contained a pre-dispute arbitration clause.

The lower court sided with the nursing home. Ultimately the matter ultimately ended up in the Florida Supreme Court, which overturned the lower court's ruling. The Florida Supreme Court reasoned that the son did not have power of attorney for his father and lacked the authority to sign for him; therefore, the contract (and required arbitration) was not enforceable. You can read the court's opinion here.

While this particular case was resolved favorably for the family, it is not difficult to see how signing a loved one’s admission contract could instead have negative consequences for a family. Had Mendez’ father applied for Medicaid long-term care benefits and been denied, whether because of excess assets or income, or another reason, the nursing home could then hold the son directly responsible for nursing home costs. 

When it comes to nursing home admissions contracts, be careful about what you sign... and how. See the do's and don't here.

Enforcement of CMS rule prohibiting pre-dispute arbitration clauses will be delayed

A new rule barring long-term care facilities from including pre-dispute forced arbitration clauses in their admissions contracts will not go into effect on November 28, as originally anticipated. (I discussed the rule in an earlier post. )

In response to a suit filed by the American Health Care Association, an industry group, a federal district court in Mississippi has granted a temporary injunction preventing enforcement of the new rule, based on the argument that the Centers for Medicare and Medicaid Services overstepped its legal authority. You can read the judge's injunction here. The issue now undergoes further consideration by the court.

Supporters of the rule have criticized the judge's ruling. George Slover, senior policy analyst for Consumers Union, stated "Congress could not possibly have intended for the Federal Arbitration Act to override every other law and leave consumers locked out of the courthouse without legal protection... and the unfairness of that is brutally clear when you consider nursing home residents who are so dependent on their caretakers, and so vulnerable to neglect and abuse."

As we wait for this issue to get sorted out in the courts, my advice remains the same: Examine the admissions contract carefully and if you spot pre-dispute arbitration language, just cross it out and don't sign that section.