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Finding A Nursing Home - The Guide - Seniors Long Term Care & Nursing Home Issues - SeniorSite.com
Finding A Nursing Home - The Guide - Seniors Long Term Care & Nursing Home Issues - SeniorSite.com
Finding A Nursing Home
The Guide

Finding A Nursing Home - The Guide - Seniors Long Term Care & Nursing Home Issues - SeniorSite.com There are alternatives to long term institutional care that may be appropriate for some people. These are options you may wish to consider before you and your health care provider decide that a nursing home is for you. Some alternatives are listed below.

Community/Home Care

One or more of a wide range of community services may be available to help you remain in your home. Check with your doctor, discharge planner, local office for the aging or local health department to see if the following programs are available in your community.

- Adult Day Health Care
- Certified Home Health Agency Care (CHHA)
- Congregate Apartment
- Enriched Housing
- Homemaker Services
- Housekeeper/Chore Services
- Hospice
- Long Term home Health Care (LTHHC)
- Meals on Wheels
- Personal Care Assistance

Institutional Care

There are also different types of residential or institutional care.

- Adult Homes With and Without Assisted Living Program
- Family-type Homes for Adults
- Hospices (for terminally ill)
- Long Term Care Facilities (Nursing Homes)
- Residences for Adults
- Shelters for Adults

Nursing homes are places to live where care is available for people who need 24-hour nursing care and supervision outside of a hospital. Although all nursing homes must provide certain basic services, some homes provide special care for certain types of clients. For example, some homes provide services for the head injured, some for those who are ventilator-dependent, some for people with AIDS and some specialize in the care of children.

After you have explored alternatives and you, your family and involved professional health care providers agree that a nursing home is required, carefully select a nursing care facility.

Information contained in this directory will aid you in selecting the right nursing home. It is written for you, the prospective resident. If someone else must organize the search and make the decisions, it is important that you be as involved as possible in the process.

Finding A Nursing Home - Planning in Advance

Finding the nursing home that will best meet your needs can be a difficult and time-consuming task. The more information you have, the easier this task will be and the more likely that you will find the home that is right for you.

Making the decision that a nursing home is the right place for you and looking around at different homes is important to do before you are hospitalized for a medical crisis.

Nursing homes generally operate at close to full capacity and a particular nursing home may not always have an available opening. It is best to have several nursing homes in mind should the need arise. With the help of your doctor and the hospital discharge planning staff, realistically assess your medical, nursing and social needs and seek facilities that can best meet these needs. For example, a facility with a strong physical therapy department might be important if you are recovering from a stroke.

Discuss nursing home placement with your family so that the eventuality of this possibility will be fully explored and your feelings known before a crisis occurs.

Watch for articles in newspapers and magazines and for television programs that deal with nursing homes. Pick up information on nursing homes from social service agencies or local offices for the aging and local health departments. Contact community group s and advocacy groups.

Ask family and friends about their own experiences. If you know someone who is in a nursing home, visit that person and ask questions. Ask questions of key personnel at the facilities you visit: the administrator, social work director, nursing director, medical director, for example. Make your own judgments. A caring home should welcome both your desire to visit and the questions you ask.

Admission

Medical need and method of payment play a large part in admission.

Medical Need

A medical assessment must be performed before you can be admitted to a nursing home. This assessment is done by a registered nurse who has been certified to perform the assessment. The assessment is a two-step process and is specifically designed by the State Health Department to evaluate your functional status as well as your appropriateness for a nursing home. The state requires that assessment forms be completed for everyone who applies for residence in a nursing home. The forms are valid for 30 days for hospitalized individuals and 90 days for those at home.

The nursing home administrator, admissions director or director of social services will be able to explain arrangements for your admission to the facility. If you are receiving care in a hospital, your doctor and the hospital social worker/discharge planner will assist in making arrangements for your placement, hopefully in the nursing home of your choice.

Waiting Lists

Although most people find that the need to enter a nursing home comes about after a serious illness treated in a hospital, you will be better off if you plan in advance. If you are applying for admission to a nursing home from a hospital, speak with the hospitals discharge planner. Nursing homes typically do not have many vacancies, so it is advisable to have several suitable facilities in mind. Regulations require formal application before you can be placed on a waiting list. Once you have made your choices, ask to be placed on the waiting list. Continue to check the status of your application by calling in regularly to the specific offices where you submitted your applications.

State regulations require that a hospitalized patient on Medicaid who no longer needs inpatient hospital care be placed in the first available bed within 50 miles of the patients home. By telling the hospital which nursing homes to apply to, you or your family can influence the location of the eventual placement.

Admissions Agreement

The admissions agreement (also called the financial agreement, admission contract, entrance contract or some other term) is a legal agreement between the nursing home and the resident to spell out conditions for admission. The contract should state the costs, services included and all legal responsibilities of the resident. Ideally, it should also include care (in accordance with intensity of need), emergency procedures and standards of food service (for example, availability of therapeutic diets, kosher diets, etc.).

Ask questions about the contract. Ask your attorney, the nursing home administrator or admissions director to explain anything that is not clear. Call an advocacy group with questions.

Paying for Nursing Home Care

Since the cost of nursing home care is so high (ranging from $3,000 to $10,000 a month), few people can afford to pay out of their own pocket for very long. Ninety percent of nursing home residents are or become reliant up on state and federal subsidies.

If you have the means and plan to pay with your own funds, you will have a much better chance of getting admitted to the nursing home of your choice.

Meet with an elder law attorney to get advice on estate planning, Medicaid, Medicare and long term care insurance before you apply to a nursing home. The State Bar Association Referral Service as well as many local bar associations will provide you with a list of elder law attorneys.

Private Payment

Nursing homes charge a basic daily rate for the services they provide and these vary from home to home. Some homes have all-inclusive rates, others have a rate for room and board and add additional charges for physicians services, laboratory tests, physical therapy, prescription drugs, etc.

Private pay rates are not regulated. Homes may charge their private pay residents whatever they wish. These rates can be expected to go up at least once a year. If you are planning to pay for nursing home care out of your own pocket, ask for a list of services that are covered by the basic daily rate. Also ask how the rates are adjusted and how residents are notified of adjustments. (Under current law, this notification must occur in writing 30 days prior to any upward adjustment in the daily rate for a service being implemented.)

The basic daily rate must cover room and meals, housekeeping, linen, general nursing care, medical records and services, recreation and personal care. There may be extra charges for items that vary from resident to resident, such as physical therapy and medications. Discuss with the homes admissions director, administrator or social worker what services are standard and what additional services might be required and what they cost.

Homes are permitted to ask for a prepayment or a security deposit. The home can ask for no more than three months prepayment. Prepayment used as security must be deposited by the home in an interest-bearing account.

If you leave the home or die, any amount paid to the home over the cost of services already provided must be refunded. It is illegal for a nursing home to demand or accept donations (to a building fund, for example) from family members to assure placement of a relative.

Most homes require full financial disclosure from residents who will be paying privately. Since many nursing home residents who enter as private pay residents eventually use up their funds and go on Medicaid, the homes want to know how long the resident will be able to pay privately and when to apply for Medicaid.

Once you are eligible for Medicaid, you have the right to have Medicaid pay for your care (if the home accepts Medicaid). When this happens, the nursing home should assist in completing the necessary forms.

You may not be moved out of a nursing home because you have exhausted your personal resources. Also, your spouse need not spend all his/her personal resources on your care if you are institutionalized.

Some homes suggest that funds be placed in a trust that the home controls, or that the residents Social Security checks be made payable directly to the home. The law guarantees residents the right to control their own financial affairs as long as they are willing and able to do so, or to assign that responsibility to a friend or family member. The nursing home may be given control over a residents finances if no one else is willing to handle them. 

Private Insurance

Private long term care insurance policies are becoming more and more available. They are advertised as a possible alternative to Medicaid or as a way to avoid exhausting resources when nursing home care is needed. They vary in the coverage they provide and should be carefully examined before purchasing. The State Insurance Department publishes materials comparing long term care policies offered by different companies.

The federal government is now permitting states to authorize Medicaid without someone exhausting his/her assets if that person first purchases a long term care insurance policy sponsored by the state. Such a policy must cover at least three years of long term care, six years of home care or an equivalent combination of both. Once an individual purchases such a policy and once the benefits for such a policy are exhausted, that person, if income eligible, will be eligible for Medicaid payment for long term care for the remainder of his/her life without consideration of his/her assets. Most importantly, however, whatever assets that person has will be protected and will not have to be used to meet long term care costs. You may hear this type of insurance referred to as a "partnership" long term care policy.

Medicaid

Medicaid, established by Congress in 1965, is a government health insurance program for people of all ages whose income is too low to provide for routine health care costs, or whose health care costs are too high to be covered by their income. This health insurance covers the cost of nursing care for as long as the care is required, if a resident is eligible.

A comprehensive application process is used to determine eligibility for the Medicaid program. This process requires that applicants provide detailed information and documentation regarding income and assets.

A Medicaid applicant must be a citizen or permanent resident in the United States, must meet State income and resource limitations and must show medical need.

Currently, a Medicaid recipient in a nursing home is allowed to retain $50 of monthly income as a personal needs allowance to meet personal expenses that are not covered by Medicaid. Call your local Department of Social Services office for additional info information on Medicaid.

Medicare

Medicare is a federal health insurance program for disabled people and people over age 65. Skilled nursing services must be needed on a daily basis to be eligible for Medicare.

Medicare will pay a maximum of 100 days of care in an approved nursing facility for patients in need of skilled care following a hospitalization of at least three full days. To qualify, the patient must be admitted to the nursing home within 30 days of discharge from the hospital.

Many people leave a hospital and enter a nursing home expecting Medicare to continue to pay for health services. This is generally not the case. Medicare will not pay for a nursing home stay if it is determined that only custodial care is required, or if skilled nursing home care and/or rehabilitative services are needed only on a periodic basis. Under Medicare rules, the need for skilled nursing care must be daily. The program has a number of specifics about what services are included and requires that you be responsible for a co-payment. For further information, contact your local Social Security office.

Visiting the Facility

Call the nursing homes you are interested in and make an appointment to meet with the admissions staff (usually a social worker).

Each nursing home has its own policies and procedures, but all must follow certain state and federal regulations and respect residents rights. A copy of the home's policies should be available upon request. Following is a list of some policies to check:

- complaint procedures;
- the use of personal belongings and furniture;
- the availability of ethnic foods or special diet preferences;
- room assignments and changes;
- reserving a bed if transferred to a hospital;
- visiting hours (should cover a 10-hour period and two meal times);
- emergency procedures;
- self-care;
- phone calls;
- leaving the facility for short visits with family or friends;
- procedures for handling theft;
- access to personal funds.

Section II of this directory provides more detailed information on what you should look for when you visit a nursing home. 

Nursing Home Administration

Nursing homes may be owned by state/local governments (public nursing homes), individuals, corporations and religious or charitable organizations. Most nursing homes are not-for-profit businesses (voluntary nursing homes) or businesses operated for profit (proprietary nursing homes). An individual or a nonprofit organization may own or operate more than one nursing home. 

Final responsibility for the operation of a nursing home lies with its governing body (voluntary nursing home) or owner (proprietary nursing home). The governing body (the board of directors or trustees) is legally responsible for the home. The governing body meets to set policies and to adopt and enforce rules and regulations for the health care and safety of the residents. The type of ownership and management are not necessarily an indication of the quality of service that you would receive.

The person in charge of the day-to-day management of a nursing home is called the administrator; the administrator is appointed by the governing body or owner. Other key personnel include the director of nursing services, the medical director, the director of social services and the director of admissions.

The administrator of the nursing home must be licensed by the State, the director of nursing services must be a registered nurse and licensed by the State and the medical director must be a State licensed physician. 

Evaluating A Nursing Home

When you visit a nursing home, look for its license. It will be prominently displayed, usually in the lobby.

Standards governing the operation of a nursing home are set by state and federal law. These standards intend to assure the highest possible quality of care and most meaningful quality of life for all residents in nursing homes. Standards cover a range of requirements including but not limited to residents rights, clinical services (including nursing, dietary, medical and rehabilitation services, for example), and administrative (including quality assurance and the physical environment, for example). Optional services are also covered by law (rehabilitation services for residents with head injuries, long term care services for people with AIDS and for ventilator-dependent residents) and adult day health care services.

Look for the latest state survey (inspection) report of how the home met the state standards set by code. 

The Department of Health, acting as the agent for the U.S. Health Care Financing Administration, has the responsibility to monitor quality of care in nursing homes. State surveyors inspect each nursing home every nine to 15 months. Surveyors interview residents, review residents records, inspect the premises and assess compliance with state and federal standards.

Surveyors may issue statements of deficiencies any time they visit a nursing home. If the need arises, state or federal survey staff may visit nursing homes more often to respond to complaints by residents or families or to monitor the progress as nursing homes correct deficiencies.

Based on the results of the inspection and the seriousness of problems noted, the Department of Health decides whether to take enforcement action. Repeat problems can result in fines and, in extreme cases, closure.

Remember, deficiencies are not necessarily the only indication of the quality of the care and administration of the home. Ask to look at the results of a few surveys so you can see if there is a pattern of deficiencies in certain areas.

Complete results of the most recent survey must be available in the facility in a place readily accessible to residents and visitors without staff assistance. Ask questions about deficiencies, if any, and how they were corrected. If you have additional questions after leaving the home, call back with follow-up questions. Or, contact the local office of the Department of Health or the Office for the Aging Long Term Care Ombudsman.

Health Care Decisions

Illness and the possibility of death are subjects few people find easy to discuss. Yet, these issues deserve consideration by both you and your family because they often involve decisions that may have to be made if life-sustaining procedures become necessary. This kind of decision does not have to be left to the family to decide. Decide in advance with the help of your family. Any course of treatment for you will be much easier to determine if your wishes are known in advance . 

Under the State Health Care Proxy Law, adults may appoint someone they trust to decide about medical treatment should they become unable to decide on their own. See Appendix C for a copy of the Health Care Proxy form and information about the Health Care Proxy Law. This form can be duplicated and does not have to be executed by an attorney. Additional copies are available from the nursing home administrator or from the State Department of Health. Most attorneys also have these forms.

Adults can also give specific instructions about treatment in advance. Those instructions can be verbal or written, and are referred to as Advance Directives.

The right to decide about treatment also includes the right to decide about cardiopulmonary resuscitation (an emergency treatment to restart the heart and lungs when breathing or circulation stops). You and your doctors should decide in advance whether or not you want resuscitation measures taken. If you wish, the doctor will give the medical staff a "do-not-resuscitate" (DNR) order.

Some nursing homes' moral or religious philosophy may conflict with your wishes about advance directives. Ask about the home's policy regarding advance directives.

Residents' Rights

Policies covering the rights of residents are established by state and federal regulations. The nursing home must implement and explain these policies to its residents and must post a summary of residents rights (a residents bill of rights) in the building for easy reading. Be sure to notice it and ask any questions you have about its provisions.

Every resident in a nursing home should receive appropriate care, be treated with courtesy and enjoy continued civil and legal rights. 

Nursing home residents have the right to:

- dignity, respect and a comfortable living environment;
- quality of care and treatment without discrimination;
- freedom of choice to make independent decisions;
- safeguard of money and property;
- safeguards in admission, transfer and discharge;
- privacy in communications;
- participate in organizations and activities of their choice;
- an easy-to-use and responsive complaint procedure.
- exercise all rights without fear of reprisals.

Long Term Care Ombudsman Program

The Long Term Care Ombudsman Program in the State Office for the Aging can help you throughout the nursing home placement process. It provides another source of information about how to go about choosing a facility, understanding the rights of residents and learning about good standards of care. However, the program does not rate or recommend specific facilities and will not choose a facility for a family or a prospective resident.

The State Ombudsman also investigates and resolves complaints made by, or on behalf of, nursing home residents, and monitors the development and implementation of laws, regulations and policies that affect nursing homes.

Finding A Nursing Home - When You Visit A Nursing Home

Physical Appearance

Take a good look around at everything.

Do residents have personal belongings decorating their rooms?
Does each resident have at least one comfortable chair?
Does each resident have his/her own dresser and closet space with a locked drawer or other secured compartment?
Is there an out-of-doors area where residents can walk or sit and is it used?
Does the equipment--wheelchairs, therapy devices--appear in good condition?
Is there a lounge or other area where residents can entertain visitors privately?

Safety

State standards require that a home provide a safe environment for residents whether they are mobile or in wheelchairs, whether they are confused or have poor eyesight. Look for:

handrails in hallways and other critical places;
wide, clear walking areas;
the absence of hazards that might cause accidents;
good lighting;
telephones and large print notices placed so that wheelchair-bound residents can make use of them;
appropriate inside temperature and whether or not residents are dressed appropriately;
clearly marked exits and well-lighted elevators.
Find out if the local fire department participates in fire drills and how often drills are held in the home. 

Cleanliness

A good home should be clean. Look in the corners of residents rooms, bathrooms, kitchens, nurses stations, etc., as well as in the main visiting lounges. Look for cleanliness EVERYWHERE.

Unpleasant odors reflect problems. If there is an odor in a particular section of the home, go back to see if it has been eliminated within a reasonable amount of time. This will give you an idea of how long it takes the home to deal with the cause of the unpleasant odor.

Residents

The average nursing home resident is old, sick and frail. A good home is aware that even frail elderly people can have good days and bad days and can be encouraged to be more active when they are feeling better and comforted when they are feeling poorly.

You may be able to judge how successful a home is in caring for residents by observing them without infringing on their privacy.

Do residents socialize with each other?
Is there activity in the corridors?
Are residents engaged in doing things or just sitting in a lounge or in the hallways?
Are residents neatly dressed and do they appear to be wearing their own clothing?
Are residents out of bed?
Do staff interact with residents in a warm and friendly manner?
Do staff address the residents by name?
Do staff respond to someone calling for help?
Are people assisted in walking for the purpose of exercising or retraining?

Ask several residents how they keep occupied and what they particularly like doing at the facility.

Room Assignments

Do residents share rooms? How many people to a room?
Does the facility try to select compatible roommates?
Are rooms assigned based on severity of illness?
How does the facility deal with problems between roommates?

Food

Mealtime is an important part of the residents day. Try to visit during meal time and observe the way food is served and how the staff and residents interact.

Is food appetizing and of good quality?
Do residents have an alternative to the main menu?
Are residents encouraged and assisted with eating (if necessary) while the food is served?
Is this a time when socializing is encouraged?
Is the dining room clean, attractive and colorful?

Many facilities try to be less "institutional" and use tablecloths, china and silver, enhancing mealtime.

Medical/Nursing Care

It is hard to observe medical/nursing practices, but you can ask questions:

Does the same nurse or aide care for the resident during each shift?
Will your family doctor be able to care for you in the facility?
If you do not have a private doctor, who will the physician be and what relationship will you or a family member have with this doctor?
How often will visits be made, and how will medical emergencies be handled?

If you need more than routine medical care, ask if a specialist can be called in and how this is done. Find out with which hospital(s) the nursing home may be affiliated. 

Special Therapies

If you might need speech, physical or special therapy, look at the therapy rooms. If possible, speak to the staff person in charge.
How frequently will therapy be offered?
Can therapies be provided on an optional basis or a for-private-pay basis?
Is the physician involved in assessing the therapy and your response to it?

Activities Program

All homes are required to offer activities for residents. As you visit homes, you may find a great difference in the way activities are offered. Ideally, a program should be designed to fit the interests and skills of each person and be available on a daily basis at various times of the day including weekends.

Ask if residents are taken out for events in the community. How often? Where do they go?
Do people in wheelchairs get to participate?
How often are outside events brought in for the entertainment of residents?
What activities are provided for bed-bound residents? 

Financial Arrangements

If you will be paying privately for care, ask about the fee schedule and be sure you find out what services and supplies ARE NOT INCLUDED and what these items will cost.

To determine how often fees increase, ask how often fees increased in the past and what the increases were. 
State Inspections

State law prohibits residents from being asked to pay more than three months in advance upon admission. (People admitted under Medicare do not have to pay anything in advance.)

The last state inspection report (survey) should be available to you in a place within the facility that is readily accessible. It will tell you if the facility failed to meet any areas of the states health code. Look for this report. If there are any deficiencies noted, specifically ask what steps have been taken to correct these violations.

Continue to » Finding A Nursing Home - Nursing Home Information

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