When long-term care becomes necessary for a family member or loved one, it can be difficult to know where to begin. What levels of care are available, and what type of medical care do each provide? Could the resident strive in an assisted living facility instead? Is dementia or Alzheimer’s in the picture, calling on the possible need for memory care?
If you have determined that skilled residential care is required to meet care needs, a special set of considerations come into play. When selecting the right facility and developing the best care plan, please consider the following concepts.
The First Step in Finding the Right Long-Term Care Facility
Make a list of long-term care facilities in your area that seem to fit the needs and preferences of the person who needs care. The more choices you have, the better your chances of making the best selection. Start with the yellow pages of your phone book. Other possible sources of information are the local health department, senior citizen groups, the local Social Security office, Department of Human Services local office, and your physician, clergyman, relatives and friends. No single individual or group can supply complete information about all possible homes.
Should I visit all the homes on my list?
No. You can eliminate some by making a few telephone calls to determine whether a home actually provides the kind of care that is needed and, if you are depending on that kind of help, whether the facility participates in Medicare or Medicaid or other federal government programs. Be aware that not all facilities will have vacancies for new residents.
When should I visit a home?
It is preferable to visit the facility more than once and at different time of day. One visit should be during late morning or midday so you can observe the noon meal being served. Another visit should be during the afternoon to observe activities being offered. Another time to visit would be during the evening meal. Plan to spend at least one hour at each visit. It is usually best to make an appointment to meet with the administrator the first time you visit the facility to explain the purpose of your visit.
Following a guided tour, it is wise to talk to residents and observe conditions by yourself without facility staff being present. If the administrator refuses to do this, you can assume he or she has something to hide.
Licenses and Certificates
Most homes display their licenses and certificates. Never accept someone’s word that certificates exist. Ask to see them and take time to examine them. Be sure they are current. The more important documents include:
Long-term care facility license. If the home is not licensed, do not use it. It is particularly important that a person requiring any kind of supervision or personal care not be placed in an unlicensed facility. Illinois requires all facilities providing such care to obtain the proper license.
Nursing home administrator license. All nursing home administrators must have state licenses. This applies to skilled nursing facilities, intermediate care facilities, and intermediate care facilities for the developmentally disabled. If the administrator does not have a current license or is unlicensed, do not use the home.
When visiting a facility, ask to see the latest state survey (inspection) report of how it met the state standards set by law.
Physical Conditions
Location. Think of whether the person needing care prefers an urban or rural setting. In either case, it is advantageous to be near a hospital. If the person wants to continue using his or her personal physician, the facility should be near where the physician practices. It is equally important that the location allows family and friends to visit easily and often, since this often affects the resident’s progress.
Accident prevention. Eliminating hazards is an important concern, especially when a resident cannot move about easily. Most good nursing homes emphasize accident prevention because even minor mishaps can be dangerous for the aged. All areas should be clear of small low objects that can cause a person to trip. There should be no throw rugs or small area rugs. Chairs should be sturdy and not easily tipped. Handrails in hallways and grab bars in bathrooms increase safety while they also encourage self-help.
Fire safety. A good facility must comply with state fire safety codes. Ask to see the report of a home’s last fire safety inspection showing that it meets state codes. Do not choose a home that has not been inspected and cleared for fire safety within the year.
Good housekeeping is important in preventing fires and in avoiding tragedy if one starts. Exits and the paths to exits must be clearly marked and must not be blocked. Doors must not be locked from the inside. Stairways must be enclosed and doors and stairways must be kept closed.
A good home puts residents through frequent fire drills to acquaint them with the quickest way to leave the building wherever they may be at the moment. A written emergency evacuation plan should be available. Adequate staff should be present at all times to aid residents who cannot get around by themselves.
Bedrooms. Each resident room must open onto a corridor and have a window. A bedroom must have no more than four beds, placed so as to permit easy access. Each resident should be given privacy when needed. Each resident who needs them should have a nurse call bell and fresh drinking water within reach. Each resident should have a reading light and room enough to maneuver a wheelchair easily. And each should have his or her own closet space and drawers for personal belongings. Ask how the home selects roommates. Putting two people together without considering their special interests or personalities can lead to conflict. Unless medical conditions prohibit it, married couples should be permitted to share a bedroom if they so desire.
Cleanliness. Among good homes, there is some variation. Does the resident prefer super-tidiness or a lived-in look? Unpleasant odors indicate a dirty home or poor attention to the incontinent. However, you may notice a slight smell of urine because it is extremely difficult to remove it completely, and good nursing homes do not mask odors with highly scented sprays.
Lobby. If used by residents as a lounge, a lobby should contain comfortable chairs and couches, plants and flowers, and a bulletin board with notices of activities and menus. License, certificates, a copy of any current order pertaining to the facility issued by the Department or by a court, and a notice regarding complaint procedures should be on display in the lobby area. These documents should be available for public inspection.
In addition, the facility also is required to post a list of materials available to the public for inspection. These documents include:
a complete copy of every inspection report the facility has received from the Department during the past five years,
a copy of every order pertaining to the facility issued by the Department or a court during the past five years,
a description of the services provided by the facility and the rates charged for those services and a list of those items for which a resident may be separately charged,
a copy of the statement of ownership, and
a record of personnel employed or retained by the facility who are licensed, certified or registered by the Illinois Department of Financial and Professional Regulation.
These are very technical nursing home requirements, and can be difficult to navigate for family members. The ombudsman program, VOYCESTL.org for St. Louis area families, is available to assist in these areas, or ANY areas for that matter. Other area agencies are available in almost all communities.
Hallways. These should be large enough to allow two wheelchairs to pass with ease and should have handgrip railings on either side. Some homes brighten their corridors with colorful paint and pictures.
Dining rooms. Dining rooms should be attractive and inviting, with comfortable chairs and tables that can be moved around to accommodate residents in wheelchairs. If you visit during meal time, sample the food. Notice whether it matches the posted menu; sometimes homes try to cut costs by substituting. Residents who need help should receive it.
Kitchen. Food preparation, garbage and dishwashing areas must be separated from one another. Food needing refrigeration, such as milk, cream sauces and mayonnaise, should never be left on counter tops.
Activity rooms. Larger facilities have at least one activity room while smaller ones often use a multipurpose room. All facilities must have sufficient space for activities. Residents who are not too sick should be engaged in activities of some kind — reading, craft work or games, for example.
Isolation rooms. There should be at least one bedroom and bathroom that can be used to isolate anyone with a contagious disease. This room should be close to a nurse’s station.
Toilet facilities. Toilet facilities should be designed to accommodate residents who must use a wheelchair, have a sink (with hot and cold running water) and grab bars on or near the toilet. A good nursing home will have toilet facilities adjacent to every bedroom and will place a nurse call bell near each toilet. Some long-term care facilities provide a bathtub or shower (look for grab bars and nonslip floors) adjacent to each bedroom; others have central bathing areas to make it easier to assist residents.
Grounds. Good long-term care facilities encourage residents to get out of doors. Even a home in an urban setting should take quality measures, and have a lawn or garden where residents can go to get fresh air, and there should be ramps to help the disabled get around. Many homes permit residents to tend small garden plots voluntarily as part of recreational or planned activities.
Services
Medical services. Every home must have physicians available in an emergency. They may be on the staff or on call. The facility also must have an advisory physician or committee. Good homes allow residents to be treated by their private physicians. They also require that residents be seen as often as necessary. If a resident will be depending on the home’s physician, find out how often he or she visits and how closely he or she supervises resident care.
All residents are required to have a thorough physical examination shortly before or upon admission. The physician and nurse also should involve the resident in making a plan for his or her care and treatment while in the nursing home and in revising the plan as the resident’s condition changes.
The final say in any matters affecting a resident’s health belongs to the resident or to his or her guardian. The resident (or guardian) has the right to know about his or her condition and to participate in planning medical treatment.
The need for other medical services, such as dental or eye care, does not stop when a person enters a long-term care facility. These often become more important as the person grows older. The facility you choose should have some arrangements with a nearby hospital or with health care professionals (dentist, podiatrist, optometrist, etc.) in the community to see that residents get all the medical treatment they need. Be sure to ask if these arrangements exist and if there are any associated costs.
Hospitalization. A good long-term care facility usually has an arrangement with a nearby hospital in case residents become acutely ill. Ask the administrator what arrangements the home has and, in their absence, what is done in case of an emergency.
Nursing services. The competence and attitude of the nursing staff probably affect a resident’s sense of well-being more than other health services. Registered nurses (RN’s), with their extensive training and minimum of two years of special education, should direct nursing services in homes with residents who are ill enough to need skilled nursing care. An RN may not be on duty during all shifts, but must be responsible for the nursing staff. Licensed practical nurses (LPNs), with at least one year of specialized training, should be on duty day and night.
Certified nurse aides (CNAs), who come into contact with residents more often than other staff members, help with bathing, eating, dressing, the use of bed pans and other personal needs. CNAs should have either a year’s experience or at least three weeks of training, followed by periodic performance evaluation and ongoing in-service training. In skilled nursing and intermediate care facilities, CNAs must have completed an approved course unless exempt through previous training or experience. Ask the administrator to explain the facility’s CNA training program to you.
Rehabilitation. Full- or part-time caregivers should be available to help residents regain lost abilities, such as walking, talking and dressing. Therapists also help residents to overcome deafness and other obstacles as well as to develop occupational and recreational skills that are personally satisfying, and to provide excellent physical therapy. The facility should provide good nursing and other excellent health-care providers.
Activities program. The most successful program reduces a resident’s isolation, both from other residents in the home and from life outside the home, to add to the resident’s quality of life. For those who can go out, activities provided by staffing should include trips to places such as theaters, museums and parks, and visits to the homes of friends and family. Community institutions, such as libraries, should bring their services to the home. People from the community should be encouraged to volunteer to work or visit with the residents. Each resident should have an activity schedule geared to his or her interests and abilities. Group activities — such as games, arts, crafts and social functions — and individual activities, such as reading and letter writing, should be included. Residents should be encouraged, but not forced, to participate.
Religious observance. Older people often like to attend religious services and to talk to their clergymen. They should be able to do both — either in the home or at a nearby house of worship. Attending religious services, of course, should always be a matter of choice.
Social services. Good homes have social workers on their staffs or as consultants to aid residents and their families in dealing with various problems. For example, a social worker may be able to help new residents overcome feelings of loneliness and isolation and learn how to live in a long-term care facility. A social worker also can help a resident’s family adjust to the long-term care situation. Residents and their families should be encouraged to call freely upon a social worker for assistance and advice.
Food. A dietitian should plan balanced, varied and tasty meals that meet all of a resident’s nutritional needs. Personal likes and dislikes should be considered when planning menus. Ask to see menus; inquire about eating rules. Good homes serve meals at normal times, allow plenty of time for leisurely eating and provide nutritious between-meal and bedtime snacks. Be sure the attendants bring meals to bedfast patients and help to feed them if necessary.
Grooming. Good homes arrange for barbers and beauticians to come in to provide services as needed.
Attitudes and Atmosphere
People who enter long-term care facilities do not leave their individual personalities or basic human rights behind. Nor do they lose their need for friendliness, encouragement and respect. A long-term care facility that treats residents like people and tries to satisfy their emotional, as well as physical, needs helps sick people to get better and healthy people to stay well.
On entering a long-term care facility, individuals should have to give up as few of their human rights as possible. They should be allowed to participate in planning their treatment, be assured of the confidentiality of their medical records and have veto power over participating in experimental research.
Residents should have freedom and privacy to attend to their personal needs. Married residents should be assured privacy during visits from spouses. If both husband and wife live in the home, they should be able to share a room unless medical reasons forbid. All residents should have freedom and opportunity to make friends and to socialize.
Residents and their relatives should be able to talk to administrators and staff about questions, problems and complaints without fear of reprisal. Administrators should be courteous and helpful and should treat residents and their requests with respect. Staff members should respond quickly to calls for assistance and treat residents with courtesy, respect and affection. A long-term care facility may meet every known standard but, if its staff treats people coldly, the residents suffer.
Residents should be allowed to manage their own financial affairs if they are able to. If they are not able to do this, they should receive a periodic accounting of their finances.
Residents should be allowed to decorate their bedrooms with personal belongings and to wear their own clothing. They should be allowed to communicate freely by letter or telephone without interference or censorship.
Those residents who wish to do their own chores should be encouraged to do so, but no one should be forced into activity. Some residents may prefer to watch rather than participate but, if most residents are passive, it may be a sign that the home has no activity program or that residents are kept on tranquilizers.
Visiting hours should be generous and set for the convenience of residents and visitors, not of the nursing home.
Residents should not be transferred or discharged arbitrarily and should be given reasonable advance notice if they must be moved.
Many of the recommendations in this section are included in the “Residents’ Bill of Rights,” a set of rules that homes certified for Medicaid and Medicare must follow. In addition, civil rights law forbids discrimination because of race, color or national origin in all nursing homes. This law applies to referrals, admissions, accommodations, room assignments and transfers; policies regarding financial matters, care services, physical facilities and resident privileges; and the assignment of medical staff and volunteers.
When you visit a long-term care facility, ask residents for their opinions of the home and whether these recommendations and the law are observed. Ask other visitors or volunteers the same question. If you see no volunteers, ask why none work in the home. If you see no visitors, ask for the names of several residents’ families. Call or write to them to find out what they think of the home.
Charges
The more services a resident requires, the more he or she will probably pay. Talk to the administrator about the basic monthly charge and exactly what the resident receives for it (the kind of nursing care, therapy, room, meals, etc.). Some homes charge extra for services like laundry that other homes include in their basic rates.
Itemize the extra services and supplies that the resident will probably need. Be clear whether special items or services (for example, a particular mattress) entail a one-time charge or a monthly rate. Find out where, if possible, you can save money. Prices may vary from facility to facility for the same or similar services. Be sure you are comparing the same services: One facility may quote a figure that includes only the base rate, with extra charges for many services, while another facility may quote a figure that includes everything.
Find out whether the resident is entitled to Medicaid or Medicare by calling the Department of Human Services local office (for Medicaid) or your local Social Security office (for Medicare). If a resident is eligible for Medicaid, the home should bill the state directly for all charges.
If the resident is not eligible for one of the government programs, check into private health insurance, such as Blue Cross/Blue Shield, or another major medical plan to see if it covers nursing home costs.
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 then must rely on Medicaid, the homes want to know how long the resident will be able to pay privately and when it will be necessary to apply for Medicaid. Once a person is eligible for Medicaid, he or she has the right to have this program pay for care (if the home accepts Medicaid). When this happens, the nursing home should assist in completing the necessary forms.
Compare the costs of several homes providing the same or very similar services. In addition to the cost of care, be sure to consider the facility’s location and how convenient it will be to visit. It is most important, however, that the individual be placed in a facility that meets his or her needs. If you look at homes before a crisis arrives, you probably will be able to find a good home at a reasonable price.
The Nursing Home Care Reform Act requires a written contract between the nursing home and the resident, spelling out the conditions under which the resident is accepted. The individual or his or her guardian, representative or family member will have to sign the contract before the person can be admitted, and will be legally bound by what it says.
The contract must state the services to be provided, the costs of those services, the terms of the contract, supplemental services that are available and the costs of each such service, the source(s) liable for payment under the contract, the amount of deposit paid, and the rights, duties and obligations of the resident. Residents’ rights may be on a separate document, but these must be given to the individual at the time of admission.
Before a contract is signed, be sure it is completely understood by all persons concerned. Ask the nursing home administrator to explain anything that is not clear. If possible, have a lawyer review the contract before it is signed.
Other considerations:
Medicare.gov provides an excellent Nursing Home Checklist, as well as a detailed Nursing Home Compare on each nursing home in the country for an excellent “Care Compare.” www.medicare.gov.
QMC
Finding excellent care, to provide the best quality of care, can be quite the project. We want our loved ones to have the best daily living possible. But achieving this goal is always possible. We hope this review has proven helpful to you. And also remember that the professionals at QMC help clients through these issues every day. We had be happy to be your partner in finding the best care for your loved one.