Chapter 28

Assisted Living and Nursing Homes

Ron W. fought against the idea of moving into an assisted living home. He felt he was too young to give up control of his life. He found that the residence was not only a home, but he gained more control over the things that really mattered to him by letting other people assist in the things that had become a problem.

 

If home care is no longer feasible, the alternatives to consider are assisted living homes and nursing homes that combine both care and a residential atmosphere.

Section 1. Assisted Living or “Board and Care” Homes

While assisted living homes are primarily for the elderly, they accept any residents who need assistance with living, short of the kind of nursing requirements provided in a nursing home. Some retirement communities offer a place to live, meals, and nursing care as needed.

Standards. Currently there are no objective standards developed to assess assisted living homes. If it is feasible, restrict your search to licensed homes. In addition to the protection of licensing, you can and should read the governing agency’s inspection report.

Tip. Either you, a family member, or a close friend should visit and inspect the premises at least once, and preferably at least one other time. It would be helpful if one of the visits was not expected by the personnel at the home so you have a chance of seeing what life is really like there.

Factors to consider.

• The cost and means available for paying for it. If your insurance or a government program will pay, will the home accept the amount as payment in full?

• The physical appearance is important. Is it a residence in which you would be comfortable living?

• Where in the home would you live? Is it acceptable?

• How sanitary are the conditions?

• Learn about what life is like in the home by talking with the residents.

• If meals are provided, time the visit for at least one meal to assess the appearance and the quality of the food. Are there arrangements for special diets? Is food delivered to residents who are unable or unwilling to eat in the dining room?

• What are the rules and regulations about life in the home, including about going out and visitors?

• What is the cost and availability of transportation?

• What help is available in the facility? What are their qualifications?

• What are your rights concerning services if you need assistance or your health fails?

• What is the cost and availability of other services?

• What quality guarantees are there?

• Who makes the determination whether you need to be moved to a nursing home or hospital and how is that decision made? What is the patient’s involvement in the decision?

Contracts. Read, or have an attorney read, the contract carefully. The contract should include all the matters you care about, including a move to a nursing home or hospital and your right to be consulted about these subjects.

Tip. Ideally, the facility should be linked to a nursing home just in case you need a higher level of care. Thus you would be able to move smoothly into the nursing home and back to the facility when appropriate.

Payment. Medicare generally does not pay for assisted living facilities unless certified skilled care is delivered, and most of these homes are not certified. In some states, depending on income, Medicaid may pay. Most insurance policies do not cover these facilities, but you can try to negotiate for coverage based on the argument that staying there is cheaper than going into a hospital.

Section 2. Nursing Homes

If it is likely that you will need twenty-four-hour nursing care and supervision, and neither home care nor assisted living homes work for you, consider a nursing home. Planning ahead is one of the best ways to ease the stress and is also the best method of finding a home compatible with your needs.

Tip. If an immediate need precludes a full assessment, at least assess each affordable home’s medical/nursing care. Once you are a resident, the full assessment of the home and alternatives can continue. Be sure you can leave on short notice, such as one day.

2.1 Locating a Nursing Home

Preferably, find a nursing home that

• you can afford (through your insurance, your own money, or a government program).

• is located where you want to be (such as close to family members and friends so it is easy for them to visit, and/or near community resources you hope to continue to use).

• combines good “nursing” care with your concept of a homelike atmosphere.

• takes care of your wants as well as your needs.

For help in locating a nursing home, consult your primary care physician, a hospital’s “discharge planner,” professionals in the long-term-care field, your local GuardianOrg or state and local offices.

2.2 Assessing a Nursing Home

Reports. Once you have located homes that fit your general needs, start assessing them by obtaining a copy of the report the appropriate regulatory body may have issued about the home. Reports can be obtained from a variety of sources and include such items as infection control, safety hazards, nutrition and taste of food, staff training and credentials, medication errors, and availability of activities. They may also include complaints against the nursing home and the conclusions of the investigations into these complaints. According to a Consumer Reports article on nursing homes: “When you read a report, don’t expect perfection. Nursing homes provide a difficult service … and even the best have deficiencies from time to time.” Potential sources for reports are

• your state or local office for the elderly. The Health Care Financing Administration (HCFA), a government agency that certifies nursing homes that accept payment from Medicare or Medicaid, requires that these offices undertake nursing home inspections.

• the Office of the Long-Term Care Ombudsman, which federal law requires each state agency on aging to have. While these offices are geared to older Americans, they will provide anyone with their information.

• the Joint Commission on Accreditation of Health Care Organizations, 1 Renaissance Boulevard, Oak Brook Terrace, IL 60181 (630-792-5000). If they have them, they will send you free reports on up to ten facilities of interest to you.

Telephone evaluation. Once you have reviewed a report, begin your own evaluation. If you start with a telephone call, you may eliminate the need to visit a particular home. Some of the key questions to cover on the phone:

• Is the nursing home certified for participation in the Medicare and Medicaid programs?

• Since nursing homes are known to allocate beds between people paying full market rates and those on Medicare or Medicaid, is there space available for you under your payment plan?

• What are the facility’s admission requirements for residents?

• What is the typical profile of a resident?

• Does the nursing home require that a resident sign over personal property or real estate in exchange for care? If so, how much?

• Does the facility have vacancies or is there a waiting list?

Tip. If no Medicare/Medicaid beds are available, consider paying the market rate for several months and then changing to Medicare/Medicaid payment. It is difficult to move people out once they are in a nursing home.

Site visit. Once you have narrowed your search, inspect the facility with a loved one or team member to determine what life would be like living there. If you’re not up to it, ask a family member or friend to do it for you. Choosing the best home for your needs is too important a decision to leave to chance.

If there isn’t time to do an inspection, be sure the information you receive about each home under consideration comes from a broad base of sources. Do not rely on any one source in choosing a nursing home.

The following suggestions are based on a Consumer Reports article on nursing homes together with the recommendations of the New York State Department of Health. The list is extensive to help you focus on things that will be important to you if you become a resident. Add whatever matters are of particular concern to you before you visit any sites so you don’t overlook them. Photocopy the list, with your additions, and take it with you, or give it to whoever will visit the site for you. Note your observations for each home visited for later comparison, or use a tape recorder.

Inspection report.

• If you haven’t already received a copy of an inspection report, ask for one on-site. Federal guidelines require nursing homes to make their latest inspection report available and readily accessible to residents and the public, but you often have to be assertive to obtain one.

Visits.

• Tour on your own, rather than with a staff member (if the home won’t let you tour alone after the first guided visit, take it off your list).

• Visit unannounced several times, at different times of the day and the week, to get a complete view of life in the home. One of the visits should be during the evening and/or on a weekend when there are usually fewer staff members on duty.

Physical appearance.

• Do they allow residents to personalize their rooms?

• Does each resident have at least one comfortable chair?

• Does each resident have his or her own dresser and closet space with a locked drawer or other secure compartment?

• Is there an out-of-doors area where residents can walk and sit and is it used?

• Does the equipment—wheelchairs, therapy devices—appear to be in good condition?

• Is there a lounge or other area where residents can entertain visitors privately?

Safety.

• Are the exits clearly marked and unobstructed?

• Are there accident-prevention features such as handrails in the hallways and grab bars in the bathrooms?

• Are the hallways wide enough for two wheelchairs to pass? Can they pass freely everywhere or are there obstructions?

• Look at safety hazards to people who walk unsteadily or with impaired eyesight.

• Is there good lighting?

• Are telephones and large-print notices placed so that the wheelchair-bound residents can make use of them?

• Are the inside temperatures appropriate, and are residents dressed appropriately?

• Are people assisted in walking for exercise or retraining?

Cleanliness.

• Check the kitchen for cleanliness.

• Check for smells (particularly for urine and feces).

• Look at the overall cleanliness of the public and activities areas.

Residents.

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

• Look at the quality of the care and the concern for the residents.

• Do the residents appear to be content, enjoying the activities, interacting with each other? Are they well groomed? If most residents are passive, it may be a sign that the home has no activity program or that residents are kept on medications.

• Are any of the residents in restraints? If so, ask the staff why. Federal law states that nursing home residents have the right to be free from any restraints administered for discipline or convenience, unless required to treat medical conditions. In addition, under the law residents have the right to be free from neglect and any type of abuse—verbal, sexual, physical, and mental.

• Ask residents what they like and don’t like about the home, and what they do when they need something to be different. Ask what they like about the staff. Ask visitors or volunteers the same questions.

• Are residents allowed to participate in the planning of their own treatment?

• If possible, speak with family members of the facility’s residents. There may even be a voluntary council of family members with whom you can speak.

• Does the home give residents the freedom and privacy to attend to their personal needs?

• Are there arrangements for residents to go home for holidays?

• Visit the activities area when in session.

• Walk through the corridors and listen to what you hear.

Staff.

• How responsive are staff? Do staff respond to someone calling for help?

• Do staff interact with residents in a warm, friendly manner?

• Do staff address the residents by name?

• Try to get a handle on staff turnover if you can. A high rate of turnover is not good.

• Find out whom to speak with if problems arise, and meet with that person.

Food.

• Try to time a visit for mealtime and taste the food. Is food appetizing and of good quality?

• What arrangements does the home have for special diets? Is there a dietitian? What effort is made to make special diets taste good?

• Is there sufficient staff and equipment to help residents who can’t easily feed themselves?

• Is sufficient time allotted for eating?

• Is food delivered to residents who are unable or unwilling to eat in the dining room?

• Are snacks available?

• Is the dining room clean and attractive?

Medical/nursing care.

• Look at the medical services, since medical and nursing care is crucial. Generally, you choose your own physician, even for emergency care. Will your attending physician be able to care for you while you are in the facility? Nursing homes also have their own physician. Find out who the physician is and how often she visits and reviews residents’ medical records.

• How are medical emergencies handled?

• If you need more than routine medical care, ask if a specialist can be called in and how this is done.

• With which hospital or hospitals is the nursing home affiliated?

• What care is given by a registered nurse and what care by an aide?

• How many residents is each nurse’s aide or direct care nurse assigned to care for? Are licensed nurses on duty around the clock?

• Does the same nurse or aide care for the resident during each shift?

• If you may need special therapy, look in the therapy rooms and speak with the staff person in charge. How frequently will the therapy be offered? How involved is the home’s physician in the establishment and in oversight of the therapy?

Activities programs.

• Ideally, a program should be designed to fit the interests and skills of each person at a variety of times daily, including weekends.

• Are residents 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 bedridden residents?

Money issues.

• Find out what services the home provides and which ones cost extra.

• How much does the nursing home charge for (1) a daily semiprivate or private room if you need one, (2) the “extras,” e.g., supplies such as diapers, catheter tubes, and for special services such as incontinence care. A daily rate seldom includes the extras. Be prepared to supply these yourself.

Tip. Prescriptions in nursing homes often cost double what they would at a local pharmacy. If the drug prices are gouging, demand the right to purchase drugs outside the nursing home.

Contracts. If a contract is required, show it to your attorney before signing. Ideally, you can cancel your stay on short notice and receive a refund of any advance payment. Preferably pay by the month.

Bottom line. Form your own impressions. After you have done all of your research, your final judgment should include your gut feeling.

2.3 Payment

Discrimination against Medicaid recipients is prohibited by federal law. However, as a practical matter, nursing homes all too often admit people who can pay with their own resources or private insurance, then those who qualify for Medicare, and then patients who are on Medicaid. If you have your own resources but are likely to run out while you are in the home, or you have little income, check with your state Medicaid agency before entering a nursing home to determine the financial eligibility requirements for Medicaid and be sure the home is Medicaid-certified.

Deposits. If you are covered by Medicare or Medicaid, nursing homes cannot ask for a security deposit or other form of advance payment. Many states also have laws banning deposits when the cost of care is covered by insurance or government programs. These laws are often breached, but you have the right to insist on their enforcement. Generally, a nursing home can request a deposit if you do not have any coverage.

Third-party guaranty. It is also illegal to require third-party guarantees if you are covered by Medicare or Medicaid.

Long-term-care insurance. See chapter 14, section 11.

Managed care. If you are enrolled in a managed care organization, ask a representative of the plan about coordination of health care services between the MCO and the nursing home (and Medicare or Medicaid if you qualify). Also ask which nursing homes the MCO works with in the area. Talk to a plan representative if you are interested in a nursing home outside the area served by the MCO. Some MCOs may also offer more medical or supportive services than those required by Medicare and Medicaid. Some do not require a hospital stay before approving a nursing home admission.

Medicare. Under some limited circumstances, Medicare Part A will pay for a fixed period of skilled nursing facility care. To qualify for Medicare payment

• the nursing home must be Medicare certified;

• you must have been in a hospital for a minimum of three days;

• you must enter the nursing home within thirty days of a hospital stay; and

• you must need skilled nursing care for the same condition that caused the hospitalization.

Medicare pays in full only for the first twenty days of skilled nursing care. The payment amount changes each calendar year after that. In any event, Medicare only pays for a maximum of one hundred days in any benefit period. A benefit period ends when a person has not been an inpatient of a hospital or a skilled nursing facility for sixty consecutive days.

Some Medicare supplementary insurance policies (MediGap) supplement this limited Medicare coverage.

Medicaid. Medicaid payments do not have a time limit, but Medicaid pays the lowest amount of any private or governmental payment plan. For this reason nursing homes try to avoid Medicaid as a source of payment.

For Medicaid to pay for nursing home care

• the nursing home must be Medicaid certified.

• you must meet income and assets tests (see chapter 15). In most states, if your income is less than the private-pay rate, you can be eligible for Medicaid. Your income (including SSD, SSI, and pension benefits) goes to the nursing home directly and Medicaid pays the difference between that income and the Medicaid rates.

If you have to move to a hospital from a nursing home, each state determines the length of time a nursing home has to hold a bed for the return of a hospitalized Medicaid resident. Days range from zero to fifteen. Even if there is no requirement to actually hold a bed, the law does require a nursing home to readmit the hospitalized resident to the next available bed.

Tip. If you anticipate that you will need nursing home care in the future, think about consulting with an attorney to discuss eligibility for Medicaid (see chapter 15).

It is illegal for a nursing home to require you to give up any rights to Medicaid or to prevent you from transferring your funds to qualify for Medicaid. It is also illegal to require payment for “extra” services that are included in the Medicaid payment, such as laundry. You can be charged for (but not required to take) real extras such as a television in your room.

2.4 Complaints

Congress has enacted federal legislation that gives residents certain enforceable rights, including the rights to dignity, choice, self-determination, and quality services and activities.

Ombudsman. If you have complaints about a nursing home, call the ombudsman. The ombudsman mediates disputes and has the clout to require action from the nursing home.

If you have trouble locating your ombudsman, call the Eldercare Locator at 800-677-1116. The Locator can give you the telephone numbers for area agencies on aging or for state and local departments of elder affairs, which in turn can give you contact information for your state’s ombudsman.