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Choosing A Nursing Home

Nursing home facilities today are providing a wider range of services than ever before, from sub acute care to rehabilitative care to their more traditional role of providing long-term care to the chronically ill. Some people come to nursing homes for a short period of rehabilitation after a serious illness or accident. In other cases, families seek nursing facility care when an elderly or disabled relative's condition reaches the point where it is no longer possible to safely care for that individual at home, even with help.

Finding the right long term care facility is very important. Individual nursing homes should be evaluated closely to ensure the specialized services you require are actually provided. It will be much easier to make an informed decision if you have adequate time to explore and review all options.

It is wise to begin the search for an acceptable facility well in advance of seeking admission. Begin to eliminate from consideration those homes that do not meet your needs. Start with a telephone call to answer questions about vacancies, admission requirements, level of care provided, specialized programs, and participation in Medicare and Medicaid. Does the facility have a contract with the Veterans Administration?

The Survey Process

Currently nursing homes receive an annual unannounced three-to-four day inspection by a team of surveyors from a state's department of health. The team usually consists of four to five professionals, including a nurse's), social worker, dietitian, and a sanitarian ( life safety inspector usually follows ). The following summary outlines this process:

Federal law requires that all nursing homes be inspected annually in order to be certified to receive Medicare and Medicaid payments. Since 1990, these inspections have focused on outcomes--quality of care, protection of patient rights, and the quality of dietary, nursing, pharmacy, and other support services. The inspections draw on a variety of data collection techniques: trained observer ratings of physical facilities, group activities, and a sample of residents (and their rooms); interviews of residents and staff; physical measurements; reviews of records; and various specialized procedures (such as checking the accuracy of a sample of medications as they are distributed and quizzing randomly selected staff concerning proper emergency procedures). These techniques are used to obtain information on a lengthy list of items that jointly characterize various aspects of the quality of nursing home services: quality of life, quality of care, and so forth.

Among the many surveyor ratings used to help assess: "quality of life" are ratings of accommodation to resident needs, resident clothing and grooming, the cleanliness and orderliness of resident rooms, the comfortableness of sound and temperature levels in resident rooms, and the degree to which the resident's room provides a homelike environment. The evaluation of "quality of care" includes observer ratings of the amount eaten by residents, the degree to which the dining environment enhances resident independence and well-being, and potential safety hazards. Surveyors rate dietary services in terms of the timeliness, appearance, flavor, temperature, and nutritional balance of the meals served. And the physical environment is evaluated with the help of surveyor ratings of the degree of visual privacy, lighting, ventilation (including presence of odors), and numerous other characteristics.

The Centers for Medicare & Medicaid Services ( CMS ) — formerly known as HFCA — contracts for the inspections (surveys) with state health departments. The field work is undertaken by full-time multidisciplinary teams of four to seven professionals--nurses, dietitians, social workers, pharmacists, sanitarians, and so forth. A typical certification inspection requires three to four days and results in a list of citations for the major problems identified. These can have serious consequences for the nursing home, including decertification.

Quality control for these inspections is exercised by CMS and the state health departments. In addition, CMS personnel completely resurvey a 5 percent random sample of inspected nursing homes in each state. These reinspections occur within two months of the state inspection. CMS is also implementing joint nursing home inspections (independent, parallel surveys with both state and federal inspection teams on site at the same time) and requiring that all surveyors pass a standard test designed by CMS

There are a total of 319 federal regulations and a hundred or more state specific regulations reviewed as part of the annual inspection ( licensure & certification ) process. The vast majority of those regulations can be cited if the care of one resident is found to be out of compliance. Thus, in a typical 100-bed home, the facility is at risk of 46,900 ways to be wrong.

Excepted from:

Regulations - For What Purpose?
By Reginald Carter, Ph.D.
http://www.hcam.org/articles/regulations.html

First, The Basics

When you first drive up to the facility, drive around and look around. Are the grounds well maintained? Is trash overflowing the dumpsters at the backside of the facility? A facility does not have to be new to be the best, but it does have to be well maintained. If management can not ensure the grounds are taken care of, what is its attitude toward patient care?

Every nursing home should have a current license issued by the state, meaning it has passed inspection and meets minimum standards. In addition to licensing, the facility may have chosen to participate in an accreditation program which has been developed to raise industry standards. Accreditation is a positive sign.

Visiting The Nursing Home

Although there may be pressure to choose a nursing home quickly, you are strongly urged to tour the facilities under consideration before making a decision. Ideally, I recommend visiting twice: once during normal business hours when administrative staff are present, then a second visit after hours or even on the weekend. Is staff coverage adequate on evenings and weekends?

During your visits, try to speak to anyone and everyone who can give you information -- family members, residents, nurses and aides, and so on -- in order to develop as full a picture as possible of the day-to-day operations of the facility.

Quality of Life - Quality of Care

Quality initiatives, accreditation, certification and state surveyors ( inspectors ) all aim to improve and/or maintain residents quality of life and ensure care practices meet professional standards. One of the most powerful factors affecting quality of life and quality of care is a visitor. Regular visits from family and friends offer reassurance to the resident that someone still cares. In fact, those residents whose families are involved in their care usually have higher morale and receive better care from the staff.

How many decubitus ulcers (bed sores) are in the building. How many are nosocomial ( developed in a hospital - or somewhere else ) and how many were developed in-house. How many of each stage ( Stage I, Stage II, Stage III, Stage IV ). Stage IV is the worst. This is a definite "red flag".

If you have special care needs such as a ventilator or Alzheimer's, make sure the staff have the training/equipment and experience working with people who have the same need or condition.

Inspection Reports ( Surveys )

Ask the administrator ( or a staff member ) for permission to review the facility's state and federal inspection reports. It should be readily available to residents and visitors.

Keep in mind that these reports will include only the negative findings; they will not point out the facility's positive aspects. Do not rule out a facility just because it had some deficiencies in its most recent survey. Ask the facility what steps it has taken to correct any deficiencies, and review reports from prior years for trends or chronic issues

All nursing homes that are certified to participate in the Medicare or Medicaid programs are visited by a team of state surveyors (inspectors) annually to be recertified for participation in one or both programs. These same surveyors usually conduct a state license renewal inspection at the same time to ensure the facility is operating within state regulations as well.

In addition to annual licensure & certification inspections, public health surveyors will respond to and investigate complaints filed by consumers, family members, facility employees.

These "complaint surveys" are available for your review as well - ask to see them.  Again, after you have had time to review the surveys, speak with the administrator. Ask for explanations, what do the allegations mean exactly, what has been done to correct the problem's) and to prevent them from happening again. Keep in mind, complaint "hotlines" are a valid, and unfortunately needed mechanisms to protect our elders -- but it is not unheard of that a disgruntled employee made an anonymous complaint. All reports have to be investigated.

Odors

Unpleasant odors may indicate a dirty home or poor attention to the incontinent. However, accidents do happen and even the best of facilities may have odors on occasion. After cleaning up, there may be a slight residual odor for a period of time. Good housekeeping does not require the masking of odors with heavily-scented sprays -- proper cleaning techniques are employed instead. If a facility uses heavily-scented aerosols throughout the building, this is another red flag.

Food

Taste the food. Is the food appropriate for the region? I have seen facilities owned and operated by large out-of-state corporations where every aspect of the facility was mandated by some consultant a thousand miles away without taking into account the region and its residents. I once experienced a near riot because the corporate menus did not allow for red beans and rice - a staple in this particular region. Does mom and dad like ham & beans but they are never on the menu? Large corporations that do not welcome input from local staff and families regarding menus and customs should be avoided.

Activities

Are there varied activities daily? Or, are the residents doing the same thing every night? Having Bingo scheduled every night is not necessarily a bad thing - in fact many people absolutely enjoy Bingo and would like nothing more than to participate every night - but is it the only thing scheduled. Are frequent outings scheduled on the activity calendar?

Financial Questions for the Nursing Home

Every article of nursing home care focuses on the monthly cost - let's say $3,000 per month. But the nursing home may add $40.00 for laundry and $15.00 for ironing. Total $3,055 per month.

Another home is substantially cheaper at $2,300 per month. But they have daily costs of $3.00 for incontinence care; $4.00 for spoon feeding; $15.00 per dozen for incontinence pads; $2.00 for tissues and $30.00 for laundry and ironing. Added together, they total more than the first home.

Additionally, many of the other costs you think are covered by your basic monthly fee are NOT. Enema supplies, catheters, rubber gloves, bandages, syringes, hand and skin lotions and urine testing materials are among those that may be added to monthly bills.

As are doctor, pharmacy and surgical company supplies. Do you need to consider the cost of renting a wheelchair, walker, cane? Maybe add in speech or physical therapy. Be prepared. Every facility can have different pricing structures - ask questions.

Other Resources

The Center's For Medicare & Medicaid
• Guide To Choosing A Nursing Home

American Health Care Association's
• Thinking About A Nursing Facility?

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Last modified: 11/04/07