Selecting a Facility
The following questions may guide you in evaluating nursing facilities throughout your selection process. Remember, each resident – young, elderly, ambulatory, bedridden, or disabled – has different needs, preferences, and desires that should be taken into account in the selection of a facility.
Location
• Visitors are important! Is the facility conveniently located for frequent visits from family and friends?
Ambiance
• Is the atmosphere welcoming and attractive?
Staff
• Observe staff interactions with residents. Do caregivers show respect and a positive attitude toward residents and others?
Activities
• Look over the activity calendar for the week or month and ask about the programs available.
• Are residents encouraged to participate?
Religion
• Are religious services held on the premises?
• What individualized arrangements can be made for residents to worship?
Rooms
• Ask to visit a typical room. Does the living space suit the needs of the resident?
• How are roommates selected?
• How are private items stored or secured?
• What is the policy for residents having a private telephone?
• What is the policy for decorating rooms with personal items?
Dining
• Observe mealtime at the facility. How is the menu managed weekly and monthly? Ask to have the dining procedures explained to you.
• What arrangements will be made if residents are unable to eat in the dining room?
• What is the practice for special dining or menu requests?
• Are snacks provided?
• Are private dining areas available when family and friends are visiting?
Care Planning
• How are residents and families encouraged to participate in developing their care plan?
• Does the facility provide services for terminally ill residents and their families?
• What special programs (Alzheimer’s, AIDS, subacute care) does the facility offer?
Medical
• Are other medical professionals (dentists, podiatrists, optometrists) available?
• Does the facility have an arrangement with a nearby hospital?
• Will a bed be available after hospitalization?
• How are prescription drugs ordered?
• Are therapy programs provided (physical, occupational, speech pathologist)?
Costs
• Are all services the resident requires covered in the basic charge?
• Request a list of specific services not covered in the basic rate. (Some facilities have schedules covering therapies, beautician services, barbers, specialty foods, personal laundry, etc.)
Patient Rights/Autonomy
• What are the patient’s rights and responsibilities?
• When are restraining devices recommended and why?
• Does the facility have Resident Council?
• Does the facility have a Family Council in which you can participate?
Licensure and Certification
• If needed by the resident, is the facility certified to provide Medicare and/or
Medicaid coverage?
• Is the latest state survey report available for review?
• Does the facility have a formal quality assurance program?
Your Role
If you are helping to select a long term care facility for a loved one, are you:
• Involving this person in the process?
• Prepared to ease the resident’s transition to the nursing facility by being with them on admission day and staying several hours to get them settled?
• Ready to visit the resident frequently and encourage friends to make similar visits?
Finally, nursing facilities should try to be like community – where residents can feel comfortable, find familiar faces, and build relationships just like they enjoyed in their own homes. By planning ahead, you can ensure that your loved one will be provided with the highest quality of care and quality of life.
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Assisted Living Facility (ALF)
1. Definition: The Assisted Living Federation of America (ALFA) defines an Assisted Living Residence as a special combination of housing, personalized supportive services and health care designed to meet the needs, both scheduled and un-scheduled, of those individuals, who need help with activities of daily living (ADLs). In Florida, Assisted Living facility (ALFs) are licensed by the Agency for Health Care Administration. ALFs are a social model that encourages dignity, independence and choice for individuals who need housing and supportive services but who do not need 24-hour nursing supervision.
2. Philosophy: Both ALFA and FALA members subscribe to a ten point philosophy of care:
- Offer cost effective quality care that is personalized for individual needs
- Fostering independence for each resident
- Treat each resident with dignity and respect
- Promote the individuality of each resident
- Allow each resident a choice of care and lifestyle
- Protect each resident’s right to privacy
- Nurture the spirit of each resident
- Involve family and friends, as appropriate, in care planning and implementation
- Provide a safe, residential environment
- Make the Assisted Living residence a valuable community asset
3. Residents
- > 1 million(USA)
- 30,000 facilities
- Average age 83/female
- Must meet “residency criteria” – Fl. regs./facility policy
- Must be dependent in at least 2 ADLs/IADLs
- Cannot have conditions that require 24-hr nursing supervision
- Only exception – existing resident who qualifies for and receives hospice services from a licensed hospice
- 1823 Form to be completed within 30 d. of move-in
4. Services and Activities
- 24-hr supervision
- Three meals a day in a group dining room; and
- A range of services that promote the quality of life and independence of the individual; such as:
- Personal care services (help with bathing, dressing, toileting, etc)
- Medication management, or assistance with self-administration of medicine
- Social services
- Supervision and assistance for persons with Alzheimer’s or other dementia and disabilities
- Social, recreational and spiritual activities
- Emergency alert and call systems
- Rehabilitative services for physical, speech and occupational therapy
- Care offered in levels – can choose the options required; if needs change can add or subtract services (see leveling tools)
- Some facilities offer specialized care for those with Alzheimer’s disease and other memory disorders
- Exercise and wellness programs
- Laundry and linen service
- Housekeeping and maintenance
- Arrangements for transportation
5. Personal Care/ Health Services
- Provide supervision or assistance with ADLs
- Coordination of services by outside health care providers
- Facilities are NOT responsible for coordinating medical care
- Monitoring of resident activities to ensure safety, well-being
- Administration or supervision of medication or personal care services
- Assist in arranging medical/dental care services – resident chooses own physician and dentist
- Can return to ALF post acute hospital/SNF stay if needed services can be provided
- “Bridge” between living at home and SNF
- No requirement for a medical director, but individual facilities are experimenting
- Non-medical environment – social model
6. Residence Accommodations
- Constructed and equipped to comply with local, state, and federal regulations
- Designed to be operated, staffed, and maintained in a manner appropriate to meet the needs and desires of residents served
7. Personnel
- Administrators or directors, who manage the residence
- Nurses, who assist residents with health care services according to state regulations
- Medication assistants who help residents with their medications
- Personal care staff, who assist residents with personal needs, such as bathing, eating, and dressing
- Marketing/Admissions personnel, who market the residence and assist with the move-in process
- Food services personnel, who prepare and serve nutritional meals to residents
- Activities coordinators, who organize recreational activities and spiritual programs for residents
- Maintenance personnel
- Housekeeping personnel
8. Pharmacy
- Utilize ALF preferred pharmacy ( if exists)
- Maintain service with private pharmacy
- Medication management – assistance/supervision of self-administration of medication
9. Regulations
- Vary from state to state
- Florida – ALFs regulated by the Agency for Health Care Administration (AHCA)
License
- Standard
- Limited Nursing Service
- Extended Congregate Care
- Administrators – certification required – week long training and successful completion of state competency exam; need continuing education as well
- Direct care staff also require specific training
- Residences must comply with State and local building codes and fire safety regulations
10. Costs/Payment
- Vary greatly depending on room size, amenities, services provided, location
- Basic fee may cover all services, or there may be additional charges for special services
- Vast majority of ALF care privately financed
- No Medicare coverage
- Residence may participate in Medicaid waiver or other internal assistance programs
- Several private health and long-term care insurance policies include assisted living coverage
11. Choosing an ALF
- Determine services needed/ acceptable price range
- Obtain list of ALFs in your area
- Visit diff. facilities
- Visit during mealtime/ lunch with residents
Priority items:
1) access to highest quality health care
2) stimulating activities program
3) comfortable with atmosphere
4) high quality food
5) amenities – transportation to doctors, appointments or local shopping, private dining rooms, religious services,
health and wellness programs, nutritional/dietary counseling, staff experience in handling your evolving/specific needs.
12. Checklist items for Prospective Residents
- Is there an electric generator?
- Facility financial stability
- Ownership – National/Regional chain or independent
- Resident turnover – ? Clinical criteria for mandated discharge
- Facility environment/landscaping
- Who are the off hrs/week-end staff?
- Proximity to fire dept./ EMS
- Are residents with preserved decision making capacity allowed to self-administer medications, if able? Where are these meds stored?
- Vaccination policy for residents/staff – ? on-site vaccination service
- What types of on-site medical services are available? Podiatry? Lab. draw?
- House physician/ARNP/PA services
- What types of menu food choices are available?? Level of accommodation/effort to provide alternative choice
- What % of residents have significant cognitive dysfunction?
- Are bathrooms handicapped equipped? Are there alarms in every room?
- What is the response system?
- What is the visitation policy?
13. Resources
American Health Care Association (www.ahca.org)
National Center for Assisted Living (www.ncal.org)
http:// www.falausa.com
http: www.assisted livingflorida.com/faq.htm
http://www.flassited living.com/assistedlivingfloridaFAQS.htm
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Skilled Nursing Facility (SNF)
1. Definition
Skilled Nursing care – Nursing and rehabilitative care that can be performed only by, or under the supervision of, licensed and skilled medical personnel
Skilled Nursing Facility
- Provides 24 – hr Nursing care for chronically ill or short-term rehabilitative residents of all ages
- Free standing or part of a Nursing Facility (NF) as a wing or beds on a regular unit
- Payor Medicare Part A/Managed Care
- Requires skilled treatment such as diabetic monitoring, IVs, stroke rehab, indwelling tubes
2. Goal of Care
Help individuals meet their daily physical, social, medical and psychological needs and to return home whenever possible “Obtain and maintain highest practicable physical, mental and psychosocial well being”
3. Services - 4 Basic Types
Medical Care - Physicians: responsible for the residents’ overall plan of care, including rehabilitative and restorative services, special diets, and treatments
- Mid-level providers – ARNP(Advanced Registered Nurse Practioner), PA (Physician Assistant)
- Visits 30-60-90 and then every 60 days
Nursing and Rehabilitative Care
- Registered or licensed practical nurse: assessment, treatments, injections, medication administration
- Rehabilitative services – physical therapy, occupational therapy, speech therapy
- Other – respiratory therapy, dietary, dental, podiatric/ lab/ x-ray/ pharmaceutical
- Personal Care – Certified Nursing Assistants: assist residents with ADLs
- Residental Care – social services, recreation therapy
4. Qualification for Admission to SNF Bed
- Necessitate skilled therapy
- 3 day Hospital stay (within 30 days)
5. Regulatory
- Highly scrutinized industry
- Oversight – Agency for Health Care Administration (AHCA) under CMS (Center for Medicare and Medicaid Services)
- Annual Survey (State)/ complaint survey
- Primary Advocacy Group – American Health Care Association (Federal/State – Fl.)
6. Advance Preparation
- Nearly ½ of population will need Long Term Care (LTC) at some point
- 1 in 5 over 50 is at high risk of needing LTC in next 12 mo.
- 2.5x with similar needs being cared for in the community
- 2008 – 1.85 mil. in 16,000 facilities
- Talk sooner rather than later
- Prepare yourself
- Prepare your loved one
- Choose the right time
- Stay positive
- Advance Directives 1) Living will 2) Medical Power of Attorney
7. Paying for Long Term Care
- Medicare (Part A) pays 100% first 20 days and 80% of day: 21-100; patient co-pay (21-100) ~$100
- Eligibility
- Nursing Home is a SNF – provides 24 hr Nursing Care
- Continuous Skilled Nursing Care or Skilled rehabilitation services (as defined by the federal govt.) are required on a daily basis
- Patient has qualifying 3 consecutive day Hospital stay and SNF admission occurs within 30 days of hospital discharge
- Physician certifies that SNF services are needed for the same or related illness for which person was hospitalized
- Services covered by Medicare
- Semi-private room
- Meals, including special diets
- Regular nursing services
- Rehabilitation services
- Drugs furnished by the facility
- Medical supplies
- Services not covered by Medicare
- Personal convenience items
- Private duty nurses
- Extra charge for a private room
- Provider (Physician, ARNP, PA, Podiatrist, etc) services covered under Medicare Part B
- Services not included under Medicare B
- Routine physical examination and tests
- Routine foot care
- Eye or hearing exams for prescribing or fitting eyeglasses or hearing aids
- Immunizations other than for the Flu or Pneumonia
- Medicaid
- Joint federal-state govt. program designed to provide health care assistance to low income level
- Eligibility – persons who meet state determined poverty level and certain related criteria, provided NF is certified
- Benefits – Medicaid will pay for care in a NF- amount state determined – covers room, board, nursing care, social activities
8. Personnel
- Administrator
- Director of Nursing
- Medical Director
- Nurses 1:40 ratio
- Certified Nursing Assistants 1:20 ratio /2.9 hrs ppd
- Dietitian
- Social services
- Recreation therapy
- Maintenance
- Housekeeping
- Consultant pharmacist
- Rehabilitative services- PT,OT, ST
9. Living in a Nursing Home: Myths and Realities
Myth: A nursing facility is like a hospital
Myth: Nursing facility patients are confused
Myth: There’s no privacy in a nursing facility
Myth: Nursing facility patients never leave
Myth: I will not be able to make my own decisions
Myth: Nursing facilities have unpleasant odors
Myth: Nursing facilities do not provide adequate care
Myth: Husbands and wives must live apart in a nursing facility
Myth: Nursing facility patients are not visited regularly by family and friends
Myth: Meals are not appetizing
Myth: Patients are controlled by medications
Myth: Physical restraints/restrictive devices are common
Myth: Nursing facilities are expensive
Myth: Medicare or my health insurance will pay for a lengthy stay in a nursing facility
10. Resources
American Health Care Association
1201 L Street NW
Washington, DC 2005
(202) 842-4444
www.ahca.org
http://www.ahcapublications.org
http://www.LongTermCareLiving.com
Nursing Home Compare www.medicare.gov/nhcompare
Administration on Aging
Alzheimer’s Association http://www.alz.org
National hospice and Palliative Care Organization http://www.nhpco.org
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Facility Cost Calculator – A Consumer’s Guide
Cost calculator and consumer checklists
The following checklists will be useful in evaluating assisted living residences during a visit. The most important consideration is that each resident has different needs, preferences, desires and financial resources that should be taken into account in choosing an appropriate residence. Remember that you cannot change the resident to fit the residence. Select the residence that best meets the needs of the resident.
The assisted living calculator provides help for estimating the monthly cost. Although residences charge different fees and provide a variety of different services, this list is provided to prompt the consumer to think about the financial costs and assist in planning for the future.
Assisted Living Cost Calculator
Family and prospective residents may use this worksheet in estimating the monthly cost of needed services. Not all items may be applicable to your situation. Space is provided to add items not covered in this calculator.
$__________Entrance and/or Initial Assessment Fee
$__________Selected Unit and Basic Service Package
$__________Cost for Meals
$__________Cost for Housekeeping
$__________Cost for Personal Laundry Service
$__________Cost for Linen Service
$__________Cost for Medication Management or Assistance
$__________Cost for Personal Care Assistance (bathing, dressing, eating, etc.)
$__________Cost for Recreational Field Trips
$__________Cost for Transportation
$__________Cost for Telephone Service
$__________Cost for Cable Television
$__________Beauty Shop Charges
$__________Other Charges
$__________Total Estimated Monthly Charges
Checklist for Consumers and Prospective Residents
When you are looking for an assisted living or residential care setting for yourself or a loved one, please consider the following checklist to help you make the best choice.
Service Planning
• Are the family and the resident involved in the service planning process? How often are residents’ needs assessed? Who completes the assessment?
• Are there special programs for memory impaired residents and residents with dementia? Are there accommodations for memory-impaired residents to be outside and exercise?
• Are there special programs for residents with disabilities?
• How are emergency situations managed? What is the protocol for such events?
• What happens if the health care needs of a resident change? Under what conditions are residents asked to move if there is a change in health status?
Services and Activities
• Does staff assist residents in administration of medication? If so, what kind of staff?
• Does the residence generally use a particular pharmacy? If applicable, does that pharmacy participate in the individual’s Medicare Part D prescription drug plan? Does the pharmacy provide a yearly review and consultation services?
• Are there professional nursing services on site? If not, does the staff assist residents and families in making arrangements through a home health agency?
• Are the services of a physical, occupational or speech therapist available or arranged?
• Does the residence provide bed linens and towels?
• Does the facility provide laundry service?
• Are there beauty shop services available on site?
• What recreational and spiritual activities are available? Obtain or review a copy of the activities calendar.
• Are the activity supplies available for resident use outside of scheduled programs?
• Is transportation provided for medical appointments and recreational purposes? Is there a fee?
• Are there resident and family councils? How often do they meet
• What are the suggestion, complaint, or grievance procedures?
• Can hospice care be offered? If so, does the facility coordinate that care with the physician and family?
Staff
• Ask about the residence’s staffing patterns and philosophy about staffing
• What training and qualifications are required for staff? Are there on-going training programs provided for staff?
• Observe staff and resident interactions. Are they positive? Courteous?
• Does staff handle resident requests in a timely way?
• Can private duty companions be hired? What is the procedure for that type of service?
• Does the facility have volunteer program? If yes, what types of activities do the volunteers perform?
• Does the administrator/director practice an “open door” policy?
Moving in
• What does the moving in process entail? What are the paperwork requirements and the timeframes involved?
• How is the initial assessment managed? Who completes the assessment?
• Is the residence affiliated with a hospital or nursing home should acute or long-term care be needed? If so, is there a priority admission process?
• If you need hospital or nursing care, is your room held? What are the associated fees? Is there a discount for unused services (e.g. meals)?
• Does the residence subscribe to a set of resident rights and responsibilities? Are printed copies of resident rights and responsibilities available?
Costs and Fees
• What is included in the basic monthly cost? Ask for a written copy.
• Does the residence have a written schedule fees for extra services? If so, request a copy.
• Under what circumstances might the fees change? How much notice is given, if there is a fee increase?
• Is there a security deposit? What is the refund policy?
• Can service agreements and or contracts be amended or modified?
Dining and Food Services
• Does the residence accommodate special diets?
• Does a dietitian or nutritionist review the menus? Request or review copies of the menus.
• How often do the menus rotate? Are residents and families involved in the menu planning?
• Are residents allowed to have guests for meals? Is there a separate guest dining room?
• What are the criteria for residents to eat meals in their rooms?
Living Space and Accommodations
• Are there adequate community areas for resident use?
• Are the resident rooms furnished or unfurnished?
• What is the policy about personal belongings?
• What is the policy for overnight guests? Are there guestrooms available? What are the guest fees?
• Is additional storage space available? Is there an extra fee?
• Does the residence meet the rules for people with disabilities?
• Can residents have automobiles? Is there assigned parking? Is there an extra fee?
• Are there patios and courtyards available for resident use? Is there an area for resident gardening?
• Does the residence provide security?
• Are pets allowed to reside in the residence? If so, are there additional fees and/or deposits? If not, are pets allowed to visit?
Licensure and Certification
• Is the residence licensed? Ask to review the last licensing or certification report.
• If the state requires the administrator to be licensed or certified, is it current?
• Does the staff actively participate in a professional association, such as a state long term care association affiliated with National Center for Assisted Living?
Safety
• Does the facility have a fire sprinkler system throughout the facility?
• Where are the smoke detectors located?
• How often does the facility have fire drills?
• Does the facility have an emergency preparedness plan?
• How are emergency and evacuation plans reviewed with resident after admission to reinforce their memory?
• What systems are used to keep residents with dementia or Alzheimer’s secure from successful exit strategies?
Location
• Is the location of the residence convenient to shopping, medical services, and entertainment areas?
• Can family members and visitors easily locate the residence for visiting?
Final Checklist prior to signing the Service Contract
This checklist is provided to the family and prospective resident as a final tool once an assisted living residence has been chosen. Use this as a reminder for issues that need to be addressed and fully understood.
Make sure you:
- Know what the basic service package includes
- Know all costs associated with your service package
- Know about additional services and their associated fees (e.g., medication management)
- Know the circumstances why fees might change and how much notice is given to families and residents
- Understand the services planning process
- Understand the service contract
- Know about the criteria and policies associated with discharge
- Understand resident rights and responsibilities
- Know the residence’s grievance policy and procedure
- Understand how many staff are available and their qualifications
- Have the name and telephone number of the staff contact person
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Talking to your loved ones about their care – Advance preparation
Signals to look for
The following are signs that is time to discuss long term care
Isolation/Depression
• Is your loved one isolated from social contact?
• Are his or her sleeping habits, eating habits or activity levels changing?
Daily activities/Eating habits
• Is your loved one having a difficult time walking, dressing or eating?
Bruises/Falls
• Has there been an increased susceptibility to falling and bruising?
Cognitive ability
• Is your loved one’s mental reasoning ability at a level where his or her personal safety and the safety of others is at risk?
Increasing medical needs
• Does your loved one need medical care that you or he or she cannot provide?
• Does your loved one’s medication need to be increased?
• Does he or she need more and more help taking medications?
• Does he or she use medical equipment like an oxygen tank or need daily or weekly treatments like dialysis?
• Is your loved one in need of rehabilitative care?
Caregiver burnout
• Is a family caregiver exhausted due to the amount of care your loved one needs?
Medication error/Missed Doctor’s appointments
• Is your loved one mixing up medications, taking them incorrectly or not taking them at all?
• Is your loved one keeping his or her doctor’s appointments?
Household management
• Can your loved one still manage the components of running a household, such as keeping a checkbook or paying bills?
• Is there a dramatic change in how the house is kept?
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We wish to thank Dr. Robert Kaplan for supplying the information above. Additional contributor, Dr. Luci Belnick.
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Resources for Culture Change in long term care facilities can be found at Pioneer Network.
http://www.pioneernetwork.net/Consumers/Choosing/
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EVEN MORE RESOURCES
Orange County Office on Aging – www.ocfl.net/seniors
Senior Resource Alliance – http://www.seniorresourcealliance.org
Florida Affordable Assisted Living – http://www.floridaaffordableassistedliving.org/index.html
