A skilled nursing facility provides room and board as well as assistance with the activities of daily living, skilled nursing care, rehabilitation and medical services, protective supervision and therapy. It is the health care services that nursing homes offer that differentiate it from Assisted Living Facilities. A SNF must be licensed to provide these services. In this article we will describe the services offered by SNF and how to choose a facility when the need arises.

Choosing a Nursing Home

Federal law defines a nursing home as an institution that provides skilled nursing care or rehabilitation services for injured, disabled, or sick persons. Skilled nursing facilities (SNF) are licensed by states as residential facilities permitted to employ medical personnel (nurses, nurses’ aides, etc.) to provide health care to the residents. The level of care, however, does not rise to the level of care provided in hospitals.

In addition to medical care, SNF also provide “custodial care”. Custodial care is typically defined as assisting the resident with the activities of daily living or ADLs. ADLs include mobility (e.g., transfer from a bed to a chair), dressing, bathing, eating and toileting. Assistance is considered nonmedical care – this is important to understand because Medicare will not, except to a very limited extent, pay for custodial care. Medicare pays for acute care services. Medicaid – the joint state and Federal health plan for the impoverished – will pay for custodial care. For seniors, Medicaid will pay for their custodial care in a SNF only after they have depleted most of their assets.

Care in a nursing home is paid for in one of several ways:

• Private pay – residents, or their family pay for their care. The monthly cost can exceed $6,000.
• Medicare patients – Medicare will pay for up to 20 days in a nursing home if the stay follows a stay in a hospital. Medicare patients are placed in the SNF to receive rehabilitation services prescribed by a doctor. After 20 days, Medicare will pay a portion of the bill for another 80 days. Because the Medicare reimbursement to the SNF is much higher than that paid by Medicaid, many SNF are limiting the number of Medicaid patients they will accept and focusing on servicing Medicare patients.
• Medicaid patients – As discussed above, Medicaid is a joint state and Federal program that will pay for custodial care in a SNF. In order to receive aid under the program you must meet its definition of “impoverished”. Beds reserved for Medicaid patients are typically limited in most SNF so a senior may find it difficult to be placed in a SNF near their home or family.
The number of elderly residing in nursing homes has been declining over the last 25 years. This is due in part to technology that is now available allowing seniors to stay at home longer. This trend is expected to continue. In the future, SNF will still be needed but the average stay in the facility will be shorter.

You can begin your search for nursing homes in your area at www.medicare.gov. Click on Compare Nursing Homes in Your Area – you can search by state and by county. Detailed information on each nursing home listed is provided. In addition the department of health in your state may also have a separate website providing information on licensed facilities in your area. During your search you will focus on the physical facility itself, the staff and types of treatment offered and on the admissions contract. We will discuss issues relating to the contract first. It is worth the expense to hire an experienced attorney to review the contract. Then we will list some of the issues and topics you need to ask about during your visits to the facility.

Admissions contract review

• How often is the fee calculated (monthly, weekly, daily)?
• When is payment required? Monthly? Weekly?
• Ask about the billing procedures.
• Is there any refund if the person departs or dies during the payment period?
• What is and is not covered by the monthly fee?
• What equipment is covered under the fee?
• What kind of equipment must be separately paid for?
• What services are provided for the basic fee?
• Are there charges for optional services? If so, for what services and at what rate?
• What is the charge for a private room?
• Does the fee vary based on the location of the room?
• Does the facility require a security deposit?
• Are there any limits on increasing the fee? Ask about past rate increases.
• Is there a requirement for advance notice for the departure of the resident?
• What happens if departure is due to death or illness requiring hospitalization?
• Will the facility hold the resident’s bed if the resident is temporarily hospitalized?
• Does the contract provide any liability limits on the facility?
• For what reasons may the facility evict the resident?
• On eviction, is there an appeals process?
• If a family member is asked to co-sign the contract, consult a lawyer.

Basic facility information

• Ask who owns the property
• Is the facility for profit or not for profit?
• Date of initial operation
• How long has the facility management been in place (high turnover of management is not a good sign)
• Managerial background and experience (does anyone in management have a health care or geriatric background?)
• Background and professional experience of the facility director
• List formal business relationships with any hospitals (the facility may be owned by a hospital or regularly accept discharged patients from a particular hospital)
• List any formal or informal relationships with any universities or other educational or training institutions (some facilities are used to train geriatric nurses and doctors).
• Check if the facility provide levels of care other than skilled nursing care (for example, care for dementia patients).
• Is the facility restricted to residents over age 65 or are younger residents accepted? Under what circumstances?

Licenses and Compliance Issues

• Facility licenses (e.g., Medicare, Medicaid)
• Inquire about licenses held by officers and professionals
• Ask to see the latest report on the facility by the state department of publich health, Medicare inspectors or other officials. Is there a public record of complaints or citations by the state
• Has this facility ever been found out of compliance with state licensing or certification programs?
• Has the facility ever been found out of compliance with Medicaid or ¬Medicare regulations?
• Have there been any complaints lodged against any of the staff or ¬professionals of the facility by a resident or family member?
• If the ownership owns more than one nursing home, have they ever been cited or complained against in regards to their ownership of other nursing homes?
• Has the state or local ombudsman ever issued a report about the ¬institution?
• Contact the local ombudsman office and ask if you can speak to the ombudsman responsible for that facility.
• Has the institution, any of its staff, or professionals been sued by any of its residents, the state, or any other organization?
• What is the reputation of the facility based upon statements made by past residents or their families?
• Ask to speak with volunteers. Wander the facility and speak to residents about the facility (but respect their privacy – do not reveal to facility management who made any particular comments).
• Does the facility have a family council? Ask to speak to a member. What is the reputation of the facility among relatives or friends of current residents?

Location Issues

• Is the neighborhood in which the facility is located safe?
• How safe and secure are the immediate grounds of the facility?
• How secure are the buildings?
• How far away from potential visitors of the resident is the building?
• Is the building within reach of public transportation?
• Is the facility so close to streets that residents would be affected by noise or fumes?
• How close are places to which a visitor might want to take a resident, such as parks, restaurants, and cultural facilities?

The Physical Plant

• Note the number of stories the building has, the number of rooms and residents.
• Are private rooms available?
• Note the number of common rooms and their location(s). How are they furnished? Does each room have a television? Check the reception. Is the control within reach of the bed? Can roommates watch different television sets without disturbing each other?
• How large is the dining room and where is it located? Walk through it – is it clean? Any odors?
• How many tables are in the dining room and how many diners does each table accommodate.
• Does the facility have a music room? A chapel?
• Visit the therapy/rehabilitation rooms. Note the types of equipment.
• Where are the toilet and bathing facilities? Are these facilities easy for someone with mobility challenges to use (i.e., using a walker or in a wheelchair)? Check the sturdiness of the handrails. Are the floors slip resistant?
• What is the ratio of residents to each toilet? To each bathing facility?
• Are the rooms clustered in living units or are they off a hall in a hospital style? More modern facilities try to look more home like rather than institutional.
• Where are the nursing or staff desks located in relationship to the residents’ rooms? How far away could the resident be from the nearest nurse or staffing desk?
• What kind of special facilities do the halls and common rooms have for the visually impaired? Are there special markings on the floor or walls for the visually impaired?
• What kind of special accommodations does the facility have for the ¬physically impaired? The hearing impaired?
• Are there rails along both sides of the halls and stairways and in common rooms for the residents?
• Are wheelchair ramps provided?
• Look at the floor – is it carpeted or tiled? A wood floor? Does it appear uneven?
• Are all hallways and doors to common areas wide enough for at least two wheelchairs to pass side by side?
• How attractive is the public entry area to the facility? What type of security is there from people just wandering in or out unnoticed?
• Are there special visiting rooms for residents and their visitors? Is it private?
• Is there a private or enclosed open space for the residents?

Treatment of Residents

• What is the relationship between staff and residents: pleasant and respectful or authoritarian?
• Do the caregivers congregate in the hallways to talk ignoring the residents?
• Do the professionals make an effort to know the residents by name?
• Check for unpleasant odors.
• Do the residents appear well cared for and clean?
• During mid morning or mid afternoon, do a large number of residents gather around the nurses’ stations appearing to have nothing to do?
• Are pets allowed? If pets are not allowed, does the facility permit visiting pets or use pet ¬therapy?
• How noisy is the facility?
• What is the meal schedule and how flexible is it? Can residents choose to eat in their rooms?
• Are the meals appetizing or generally bland and served cold? Is one dished overserved (e.g., chicken)?
• Visit the facility at mealtime. Do the residents seem to be eating their meals?
• What form of assistance is offered the patients with their eating? Are the residents waited on by staff or is there a buffet style alternative?
• How are special dietary needs accommodated?
• Is there a special plan in place to prevent residents from becoming dehydrated?
• Note if the ambulatory patients appear cheerful or morose
• Talk to bedridden patients – what is their attitude?
• Ask about how bedsores are prevented and treated when they do occur.
• What is the facility policy on physical or chemical restraints? Is it a “restraint free” facility?
• Are the patients involved in meaningful activities?
• Do residents in common rooms merely watch TV or are they interacting with themselves or the staff?
• Is it a smoke free environment? If not, how are residents who smoke accommodated?
• Are patients permitted to have alcohol?
• What kind of outside activities are offered?
• Are holiday meals offered that family members can attend?
• Check the activity calendars that should be placed on a bulletin board in the hallways or common rooms. Note the frequency and types of programs offered.
• Does the facility provide transportation off site? Is there a wheelchair accessible van?
• Is there a resident council or family council? A resident council may be held monthly – ask to attend a meeting. Permission to attend must be granted by the council.
• How does the facility handle complaints or problems raised by residents or families? Check the bulletin boards for notices regarding long term care ombudsman – a phone number and other contact information should be provided.
• Is hospice provided for terminally ill patients?

Dementia

• Does the facility accept patients with dementia?
• What special qualifications does the facility have for offering dementia care?
• Does the facility evict patients who act out or are violent?
• Does the facility have special physical facilities for demented patients?
• How does the facility prevent patients with dementia from wandering off the premises?
• Ask to visit the dementia wing – often these are placed above the first floor and have secured access.
• Are there special enclosed outdoor areas for use by demented patients?
• Are the demented patients segregated from the other patients?
• How does the facility determine whether a patient is suffering from dementia or mental illness?
• Does the facility offer special therapy for demented patients?
• What programs does the facility offer for demented patients?

Resident Issues

• How are the rooms selected for the residents?
• Are couples accommodated?
• For residents who have roommates, how are they selected? Do the residents have a say in the process?
• What are the views from the various rooms for the residents?
• How much privacy is arranged for within or outside the rooms for residents?
• How much space for personal effects does the resident have?
• What sorts of personal effects can the resident bring into the facility?
• Is staff assigned permanently to residents or rooms? It is typically better if staff is assigned to the resident and becomes more familiar with their needs.
• What is the staff turnover?
• May a resident obtain food between formal meal times? Is a snack delivered to the rooms just before residents are going to sleep?
• Are there pop and snack machines available? How accessible are they to the residents?
• Where are personal effects stored? How secure are they?
• How does the facility go about creating a care plan? How often is it updated? Are special care plan meetings called if the need arises (for example, a resident is experiencing frequent, unexplained falls)?
• How does the facility handle medication or a resident who refuses to take medication? When is the family informed of the refusal.
• How long must a resident wait for care after using a call button? Is the staffing at night adequate to be responsive?
• How much freedom does the resident have in his or her daily activities?
• Does the resident decide when to wake up and what time to go to bed?
• Does the facility attempt to provide outlets for personal resident interests? Is this incorporated into their care plan.
• If a resident is unsatisfied with his or her room can a change be made?
• How does the facility provide for the spiritual needs of the residents?
• Is there a dominant ethnicity, religion or race of the residents?
• Are residents permitted to have telephones and televisions in their rooms?
• Are residents adequately protected from noise, assaults, or other distractions by other residents?
• How does the facility provide laundry for the residents? Do items sent to the laundry typically end up missing?
• Are residents permitted to leave the facility for walks with or without an escort?
• What are normal visiting hours? Can special exceptions be made?