The purpose of the following publication is provided as a public service to point out some of the conditions that may make it appropriate to consider placing a parent or close relative into a long term care facility when they reach that stage in life when they are no longer safely able to care for themselves at home.

This information is intended as a guide as to what services are available to make that choice the best choice possible. I must advise that each individual situation is different and that no one thing is right for everybody. This information is written in an easy to read format to advise interested parties what can be expected on their way to getting help.

In a society where multiple family members work, either to help support the family or just because they choose to do so, one should not feel guilty for making the decision to seek help through professional care giving services. Technology, combined with a very rigid set of regulations that protect the elderly and the sick, has made placement into the hands of long term care providers the most ethically sound thing to do. But there are many things that potential residents and their families must be aware.

Over the next several pages I intend to address the issues of what the public needs to know in order to make that right ethical decision. What services can be provided right there in the Nursing Home? Who are these care givers and how does one know that they are capable to care for their parent? How can one be sure that their parent is safe and secure? How will Mom or Dad sleep comfortably, eat well balanced meals, and receive good clean entertainment? Does Mom or Dad loose any of their civil rights and liberties? Who pays for all of these services?

There are quite a few questions that need to be answered. Upon examination of these issues and the answers that I will provide, one should feel persuaded that a long term care facility can provide that ethically sound option to caring for an ailing parent, especially while dealing with the stress of a demanding job, demanding immediate family, and ailing parents. This sandwiching between generations does not have to be overwhelming and overly stressful. There is help available through the useful advantages of a well qualified long term care facility and its certified and resourceful staff.

To start, we must become familiar with and take a critical look at the services commonly provided by the larger, more modern nursing home chains, which in turn tends to create trends that smaller homes will eventually follow. I will describe these separately as each service is provided by separate professionals, each having seperate realms of responsibility.

First, Let's Look At Nursing:

Specialized and personalized nursing care is provided by three separate levels of nursing staff. The Certified Nursing Assistant assists with daily living activities such as bathing, dressing, making beds, serving meals, general patient comforts, some transportation from place to place, and many of the detailed tasks of every day life. The Licensed Professional Nurse provides each resident with daily routine medications and necessary medical treatments such as wound care and other related treatments as prescribed by the attending physicians. This is conducted on a timed schedule or as required for the resident to be comfortable. All nursing services are supervised by several levels of Registered Nurses that include Unit Directors, Assistant Directors of Nursing, Directors of Nursing, with easy and direct access to consultation from Inservice Instructors, Case Managers, and Specialists from various fields. All medical treatments must be approved by each resident's personal attending physician. Extensive and detailed computerized and written records are maintained to keep track of what services are provided to each resident. In addition to all of the medical work, these nurses often help with other things such as outside (of the home) appointments and family communications. All professional nursing staff are required to be licensed through their state board for the state in which they practice. This includes required technical education and passing of state board approved examinations for that particular level of nursing practice.

Next, Let's Look At Rehab And Special Services Provided:

In most facilities, rehabilitation services are provided for those who are in medical need or for those who could benefit from the extra help. Many states have regulations that require regular screenings every few months, depends on state guidelines as to exact frequency of screens. Screens help determine if the extra treatments could benefit residents in some way. Services that are routinely provided would include the following.

Physical Therapy, which helps to build muscles in back and lower extremities, trains people to walk better or move around with their new handicaps, helps relieve pain, and helps to heal those hard to heal wounds.

Occupational Therapy, which helps to build muscles in the upper extremities, trains people to move around with their new handicaps, helps relieve pain, and trains people on ways to accomplish daily living activities such as bathing, dressing, and eating through use of special adaptive equipment.

Speech Therapy, which helps to restore cognitive skills, increases ability to communicate, troubleshoots and treats swallowing disorders, and helps to increase ability to ingest required nourishments.

Respiratory Therapy, which helps to treat breathing disorders in a routine treatment fashion so that residents are more comfortable and can be more productive in their daily routines.

Psychological Services are also provided to ease resident's minds about things that might be troubling them. This is done through routine counseling sessions right there in the privacy of their rooms (or another private spot in the home).

Other professionals that may frequent the nursing home include foot doctors, eye doctors, dentists, x-ray technicians, and hair stylists.

Depending on specifics of negotiated services, these professionals, who are all licensed to practice in their fields through the appropriate state boards, come into the nursing home to provide their services. This really makes things a lot easier for both residents and their families. Families can rest their worries a bit because these services are coordinated through the Nursing Department and these professionals try their best to make themselves available to answer family's questions, as permitted by privacy laws and the rights of the patient.

Third, We Can Look At Social Services:

Each facility is required by law to allow residents access to a facility provided social worker with special training in how to resolve resident problems. In most cases this person is licensed by the state or accredited through a related organization. These individuals can help residents with things as diverse from finding a new place to live (if dissatisfied) to obtaining a new battery for their hearing aid. Social workers can also help residents to review and deal with legal situations, medical situations, and social situations that may be occurring in that residents life. Social Workers tend to be an excellent communication tool for family members as well.

Fourth Concern, We Look At Physical Surroundings:

Each facility has a separate department that focuses its efforts on cleaning, maintaining, and making the facility safe for residents. Depending on the size of the facility, the size and quality of this particular staff may vary. Families will find that larger facilities will have larger staffing and in some cases a wider variety of services that can be offered to residents. But in most cases these individuals go from room to room providing a basic daily housekeeping routine. Most places schedule more thorough cleaning projects as needed or as dictated per facility procedures. While most places have maintenance and housekeeping available weekdays during normal business hours, many facilities do offer night or weekend service. In part, this means that if a resident gets new family pictures to be hung on a wall, or a new television / video recorder combination, a maintenance man can help to assemble things promptly. While their main function is to clean and repair buildings and equipment, these department staff can be very supportive when making changes or adjustments to resident accommodations. Whatever this might involve, especially in situations where lots of manpower can quicken the pace for a change, Physical Plant staff can help when on duty.

Housekeeping Staff usually consists of a director, who supervises the daily operations and can resolve individual concerns about the cleanliness of any given area. This includes the resident's room and private area. Several housekeeping staff handle the general cleaning of the building, usually, with individual housekeepers assigned to specific jobs (ie. one does floors, one does special projects, several may each be assigned specific areas to do on a regular basis, etc.). The Housekeeping Director or their appointee is responsible to provide coverage for all areas as per facility policy.

The Maintenance Department is responsible for all buildings and grounds repairs, renovation projects, and preventive maintenance. Security in a nursing home has many shapes and forms. Security would include electrical and electronic surveillance, physical supervision, and providing for a safe and accident free type of environment. While the personal supervision part of security tends to be every staff member's job (if one sees a resident in an inappropriate situation, staff are expected to correct it or get help immediately), functional measures to provide security and maintain this security generally fall under the Maintenance Department.

To further understand how this all ties together one must understand that in many cases, the elderly or the severely ill residents become like young children who are partially or totally dependent upon their parents. Since the home then functions as those parents it must equip itself to handle the worst cases. To protect the public from inappropriate care givers, various levels of government have enacted laws that require nursing homes and other medical facilities to maintain buildings under strict guidelines to include separate divisions that enforce structural and fire integrity. These various levels of government conduct frequent inspections to insure compliance. Even though regulations may vary from federal to state to local ordinances, the rule of thumb is to maintain the strictest code applicable, thereby providing the safest possible environment.

The maintenance staff also varies in size according to size of the facility. There is a Maintenance Director who supervises the entire department. He will then employ one or more assistants who are trained usually by a technical trades type of school with abilities to make repairs to walls, handrails, flooring, toilets, sinks, showers, electrical outlets, lights, boilers, air-conditioning, special beds, and various other equipment commonly found in a medical facility. Additionally there may be a security guard who performs a combination of physical walk through as well as some minor or emergency maintenance. The security guard is usually an evening or overnight position since there is usually a larger staff present during routine business hours. The Maintenance Department also has responsibility to insure that there is sufficient lighting throughout the facility, that all call bells and other various alarms are working, that all electrical and electronic surveillance equipment is functioning, that fire safety policies are constantly maintained, and that all emergency systems are always ready to deal with unexpected situations that tend to occur from time to time.

Diet And What Residents Eat Is Important:

The Dietary Department prepares all food and snacks according to individual tastes, while adhering to the strictest of guidelines set forth by various levels of government. This department consists of an organizationally certified manager, an assistant manager, cooks, and helpers. Menus are supervised by state registered dietitians and organized by certified technicians.

Trays are prepared to a resident's preference in consideration of any special dietary restrictions that might apply to benefit their health. Meals are always nutritionally sound with a scientific coordination of nutrients to ensure that residents with special needs get all that they need.

A balanced breakfast might be as nice as chilled orange juice, hard cooked egg, hot oatmeal cereal, cinnamon French toast, fresh parsley, coffee or tea, low fat milk, maple syrup, and some condiments.

A balanced lunch might include seasoned beef roast, baked potato, beef gravy, seasoned mixed vegetables, fresh dinner roll, sour cream with chives, sunshine lemon bars, fresh parsley, coffee or tea, low fat milk, and some condiments.

A balanced dinner might consist of New England Clam Chowder soup, crisp saltine crackers, Grecian D'Light sandwich, seven layer salad, chilled cantaloupe, fresh orange slice, coffee or tea, low fat milk, and some condiments. Soda is always an option for those who prefer it, as is another choice of entree or dessert.

In most cases residents can make food choices according to their individual tastes then the dietitian or the technician will adjust portions to balance out within dietary guidelines for that particular person. Food may be served either in the privacy of one's room, or residents can delight with friends in the social setting of a large central dining room.

Is There Any Entertainment?:

The Activities Department is responsible for coordinating entertainment for the variety of residents in each facility. This includes some different religious services for larger groupings of one or another type of religion. The Activities Department consists of an Activities Director specially educated in recreation therapy, music therapy, or something closely related. Additionally, many of these directors, are certified by national organizations that relate to this field. There are also one or more assistants whose hours of service vary to promote activities at different times of the day. In addition to coordinating large group activities, these staff members make room to room visits to promote individualized activity therapy programs.

Although the schedule will vary day to day and month to month, one might find that on Thursday during Lent, for Catholics in the facility, the schedule looks something like:

10:00a.m. Stations of the Cross in the Recreation Room,
10:30a.m. Sensory Stimulation in the Lounge,
1:45p.m. Mass With Father Boyle in the Recreation Room,
3:00p.m. Music With Jack Riley in the Main Dining Room,
4:00p.m. Horticulture Therapy in the Recreation Room,
6:45p.m. Pokeno in the Recreation Room.

The next day the schedule may be a little less intense with:

10:00a.m. Coffee and Video Movie in the Recreation Room,
11:00a.m. Food Committee Meeting in the Recreation Room,
11:00a.m. Candy and Gift Cart Visits Room to Room,
2:00p.m. Woodworking in the Recreation Room,
4:00p.m. "Remember When?" in the Recreation Room.

Residents are free to choose the activities of their own interests, watch television in one the lounges, socialize freely with others, or just spend quiet time in their rooms. If there is some special activity that crosses their minds, in many cases the Activities Department can help to make it come to be. In addition to all of the in-house activities, trips to local restaurants and malls are frequently scheduled, but this varies according to availability to transport the handicapped residents; some places have buses with wheelchair lifts and some do not.

Administration:

To supervise all of the activity mentioned, there is a separate team of managers and business experts referred to as Administration.

Each facility has a general manager with the title of Administrator or Executive Director who must, by law, be licensed by the state in which they operate to run such a facility. The licensing process requires a set standard of minimum education, experience, and passing of rigid examinations.

By the Administrator's side is an Assistant Administrator who usually is either licensed or working towards that license. In many cases this person may also have experience, along with the appropriate credentials, in one or more departments such as Nursing, Social Services, Business Office, Medical Records, or some other area of the nursing home.

Administration would also include an Admissions Director, a marketing person, that may sometimes double as a social worker, to help residents and their families adapt to the new environment, as well as, review pertinent legal issues that may apply currently or in the future.

A Medical Records Supervisor and required staff that help to keep track of all the legally required medical record information specific to each resident.

A Business Office Supervisor and required staff that coordinate with Medical Records to bill responsible third party payor sources such as Medicare, Medicaid, Blue Cross, and other Health Insurance companies. The Business Office is also responsible for paying the Nursing Home's bills, maintaining accounting records, keeping track of resident's personal funds, billing residents and their families as applicable, and a whole lot of other business and legal things that routinely occur in the operation of every business.

Administration may include several receptionists, secretaries, and assistants that provide a wide range of clerical and other essential tasks.

Residents Have Rights:

Next we need to take a critical look at what rights and obligations our parent will have as a resident of a long term care facility. While the following list is not all inclusive, it can give one a basic review as to what to expect.

Each resident has the right to be fully informed as evidenced by written acknowledgments, prior to and during his / her entire stay, of these rights and all rules and regulations governing resident conduct.

Each resident has the right to be fully informed of services available in the facility, or to be coordinated through the facility, and the charges for those services, whether or not they are included in the facility's per diem rate, and how they are to be provided.

Each resident has the right to be fully informed by a physician of his / her medical condition, unless medically contraindicated, and to be afforded the opportunity to participate in the planning of medical treatments. This also includes the right to refuse any experimental or otherwise undesirable treatments or medications, as permitted by law.

Residents also must be advised of the consequences of such refusals.

Each resident has the right to be given a reasonable advance notice of transfer or discharge and the accompanying reason for that particular action. Reasons may include medical, financial (lack of payment), or for the resident's or another resident's welfare. These reasons are to documented in the resident's records.

Each resident should be encouraged, and if needed, assisted to exercise his / her rights as a resident and as a citizen, to voice grievances, recommend changes in related facility policies, recommend changes in staff and outside representation of the resident's choice. Residents are to be free of restraint, interference, coercion, discrimination, and reprisal.

Each resident has the right to manage his / her personal financial affairs or to be given at least a quarterly accounting of financial transactions made on the resident's behalf, should the facility accept his / her written delegation of this responsibility.

Each resident has the right to be free from mental and physical abuse, and to be free from physical and chemical restraints, with exception to emergencies or as authorized in writing by physician or another person legally authorized to prescribe care, only for a specified and limited period of time, or when necessary to protect the resident from injury to themselves or to others.

Each resident has the right to be assured confidential treatment of his / her personal medical records and to approve or refuse their release to any individual outside the facility, except in the case of transfer to another health facility, or as required by law or third party payment contract.

Each resident has the right to be treated with consideration, respect, with recognition to resident's dignity and individuality. This includes privacy in treatment and in care of the resident's personal needs.

Residents must not be required to perform services for the facility that are not part of a therapeutic nature as stated in the resident's plan of care.

Residents may associate and communicate freely and privatelywith persons of the resident's choice. They can send and receive personal mail unopened, unless medically contraindicated.

Residents may meet with others and participate in activities of social, religious, and community groups, unless medically contraindicated.

Residents may retain and use their own personal clothing and possessions as space permits, unless to do so would infringe upon the rights of other residents and unless medically contraindicated.

If the resident is married, he / she is assured of privacy for visits by the resident's spouse. If both are residents of the facility, they may be permitted to share a room, unless medically contraindicated.

Residents may have daily visiting hours established.

Residents may have visits from members of the clergy at any time at the request of the resident or the resident's guardian.

Resident's relatives, or their responsible parties may visit at any reasonable hour, especially in cases of the critically ill, unless medically contraindicated. Visits with family, friends, clergy, social workers, for professional or for business purposes must be kept private, especially if requested.

Regardless of personal assets, residents must be given access to a telephone from which confidential calls may be made or received.

Residents must be fully informed and assisted if necessary on procedures and in action to contact a state Ombudsman, or related state official regarding complaints about facility policies, environmental conditions, or treatment procedures.

Residents have rights to inspect and / or purchase copies of all medical records. This includes a full explanation in terms that they understand as to the contents of such records. The same is true in regards to any facility - resident financial records.

All other civil rights, such as voting and various other rights, remain in tact until medically or legally contraindicated. All rights are protected by law and may be enforced through a number of federal, state, and local authorities depending on the exact nature of the crime. For example, physical abuse charges would be investigated by the State Department of Health with local police making arrests and prosecuting the suspected criminals.

Residents Have Responsibilities:

Residents, in turn, also have responsibilities. Some of these are listed here to give one some feeling about what to expect.

Residents are responsible for providing, to the best of their knowledge, accurate and complete information about present complaints, past illness and hospitalizations, medications, and other matters relating to his / her health.

Residents are responsible for reporting unexpected changes in his / her health or condition to the responsible practitioner.

If possible, residents are responsible to make it known to practitioners as to whether or not he / she clearly comprehends a contemplated course of action and what is expected in cooperation and intended results.

Residents are expected to follow treatment plans as recommended by professionals performing related treatments as per their specialties.

Residents are expected to follow related facility rules and regulations that affect his / her care and conduct.

Residents are responsible for following the instructions of nurses and other health professionals as they carry out the coordinated plan of care and implement the responsible practitioner's orders, and as they enforce the applicable facility rules and regulations.

Residents are responsible for their actions if they refuse treatment or do not follow the practitioner's instructions.

Residents are responsible for being considerate of the rights of other residents and facility personnel and for his / her personal behavior in the control of noise, smoking, and number of visitors.

Residents are responsible for being respectful of the property of other persons and of the facility.

Residents are responsible for assuring that the financial obligations of his / her health care are fulfilled as promptly as possible.

While not all residents may not be capable of meeting all obligations, dependent upon their physical and mental conditions, compliance with as many as possible is expected. If necessary, health care providers rely on close family members or legal guardians to cooperate and comply on behalf of the residents as needed.

Financial Matters May Become An Issue As Tim Progresses:

To address the issues regarding payment for services as listed previously, age and type of illness must be considered. For those over the age of sixty-five, which covers the largest population; Medicare, Supplementary Insurance, Private Financial Resources, and Medicaid all play a part. For those individuals not over the age of sixty-five, other factors such as Private Insurance Policies, Veteran's Benefits, Private Financial Resources, and Medicaid may cover various expenses. In some cases benefits overlap to cover a wider range so that individuals need to contribute less out of their own pockets. One must examine their own financial status to best determine which situations apply.

Since Medicare and Supplementary Insurance Coverage is the most common method of payment to nursing homes, a brief review of how this works will give one a basic idea of what to expect and help to understand where some of the financial problems may arise.

To be admitted into a nursing home under the Medicare Program, both the home and the bed the resident that is to be placed must be certified for that program by the State Department Of Health.

Admission must take place after a three day hospital stay, but within thirty days of discharge from that hospital. The resident's medical condition must require the skills of a licensed nurse or therapist on a daily basis. Medicare A generally covers room and board for the first 20 days along with many supplementary services. From day twenty one to day one hundred it covers about eighty percent of the room and board with supplementary insurance or private funds covering the balances. Medicare B, which is a supplementary form of Medicare (one pays for this additionally out of his / her social security) often covers supplementary services and supplies not covered by Medicare A. If Medicare agrees to pay for their part of covered services, then supplementary insurance usually follow suit. The same is true for denials. If Medicare denies a claim for coverage of services, then it can be expected that the supplementary carrier may also deny the claim. In these cases the nursing home will bill the resident or his / her responsible party for the denied services, which can tend to be quite expensive. Medicare works on a one hundred day period of illness, with a sixty day minimum break between illness periods.

Supplementary Insurance may pick up room, board, supplementary services, and supplementary supplies for a long while after Medicare has been exhausted, but these policies usually carry lifetime limitations on particular issues, so different service coverage will be exhausted at different times over the course of one's stay in a nursing facility. Note that a good three day hospital stay after a sixty day break from the end of Medicare's last period of illness can start the Medicare Coverage over again. Also, for those who qualify, Medicare B may pick up some therapy services, or special medical supplies even when Medicare A and Supplementary Insurance have been exhausted.

The moral of this story is to know and understand your insurance coverage. Ask for help if you have questions. Get involved with the financial process if something doesn't seem to be working right. Once all the insurance are exhausted, the homes exhaust all available private funds. Once all private assets are diminished, there is a process to qualify for government medical assistance (Medicaid). From there, once qualified, the Nursing Home's Business Office can coordinate bills for services between Medicare A and B, any left over Supplementary Insurance, and Medical Assistance. By this time, residents and their responsible parties have exhausted all personal assets and are considered as welfare recipients, regardless of previous standing in society.

Where finances are concerned, it may be a wise choice to plan a bit ahead. Consult some experienced experts as to what one has, what one needs, and what one should do to prepare for this entire nursing home process. Then start to consider a new home for Mom or Dad.

Works Consulted Or Cited: The information contained in the preceding publication was based on over fifteen years of experience in direct management of hospitality and skilled nursing health care facilities. Some additional thoughts, ideas, and facts were obtained from the following:
Chapel Manor, A Nursing Facility, Philadelphia: Crozer-Keystone Health System, n.d.. Langhorne Gardens Monthly Activities Calendar, Langhorne: Langhorne Gardens Nursing Center, March 1996. Langhorne Gardens Rehabilitation and Nursing Center, "Quality Care in a Country Setting". N.p.: Unicare Health Facilities, Inc., n.d.. Long Term Care Facilities Licensure Regulations. Harrisburg: Pennsylvania Department of Health, 1987. New Life Styles. Dallas: Corporate Communicators, Inc., 1996. Nursing Care and Rehabilitation Services. N.p.: Unicare Health Facilities, Inc. in conjunction with Nova Care, Inc., 1994. Patient / Resident Rights and Responsibilities. Plymouth Meeting: Integrated Health Services of Pennsylvania at Plymouth, Inc., 1996. Twelve Important Questions About How Medicare Affects You. N.p.: Unicare Health Facilities, Inc., 1995. Unicare Dietary Systems Weekly Menu Calendar. Langhorne: Langhorne Gardens Nursing Center, Week ending March 16, 1996.

Copyright 1996, Revised 1999, 2001 By Bob Singer, BS, NHA, PCHA, Author.