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I. ABOUT THIS PUBLICATION

The Barren River Long-Term Care Ombudsman Program (BRLTCOP) publishes this guide as a resource for consumers to help them make educated, informed decisions about long-term care and to have a better overall understanding of the long-term care system. It is designed to assist consumers in their search for a suitable long-term care facility in the Barren River Area Development District (BRADD) which consists of ten counties: Allen, Barren, Butler, Edmonson, Hart, Logan, Metcalfe, Monroe, Simpson, and Warren.

Finding appropriate long-term care placement can be a bewildering task and news coverage of long-term care facilities is often less than favorable. So to better help you find the right facility for your loved one, there is a comprehensive list of licensed long-term care facilities in the BRADD area at the end of this guide.

The information in this guide is current as of the date of publication and quotes 2010 coverage. If needed, more current information concerning long-term care and benefit programs can be obtained from the Ombudsman Program.

II. THE PLACEMENT CRISIS

It is estimated that 54 million Americans provide some type of assistance on a regular basis to a frail, ill or disabled family member (National Family Caregivers Association, 2000). This often requires searching for home care resources in the community or helping a loved one find appropriate placement in a long-term care facility. Consumers frequently find themselves unprepared to make those decisions.

Often, the recommendation to consider long-term care placement in a nursing facility is unanticipated and usually follows an unexpected hospital stay. Decisions must be made quickly and at a time when the loved one may be too ill to participate in the decision making. When Medicare determines that hospital (acute) care is no longer covered, the patient is given only three days to make the necessary arrangements to place the patient in a facility. When this happens, there isn’t time to visit several facilities to select the one that best fits the patient’s needs. This guide has been written to help consumers make informed decisions.

The Barren River Long-Term Care Ombudsman Program advocates for improved quality of life and care for residents in licensed long-term care facilities, including nursing facilities, personal care homes and family care homes. The Barren River District Ombudsmen can answer questions regarding facilities in the BRADD area and can be contacted at 1-800-355-7580.

The Barren River Area Agency on Aging and Independent Living is dedicated to enhancing the quality of life for older adults and their families by providing information and access to a variety of services in our local communities. It works to identify the needs of the elderly and strives to meet those needs through a system of home and community based services. Services enable the elderly to remain independent in their home and community and prevent premature institutionalization. The agency also offers a program to assist family caregivers of the elderly.

The Barren River Family Caregiver Support Program provides assistance to family caregivers who are providing care for a person 60 years of age or older. Recognizing the stress that caregivers face, the Caregiver Support Program provides families with someone in the community they can turn to for assistance in coping with the demands of being a family caregiver. The program offers information, referral, assistance, support groups, educational trainings, counseling, respite care, and supplemental services. Both programs work to avoid or delay out-of-home placement. To contact the Barren River Area Agency on Aging and Independent Living, call 1-800-598-2381.

A. The Home Care Alternative

Many patients are now being cared for in their own homes, rather than in a nursing facility thanks to the development of several home health care options. Home health care providers offer home visits from licensed nurses and other non-licensed nursing personnel and can usually provide all the nursing services needed. Adult Day Care centers allow family caregivers to continue working and maintain their own lives. Home delivered meals can often be obtained for homebound seniors. A list of available home care service providers in the Barren River Area is included in this guide (see page 41).

Private insurance policies will sometimes cover care provided in the home. Medicare Part A will pay for a limited number of skilled nursing services and therapies provided in the home. Persons eligible for Medicaid coverage in a nursing facility are also eligible to receive nursing care in their homes under the Kentucky Medicaid Home and Community Based (HCB) Waiver program. Waiver services are available through home health agencies and adult day health care centers. These services may include:

· Assessment and reassessment to evaluate the client's physical, mental and emotional health, social supports, living environment and to identify services the patient needs but cannot arrange for themselves or through family members.

· Case management to coordinate the delivery of services such as transportation, volunteer services, informal support services and physician or clinic visits. When necessary, a case manager may also arrange for drugs, supplies or related medical equipment.

· Homemaker services including general household activities such as meal preparation and household cleaning.

· Personal care services to meet patient's physical needs, such as bathing.

· Respite care services provided on a short-term basis for patients whose primary care taker is temporarily absent.

· Home adaptation to make homes more functional for patients by adding devices

such as shower bars or wheel-chair accessible ramps.

Medicaid has begun to explore some creative ways of paying for long term care received in the home. One such program, the Consumer Directed Option Program (CDO), allows Medicaid to pay non-traditional providers to care for persons under the Medicaid Home and Community Based Waiver Program, Supports for Community Living Waiver Program and Acquired Brain Injury Waiver Program. Under CDO, persons receiving care may be able to hire family members, friends or neighbors to provide their non-medical waiver services.

Service providers must be at least 18 years old, undergo a criminal background check and complete training on person-centered planning and self-determination. Members who need assistance in directing their services can select a representative to assist them. For more information about the CDO Program, contact the Barren River Area Agency on Aging and Independent Living at 1-800-598-2381, the Medicaid Division of Long Term Care and Community Alternatives at 502-564-7540 or Medicaid Member Services at 1-800-635-2570.

The Kentucky Transitions Program is another unique option for individuals who are already in a nursing facility, but wish to return home. In 2007, Kentucky was awarded a grant from the Centers for Medicare and Medicaid Services (CMS) to implement this program, its purpose being to assist the elderly, disabled and those with mental retardation or acquired brain injuries to make a transition from institutional care back into the community.

In order for a person to be eligible for the Transitions Program, they must: have lived in a nursing facility or facility for the mentally retarded for at least 6 continuous months; be eligible for Medicaid and have been receiving services through Medicaid for at least one month prior to transition; and have the ability to live in the community with support and services. Once a person’s eligibility has been determined, a transitions team assists the person in finding appropriate housing and works with various state and community agencies to ensure that the individual is provided the necessary assistance needed to make a successful move into the community. For more information on Kentucky Transitions, call 877-564-0330.

B. Limited Bed Availability

Unfortunately, when the time comes for long-term care placement, the assumption that there will be a bed available nearby may not be true. Facilities often inform inquirers that they will be placed on a waiting list. Even if the facility does maintain such a list, facilities are not required to admit persons based on waiting lists and most do not. When determining whether or not to admit a patient, the facility will take several factors into account.

First, they will determine if the patient can be cared for in the facility in accordance with the licensing criteria of the facility and the facility’s current staff levels. Next, the facility will compare the amount of money it will receive against the expenses they will likely incur. Some disabilities or diagnoses may require care that is particularity labor intensive. Nursing facilities may hesitate to admit such persons because the money they will receive to care for that person is not adequate to cover their costs.

There are no limits on what a facility can charge those who pay privately. However, there are limits to what a facility will receive from Medicare and Medicaid. When Medicare or Medicaid is paying, the patient must also meet the patient status criteria (see page 17). In addition, the care provided must be in a Medicare or Medicaid certified bed in order to participate in the program.

Using these criteria, the most desirable patient is the easy to care for private-pay patient with few needs or the compliant Medicare eligible patient with skilled nursing needs. The least desirable patient is the Medicaid eligible patient requiring expensive supplies or services or extensive supervision. Persons who find themselves screened out have few alternatives.

Difficult-to-place patients may be pressured by hospital discharge planners and others to accept less than desirable arrangements. They may be encouraged to accept placement in unfamiliar and distant areas or other states where family visits will be difficult. Patients may even be told they must accept certain arrangements. Some persons may be able to stay at home with home health services, but for others, this may not be a practical solution.

These situations can be very stressful. If you find yourself in this situation, remember:

· The primary responsibility for finding appropriate placement falls with the hospital

discharge planner who is charged with finding a safe and suitable placement. Family members can be excellent resources, but are not primarily responsible for locating placement following a hospital stay.

· Don’t allow hospital discharge planners to pressure you into taking someone

home while you are waiting for a placement unless you are able to provide that care over an extended time. Placement may never become available for a difficult-to-place patient. The person who agreed to provide temporary care may find they have become the permanent caregiver.

· You may be responsible for medical bills incurred by your minor children or a

spouse, but you are generally not personally responsible for the medical expenses of other family members unless you have agreed to be responsible for the expense of their medical care prior to the service being rendered.

· Patients cannot be admitted to a nursing facility against their will, but they can be

admitted against the wishes of a family member.

III. LEVELS OF CARE

The term “level of care” refers to the particular way a facility or section of the facility is licensed and certified. They are licensed to provide a particular range of services. Long-term care facilities are required to provide only those services within the scope of their license. In addition, nursing facilities must be certified to participate in reimbursement programs such as Medicare or Medicaid. One building may house more than one facility. For instance, one building may house a nursing facility and a personal care home under the same roof. The building may look the same in both facilities, and they may use a common dining area. Never-the-less, the services and reimbursement options available in the nursing facility are much different than those available in the personal care wing. Moving from one to the other is not simply a room change. It is a discharge from one facility and an admission to another.

Facilities often find it more cost effective to house residents needing heavier care or specialized services together, and staff those areas accordingly. They may choose to admit only persons with specific needs to those areas and may refer to them as being in another level of care. Therefore, services available in a facility with a particular license must be uniformly available throughout the facility. The reimbursement obtainable in a particular section of that facility, such as the “skilled” or “non-certified” wing, may be limited based upon how the beds are certified. (see page 45).

A. Personal Care

Personal Care Homes (PCH) are licensed, long-term care facilities, but do not provide medical services and cannot be certified to participate in Medicare or Medicaid. Most personal care facilities have an agreement with Kentucky to provide care at a fixed rate to persons who qualify for state assistance through the State Supplementation Program. The State Supplementation is a monthly income supplement that brings the resident’s income up to the state standard for a personal care home. At the time of the printing of this guide, the state standard was $1,194 per month and is $60 above what the facility may charge for care. The resident retains the $60 per month to use as personal spending money.

Personal care facilities can be different sizes with as few as 20 residents or as many as several hundred. Some are free-standing institutions, while others are located on a particular wing of a nursing facility or other medical institution. Personal care facilities are not required to have nurses on staff. While a doctor must regularly visit a resident in a nursing facility, no such physician visits are required at a personal care home.

Licensed personal care homes provide personal care services, activities, residential and health related services. Personal care services help residents achieve and maintain good personal hygiene. This would include assistance with washing, bathing and grooming. The facility must also provide a planned activity period for each day during which a variety of social and recreational opportunities are offered. The purpose of these activities is to: stimulate physical and mental abilities; to encourage and develop a sense of usefulness and self respect; and to prevent, inhibit or correct the development of mental regression due to illness or old age. Residential services include housekeeping and maintenance services, dietary services which includes three meals per day and snacks, and the laundering of resident's clothing and bed linens.

While personal care homes do not offer medical care, they do provide health related services. These services include: continuous supervision and monitoring of the resident to assure that the resident's health care needs are met; supervision of self-administered medications; storage and control of medications; arranging for therapeutic services ordered by the resident's physician which are not available in the facility; and promptly obtaining medical care by a licensed physician in case of an accident or acute illness.

Many frail elderly persons, who may have sought placement in a personal care facility in the past, now find their needs can be met at home with the assistance of home health care. As a result, several personal care homes have chosen to market their services to younger persons with various physical or mental disabilities. Personal care placement can be an appropriate living arrangement for persons capable of managing many of their own activities of daily living but who cannot live independently because of a disability.

B. Family Care

A Family Care Home (FCH) is a private residence, licensed by the state to provide 24-hour supervision and personal care for no more than three people. Residents must be 18 years of age or older. Family care home placement is appropriate for those who do not function well enough to take care of themselves, but who do not need nursing care.

There are places that market themselves as family care homes, but are not licensed or regulated such as a boarding home. Boarding homes do not provide supervision and personal care. This means that no one is monitoring the quality of care they provide, and they may be providing services in violation of state regulations. Check this before making a placement decision.

Family care homes do not provide medical care and are not certified to participate in Medicare or Medicaid programs. Like personal care residents, family care residents can apply for State Supplement if they are residing in a home that participates in this program. The supplement will raise their income up to the state standard for persons residing in family care homes. At the time of the printing of this guide, this standard was $864 per month, which is $40 above what the home may charge for care. The resident is allowed to keep the $40 a month for spending money. To participate, the family care home must accept the state rate as full payment. This is much less than the private pay rate and few family care home operators are willing to accept this amount.

C. Nursing Facilities and Nursing Homes

A Nursing Facility is a facility licensed by the state of Kentucky to provide nursing facility services. A person is appropriately placed in a nursing facility when they have a stable medical condition with: a complicated problem; a combination of problems that require daily or intermittent nursing or rehabilitative services; continuous personal care; or need supervision in an institutional setting.

If Medicare or Medicaid will be paying, a reviewer will automatically screen the chart to assure that the resident is receiving necessary covered services. All persons seeking admission to a nursing facility are screened to determine if the resident has mental health needs that cannot be provided in a nursing facility setting. A person who needs active mental health treatment that cannot be provided in a nursing facility setting cannot be admitted to a nursing facility.

Nursing facilities have chosen to certify some or all of the beds for Medicaid and/or Medicare. Because they receive Medicare or Medicaid reimbursement, they must comply with both state regulations and the Federal conditions of participation for nursing facilities. Some nursing facilities also facilitate contracts with the Veterans Administration to provide care to disabled veterans.

There are a few facilities in Kentucky that are licensed to serve special populations such as Intermediate Care Facilities for the Mentally Retarded and Developmentally Disabled (ICF/MRDD) and Alzheimer’s Facilities. The Alzheimer's facilities must comply with state regulations for Alzheimer's facilities. If these facilities are certified for Medicare or Medicaid, they must also comply with federal guidelines for nursing facilities. There are a few facilities designated as “ICF” only facilities. They are licensed by the state and provide a lower intensity nursing facility level of care.

Nursing facilities are required by both Federal and state regulations to provide all services necessary to assist the resident in attaining and maintaining their highest practicable physical, mental, and psycho-social well-being. They must do so in a manner that makes reasonable accommodation for the individual resident's needs and which provides a homelike atmosphere. Some of the services provided are: nursing services; personal care; administration and supervision of medication; therapeutic diets; physical, respiratory, and occupational therapy; activities; and social services.

Medicare only pays for skilled care provided by a nursing facility to a patient in a Medicare certified bed. Skilled services include treatment of medical conditions which must be provided by skilled (licensed) medical personnel, such as a registered nurse or a physical or other professional therapist (see Section D below).

Medicaid will pay for both high-intensity (skilled) and low-intensity (intermediate) care in a nursing facility. In order to qualify for Medicaid coverage in a nursing home, you must meet the Medicaid patient criteria for nursing facility level of care. In addition, the care must be provided by a nursing facility certified to receive Medicaid, and you must occupy a Medicaid certified bed.

In Kentucky, all nursing facilities are expected to be able to provide skilled care as well as low-intensity nursing facility care in all of their beds. Medicaid covers all nursing facility care, but requires that persons receiving skilled services be in a bed which is also certified for Medicare. In other words, in order to receive high-intensity Medicaid coverage, the patient must be in a bed that is certified to receive both Medicare and Medicaid payment. Low-intensity care can be provided in any bed certified to receive Medicaid payment including those that are dually certified.

A Nursing Home is a similar facility but is not certified for Medicaid or Medicare reimbursement and residents must pay privately for their care. Nursing homes must comply with state licensing requirements but are not required to comply with Federal conditions of participation

D. Skilled Care

The section of a nursing facility referred to as the “skilled” section is usually the section certified to participate in Medicare. Facilities commonly assign more of their licensed staff (RN and LPN) to this section. Skilled patients need ongoing care that can only be provided by licensed professionals.

Nursing facilities often encourage Medicaid residents who were receiving skilled services but no longer need them to move to the section of the facility that is not certified for Medicare. They do this in order to keep the Medicare certified beds available for persons who require skilled services. However, the resident cannot be required to move from the Medicare section to the section of the facility that is not certified for Medicare, so long as there is another method of payment available. Medicaid will also pay for skilled care if the bed is certified to receive both Medicare and Medicaid.

E. Assisted Living

In Kentucky, Assisted Living is a housing arrangement that offers a supportive environment and easy access to home health care. Residents in assisted living must be ambulatory (able to walk without assistance) or mobile non-ambulatory (unable to walk without assistance, but able to move from place to place with the use of a device such as a walker or wheelchair). Assisted living facilities are not licensed health care facilities and do not offer the full range of services that a nursing facility offers. However, they must be certified by the Department of Aging and Independent Living.

To receive certification each living unit in an assisted living facility must contain: at least 200 square feet of space for single occupancy or double occupancy if shared by mutual agreement; at least one unfurnished room with a lockable door; a private bathroom with a tub or shower; provisions for emergency response; individual thermostat controls if the facility has more than 20 units; a window to the outdoors; and a telephone jack. Some facilities built before July 14, 2000 may be grand-fathered in and may not fully meet this requirement. A list of the certified assisted living facilities in the BRADD is included in this book (see page 39).

Assisted living facilities must have staff available 24-hours a day, seven days a week who are trained in emergency care, cardiopulmonary resuscitation, client rights, the aging process and assistance with self-administration of medicine. The services offered by assisted living communities should include:

· Assistance with activities of daily living including bathing, dressing, grooming, transferring, toileting, and eating.

· Assistance with instrumental activities of daily living that include, but are not limited to: housekeeping, shopping, laundry, chores, transportation, and clerical assistance.

· Three meals and snacks made available each day.

· Scheduled daily social activities that address the general preferences of clients.

· Assistance with self-administration of medication.

The Kentucky Ombudsman Program does not currently offer complaint investigation and resolution services in assisted living facilities. In Kentucky, Ombudsman services are only available to residents of licensed long-term care facilities. However, the program has been made aware of some of the complaints that consumers have had involving assisted living facilities. Some complain that these facilities promise services they are not equipped to deliver. Complaints are also made that the assisted living facility misleads the consumer into thinking that their loved one will be cared for at one price and then, shortly after admission, reassesses the resident to need more costly services than originally discussed. Others allege that assisted living facilities attempt to provide higher level nursing services without properly trained staff.

The key to understanding the services offered by an assisted living facility is the “lease agreement.” The lease agreement must state what can be expected from the facility and inform residents of any special programs or costs for additional services. Among other things, the lease agreement should include:

· the terms of occupancy;

· information regarding specific services provided;

· a description of the living unit;

· associated fees;

· provisions for modifying client services and fees to include a provision for a 30 day notice any time the fee structure changes;

· the facility’s policy for terminating the lease agreement to include a provision for a 30 day notice if the client is asked to move out for non-payment;

· a description of any special programming, staffing, or training for clients with special needs;

· the facility’s grievance policy; and

· refund/cancellation policies.

Persons residing in assisted living pay privately at rates set by the provider. Some long-term care insurance policies will cover care provided by assisted living facilities, but others will not. Medicare and Medicaid do not cover assisted living services. However, skilled services provided by a licensed home health agency to someone living in an assisted living facility may be reimbursable under Medicare Part B benefits.

If you are considering placement in an assisted living facility, you should find out if the facility is certified and obtain assurances that the facility is capable of providing all the services which the resident needs or is likely to need in the future. Ask how the resident will be assessed to determine what supportive and health care services are needed.

You will want to know who will be monitoring the resident's health to insure that any changes in the resident’s condition are addressed. Ask how supervision will be provided to insure that the services provided are quality services. Find out how the needs of the resident will be monitored and how the staff is trained to meet those needs. In addition, you will want to know the process for determining when the resident is no longer able to live in the assisted living facility.

F. Special Care Units for Alzheimer’s

Although most nursing facilities admit patients with Alzheimer’s disease, few offer specialized services specifically designed for the dementia patient. There are a few facilities in KY that are licensed as an Alzheimer’s Facility. Regulations for Alzheimer’s facilities do little to direct the home in how to provide specialized services. Regulations address mostly environmental issues. Some facilities advertise that they provide special care for Alzheimer’s patients when in fact, other than a lock on the door of their “dementia unit,” the unit is really no different from the rest of the facility. Other facilities may indeed provide specialized services for dementia patients.

Kentucky law requires that any long-term care facility claiming to provide special care for persons with Alzheimer's disease or other related disorders must inform consumers regarding those services that distinguish the care as especially appropriate for persons with dementia.

Alzheimer’s patients need a safe comfortable space where they can move around freely in an interesting and safe environment. However, Alzheimer’s patients are easily agitated in an environment that is overly stimulating. Cognitively impaired persons often need meals prepared and served differently. They may need cuing to perform daily tasks and be reminded to eat. Short attention spans make them unable to participate in group activities designed for the cognitively intact residents. They need to be involved in failure-free activities.

Persons with dementia need continual intervention and redirection by staff members who are specially trained to understand the unique challenges of caring for such persons.

IV. MEDICARE

Medicare Part A covers a limited number of days in a nursing facility, but only if the patient is receiving a medically necessary skilled service, is occupying a Medicare certified bed and was admitted following a Medicare covered hospital stay of at least three days. Medicare Part B covers physician services while in a nursing facility and some therapies and supplies. Medicare Part D covers drugs.

A. Medicare Part A - Skilled Nursing Coverage

Medicare Part A will cover the cost of a semi-private room, meals, skilled nursing and rehab services and supplies. It pays for 100 days, and coverage for the first 20 days is 100%. From the 21^st day through the 100^th day, there is a deductible of $137.50 per day, and nothing is paid thereafter.

If Medicare Part A is the primary payer, nursing facility personnel will regularly review the care to determine if it meets Medicare's definition of medically necessary skilled services. When they believe the residents needs no longer meet these criteria, the doctor is notified. If the physician disagrees with the facility's decision, the nursing facility can request their decision be reviewed by the Peer Review Organization.

Peer Review Organizations (PRO) are groups of practicing doctors and other health care professionals who monitor the care received by Medicare patients. The reviewer will determine if the care qualifies as medically necessary under Medicare's criteria for skilled care. The decision will not be reviewed by the PRO if the nursing facility and the doctor agree unless the patient requests a review.

B. Medicare Part B - Physician and Therapy Coverage

Medicare Part B covers the physician’s visits, outpatient medical and surgical services, some supplies, diagnostic tests, durable medical equipment (such as wheelchairs, oxygen, and walkers) and some therapies. Medicare pays 80% of the approved cost after a deductible of *$155 per spell of illness. Medicare limits the amount of physical, speech and occupational therapy it will pay for under Part B. There is an “exceptions process” that would allow services to be continued under certain circumstances.

C. Medicare Part D - Drug Coverage

Beginning in January 2006, Medicare eligible residents whose medications were previously covered lost that coverage in favor of coverage under one of many drug plans available through the Medicare Part D Drug Coverage Plan.

Long-term care facilities cannot choose a plan for residents. Facilities cannot steer a resident to a particular plan or require that a resident have a plan as a condition of admission or continued stay. What they can do is provide residents with factual information about enrolling in Medicare Part D and inform them about which prescription drug plans include the pharmacy that the facility uses. They can also assist residents in filing exceptions and appeals when their plan does not cover a medication the resident needs. Generally, the resident or someone with legal authority under state law such as a guardian or power of attorney must actually select the plan. Residents who are dually eligible for both Medicare and Medicaid and who do not select a plan will be randomly enrolled in a plan without regard for how well the plan covers what the resident needs.

It is important that residents choose the plan that will cover the drugs they are taking from a pharmacy which contracts with the facility in which they are residing. Each plan differs somewhat in what drugs they will cover and which pharmacies they can contract with. Certain drug plans are forbidden from covering some drugs. Medicaid may continue to cover the excluded drugs for eligible residents, but others may find themselves paying out-of-pocket for these as well as other drugs not included on their plan’s formulary list.

Some Medicare D drug plans require deductibles be met and require co-insurance payments. Premiums average $37 a month, and deductibles can go as high as $4,550 a year before catastrophic coverage kicks in. Medicaid-eligible residents of nursing facilities are exempt from both deductibles and co-payments under the Medicare plan, so out of pocket expenses should not be a problem for them. Personal care home residents are exempted from deductibles, but do have to pay co-payments each time a prescription is filled. So it is better for a personal care resident to select a plan with low co-insurance payments even if the premiums are higher.

The amount of co-payment will vary depending upon the plan. Co-payments cannot exceed $2 per prescription for a generic version of a drug on the plan’s formulary or $5 for a premium version of a drug on their formulary. If the drug is not on the formulary, they may have to pay as much as 25% of the cost themselves.

Nursing facilities must make sure that each resident is receiving all medications prescribed by the physician, in the correct dose, form and timeframe. The facility must provide any drug that is included in the resident’s care plan even if there is no source of payment. This includes over-the-counter drugs. That does not mean that the facility cannot charge the resident for providing these drugs. It means that the facility must provide them. The issue of who will pay for them is secondary. If a resident does not get medically necessary medications, the facility may be cited with a deficient practice. In addition, facilities cannot require a resident’s family to agree to pay for a prescription drug when there is no other source of payment. It is unclear if personal care facilities have this same obligation.

If a facility uses a pharmacy that is not part of the resident’s plan, then the facility must use a pharmacy that is in the resident’s network. Medicare requires drug plans to contract with any provider who is willing to comply with the Center for Medicare/Medicaid Service rules and the rules of the plan. The resident can also change to a plan that contracts with the pharmacy the facility is using.

If the resident is prescribed a drug that is not covered by their plan, they can work with their physician to select an alternative drug that is covered. Some drugs may require prior authorization in order to be covered. They can also file an exception with their drug plan and try to persuade the plan that the drug is medically necessary. If that fails, the resident may file an appeal with an administrative law judge. Or they can change to another plan which does include the needed drug on its formulary. Nursing facility residents who are Medicaid eligible can apply the out-of-pocket cost of most drugs to their allowable medical expense deduction thereby lowering the amount they pay to the facility that month and recover the out-of-pocket expense.

Unlike those in the community, persons living in nursing facilities will be allowed to change plans every 30 days in order to maximize their coverage. Plans are required to cover the “first-fill” of an emergency drug not included on their formulary while the resident is in transition from a plan that does not cover the drug to one that does or while they are waiting for a determination when they have filed for an exception.

Over the counter drugs are not covered under any plan. However, they are considered covered as part of the daily rate paid to the facility under Medicare Part A and under Medicaid.

A list of available plans can be accessed at the Medicare website at www.medicare.gov by clicking on Compare Medicare Prescription Drug Plans.

V. MEDICAID

The Kentucky Medicaid Program provides medical services to the aged, blind or disabled poor. Applicants must be citizens or residents of the U.S. and meet resource and income limits. Persons receiving Supplemental Security Income (SSI) are automatically eligible for Medicaid; others can apply at the Department for Community Based Services, Division of Family Support. Medicaid covers nursing facility care in a Medicaid certified bed and the resident must meet the Medicaid patient need criteria.

Medicaid nursing facility coverage only begins after the patient’s Medicare coverage has ended. It pays for skilled services and the lower intensity intermediate care. Medicaid will also cover the Medicare deductibles. The information which follows was correct at the time of printing. However, changes to the regulations can occur at any time. Consumers can consult the Department of Medicaid Services website for more current information. The web address is: http://chfs.ky.gov/dms/mnfs.htm

A. Resources

Resources are defined as: cash money and other personal property or real property that an individual or couple owns; has the right, authority or power to convert to cash; and is not legally restricted from use for support and maintenance. Resources may include, but are not limited to: checking and savings accounts, stocks or bonds, certificates of deposit, automobiles, land, buildings, burial reserves and life insurance policies.

Medicaid applicants must fall below the available resource guidelines in order to qualify for benefits. As of the date of the printing of this guide, a nursing facility resident must have $2,000 or less in available resources to qualify. If the resident has a spouse living in the community, the spouse may keep $21,912 of the couple’s combined resources or one half of the couple’s combined resources, whichever is greater, so long as the spouse’s resources do not exceed $109,560.

Certain types of resources are excluded and are not considered in the Medicaid eligibility determination. These resources include, but are not limited to: the first $10,000 of a burial reserve or a life insurance policy, one automobile used for employment or to obtain medical treatment, burial spaces and plots, life estate interests, IRAs, KEOGH, retirement funds and other deferred tax protected assets until accessed. Individuals who do not access IRA funds when they are available for withdrawal are technically ineligible for Medicaid. IRA funds normally become available when the individual reaches age 59½. If the beneficiary is 70½, the IRS sets a minimum required distribution, and Medicaid will expect beneficiaries of that age to take the minimum required distribution.

The resident’s home is only considered an exempted asset for the first 6 months of the resident’s facility stay if the total value is at or below $500,000. After the resident has been in the facility for 6 months, the resident must show that they are trying to sell the home and have listed their home for sale. This will allow the home to remain exempt for another 6 months. In order to remain exempt beyond that, a special exemption will need to be granted at the discretion of Medicaid and will be based upon provision of proof that efforts to sell were unsuccessful.

If the resident has a spouse, dependent child, or other dependent family member still living in the home, then the home remains an exempted asset. If the resident sells the home for less than the fair market value, a penalty period of ineligibility will be assessed. Once the home is sold, the money obtained will be considered an available asset and will disqualify the resident until that money is spent.

A resident whose home is deeded to someone else but who retains a life care estate will be considered to have homestead property with a countable value subject to the new rules above. The value of the life care estate will be calculated based upon the age of the resident and the value of the property.

It is possible to maintain the homestead as an excluded asset if the resident intends to return home. The individual must provide a written statement that they plan to return to the home and estimate when that will be (number of months). The statement must be signed by the resident. If the resident is unable to sign, the statement may be signed by the power of attorney or, if there is no one authorized as power of attorney, the resident’s representative. The plan must be reviewed and approved by Medicaid.

B. Income

In order to determine Medicaid eligibility, all of the resident's available income is considered and must be within Medicaid program guidelines. As of the time of the printing of this guide, if the nursing facility resident's net income is at or below $2,022 per month, the nursing facility resident is income eligible. Income is defined as money received from statutory benefits (Social Security, VA pension, Black Lung benefits and Railroad Retirement benefits), pension plans, rental property, investments or wages for labor or services. Income may be earned or unearned.

Persons with income in excess of $2,022 can still qualify for Medicaid nursing facility coverage by placing all of their excess income into a Qualifying Income Trust (QIT). The trust must be irrevocable and designate that Medicaid gets what is in the trust when the beneficiary dies. Legal assistance will be needed in order to draw up the trust. Only the income in excess of $2,022 must be placed in the trust. However, the resident can choose to put all their income in the trust if they want. Only income, not resources, can be placed in the trust. The money in the trust is not counted as income when determining Medicaid eligibility. The person named as trustee must consult with Medicaid before making any payments from the trust. Funds from the trust can be used to pay for the cost of the resident's care. Other expenditures must be approved before

being paid from the trust.

At the time of application, Medicaid calculates if the resident’s income is below the income guidelines. This determines both eligibility and the amount that the resident will have to pay to the facility from their available income. The amount will be equal to the applicant’s gross income after deductions. A deduction of $40 for personal spending will be allowed. Some other allowable deductions include: payments for maintenance of a community dwelling, payments for allowable medical expenses, health insurance premiums, and any other allowable payments.

The nursing facility resident can deduct an amount for spousal maintenance to bring a spouse’s income up to $1,750. The spouse may be allocated an additional amount of their combined income if the spouse can document shelter expenses (rent, utilities, telephone, etc.) to exceed $525 a month. However, the spouse’s income cannot exceed $2,739 even with the extra shelter expenses.

The portion of the resident’s income that is left after these deductions is called the “patient liability.” The patient liability portion is also what the resident will pay out-of-pocket to the nursing facility. Both the facility and the resident should receive a notice from the Division of Family Support informing them of the amount Medicaid has calculated to be the patient’s portion. The facility should collect only that amount from the patient. Medicaid will pay the difference between this patient liability amount and the cost of the resident’s care.

If Medicare is paying a portion of the bill, the resident must pay all Medicare co-insurance amounts until the out-of-pocket expense each month is equal to his patient liability amount. Once that amount is reached, Medicaid will begin to pick up the co-insurance.

C. Medicaid Estate Recovery

Any person over the age of 55 who received services in a nursing facility or received community based services as an alternative to nursing facility care after February 2, 1994 are subject to Medicaid estate recovery. Younger persons receiving the same services for two years or more are also subject to estate recovery. Persons subject to estate recovery will have liens applied to their estate by Medicaid. This Medicaid bill will be just one of many bills the estate has to pay.

Recoverable property is defined as everything the executor lists as property for probate court including the resident’s home. There are exemptions for family farms or family businesses where the remaining family members are dependent on the farm or business for their livelihood, and if other income does not exceed $50,000 per year per person in the family unit.

Medicaid will not recover from homestead property if it is deeded to a child with a disability or a child under the age of 21 who is a dependent of the now deceased Medicaid recipient. If there is a surviving spouse, the entire estate will be exempt. Property may be considered exempt from Medicaid eligibility if it is being inherited by a relative who delayed the resident’s institutionalization for a period of time by caring for the resident by moving in with them.

D. Transferring Assets

Transferring property to another person for the purpose of qualifying for Medicaid or to avoid estate recovery may cause problems. Property which has been transferred to another person prior to the death of the Medicaid recipient and not owned by them at the time of their death is not considered part of their estate, and therefore is not recoverable. However, transferring property at less than fair market value to another person in order to avoid Medicaid Estate Recovery may have other consequences.

Medicaid also looks at the resources of an applicant when determining eligibility. A Federal rule requires states to search back five years from the date of application to see if there were any resources transferred for less than fair market value to individuals or to trusts. Property transferred for less than fair market value within this five year period is considered an available resource and may put the Medicaid applicant over the resource limit. This would render them ineligible for Medicaid for a period of time even though they no longer own the property or other resources.

To calculate the number of months during which the resident is considered ineligible, Medicaid divides the amount of money transferred by the average cost to Medicaid for a day’s care which is currently $179.51. The period of ineligibility will begin on the date that the person would have otherwise become eligible for Medicaid.

This is significant since the resident will have no funds and will also be unable to pay for the care they need without the resources that have been given away. Medicaid pays less for care than the average private pay person, so the period of ineligibility is very likely to be longer than the number of months the resident could have paid for had they kept the resource.

Each state will be required to have a hardship waiver which can be applied for by either the resident or the nursing facility if the penalty would result in the resident being deprived of medical care that would endanger the applicant’s health or life or deprive the resident of food, clothing, shelter or other necessities of life.

There are a few exceptions to this transfer rule. A nursing home resident may transfer their home without penalty to the following persons:

Ÿ A disabled child of any age;

Ÿ A child whose name is also on the deed; has lived with the resident and provided care for the resident for at least a year thereby avoiding institutionalization; or

Ÿ A child who has lived with the resident and provided care for the resident for at least two years thereby avoiding institutionalization.

E. How to Apply for Medicaid

You must apply for Medicaid at the Department for Community Based Services (DCBS), Division of Family Support office in the county where the nursing facility is located. You cannot apply until after the resident is actually admitted in the facility. It is advisable to make an appointment with your county DCBS/Division of Family Support office; otherwise you will have to wait to be seen by a worker. You will need to bring:

· the nursing facility resident's Social Security Card;

· the resident's Medicare number;

· the resident's date of birth;

· the resident's last three bank statements;

· proof of the resident's income;

· premium notices of any health insurance policies on the resident;

· the resident's life insurance policy and a written statement from the company stating the cash surrender value; and

· tax evaluation of any property (other than the resident's home) the resident owns.

If the resident is not enrolled in Medicare, does not receive SSI and is not a “qualified alien” they must also bring satisfactory documentation of citizenship.

F. Patient Status Eligibility

In addition to meeting the income and resource guidelines, a Medicaid eligible person must also meet the patient need criteria for either high-intensity or low-intensity care as defined by Medicaid in state regulations 907 KAR 1:022. Persons in need of skilled care must meet the high-intensity criteria. Low-intensity criteria require the patient meet at least 2 out of 12 designated care need areas. If the resident does not meet the criteria, they will not be eligible for Medicaid nursing facility payment despite the recommendation of the resident’s personal physician that nursing facility care is needed.

Once the resident has been in the facility for 18 months, they can apply for a transfer trauma exception if they do not meet these criteria. To get this exception, the resident’s doctor must document to Medicaid’s satisfaction that the resident will suffer physical or mental harm if they are moved. Persons receiving a transfer trauma exception are reevaluated every 6 months.

As part of the admission process, the facility will call and request approval for a new Medicaid covered admission. The facility will provide information to the Medicaid field review nurse who, based upon the information provided by the facility, determines whether or not the patient meets the Medicaid patient need criteria for high or low-intensity nursing facility care. If the determination is yes, then a pre-certification number is given and the facility can bill Medicaid.

Sometimes it can take up to 30 days for Medicaid to determine if the patient meets the criteria. If the determination states the patient does not qualify, a Medicaid payment is denied and the patient is responsible for paying the facility for care. The good news is the decision can be appealed but the facility can continue to demand payment from the resident while the appeal is pending. If Medicaid approves the admission, they will usually certify the patient as needing the care for at least 30 days and the patient is reevaluated at the end of that time.

Medicaid nursing facility payment stops anytime the resident: no longer meets the criteria; qualifies for Medicare nursing facility coverage; or goes into the hospital. When the resident returns from the hospital or when Medicare benefits stop, a request for a new Medicaid covered nursing facility admission must be made. The patient is then reevaluated to determine if they met the patient need criteria at that time. The following is the patient need criteria for Medicaid coverage in a nursing facility.

MEDICAID HIGH INTENSITY CRITERIA

(It is often referred to as skilled because it is similar to the Medicare criteria for skilled nursing payment).

An individual shall qualify for high-intensity nursing care if, on a daily basis, the individual's needs mandate high-intensity nursing care services or high-intensity rehabilitation services and the care can only be provided on an inpatient basis.

The inherent complexity of a service prescribed for an individual exists to the extent that it can be safely or effectively performed by or under the supervision of technical or professional personnel, or the individual has an unstable medical condition manifesting a combination of at least two or more care needs in the following areas:

· Intravenous, intramuscular or subcutaneous injections and hypodermoclysis or intravenous feeding;

· Nasogastric or gastrostomy tube feedings;

· Nasopharyngeal and tracheotomy aspiration;

· Recent or complicated ostomy requiring extensive care and self-help training;

· In-dwelling catheter for therapeutic management of a urinary tract condition;

· Bladder irrigations in relation to previously indicated stipulation;

· Special vital signs evaluation necessary in the management of related conditions;

· Sterile dressings;

· Changes in bed position to maintain proper body alignment;

· Treatment of extensive decubitus ulcers or other widespread skin disorders;

· Receiving medication recently initiated, which requires high-intensity observation to determine desired or adverse effects or frequent adjustment of dosage; or

· Initial phases of a regimen involving administration of medical gases; or

· Receiving services which would qualify as high-intensity rehabilitation services if provided by or under the supervision of a qualified therapist. For example:

o Ongoing assessment of rehabilitation needs and potential;

o Therapeutic exercises which shall be performed by or under the supervision of a qualified physical therapist;

o Gait evaluation and training;

o Range of motion exercises which are part of the active treatment of a specific disease state which has resulted in a loss or restriction of mobility;

o Maintenance therapy if the specialized knowledge and judgment of a qualified therapist is required to design and establish a maintenance program based on an initial evaluation and periodic reassessment of the patient’s needs, and consistent with the patient’s capacity and tolerance;

o Ultrasound, short wave, and microwave therapy treatments;

o Hot pack, hydro collator infrared treatments, paraffin baths, and whirlpool if the patient’s condition is complicated by circulatory deficiency, areas of

desensitization, open wounds, fractures or other complications, and the skills, knowledge, and judgment of a qualified physical therapist are required; or

o Services by or under the supervision of a speech pathologist or audiologist if necessary for the restoration of function in speech or hearing.

MEDICAID LOW INTENSITY CRITERIA

(Sometimes called Non-skilled or Intermediate)

An individual shall be determined to meet low-intensity patient status if the individual requires, unrelated to age appropriate dependencies with respect to a minor, intermittent high-intensity nursing care, continuous personal care or supervision in an institutional setting. In making the decision as to patient status, the following criteria shall be applicable:

· An individual with a stable medical condition requiring intermittent high-intensity nursing care services not provided in a personal care home shall be considered to meet patient status;

· An individual with a stable medical condition, who has a complicating problem which prevents the individual from caring for himself in an ordinary manner outside the institution, shall be considered to meet patient status. For example, an ambulatory cardiac patient with hypertension may be reasonably stable on appropriate medication, but have intellectual deficiencies preventing safe use of self-medication or other problems requiring frequent nursing appraisal, and thus be considered to meet patient status; or

· An individual with a stable medical condition manifesting a significant combination of at least two or more of the following care needs shall be determined to meet low-intensity patient status if the professional staff determines that the combination of needs can be met satisfactorily only by provision of intermittent high-intensity nursing care, continuous personal care or supervision in an institutional setting:

o Assistance with a wheelchair;

o Physical or environmental management for confusion and mild agitation;

o Must be fed;

o Assistance with going to bathroom or using bedpan for elimination;

o Old colostomy care;

o Indwelling catheter for dry care;

o Changes in bed position;

o Administration of stabilized dosages of medication;

o Restorative and supportive nursing care to maintain the individual and prevent deterioration of his condition;

o Administration of injections during time licensed personnel is available;

o Services that could ordinarily be provided or administered by the individual but due to physical or mental condition is not capable of self-care; or

o Routine administration of medical gases after a regimen of therapy has been established.

Criteria Not Considered By Medicaid

An individual shall not be considered to meet patient status criteria if care needs are limited to the following:

· Minimal assistance with activities of daily living;

· Independent use of mechanical devices, such as assistance in mobility by means of a wheelchair, walker, crutch or cane;

· A limited diet such as low salt, low residue, reducing or another minor restrictive diet; and

· Medications that can be self-administered or the individual requires minimal supervision.

G. What Medicaid Pays For

Medicaid will cover most everything in a nursing facility. Nursing facilities may not charge a Medicaid eligible resident for items or services covered under the Medicaid state plan. They may, however, charge a resident for an item that is requested by the resident that is not covered under the state plan.

The facility may not charge extra for an item or service not requested by the resident. The facility cannot require the resident to request any item or service as a condition of admission or continued stay (this includes requiring a sitter).

Routine, necessary personal hygiene items and services must be furnished at no extra charge to residents who are eligible for Medicaid. These include, but are not limited to, the following items:

Ÿ hair hygiene items including shampoo, conditioner, comb, brush and bath soap;

Ÿ disinfecting soaps or cleaning agents needed to treat skin problems or infection;

Ÿ razors, shaving cream;

Ÿ toothbrush, toothpaste, denture adhesive, denture cleaner, dental floss;

Ÿ moisturizing lotions;

Ÿ tissues, cotton balls, cotton swabs;

Ÿ deodorant;

Ÿ incontinence supplies, sanitary napkins and related supplies;

Ÿ towels and wash cloths;

Ÿ hospital gowns;

Ÿ over-the-counter drugs (such as aspirin and cough syrup);

Ÿ services necessary for nail hygiene, hair hygiene, bathing, or shaving; and

Ÿ personal laundry (excluding dry cleaning, mending and hand washing).

These items and services must be provided in sufficient quality and quantities to effectively meet the individual needs of the residents. If a resident requests a special preferred product that costs more than the item the facility normally furnishes, the facility may charge the difference between the preferred product and the furnished product. However, the furnished product must be a product the resident can use. If the resident cannot use the product normally furnished, then another product the resident can use must be substituted. Facilities may not charge for the use of routine equipment.

VI. LONG-TERM CARE INSURANCE

You need to read the terms of your policy very carefully for the specific benefits and exclusions because not all long-term care insurance policies are the same.

The type of facility the long-term care insurance covers will vary. Each policy has certain “benefit triggers” or conditions that trigger the policy to begin paying benefits. In Kentucky, a long-term care policy must provide a “benefit period” (the length of time you will receive benefits) of at least 12 months.

Nursing facilities, personal care homes, assisted living facilities and even your own home may be covered and if so, you must use the type of care and services your policy requires. Some policies require services that are “medically necessary”. This means certain medical conditions must exist in order for benefits to be paid. Each policy will have its own definition of medically necessary. Some rely on your physician’s opinion, while others may make their own determination. In Kentucky, long-term care policies cannot require the beneficiary be hospitalized or in a higher level of institutional care prior to payment of benefits and they cannot limit coverage to skilled care only.

Your policy may have some “exclusions” - conditions or medical expenses for which they will not pay. Policies sold in Kentucky cannot exclude or limit benefits on the basis of Alzheimer’s disease. Some policies exclude personal care or custodial care. This can be confusing since each policy will have its own definition of personal or custodial care. However, it generally means that the beneficiary requires services that can be provided by persons without medical skills such as bathing, dressing, or other routine activities of daily living. This could include personal or custodial services provided in a nursing facility setting.

Your policy may have a lifetime maximum benefit limit. This may be measured in days or in dollars. Long-term care policies usually pay a flat amount per day. The amount they pay will vary and seldom covers the full cost.

Another option to consider is a new type of policy called the Kentucky Long-Term Care Partnership Program. Through this program, an agreement has been made between the state of Kentucky and private insurance companies to assist consumers in planning for long-term care needs. Consumers who purchase and utilize benefits from a qualified long-term care partner policy will be exempt from Medicaid spend-down requirements equal to the amount of benefits paid by the policy.

For more information on long-term care insurance or the Kentucky Long-Term Care Partnership Program, contact the KY Office of Insurance at 1-800-595-6053 (KY only). A helpful consumer guide called Long-Term Care Insurance Guide can also be found on their website at http://doi.ppr.ky.gov/kentucky/ALSearch/Information/fpubs.aspx.

VII. VA BENEFITS

The Department of Veterans Affairs administers a special monthly pension benefit called the Aid and Attendance Pension (A&A). The pension benefit may be available to wartime veterans and surviving spouses who have in-home care or live in a nursing facility or assisted living facility.

The Aid and Attendance Pension provides benefits for veterans and surviving spouses who require the regular attendance of another person to assist in eating, bathing, dressing/undressing or taking care of the needs of nature. It also includes individuals who are blind or a patient in a nursing facility because of mental or physical incapacity. Assisted care in an assisting living facility also qualifies.

As of the printing date of this guide, the A&A Pension can provide up to $1,644 per month to a veteran, $1,056 per month to a surviving spouse, or $1,949 per month to a couple. Eligibility must be proven by filing the proper Veterans Application for Pension or Compensation. This application will require a copy of the DD-214 (see below for more information) or separation papers, medical evaluation from a physician, current medical issues, net worth limitations, net income and any out-of-pocket medical expenses.

A DD-214 is issued to military members upon separation from active service. DD-214s were issued to separate service members beginning in the 1950's. The term "DD-214" is often used generically to mean "separation papers" or "discharge papers", no matter what form number was used to document active duty military service. If the VA has a copy of a DD-214, it is usually because the veteran attached a copy (or sometimes, the original) to his or her application for disability or education benefits. If you’ve lost your original DD-214 or a copy and you are receiving (or applied for in the past) disability or education benefits from the VA, they may have a copy (or the original, if you gave it to them) on file. At the very least, if you are currently receiving benefits (or did in the past); they should be able to provide a Statement of Service, which can be used instead of a DD-214.

Additional information and assistance in applying for the Aid and Attendance Pension may be obtained by calling the Kentucky Department of Veterans Affairs Field Operations Branch at 1-800-928-4012 or any local veterans’ service organization. Information is available on the internet at http://www.va.gov/ or http://veterans.ky.gov/.

In addition, there are three Veteran’s Centers in Kentucky: Thomson-Hood Veterans Center in Wilmore, KY; Eastern Kentucky Veterans Center in Hazard, KY and Western Kentucky Veterans Center in Hanson, KY. Western Kentucky Veterans Center serves the Barren River area, and may be contacted at (877) 662-0008.

VIII. SELECTING A FACILITY

A. The Location

It is best to try to find a placement in a facility that is located where family and friends can visit frequently. This will assure the resident has social interaction and will enable family and friends to gauge the quality of care the resident is receiving and to help them advocate for the resident. Each facility has a "personality." If possible, match the personality of the resident with that of the facility. For example, a person who lived in the country all of his life might prefer living in a facility in a rural setting. And some facilities specialize in giving care to military veterans.

B. Visiting the Facility

Look beyond the furnishings. Homes are often designed to appeal to the middle-

aged children of potential residents and may not be as attractive to older adults. Try to see the home from the perspective of the potential resident. A floor waxed with a high gloss may be very appealing to family members looking for a well-maintained facility, but the resulting glare may pose a visual barrier for the aging person who will live there.

Ask for an explanation of services offered by the facility. Check the activities calendar. Is there variety? Are there activities that would interest the potential resident? Visit some activities and note whether the residents are enthusiastically participating or just observing the activity. Ask what therapy programs are available. Ask about other services the potential resident may need or want such as dental care, barber or beautician services or off-site trips.

Warm staff and resident interaction is critical to quality care. Staff should treat residents with respect and concern regardless of condition, and should respond patiently to residents’ requests for assistance or attention. Notice if the staff treat each other with respect. Do they seem to enjoy their work?

Visit the facility several times at a variety of different days and times. Visit the facility late on a Saturday afternoon or on a holiday when staffing levels are at their lowest.

Talk with residents and observe the care that they receive. (Remember that the resident's room is his home, so knock before entering). Do they talk about friends and activities at the facility? Are residents appropriately dressed and groomed? Do they appear comfortable and content or are they agitated and crying out for attention? Look for restraints--belts, vests, or mitts that restrict movement. There should be few, if any, of these. Instead, residents should be comfortably seated with pillows or other positioning aids as needed for support.

The resident may live in the facility for the rest of his or her life, so examine the building closely. Is it a place where you or the resident would want to live? Is it attractively furnished, neat, and clean? Are there unpleasant odors? Do unanswered call bells, a loud public address system or blaring televisions make the environment too noisy? Are there comfortable, home-like common areas? Is there adequate space? Finally, are resident rooms individualized?

Mealtimes are often highlights of the day for residents. It is important that food be tasty and appealingly served. Ask to eat a meal with the residents. How does the meal taste? Are the residents eating and enjoying the food? Are residents who need it receiving assistance with their food? Is the food being served at the right temperature?

If possible, attend a meeting of the Family Council of the home you are evaluating. The Family Council is a group of family members and friends of residents who meet for mutual support and to advocate for the residents. The council attendees should be able to provide valuable insights into the home's good and bad points.

Even after a careful inspection of a facility, you may have questions. Please feel free to contact the Ombudsman for additional information at (800) 355-7580. The Ombudsman's name and telephone number are posted in each facility.

C. Quality of Life Issues

Researchers have found eleven areas that define quality of life for long-term care residents. Quality of life includes the ability to:

· make choices and maintain independence;

· express individuality;

· be involved in meaningful activities;

· maintain relationships with family and friends;

· get what is needed when it is needed;

· have privacy and confidentiality respected;

· be treated with dignity and respect; feel comfortable, safe and secure;

· maintain a sense of spiritual well-being; and

· the ability to find enjoyment.

When evaluating the long-term care facility, also think about: how will the resident

will be able to maintain their normal activities and routines; how will the facility accommodate the resident’s individual needs; and focus on areas of the facility other than the resident’s room that will be accessible to the resident. For example: Is there an outside area available if the resident wants to sit in the sunshine?

D. Five-Star Rating System

The Medicare website at www.Medicare.gov/NHCompare now features a system that assigns each nursing facility a rating between one and five stars. This rating is calculated based on three separate categories. It includes information collected by health inspectors, information collected on residents by the facility (these are called quality measures) and staffing levels as self-reported by the facility. The rating system is useful information, but it is only one of several things you will want to consider when choosing a nursing facility. There are many quality factors that this rating system does not take into account, and consumers should not rely on this rating alone. Ratings are not available for personal care or family care homes.

E. Inspections of Long-Term Care Facilities

Kentucky law requires that unannounced inspections of long-term care facilities be conducted approximately once per year by the Office of Inspector General, Division of Health Care. The purpose of this inspection or "survey" is to determine if the facility is providing care in a manner that meets Federal and state regulatory requirements.

The Centers for Medicare and Medicaid Services (CMS) maintains a website at www.medicare.gov where consumers can get information about inspections conducted in facilities which receive Medicare or Medicaid. However, the information provided is not specific enough to always give the consumer a good picture of what the circumstances was that resulted in a finding of deficient practice.

Facilities are required by law to make copies available to the public of all inspections conducted over the last three years, including the most recent survey. Copies of inspection reports can also be obtained under open records by writing to the Office of Inspector General, Division of Health Care; 275 East Main Street 5E-A; Frankfort, KY 40621.

When reviewing the written report, note that it is divided into two sections. The left side of the page describes the inspectors’ findings, and the right side details the facility’s response. If the facility has been found to be out of compliance with a particular regulatory requirement, a tag number (e.g. F272) will appear in the far left column. This number cites the actual regulation. The report will describe the requirement that was not met and provides examples of observations the inspectors made that caused them to make that determination. If the requirement was a Federal requirement, it will also include a Scope and Severity score (e.g. SS=F) which describes how many residents were affected and how much harm or potential for harm the violation caused. Scope and Severity scores range from A to L. Generally speaking, the higher the letter, the more serious the problem.

The facility’s plan to correct the deficiency should appear on the right side of the page. An acceptable plan of correction not only corrects the specific examples that the regulators cited, but also identifies and corrects the systemic cause of the deficiency.

F. Quality Indicators

The Centers for Medicare and Medicaid Services (CMS) also provides quality indicators on each nursing facility which receives Medicare or Medicaid at www.medicare.gov. This information is collected from the resident assessments which are completed on each patient entering the nursing facility. The assessment, often called an “MDS” for Minimum Data Set, is used to determine how the facility is reimbursed by Medicare and Medicaid. It also identifies problems that each patient has and is used as the basis for the individualized patient care plan that the facility staff develops. Information collected on these assessments includes the resident's health, physical functioning, mental status, and general well-being. All of this data is reported by the nursing facilities themselves. Medicare uses this data to look at the number of residents whose condition during previous days prior to the assessment has improved or declined

These numbers can give some helpful information. Consumers can use the information to narrow their search and to focus their discussions with facilities about the care they provide. However, it is important to remember that there may be a number of factors besides the quality of care provided that could account for some of these numbers.

G. Staffing in Long-Term Care Facilities

Many times Ombudsmen are told that facility residents feel there just are not enough direct caregivers available to give them the assistance they need. This same concern is repeatedly voiced by family members of residents and by the staff themselves. Nursing assistants often complain of having to work long hours and being assigned too many patients. Nursing supervisors and administrators often address complaints of unsatisfactory care by stating that they do not have staff members available to provide the specific kinds of assistance needed by particular residents.

Federal law does not require nursing facilities to meet staffing ratios. And Kentucky, like many other states, does not require staffing ratios although a bill suggesting such a requirement has been offered to the state legislature almost every year. However, both Federal and state regulations do require facilities to have sufficient staff to meet the needs of the residents.

Nursing facilities must have at least one Registered Nurse (RN) for at least 8 straight hours a day, 7 days a week and either an RN or Licensed Practical Nurse (LPN) on duty 24 hours per day. Before investigators can find that a facility’s staffing is inadequate, they must discover by a preponderance of evidence that residents’ needs have not been met because staff has either not been available or has not been sufficiently trained.

Facilities are required to post this information for the entire facility but not for each unit, so consumers will still have to do their own count to determine how many nursing staff is actually available to care for residents in different sections or wings of the facility. During annual surveys of facilities, state agencies monitor to see that this information is posted. They do not investigate to see if the information is factual. The expectation is that the information should be accurate for every day for every shift and displayed in a uniform and understandable manner. Every nursing facility must post:

· How many registered nurses, licensed practical nurses, and certified nurse aides giving direct care are available on each shift;

· The number of residents living at the facility;

· The information in a clear and readable format in a prominent place that is readily accessible to residents and visitors; and

· Provide a copy of the posting to family members and other visitors upon request. The facility can charge for making copies of the posting.

Information regarding the staffing levels of particular nursing facilities is available on the Medicare web site at www.medicare.gov. These numbers are based on information provided by the facility and likewise, are not checked for accuracy. During the survey process, each facility must report its nursing staff hours for a two week period prior to the time of the state inspection to the survey agency. The Centers for Medicare and Medicaid Services then converts the reported nursing staff hours into the number of staff hours per resident per day and posts that number on their web site. Hours-per-resident-per-day is the average amount of hours worked divided by the total number of residents. It does not necessarily indicate the number of nursing staff who are present at any given time nor does it report how many of these staff members were available to provide direct care.

Supervisory nurses who do not provide direct care should not be included in the numbers. Non-nursing staff (such as social workers, recreation therapists or physical therapy aides) should also not be included. Single-task workers who do not meet nurse aide training and certification requirements should not be included. Many advocates believe that temporary agency nursing staff should be counted separately from permanent staff since heavy reliance on temps may indicate poor care. It is also important to count only those persons who are actually working.

While some nursing facility providers support minimum standards, many are fearful that they will not be able to recruit enough staff to meet higher requirements. Those who oppose staffing ratios have argued that requiring facilities to meet minimum staffing ratios will impose standards that will be difficult for many facilities to meet. They insist that the cost of increasing staff will affect facility profits and state Medicaid budgets without assuring that the problems will be resolved. They contend that how well direct care staff is managed is as important as number of staff. Supporters of staffing ratios argue that current regulations have failed to guarantee adequate staffing and that there are minimum ratios without which adequate care cannot exist despite good management.

The National Citizens Coalition for Nursing Home Reform (NCCNHR), a grass-roots consumer organization representing nursing facility residents, is calling upon the Federal government to establish minimum staffing ratios. They recommend ratios be established averaging at least 4.13 hours of nursing care per resident per day. The Coalition's resolution endorses requiring all nursing facilities to have at least the following professional nursing staff available:

· A full-time RN Director of Nursing;

· A full-time RN Assistant Director of Nursing in facilities of 100 beds or more;

· A full-time Director of In-service Education; and

· An RN Nursing Supervisor on duty at all times (24 hrs per day, 7 days per week).

In addition to the above, the recommendation endorses the following minimum ratio of direct care-givers be present:

· Nurses to include RNs or LPNs at a ratio of 1:15 during the day, 1:50 in the evening and 1:35 at night; plus

· Direct caregivers to include RNs, LPNs or nursing assistants at a ratio of 1:5 during the day, 1:20 in the evening and 1:15 at night.

There is research indicating that there are minimum ratios below which residents cannot get quality care. In July 2000, the Centers for Medicare and Medicaid Services (CMS) released a report on nursing facility staffing. It established a correlation between numbers of nursing staff present and quality of care. It provides evidence that many of the nation’s nursing homes are inadequately staffed. The study did not recommend specific staff-to-resident ratios. However, the report did indicate that facilities where residents receive less than 2.0 hours of direct-care nursing assistance each day experience more negative outcomes such as bed sores and infections. Another study indicated that it takes an average of at least 2.9 hours of direct-care nursing assistance each day to provide residents basic services.

IX. THE ADMISSION PROCESS

A. Admission Contracts

An admission contract is a legal document which describes the relationship between the facility and the resident. Therefore, it is crucial that you read and understand this document before signing it. The agreements made in this contract are significant because it outlines the services the facility provides, the rights and responsibilities of the resident and the charges for care. Remember, the facility drafted this contract and took care to ensure it protects the interests of the institution first. Some admission contracts contain unenforceable clauses which attempt to mislead the residents into thinking that they have fewer rights than they actually have, and that the facility has fewer responsibilities than it actually does.

B. Admission Deposits

Persons seeking placement in a nursing facility are often required to put up large deposits in order to be admitted. A facility may require a cash deposit before admission if the care will not be covered by Medicare or Medicaid. It is unlawful for a facility to require a cash deposit of persons covered by Medicare or Medicaid. Federal law prohibits facilities from requiring prepayment as a condition of admission for care covered under either Medicare or Medicaid.

The facility may request that a Medicare beneficiary pay co-insurance amounts and other charges for which a beneficiary is liable. These should be paid as they become due and not in advance.

A nursing facility may not require a deposit from persons who demonstrate proof of their eligibility for Medicaid. If a resident is applying for Medicaid, but a determination of eligibility has not been made, the facility may collect a refundable security deposit. If the resident is later determined to be eligible for Medicaid, the facility must refund the deposit prior to billing Medicaid. A facility cannot require a third party guarantor for a Medicaid eligible applicant as a condition of admission.

C. Notification of Residents’ Rights

In all facilities there are rules and procedures to keep things running smoothly. Residents do, however, have specific legal rights which are protected by both state and Federal law. Residents must be given full information of all these rights at the time of admission. The resident must acknowledge, in writing, that they have been informed of these rights and the facility must keep a copy of the acknowledgment in the resident's file. Some of these rights require that facilities provide specific information to residents at the time of admission.

The resident must be fully informed both in writing and orally, in a language they can understand, of all services available. A copy of these services (with the resident’s signature) must be kept by the facility in the resident’s file. The resident must be given information, in writing, about Medicaid benefits at the time they are admitted. The resident must be given full information of all expected charges. Each resident should be informed of charges included under the basic rate and any extra charges for additional services.

Residents should be informed in writing of other specific legal rights related to receiving information, making decisions, coming and going at will, communicating with others, receiving fair and dignified treatment and other more specific rights. Each resident must also receive information about the existence of the Ombudsman Program. Resident Rights are listed on page 34.

D. Smoking Policies

Long-term care facilities are rapidly declaring themselves to be smoke free. They are doing so for several reasons. Facilities are concerned that they may be held legally responsible for the consequence of smoke exposure to their staff and clients. They see smoking as inconsistent with their health orientation and most of all, they are afraid of fire. And these fears are real. The media has covered several facility fires recently. Evacuating a long-term care facility full of disabled individuals is a difficult task and exposes those evacuated to trauma. In order keep the facility safe, many facilities are establishing rather ridged smoking routines.

Facilities do have a responsibility to provide a save environment which protects their staff and non-smoking residents from exposure to second hand smoke. However, they are also required to provide a homelike atmosphere which supports personal autonomy as much as possible. Smoking policies will most likely be resented and not be followed by residents who are addicted to nicotine. These residents are likely to hide and smoke unsafely out of the view of others. Rather than reducing the risk of smoking related fires, policies which are too strict could actually create greater risk.

The smoking policy of the facility should be communicated to all employees and residents prior to its effective date, at the time of employment or admission, and prior to the signing of an admission agreement or contract. A written copy of the smoking policy should be supplied upon request.

Generally, the facility should not require supervised smoking unless a comprehensive assessment determines the resident needs supervision and no practicable precautions can be taken which would allow the resident to smoke independently. Residents have the right to keep and use their own personal possessions including legal smoking materials and paraphernalia. Facility staff may confiscate smoking items and paraphernalia when it is determined these create the danger when in the resident’s possession. Confiscated items should be made available for use by the resident at times when supervision can be provided or other precautions can be taken to address the assessed danger. Facilities can also offer smoking cessation programs and encourage the use of smokeless tobacco products as a substitute.

E. Use of Electric Wheelchairs

Some nursing homes have a policy disallowing the use of electric wheelchairs. These facilities site safety and liability issues as the reason for their policy. This practice violates both state and Federal law.

The Americans with Disabilities Act protects the rights of disabled persons, including nursing facility residents. Nursing facilities are public accommodations, and if they are receiving Federal or state reimbursement or funding, they are prohibited from discriminating on the basis of disability. This would prohibit nursing facilities from implementing blanket policies denying the use of electric wheelchairs. Such policies also violate a nursing facility resident's rights to retain and use his or her own personal possessions unless the use infringes upon the rights of others.

A facility could bar an individual resident’s use of an electric wheelchair if the use poses a direct threat to others or fundamentally alters a program. However, the use of the electric wheelchair would have to pose a substantial risk of serious harm to the health and safety of others that could not be remedied.

The determination that an electric wheelchair user poses a direct threat may not be based on generalizations or stereotypes. It must be based on an individualized assessment that considers the particular activity and the actual abilities and disabilities of the individual. The direct threat must be based on an individualized evaluation that considers the particular activity and the actual abilities and disabilities of the individual electric wheelchair user.

F. Binding Arbitration Clauses

More and more long-term care facilities are presenting residents with binding arbitration agreements as part of the admission process. Binding arbitration agreements limit the resident’s ability to sue the facility if something goes wrong. Instead, the resident must agree to abide by an arbitration process in which the decision is binding and cannot be appealed in the courts. The agreement obviously offers some benefits to the facility or they would not be promoting its use. Some facilities even present the agreement as a condition of admission. Providers see it as limiting their exposure to windfall awards and therefore reducing their need to practice defensive medicine.

For consumers, arbitration can be less costly and quicker. However, if you choose to sign such an agreement, read it carefully. By signing the agreement, you are entering into a legal contract. You have the right to have your attorney look over the agreement. Some agreements can be revoked within a period of time, such as 30 days. That may give you time to read it more closely or to have your attorney review it. However, unless otherwise stated, it is effective immediately.

Make sure you understand the dispute resolution process that is incorporated into the agreement and how the arbitrator will be chosen. Make sure the agreement complies with the rules of procedure, the provisions of Kentucky’s Uniform Arbitration Act. Note whether or not the agreement limits the amount of time which can pass between the event in dispute and the request for arbitration. See when the agreement expires. Some binding arbitration agreements remain in effect even following the resident’s discharge and readmission to the facility. That might be OK if the resident is discharged to the hospital and then readmitted, but not if it covers all future admissions.

The agreement will usually apply to any and all disputes you may have with the facility. That could include disputes regarding a bill, the availability of services, the quality of care or any other dispute. So make sure you understand the other aspects of the admission contract. Admission contracts sometimes contain clauses that limit what the consumer can expect the facility to provide in the way of care, restrict rights or even hold the facility to a standard that is less than the regulatory requirements. Also, check to see if the agreement limits the amount of the award. Juries are much more likely than arbitrators to grant large awards.

X. WHEN OTHERS MUST DECIDE

Persons with impaired thinking may not always agree that long-term care placement is needed. Conversely, family members sometimes attempt to make decisions for a capable elder. It is important to remember that an older person’s choices may be viewed as unwise by others because individual values may be different. Children often value a parent's safety above all else, whereas the elder may place higher value on autonomy (the ability to self-direct). Facilities cannot legally admit a person against his or her will. However, when an elder lacks decisional capacity, others often must make necessary arrangements.

A. Decisional Capacity

“Decisional capacity” is defined as “the ability to make and communicate a wish.” This is not an either/or situation. A person may be able to rationally formulate a choice of where to live but not be able to handle financial situations. “Capacity” should be determined specific to the decision being made. A physician or social worker can often assist in evaluating a person’s decisional capacity.

By law, all persons over the age of 18 are capable of decision making unless evidence is shown to the contrary. When this happens, a guardian is appointed to assist the individual in making the decisions unable to be made by the individual. Since the right to direct one’s own life is a basic civil liberty, such a determination requires a jury hearing.

B. Advanced Directives

The need for a formal court determination of capacity can sometimes be avoided if a person has executed an advanced directive such as a Durable Power of Attorney, Health Surrogate or if he has left written instructions in a Living Will. This kind of planning must be done while the individual is still able to make decisions and empowers the person(s) appointed to make financial or health care decisions in the manner believed to be the individual’s choice if able to make such choices. Health care providers are required by law to inform patients at the time of admission of the right to execute an advanced directive. However, a facility cannot require that a resident have a living will, power of attorney or other advanced directive as a condition for admission. Advance directive forms furnished by the facility should be reviewed cautiously.

Many long-term care facilities interchange “Living Will” with “DNR”. There is a vast difference. A “DNR” means “do not resuscitate” or make any attempt to revive the patient. A “Living Will” expresses specific end-of-life wishes. It is important that an advanced directive apply to any health care setting, not just the facility to which the person is being admitted. The resident may be transferred to another setting at some future time which might render the resident unable to execute an advanced directive. If an ambulance service is called, the ambulance will provide all care unless a specific EMS DNR form is provided at the time of transfer.

C. Power of Attorney

Sometimes a person appointed to act as a Power of Attorney is said to have "power over" an individual. This is not true. Usually, a Power of Attorney gives authority to handle financial and property decisions rather than health care decisions, but it can be utilized to authorize both. Neither a Power of Attorney nor a Health Care Surrogate authorizes an individual to act against the wishes of any person who is capable of forming and expressing his or her intentions. Nursing facility residents retain the right to direct their own life and care decisions so long as they are able.

Kentucky law governs health care decision making by persons other than the individual. Three specific terms are used to describe the persons or instructions which will assist health-care decision making when the patient is unable. They are Health Care Surrogate, Living Will Directive and Responsible Party.

D. Health Care Surrogate

A Health Care Surrogate is someone voluntarily appointed by an adult patient who is the “grantor”. The grantor must be capable of expressing the wish that the person appointed will make decisions for the grantor. A Health Care Surrogate is given the power to make decisions in accordance with the desires of the patient after consulting with the physician. A Health Care Surrogate may not make any decision that the patient is capable of making for himself, unless specifically authorized within the document.

A Health Care Surrogate may make decisions authorizing the withdrawal of food or hydration but only in limited circumstances such as: when death is imminent; when the patient is in a permanent unconscious state and has a living will requesting such withdrawal; when food cannot be physically assimilated; and/or the burdens outweigh the benefits. Withdrawal of food and hydration cannot be authorized if it is needed for the relief of pain or when the patient is pregnant.

An owner, director, or officer of the facility providing care cannot be named a surrogate unless he is a blood relative or member of the same religious group. A surrogate may resign at any time by giving written notice and a patient can revoke a designation of Health Care Surrogate at any time.

E. Living Will Directive

Under KRS 311, a Living Will Directive is a written document used to designate a Health Care Surrogate. It expresses wishes relating to the withholding or withdrawal of food and hydration or life-prolonging treatment. The statute contains a suggested living will directive form which does not require an attorney and is readily recognized by emergency medical personnel. Some attorneys, however, advise their clients not to use this standardized form suggesting that it is confusing and easily misunderstood. Be aware that emergency medical responders or paramedics may not recognize wishes to not be resuscitated if a state approved standard form is not used.

A living will directive must be: dated; signed by the patient or at the patient's direction; properly witnessed by two adults in the presence of the patient and in the presence of each other; or acknowledged before a notary public. None of the following may act as a witness: a blood relative, a beneficiary, an employee of a health care facility where the resident is a patient (unless the employee is a notary), an attending physician, or any person directly financially responsible for grantor's health care. A patient can revoke or change a living will directive at any time. Any new directive automatically revokes a previous directive.

F. Responsible Party

The term Responsible Party can be confusing. Under Kentucky law, a responsible party is someone with the authority to make a health care decision for a patient who has not executed a living will or appointed a health care surrogate and the patient lacks decisional capacity. The responsible party is the following person or persons in hierarchical order. First, a court appointed guardian, then the patient's spouse, next an adult child or majority of adult children reasonably available, then the parents of the patient and lastly, the nearest living relative.

This term is also used to designate the next of kin or the person the facility will call if there is an emergency. However, nursing facilities often use this same term to mean guarantor of the bill. The responsible party is not the guarantor of the bill unless a voluntary contractual arrangement is entered into between the responsible party and the facility. Consumers should cautiously review any admission contracts for such clauses and understand what they are signing. Under some circumstances, it may be illegal for the facility to require a responsible party to be guarantor. For instance, a facility may not require a third party guarantor for a resident who has provided proof that they are Medicare or Medicaid eligible.

XI. RESIDENT RIGHTS

Residents in all long-term care facilities are guaranteed specific rights under the law. Persons living in nursing facilities that receive Medicaid and Medicare funding have additional rights.

Resident Rights include the:

· Right to see the state survey reports of the nursing home and the home's plan of correction;

· Right to be notified in advance of any plans to change their room or roommate;

· Right to daily communication in their language; and the

· Right to assistance if they have a sensory impairment.

· Right to participate in their own care, which includes the:

· Right to receive adequate or appropriate care;

· Right to be informed of any changes in their medical condition;

· Right to participate in planning their treatment, care, and discharge;

· Right to refuse medication and treatment;

· Right to refuse chemical and physical restraints; and the

· Right to review their medical record.

· Right to make independent choices, which includes the:

· Right to make independent personal decisions, such as what to wear and how to spend free time;

· Right to reasonable accommodation of their needs and preferences by the facility;

· Right to choose their own physician;

· Right to participate in community activities, both inside and outside the nursing home; and the

· Right to organize and participate in a Resident Council.

· Right to privacy and confidentiality, which includes the:

· Right to private and unrestricted communication with any person of their choice;

· Right to privacy in treatment and in the care of their personal needs; and the

· Right to confidentiality regarding their medical, personal, or financial affairs.

· Right to dignity, respect, and freedom, which includes the:

· Right to be treated with the fullest measure of consideration, respect, and dignity;

· Right to be free from mental and physical abuse, corporal punishment, involuntary seclusion, and physical and chemical restraints; and the

· Right to self-determination.

· Right to security of possessions, which includes the:

· Right to manage their own financial affairs;

· Right to file a complaint with the state survey and certification agency for abuse, neglect, or misappropriation of their property if the facility is handling their financial affairs; and the

· Right to be free from charge for services covered by Medicaid or Medicare.

· Rights during transfers and discharges which includes the:

· Right to remain in the nursing facility unless a transfer or discharge:

· is necessary to meet the resident's welfare;

· is appropriate because the resident's health has improved and the resident no longer requires nursing home care;

· is needed to protect the health and safety of other residents or staff; and

· it’s required because the resident has failed to pay the facility charge for an item or service provided at the resident's request after reasonable notice.

· Right to receive a thirty day notice of transfer or discharge. The notice must include the reason for transfer or discharge, the effective date, the location to which the resident is transferred or discharged, a statement of the right to appeal, and the name, address, and telephone number of the state long-term care ombudsman;

· Right to a safe transfer or discharge through sufficient preparation by staff.

· Right to complain which includes the:

· Right to present grievances to the staff of the facility or to any other person, without fear of reprisal.

The Nursing Home Reform Act also grants nursing home residents these specific rights:

· The right to be fully informed which includes the:

· Right to be informed of all services available as well as the charge for each service;

· Right to have a copy of the nursing home's rules and regulations, including a written copy of their rights; and the

· Right to be informed of the address and telephone number of the State Ombudsman, State Licensure Office, and other advocacy groups.

MAKE A DIFFERENCE - JOIN YOUR FAMILY COUNCIL

When Al’s mother was placed in a nursing home he sought out the support of the facility’s family council. Al knew that there are benefits to family members working together. It offered him an opportunity to receive emotional support and empathy from others in the same situation. In addition, he knew that other resident’s family members could look out for his mother while he was on vacation or at times of the day when he could not be at the facility. He suspected that his mother would receive more attention if the facility knew that families communicated with each other.

A Family Council is an organized self-led, self-determining, consumer group of relatives and friends of residents. Al’s family council, like most, met monthly. At meetings mutual concerns were identified and information was shared. Formal communications to the facility administration were prepared. Al found it to be an effective way to bring about positive change in his mother’s nursing home.

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Information provided by the South Central KY Area Health Education Center

Promoting the CommonHealth throughout the Commonwealth

XII. IMPORTANT WEBSITES AND PHONE NUMBERS

Medicare: www.medicare.gov

This is the official site for persons with Medicare. Beneficiary Customer Service can also be obtained at 1-800-MEDICARE (1-800-633-4227, TDY/TDD 1-877-486-2048). The web site also provides information about facilities receiving Medicare or Medicaid including a summary of the most recent inspections and information about staffing levels and quality indicators. Look for a link that says “Find and Compare Nursing Homes” at www.medicare.gov/NHCompare.

Department for Community Based Services/Division of Family Support offices processes applications for Medicaid.