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 nursing homes is often less than
favorable. So to better help you find the right nursing home 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 2009 coverage. If needed, more current information
concerning nursing homes and benefit programs that cover nursing home care can
be obtained from the Long Term Care Ombudsman.
II.
THE PLACEMENT CRISIS
It is estimated that 54 million or one out of every three
Americans provide some type of assistance on a regular basis to a frail, ill or
disabled family member. 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 home 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 (3) days to make the necessary arrangements to place the patient in a
facility. When this happens, there isn’t time to visit several nursing homes
to select the facility that best fits the patients’ 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 nursing homes. Ombudsmen
can answer questions regarding nursing homes in the BRADD area. The Barren
River District Ombudsman can be contacted at 1-800-355-7580.
Another
helpful resource is the Barren River Area Agency on Aging. This agency 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 of
this agency 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.
These programs may assist in avoiding or delaying out-of-home placement. To
contact the Barren River Area Agency on Aging program 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 home 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 38.)
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. Under this program, 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 BRADD Agency on Aging at 270-781-2381, the Medicaid
Division of Long Term Care and Community Alternatives at 502-564-7540 or
Medicaid Member Services at 1-800-635-2570.
B. Limited Bed Availability
Unfortunately, when the time comes for nursing home
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.
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.
When Medicare or Medicaid is paying, the patient must
also meet the patient status criteria (see page 17 Patient Status Eligibility).
In addition, the care provided must be in a Medicare or Medicaid certified bed
in order to participate in the program.
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 not ever become available for a difficult to
place patient. The person who agreed to provide care temporarily may find they
have become the permanent care giver.
·
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
the heavier care patients together and the patients requiring specific
specialized services together, then 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, the 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 42 Level of Care grid)
A. Personal Care
Personal care facilities can be small different
sizes. They can have 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.
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.
State Supplementation is an income supplement that brings the resident’s income
up to the state standard. At the time of the printing of this guide, the state
standard was $1,194. This is $60.00 above what the facility may charge them
for care.
Licensed personal care homes provide services related
to personal care, activities, residential services, 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 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 including three meals per day and snacks; and laundering
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 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. 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.
Boarding homes that do not provide supervision and
personal care are not licensed or regulated. There are places that market
themselves as family care homes, but are not licensed. 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. Residents
can apply for State Supplement if they are residing in a home that participates
in this program. This is a monthly check which will raise their income up to
the state standard for persons residing in family care homes plus $40 spending
money. At the time of the printing of this guide, this standard was $864. 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 Homes and Nursing Facilities
A "Nursing Facility" is a facility licensed
by the state of Kentucky to provide nursing facility services. 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.
A similar facility which is not certified for Medicaid
or Medicare is called a "Nursing Home". These facilities do not
accept Medicare or Medicaid 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
There are 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
Facilities. The Alzheimer's facilities must also 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.
A few facilities are designated as “ICF” only facilities. They are licensed by
the state and provide a lower intensity nursing facility level of care.
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 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 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 a skilled
(licensed) medical person such as a registered nurse or a physical or other
professional therapist (see next section.)
Medicare will pay for 100 days of skilled care in a
nursing facility. 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-intensive 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.
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
professions.
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. 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 unit must contain at
least 200 square feet of space; a private bathroom with a tub or shower; and if
the facility serves more than 20 persons, individual thermostat controls. 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 (page 37).
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 currently does not
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 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 policies will cover care
provided by assisted living facilities, 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. A few Kentucky facilities 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 home 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 home 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 the first 20 days of coverage is at 100%. From the 21st day
through the 100th day, there is a deductible of $133.50 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 that it no longer meets these criteria, the doctor is notified. If the
physician disagrees with the facility's decision, the nursing facility can
request that 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 *$135 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 was 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, which pharmacies they can contract with and 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
$30.36 a month, and deductibles can go as high as $3,600 a year before catastrophic coverage kicks in. Medicaid-eligible
residents of nursing homes 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. However,
they 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 CMS 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. Or, they can file an exception with their drug plan
and try to persuade the plan that the drug is medically necessary and if that
fails, 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 web site at www.medicare.gov by clicking on The Prescription
Drug Plan Finder.
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 of Community Based Services, Division of
Family Support. Medicaid covers nursing facility care in a Medicaid certified
bed. Facility residents must meet the Medicaid patient need criteria for
nursing facility services.
Medicaid nursing facility coverage only begins after
the patient’s Medicare coverage is ended. Medicaid pays for skilled services
and the lower intensity intermediate care. Medicaid will also cover the
Medicare deductibles. The information which follows regarding Medicaid
eligibility 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 web site for more current information.
(http://chs.state.ky.us/dms/services/nursfac)
A. Resources
Resources are defined as: cash money and any 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 using 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 January 2009, a nursing
home 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 70.5 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 nursing home 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 nursing home 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 stating that they plan to return to the home and
estimate when that will be (number of months). The statement must be signed by
the nursing home resident. If the nursing home 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 January 2009, 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 unearned or earned.
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 Medicaid 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
they can be paid from the trust.
At the time of application, Medicaid calculates to determine
if the resident’s income is below the income guidelines. This determines both
eligibility and the amount that nursing home 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
nursing home 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 home or received community based services as an alternative to
nursing home 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
their 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 new 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 $179.51
in 2009. The period of ineligibility will begin on the date that the person
would have otherwise have 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 home 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, and who 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 home is located. You cannot apply until after the
resident is actually admitted in the facility. It is advisable to make an
appointment with county DCBS/Division of Family Support office so that you will
not have to spend as long waiting. 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 resident's home) that 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
documentary evidence 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 that the patient must
meet the criteria in at least 2 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 is that the
patient does not qualify, payment is denied and the patient is responsible for
paying the facility for care. The decision can be appealed. However, the
facility can demand payment from the nursing home 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. 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 to 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
only 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 (2) or more of care needs in the following areas:
1. intravenous,
intramuscular, or subcutaneous injections and hypodermoclysis or intravenous
feeding;
2. Nasogastric or
gastrostomy tube feedings;
3. Nasopharyngeal
and tracheotomy aspiration;
4. Recent or
complicated ostomy requiring extensive care and self-help training;
5. In-dwelling
catheter for therapeutic management of a urinary tract condition;
6. Bladder
irrigations in relation to previously indicated stipulation;
7. Special vital
signs evaluation necessary in the management of related conditions;
8. Sterile
dressings;
9. Changes in bed
position to maintain proper body alignment;
10. Treatment of
extensive decubitus ulcers or other widespread skin disorders;
11. Receiving
medication recently initiated, which requires high-intensity observation to
determine desired or adverse effects or frequent adjustment of dosage; or
12. Initial phases of
a regimen involving administration of medical gases; or
13. Receiving services
which would qualify as high-intensity rehabilitation services if provided by or
under the supervision of a qualified therapist, for example:
a. Ongoing assessment of
rehabilitation needs and potential;
b. Therapeutic exercises which
shall be performed by or under the supervision of a qualified physical
therapist;
c. Gait evaluation and training;
d. Range of motion exercises which
are part of the active treatment of a specific disease state which has resulted
in a loss of, or restriction of, mobility;
e. 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;
f. Ultrasound, short wave, and
microwave therapy treatments;
g. 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
h. 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)
(3) 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:
(a) 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;
(b) 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
(c) An individual with a stable medical condition
manifesting a significant combination of at least two (2) 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:
1. Assistance with
wheelchair;
2. Physical or
environmental management for confusion and mild agitation;
3. Must be fed;
4. Assistance with
going to bathroom or using bedpan for elimination;
5. Old colostomy
care;
6. Indwelling
catheter for dry care;
7. Changes in bed
position;
8. Administration of
stabilized dosages of medication;
9. Restorative and
supportive nursing care to maintain the individual and prevent deterioration of
his condition;
10. Administration of
injections during time licensed personnel is available;
11. 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
12. 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:
1. Minimal
assistance with activities of daily living;
2. Independent use
of mechanical devices, such as assistance in mobility by means of a wheelchair,
walker, crutch or cane;
3. A limited diet
such as low salt, low residue, reducing or another minor restrictive diet;
4. 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
Long-term care insurance policies are not all the
same. You will need to check your outline of coverage for a summary of the
benefits and exclusions in your particular policy. 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. There may be an “elimination
period.” This is the number of days you must be in a nursing home before the
benefit period begins.
Your policy will most likely require that the nursing
home services 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. Long- term care policies sold
in Kentucky cannot require that the beneficiary is hospitalized or in a higher
level of institutional care prior to payment of nursing home benefits, nor can
they 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.
The KY Department of Insurance publishes a helpful
consumer guide called Long-Term Care Insurance Guide”. Information on ordering this guide
can be found at http://doi.ppr.ky.gov/kentucky/fpubs.asp
or by calling 1-800-595-6053.
VII. VA BENEFITS
The Department of Veterans Affairs administers a
special monthly pension benefit called Aid and Attendance. The pension benefit
may be available to wartime veterans and surviving spouses who have in-home
care, or live in a nursing home or assisted-living facility.
The Aid and Attendance
(A&A) Special 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 home because of
mental or physical incapacity. Assisted care in an assisting living facility
also qualifies.
The A&A Pension can
provide up to $1,644.66 per month to a veteran, $1,056.75 per month to a
surviving spouse, or $1,949.66 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 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 benefit may be obtained
by calling 1-800-827-1000. Information is available on the Internet at http://www.va.gov/ or
from any local veterans’ service organization. Applications may be submitted
on-line at http://vabenefits.vba.va.gov/vonapp/main.asp.
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 Hansen KY 42413. The Hansen facility serves the Barren River Area
and their number is (270) 322-9087.
VIII. SELECTING A FACILITY
A. The Location
It is best to try to find a placement in a nursing
home 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 and to advocate for the resident. Each nursing
home has a "personality." If possible, it is important to match the
personality of the resident with that of the facility. For instance, a person
who lived in the country all of his life might prefer living in a facility in a
rural setting. 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. Family Councils are groups of family and friends
of nursing home residents who meet for mutual support and to advocate for
residents. The people at the meeting should be able to provide valuable
insights into the home's good and bad points.
Even after a careful inspection of a nursing home, you
may have questions. Please feel free to contact the Ombudsman for information.
The Ombudsman's name and telephone number are posted in the nursing home.
C. Quality of Life issues
Researchers have found eleven
areas that define quality of life for nursing home residents. Quality of life
includes: the ability to make choices and maintain independence, to express
individuality, to be involved in meaningful activities, to maintain
relationships with family and friends, to get what is needed when it is needed,
to have privacy and confidentiality respected, to be treated with dignity and
respect, to feel comfortable, safe and secure, to maintain a sense of spiritual
well-being and the ability to find enjoyment. When evaluating a long-term care
facility, consider each of these things. Consider how the resident will be
able to maintain their normal activities and routines and how the nursing home
will accommodate the resident’s individual needs. Consider the areas of the
facility besides the resident’s room that will be accessible to the resident. 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
now features a system that assigns each nursing home 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 nursing home (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.
There are many quality factors that this rating system does not take into
account. Consumers should not rely on this rating alone.
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 Facilities and Services. 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
maintains a web site 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 Facilities and Services, 275 East Main Street, Frankfort KY 40821.
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 provide 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 Center for Medicare Services (CMS) also posts on
its website 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 homes 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 nursing homes 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 nursing home 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. Like many other states, Kentucky does not require
staffing ratios, although a bill suggesting such a requirement has been offered
to the state legislature almost every year. Both federal and state regulations
do require facilities to have sufficient staff to meet the needs of the residents.
Nursing homes must have at least one RN for at least 8 straight hours a day, 7
days a week and either an RN or LPN/LVN on duty 24 hours per day.
However, in order for investigators to find that a
facility’s staffing is inadequate, they must find 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.
All nursing homes that participate in Medicare and
Medicaid are required to post information that residents and visitors can read about
the staffing at 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 home must do the following:
·
Post how many
registered nurses, licensed practical nurses, and certified nurse aides giving direct
care are available on each shift.
·
Post the number
of residents living at the facility.
·
Post this
information in a clear and readable format in a prominent place that is readily
accessible to residents and visitors.
·
Provide a copy
of the posting to family members and other visitors. The facility can charge
for the copies they make.
Facilities are required to post this information for
the entire facility and 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.
Information regarding the staffing levels of
particular nursing homes is also available on the Medicare web site at www.medicare.gov. These numbers are also
based on information provided by the nursing home and are likewise not checked
for accuracy. During the survey process, each nursing home 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 home 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 wk).
In addition to the above, the recommendation endorses
the following minimum ratio of direct care-givers be present:
·
Licensed
Practical Nurses to include RNs, LPNs, or LVNs at a ratio of 1:15 during the
Day, 1:50 in the evening, and 1:35 at night, plus,
·
Direct
care-givers to include RNs, LPs, LVN's, 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 home
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 nursing home and the resident. The
agreements made in this contract are significant because these agreements outline
the services the facility provides, the rights and responsibilities of the
resident, and the charges for care. This is a legal document. Therefore, it
is crucial that you read and understand this document before signing it. Remember
that 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 home 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 nursing homes, 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. Each resident must also receive information about the
existence of the Ombudsman Program. 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. The Long Term Care
Ombudsman can also provide information about these legal rights. A list of
these rights are listed on page 33.
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, because they are afraid of
fire. And these fears are real. The media has covered several nursing home
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 nursing homes 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 a 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
homes 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
residents’ 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 whose 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. If you chose to sign 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. Nursing
homes 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 and/or to express
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 not to 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
and 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;
·
The right to be
notified in advance of any plans to change their room or roommate;
·
The right to
daily communication in their language;
·
The right to
assistance if they have a sensory impairment;
·
The right to participate
in their own care, including:
·
The right to
receive adequate or appropriate care;
·
The right to be
informed of any changes in their medical condition;
·
The right to
participate in planning their treatment, care, and discharge;
·
The right to
refuse medication and treatment;
·
The right to
refuse chemical and physical restraints;
·
The right to
review their medical record;
·
The right to make
independent choices, including:
·
The right to
make independent personal decisions, such as what to wear and how to spend free
time;
·
The right to
reasonable accommodation of their needs and preferences by the nursing home;
·
The right to
choose their own physician;
·
The right to
participate in community activities, both inside and outside the nursing home;
·
The right to
organize and participate in a Resident Council;
·
The right to privacy
and confidentiality, including:
·
The right to
private and unrestricted communication with any person of their choice;
·
The right to
privacy in treatment and in the care of their personal needs;
·
The right to
confidentiality regarding their medical, personal, or financial affairs;
·
The right to dignity,
respect, and freedom, including:
·
The right to be
treated with the fullest measure of consideration, respect, and dignity;
·
The right to be
free from mental and physical abuse, corporal punishment, involuntary
seclusion, and physical and chemical restraints;
·
The right to
self-determination;
·
The right to security
of possessions, including:
·
The right to
manage their own financial affairs;
·
The right to
file a complaint with the state survey and certification agency for abuse,
neglect, or misappropriation of their property if the nursing home is handling
their financial affairs;
·
The right to be
free from charge for services covered by Medicaid or Medicare;
·
Rights during
transfers and discharges, including:
·
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; is 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.
·
The right to
receive notice of transfer or discharge. A thirty-day notice is required. 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;
·
The right to a
safe transfer or discharge through sufficient preparation by the nursing home;
·
The right to complain,
including:
·
The right to
present grievances to the staff of the nursing home, 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, including:
·
The right to be
informed of all services available as well as the charge for each service;
·
The 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.
I HAVE HEARD
THAT A LOT OF THINGS GET STOLEN IN NURSING HOMES, DOESN’T THE FACILITY HAVE TO
KEEP MY POSSESSIONS SAFE?
Loss and theft of personal items is the most common
problem in nursing homes. Missing items may include clothing, dentures,
eyeglasses, radios, televisions, money, food and similar possessions. Loss of a
personal possession is always upsetting. For nursing home residents, it adds to
feelings of insecurity, loss of dignity and self-worth which may exist for
other reasons. Nursing homes should . . .
ü
Allow residents to keep and use
personal clothing and possessions unless doing so would
endanger others.
ü
Provide reasonable space for
storing personal possessions.
ü
Inventory clothing and personal
items and mark with the residents name.
ü
Individually store the clothing
of each resident.
ü
Provide a place for the
safekeeping of personal possessions and money.
ü
Take reasonable and prudent
precautions to prevent property losses.
ü
Thoroughly investigate reports of
losses.
ü
Assist residents in filing police
reports of losses.
ü
Replace items lost because the
facility failed to take reasonable precautions.
======================================================================
Information provided by the
South Central KY Area Health Education Center
Promoting the CommonHealth
throughout the CommonWealth
XII.
IMPORTANT WEB SITES 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, 1-800-999-7608, TDY/TDD 1-800-486-2048. 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 “Compare
Nursing Homes in Your Area” at www.medicare.gov/NHCompare.
Department for Community Based Services/Division of Family
Support offices:
Processes Applications for Medicaid.
