medicare guide to choosing a nursing home 2011.pdf

7/29/2019 Medicare Guide to Choosing a Nursing Home 2011.pdf

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This ocial government booklet explains:

How to fnd and compare nursing homes

How to pay or nursing home care

Your nursing home resident rights

Alternatives to nursing home care

Use the handy checklist to compare nursing homes.
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Te Guide to Choosing a Nursing Home is prepared by the Centers or Medicare &Medicaid Services (CMS). CMS and states oversee the quality o nursing homes. Stateand Federal government agencies certiy nursing homes to participate in Medicare andMedicaid.

Te Guide to Choosing a Nursing Home isnt a legal document. Ocial Medicare andMedicaid Program legal guidance is contained in the relevant statutes, regulations, andrulings.

Te inormation in this booklet was correct when it was printed. Changes may occur aerprinting. Call 1-800-MEDICARE (1-800-633-4227), or visit www.medicare.govto get themost current inormation. Y users should call 1-877-486-2048.
http://www.medicare.gov/http://www.medicare.gov/


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Contents

SECTION 1: WelcomeBeore you get startedI youre helping another personI you have MedicareHow to use this bookletWhere to get help with your questions

SECTION 2: Choosing the Type o Care You Need

Agencies that can help with long-term care choicesAlternative long-term care choices

SECTION 3: Steps to Choosing a Nursing Home

Step 1: Find out about nursing homes in your area.Step 2: Compare the quality o the nursing homes youre considering.Step 3: Visit the nursing homes youre interested in, or have someone visit or you.Step 4: Choose the nursing home that meets your needs.

SECTION 4: Paying or Nursing Home Care and Other Health Care Costs

OverviewPersonal resources

Help rom your state (Medicaid)Long-term care insuranceNewTe Community Living Assistance Services and Supports (CLASS) ProgramMedicare or your health care and prescription drugs

SECTION 5: Living in the Nursing Home

Care plansReporting and resolving problemsYour resident rights and protections

SECTION 6: For More Inormation

Free booklets on Medicare, Medicaid, and related topicsFor inormation on specic questions and diseasesImportant phone numbers

SECTION 7: Denitions

SECTION 8: Index
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4

Its helpul to plan ahead, consider all your long-term care options, and make good

nancial plans early.


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SECTION 1: WelcomeTe Guide to Choosing a Nursing Home is designed to help you make inormeddecisions about nursing home care, whether youre planning ahead or need to make anunexpected decision. Its helpul to plan ahead, consider all your long-term care options,and make good nancial plans early.

Beore you get started

You may have other long-term care options, like community services, home care, orassisted living, depending on your needs and resources. Its also possible you may be

eligible or home and community-based services covered by Medicaid. Beore choosinga nursing home, you can check to see i one o these other options is available to you ori they might help aer a nursing home stay. Tese and other long-term care choices areexplained briey in Section 2.

Not all nursing homes are certied to participate in Medicare or Medicaid. See moreinormation on how these programs protect nursing home residents.

I youre helping another person

Helping another person choose a nursing home or make other long-term care choices canbe dicult. Your support is important and can help your loved one adjust to getting newservices or living in a new place like a nursing home. Be sure to include the person yourehelping in decisions whenever possible. Always make decisions with his or her needs andpreerences in mind.

I you have Medicare

Medicare generally doesnt cover long-term stays (room and board) in a nursing home.See Section 4 or more inormation.
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6 Welcome

How to use this booklet

Is a nursing home your only choice?

Section 2 explains some o the long-term care choices that may be available to youdepending on your needs and resources.

Do you need to nd a nursing home?

Section 3 outlines steps to nd and compare nursing homes and explains where to getanswers to your questions. ake the handy tear-out checklist with you when you visitnursing homes.

Once youve chosen a nursing home, whats next?

Section 3 tells you what inormation you need to have when you make your arrangements

to enter a nursing home.

How do you pay or nursing home and other health care?

Section 4 explains how to pay or nursing home and other health care, including personalresources, help rom your state, Medicaid, long-term care insurance, and Medicare.

What do you need to know about living in a nursing home?

Section 5 explains how to make the transition rom living at home to living in a nursinghome easier, how to resolve problems, how your nursing home care is planned, and your

resident rights and protections.Where can you get more inormation?

Section 6 tells you how to get ree Medicare booklets, inormation about specic healthconditions and diseases, and important phone numbers o organizations that can helpanswer your questions.

What do the highlighted words mean?

Section 7 denes the words highlighted throughout this booklet.

How can you nd specic inormation in this booklet?Section 8 is an index (alphabetical list) o whats in this booklet and the page number(s)where you can nd specic topics.


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Welcome

Where to get help with your questions

Administration on Aging (AoA)

Te AoA is a Federal agency that can give you a list o the long-term care choices in yourstate including community services. Tey can also help you nd nursing homes. Visitwww.aoa.govor call 1-202-619-0724.

Centers or Medicare & Medicaid Services (CMS)

CMS has ree booklets about Medicare and Medicaid coverage, home and community-based services, and other health related topics. [more ino]

For inormation about the location and quality o nursing homes, visit www.medicare.gov/NHCompare. You can also call 1-800-MEDICARE (1-800-633-4227). Tis is a 24-

hour helpline. Y users should call 1-877-486-2048.

Eldercare Locator

Te Eldercare Locator is a nationwide toll-ree service to help older adults and theircaregivers nd local services. Visit www.eldercare.govor call 1-800-677-1116 (weekdays9:00 a.m. to 8:00 p.m. ES).

Long-Term Care Ombudsman

ALong-erm Care Ombudsman advocates or residents o nursing homes, board and

care homes, and assisted living acilities. [State phone numbers]Quality Improvement Organization (QIO)

A QIO is a group o practicing doctors and other health care experts paid by the Federalgovernment to check and improve the care given to people with Medicare. o get thephone number or your QIO, visit www.medicare.gov/contacts or call 1-800-MEDICARE.

State Health Insurance Assistance Program (SHIP)

State Health Insurance Assistance Programs (SHIPs) are state programs. Tey get moneyrom the Federal government to give ree health insurance counseling to people with

Medicare. Call them with questions about Medicare, insurance and health plan decisions,and your rights. [State phone numbers].
http://www.aoa.gov/http://-/?-http://www.medicare.gov/NHComparehttp://www.medicare.gov/NHComparehttp://www.eldercare.gov/http://www.medicare.gov/contactshttp://www.medicare.gov/contactshttp://www.eldercare.gov/http://www.medicare.gov/NHComparehttp://www.medicare.gov/NHComparehttp://-/?-http://www.aoa.gov/


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8 Welcome

State Medical Assistance (Medicaid) Oce

Your State Medical Assistance (Medicaid) oce has inormation about state programs

that help pay health and nursing home costs or people with limited incomes andresources. [State phone numbers]

State Survey Agency

Your State Survey Agency can help with questions or complaints about the quality o careor the quality o lie in a nursing home. [State phone numbers]


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9

SECTION 2: Choosing the Type o Care

You NeedDepending on your needs and resources, you may have other long-term care optionsavailable to you. For example, you may be able to get the services and support you need inyour own home or in other types o community housing. I youre in a hospital, nursinghome, or working with a home health agency (HHA), one o the ollowing can explainyour options and help arrange your care: a discharge planner, a social worker, or arepresentative rom a local contact agency or community living.

Each state and community has diferent services and options. Te agencies listed below

can give you more inormation. [more ino about alternative long-term care choices].American Indian/Alaska Natives can contact their local Indian health provider or moreinormation.

Agencies that can help with long-term care choices

Area Agencies on Aging (AAAs)

AAAs assist adults age 50 and older and their caregivers. o nd the AAA in your area,visit www.eldercare.govor call Te Eldercare Locator at 1-800-677-1116 weekdays rom

9:00 a.m. to 8:00 p.m. (ES).

Aging and Disability Resource Centers (ADRCs)

ADRCs assist people o all incomes and ages. Forty-nine states and some territories haveADRCs. o nd out i your area is served by an ADRC, visit www.adrc-tae.org.

Centers or Independent Living (CILs)

CILs assist people with disabilities o all incomes and ages. A state-by-state directory oCILs can be ound by visiting www.ncil.org/directory.html.

State Technology Assistance ProjectTe State echnology Assistance Project has inormation on medical equipment andother assistive technology. Visit www.resna.org or call the Rehabilitation Engineeringand Assistive echnology Society o North America (RESNA) at 1-703-524-6686 to getthe contact inormation or your state.
http://www.eldercare.gov/http://www.adrc-tae.org/http://www.ncil.org/directory.htmlhttp://www.resna.org/http://www.resna.org/http://www.ncil.org/directory.htmlhttp://www.adrc-tae.org/http://www.eldercare.gov/


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0 Choosing the Type of Care You Need

State Medical Assistance (Medicaid) Oce

Your State Medical Assistance (Medicaid) oce has inormation about state programs

that help pay health and nursing home costs, as well as services in the community, orpeople with low incomes and limited resources. [State phone numbers]

Alternative long-term care choices

Listed below are some o the more common kinds o long-term care. alk to your amily,your doctor or other health care provider, or a social worker or help deciding what kindo long-term care you need.

Note: I you have limited income and resources, there may be state programs that help

cover some o your costs in some o the long-term care choices mentioned here. Call yourState Medical Assistance (Medicaid) oce or more inormation. [State phone numbers]

Community services: A variety o community services might help with your personalcare and activities, i these services arent covered by your health insurance. Someservices, like volunteer groups that help with things like shopping or transportation,may be low cost or the group may ask or a voluntary donation. Some services may beavailable at varied costs, depending on where you live and the services you need. Below isa list o home services and programs that are ound in many communities:

Adult day care

Meal programs (like Meals-on-Wheels)

Senior centers

Friendly visitor programs

Help with shopping and transportation

Help with legal questions, bill paying, or other nancial matters


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For inormation about community services, call your local Area Agency on Aging, Agingand Disability Resource Center, or Center or Independent Living. [more ino]

Home Care: Depending on your needs, you may be able to get help with your personalcare activities (such as laundry, shopping, cooking, and cleaning) at home rom amilymembers, riends, or volunteer groups. I you think you need home care, talk to youramily to see i they can help with your care or help arrange or other care providers.Tere are also some home health care agencies that can help with nursing or attendantcare in your home. I youre eligible or Medicaid, personal care services in your homemay be covered.

Remember, Medicare only pays or home health care i you meet certain conditions. oget a ree copy o the Medicare booklet Medicare and Home Health Care, go here.

Accessory dwelling units (ADUs): I you or a loved one owns a single-amily home,adding an ADU to an existing home may help you keep your independence. An ADU,sometimes called an in-law apartment, an accessory apartment, or a second unit, isa second living space within a home or on a lot. It has a separate living and sleeping area,a place to cook, and a bathroom. Space such as an upper oor, basement, attic, or spaceover a garage may be turned into an ADU. Family members might be interested in livingin an ADU in your home, or, you may want to build a separate living space at a amilymembers home.

Check with your local zoning oce to be sure ADUs are allowed in your area and ndout i there are special rules. Te cost or an ADU can vary widely depending on how bigit is and how much it costs or building materials and workers.

Subsidized senior housing: Tere are state and Federal programs that help pay orhousing or some older people with low to moderate incomes. Some o these housingprograms also ofer help with meals and other activities, such as housekeeping, shopping,and doing the laundry. Residents usually live in their own apartments within anapartment building. Rent payments are usually a percentage o your income (based on a

sliding scale).
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Board and care homes: Board and care homes are group living arrangements designedto meet the needs o people who cant live independently but dont need nursing homeservices. Most board and care homes provide help with some o the activities o dailyliving, such as bathing, dressing, and using the bathroom. Board and care homes aresometimes called group homes. Many o these homes arent paid or byMedicare orMedicaid. Te monthly charge is usually a percentage o your income (based on a slidingscale) that covers the cost o rent, meals, and other basic shared services.

Assisted living acilities: Tese acilities vary rom state to state, but generally theyprovide help with activities o daily living, such as bathing, dressing, and using thebathroom. Tey may also help with care most people do themselves, like taking medicineor using eye drops, and additional services, like getting to appointments or preparing

meals.

Residents oen live in their own room or apartment within a building or group obuildings and have some or all o their meals together. Social and recreational activitiesare usually provided. Some o these acilities have health services on site.

In most cases, assisted living residents pay a regular monthly rent and pay additional eesor the services they get. Assisted living acilities arent paid or byMedicare. Te termassisted living may mean diferent things in diferent acilities within the same state.Not all assisted living acilities provide the same services. Its important that you contact

the acility and make sure they can meet your needs.

Continuing Care Retirement Communities (CCRCs): CCRCs are retirementcommunities that ofer more than one kind o housing and diferent levels o care. In thesame community, there may be individual homes or apartments or residents who stilllive on their own, an assisted living acility or people who need some help with dailycare, and a nursing home or those who require higher levels o care.

Residents move rom one level to another based on their individual needs, but usuallystay within the CCRC. I youre considering a CCRC, be sure to check the quality

inormation [more ino] and inspection report (posted in the acility) o its nursinghome. Your CCRC contract usually requires you to use the CCRCs nursing home i youneed nursing home care. Some CCRCs will only admit people into their nursing home ithey are already living in another section o the retirement community.


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Many CCRCs generally require a large payment beore you move in (called an entry ee)and charge monthly ees. o nd out i a CCRC is accredited and get advice on selectingthis type o community rom the Commission on Accreditation o RehabilitationFacilities and the Continuing Care Accreditation Commission (CARF-CCAC), visitwww.car.org or call 1-202-587-5001.

Hospice care: Hospice is a special way o caring or people who are terminally ill(expected to have 6 months or less to live) and or their amilies. Hospice care includesphysical care and counseling. Te goal o hospice is to provide comort or terminalpatients and their amilies, not to cure the illness.

I you qualiy or hospice care and you choose hospice, you can get medical and supportservices, including nursing care, medical social services, doctor services, counseling,homemaker services, and other types o services. As part o hospice care, you will havea team o doctors, nurses, home health aides, social workers, counselors, and trained

volunteers to help you and your amily cope with your illness. In many cases, you andyour amily can stay together in your home.

Medicare covers hospice care i you qualiy. Depending on your condition, you may gethospice care at home, in a hospice acility, hospital, or nursing home. Medicare doesntcover room and board i you get general hospice services while youre a resident o anursing home or a hospices residential acility. I youre eligible, Medicaid may pay or

some services that Medicare doesnt cover, such as personal care assistance at home.Medicare doesnt pay or 24-hour assistance i you get hospice services at home.

Respite care: Some nursing homes and hospice care acilities provide respite care. Respitecare is a very short inpatient stay in a nursing home or hospice care acility or a hospicepatient so that the usual caregiver can rest. Medicare covers inpatient respite care or upto 5 days i youre getting covered hospice care services. Room and board are covered orinpatient respite care and during short-term hospital stays. I youre eligible, Medicaidwill pay or some o these services at home that arent covered by Medicare.

For more inormation about Medicare coverage o hospice care and who qualies, get aree copy o the booklet Medicare Hospice Benets. [more ino]
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Programs o All-inclusive Care or the Elderly (PACE): PACE is a Medicare andMedicaid Program that manages all o the medical, social, and long-term care servicesor older people with multiple care needs. It allows people to remain in their homes andmaintain their quality o lie. PACE is available only in states that have chosen to oferit under Medicaid. Te goal o PACE is to help people stay independent and living intheir community as long as possible, while getting the high quality care they need. o beeligible or PACE, you must meet the ollowing conditions:

Be 55 or older

Live in the service area o a PACE program

Be certied as eligible or nursing home care by the appropriate state agency

Be able to live saely in the community

o nd out i there is a PACE program in your area, visitwww.cms.hhs.gov/PACE or call your State Medical Assistance (Medicaid) oce. [Statephone numbers]

Home and Community-Based Waiver Programs: I youre already eligible or Medicaid(or, in some states, would be specically eligible or Medicaid coverage or nursing homeservices), you may be able to get help with the costs o some home and community-basedservices, like homemaker services, personal care, and respite care. States have home and

community-based waiver programs to help people keep their independence while gettingthe care they need outside o an inpatient acility.

For more inormation, call the Area Agency on Aging or the Eldercare Locator [moreino] , or your State Medical Assistance (Medicaid) oce. [State phone numbers]
http://www.cms.hhs.gov/PACEhttp://www.cms.hhs.gov/PACE


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5

SECTION 3: Steps to Choosing a Nursing

HomeFollow these steps to nd the nursing home that meets your

needs:

Step 1: Find nursing homes in your area. See below.

Step 2: Compare the quality o nursing homes youre considering. [more ino]

Step 3: Visit the nursing homes youre interested in, or have someone visit or you.[more ino]

Step 4: Choose the nursing home that meets your needs. See [more ino]

Step 1: Find out about nursing homes in your area.

Learn about the nursing homes in your area by ollowing these tips:

Ask people you trust, like your amily, riends, neighbors, or clergy i they have hadpersonal experience with nursing homes. Tey may be able to recommend a nursinghome to you.

Ask your doctor i he or she provides care at any local nursing homes. I so, ask whichnursing homes he or she visits so you may continue to see your doctor while youre inthe nursing home.

Visit the Eldercare Locator at www.eldercare.govor call 1-800-677-1116 or moreinormation on long-term care choices in your area. You can also contact your localAgency on Aging or Senior & Community Activity Center.

I youre in the hospital, ask your nurse about discharge planning as early in your

hospital stay as possible. Te hospitals staf should be able to help you nd a nursinghome that meets your needs and help with your transer beore your hospital discharge.

I you or someone you know has access to the Internet, visit Medicares Nursing HomeCompare at www.medicare.gov/NHCompare to help you nd and compare nursinghomes in your area. You can search by nursing home name, city, county, state, or ZIPcode. Your local library may be able to help you nd the inormation on Nursing HomeCompare i you dont have access to the Internet. You can also call 1-800-MEDICARE(1-800-633-4227) to ask or a printed copy o Nursing Home Comparison be mailed to

you. Y users should call 1-877-486-2048.
http://www.eldercare.gov/http://www.medicare.gov/NHComparehttp://www.medicare.gov/NHComparehttp://www.eldercare.gov/


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6 Steps to Choosing a Nursing Home

Step 2: Compare the quality o the nursing homes youre

considering.

Its important to compare the care that nursing homes give in order to nd the nursing

home that meets your needs. I you or someone you know has Internet access, you cancompare nursing home quality on Nursing Home Compare at www.medicare.gov/NHCompare. Nursing Home Compare has inormation about certied Medicare andMedicaid nursing homes. Maps and directions to nursing homes are also available.

On Nursing Home Compare, you can compare the nursing homes youre considering bythe ollowing:

Te Five Star Quality Rating

Detailed inormation on health inspections

Nursing home stang

Quality measures

Fire saety inspections

Note: Inormation on Nursing Home Compare isnt an endorsement or advertisement orany nursing home. You may want to use a variety o resources when choosing a nursinghome. Dont rely only on the nursing homes star rating to make a nal decision. Visit thenursing homes youre considering, i possible, or have someone visit or you.

Tese ratings are combined or an overall quality rating. Inormation about re saetyinspections is included on Nursing Home Compare to give you more inormation about anursing homes overall quality.

Five Star Quality Rating System

Te Five Star Quality Rating System on Nursing Home Compare is designed to:

Give an overall picture o nursing homes so you can see meaningul diferencesbetween high- and low-perorming nursing homes

Give you easy-to-use inormation to help you choose a nursing home or yoursel orothers

Give you inormation about the care in nursing homes where you or a amily membermay already live

Guide you in talking to nursing home staf about the quality o care
http://www.medicare.gov/NHComparehttp://www.medicare.gov/NHComparehttp://www.medicare.gov/NHComparehttp://www.medicare.gov/NHCompare


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Health inspections

o be a certied provider under Medicare and/or Medicaid, nursing homes have to meetmore than 150 regulations that Congress has set to protect nursing home residents. Teseregulations cover a wide range o topics, rom protecting residents rom physical ormental abuse and inadequate care to the sae storage and preparation o ood.

Note: Not all nursing homes are certied to participate in Medicare or Medicaid.Remember to ask whether the nursing home youre visiting participates in one or both othese programs.

Te Centers or Medicare & Medicaid Services (CMS) has contracts with stategovernments to do health and re saety inspections o these certied nursing homes andinvestigate complaints about nursing home care. Te health inspection team consists otrained surveyors, including at least one registered nurse. Tese inspections take place, onaverage, about once a year, but may be done more oen i the nursing home is perormingpoorly.

Using the Federal regulations, the state inspection team looks at many aspects o lie inthe nursing home including the ollowing:

Te residents care and how care is given by the staf

How the staf talks to and treats the residents

Te activities and daily lie o the residents

Te condition o resident rooms and the cleanliness, sanitation, and maintenance o thenursing home

In order to do this, the surveyors review the residents clinical records, interviewresidents about their lie in the nursing home, interview amily members about the caretheir loved one gets, and interview staf, such as nursing aides, activities staf, dietarystaf, and administrative staf.

You can use health survey inormation on Nursing Home Compare to see what healthand saety regulations a nursing home ailed to meet during recent health surveys.


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Nursing home stang

Federal law requires all Medicare and/or Medicaid-certied nursing homes provide

enough staf to provide care or each resident based on their needs, but there is no currentFederal standard or the best stang levels.

Te Medicare and/or Medicaid-certied nursing home must have at least one licensedRegistered Nurse (RN) or at least 8 hours per day, 7 days a week, and other nursing staf,such as an RN or Licensed Practical Nurse/Licensed Vocational Nurse (LPN/LVN), onduty 24 hours per day. Certain states may have additional stang requirements. CertiedNursing Assistants (CNAs) are generally on staf 24 hours per day. Tey work underthe supervision o a licensed nurse to help residents with daily activities, such as eating,bathing, and dressing. All CNAs must complete a competency evaluation program or a

nurse assistant training within 4 months o their permanent employment. Tey must alsotake continuing education training each year.

Some nursing homes may require more staf due to the specic conditions o theirresidents, along with other actors such as whether the nursing home has special careunits. Look at the Nursing Home Checklist or questions or observations about stangthat can help you evaluate the nursing homes you visit.

Te stang numbers on Nursing Home Compare are based on inormation reportedby the nursing home or a 2-week period prior to the time o the state inspection. Tis

stang inormation is checked only or unusual reporting issues. Its important or youto check out the stang when youre visiting the nursing home.
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Quality measures

Nursing homes regularly collect certain inormation about the health, physical

unctioning, mental status, and general well-being o residents, using a screening toolcalled the Minimum Data Set (or MDS). Nursing homes are required to completethe MDS on each nursing home resident on admission and whenever the residentscondition changes. Te inormation rom the MDS is collected electronically by CMSor each person living in a certied nursing home in the country. CMS uses some o theMDS inormation to measure the quality o certain aspects o nursing home care, such aswhether residents have developed a pressure ulcer, are in pain, or are losing weight. Tesemeasures are called quality measures.

Te quality measures on Nursing Home Compare are based on the best research

currently available. As this research continues, scientists will keep improving the qualitymeasures used on Nursing Home Compare. However, CMS doesnt set benchmarks,thresholds, guidelines, or standards o care or Medicare and/or Medicaid-certiednursing homes. Te quality measures are based on care provided to the population oresidents in a acility, not to any individual resident. Te quality measures were chosenbecause they show important ways nursing homes difer rom one another.

Fire saety inspections

Fire saety specialists inspect nursing homes to see i they meet Lie Saety Code

(LSC) standards. Te LSC is a set o re protection requirements designed to provide areasonable degree o saety rom re.

Te re saety inspection covers a wide range o aspects o re protection, includingconstruction, protection, and operational eatures designed to provide saety rom re,smoke, and panic. When an inspection team nds that a nursing home doesnt meet aspecic LSC regulation, it issues a deciency citation.

You can use the inormation about re saety inspections on Nursing Home Compare tosee what re saety standards a nursing home ailed to meet, the level o potential harm,

the number o residents this afected, and the date o correction.

Important: While comparing nursing homes, you may want to contact the nursing hometo nd out about their sprinkler system.


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Other ways to nd out about nursing home quality

Call your Long-erm Care Ombudsman. [State phone numbers] Te Ombudsman

program helps nursing home residents solve problems by acting on their behal.Long-erm Care Ombudsmen:

Visit nursing homes and speak with residents throughout the year to make sureresidents rights are protected

Work to solve problems with your nursing home care, including nancial issues

Discuss general inormation about nursing homes and nursing home care

Help you compare a nursing homes strengths and weaknesses

Answer questions, such as how many complaints they have gotten about a specic

nursing home, what kind o complaints they were, and i the issues were resolvedin a timely manner

Call the local oce o consumer afairs or your state (look in the blue pages in thephone book). Ask i they have written inormation on the quality o care given in localnursing homes.

Call your state health department or state licensing agency (look in the blue pages in thephone book). Ask i they have written inormation on the quality o care given in localnursing homes.

Resident-directed care and the culture change movement

Tere is a growing, nationwide movement among many nursing homes to change thenursing home culture rom rigid institutional living to living in a setting more like ahome. Nursing homes involved in this culture change practice resident-directed orresident-centered care which promotes greater resident choice over their schedules (suchas getting up, going to sleep, method and timing o bathing) and their activities. It alsoinvolves changes to the building environment to enhance the residents quality o lie.

Many homes involved in this culture change have households within their ormerliving units, which include small groups o residents (usually less than 20). Tis group oresidents has the same staf assigned to them and has activities and meals together. Eachhousehold has a kitchen, dining room, and living room space.


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A small number o nursing homes have sets o ree-standing houses on-campus thatcontain approximately 1012 residents, each with private rooms and settings much morelike that o a large, private home. Other homes have remodeled their buildings to includemore private rooms and a new style o privacy-enhanced, shared rooms which have apartial wall separating each residents hal o a room.

Whether in small houses or households in larger buildings, assigning the same staf onmost days lets the nursing home staf and residents orm close relationships. Tis way,staf can more ully meet residents needs and preerences and help them reach theirhighest level o well-being and unctioning. Some homes have been unable to remodelinto households but have embraced the principles o culture change by assigning thesame staf to residents and giving residents much greater resident choice in their daily

lives.

Oen culture changing homes have resident dogs and cats and some let a resident bringin his or her own pet (with staf or volunteers assisting the resident with pet care). Otherhomes have connections to a day care setting in which elders and children interactregularly. For more inormation on resident-directed care and the culture changemovement, look at Web sites or culture change, such as Pioneer Network, a non-protorganization at www.pioneernetwork.net .

Facility quality assurance and quality improvement campaigns

All nursing homes are required to have a committee to review any issues o concernwith the quality o care and quality o lie o residents. Te committees must alsoaddress and correct these issues on an ongoing basis using principles o continuousquality improvement. Also, many nursing homes are currently participating in publicquality improvement campaigns. Knowing that a nursing home participates in one maybe a good indicator o the homes commitment to improving quality. One example oa quality improvement campaign is the Advancing Excellence in Americas NursingHomes, a coalition-based campaign to improve the quality o lie or residents and

staf in Americas nursing homes. Tis particular campaign includes long-term careproviders, caregivers, medical and quality improvement experts, consumers, governmentagencies, and other quality-ocused organizations. For more inormation, visit www.nhqualitycampaign.org.

Visit Nursing Home Compare at www.medicare.gov/NHCompare or moreinormation.
http://www.pioneernetwork.net/http://www.nhqualitycampaign.org/http://www.nhqualitycampaign.org/http://www.medicare.gov/NHComparehttp://www.medicare.gov/NHComparehttp://www.nhqualitycampaign.org/http://www.nhqualitycampaign.org/http://www.pioneernetwork.net/


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Step 3: Visit the nursing homes youre interested in, or have

someone visit or you.

Beore you visit any nursing homes, consider whats important to you and think aboutthe ollowing questions:

Quality o lie

Will I be treated in a respectul way?

Can I participate in social, recreational, religious, or cultural activities that areimportant to me? Can I decide when I want to participate?

Do I get to choose what time to get up, go to sleep, or bathe?

Can I get ood and drinks that I like at any time? What i I dont like the ood that isserved?

Can I have visitors at any time?

Is transportation provided to community activities?

Can I bring my pet or can my pet visit?

Can I decorate my living space any way I want?

Will I have privacy when I have visitors or personal care services?

Would I be able to leave the acility or a ew hours or days i I choose to do so?


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Quality o care

Whats a plan o care and what does it look like?

Who makes the plan o care and how do they know what I want, need, or what shouldbe in the plan?

Will I be included in planning my care?

Will my interests and preerences be included in the care plan?

Will I be able to change the plan i I eel there is a need?

Will I be able to choose which o my amily members or riends will be involved in theplanning process?

Will I get a copy o my care plan?

Is there enough staf to give me the care I need?

Who are the doctors that will care or me? Can I still see my personal doctors? Whowill help me arrange transportation i I choose to continue to see my personal doctorsand they dont visit the nursing home?

Who will give me the care I need?

I a resident has a problem with conusion and wanders, how does the staf handle thistype o behavior in the acility to protect the resident?

Does the nursing homes inspection report show quality o care problems (deciencies)? What did the quality inormation on Nursing Home Compare at www.medicare.gov/

NHCompare show about how well this nursing home cares or its residents?

Location

Is the nursing home close to my amily and riends so they can visit oen?

Availability

Is a bed available now or can I add my name to a waiting list?

Note: Nursing homes dont have to accept all applicants, but they must comply withlocal, state, and Federal civil rights laws that prohibit discrimination.
http://www.medicare.gov/NHComparehttp://www.medicare.gov/NHComparehttp://www.medicare.gov/NHComparehttp://www.medicare.gov/NHCompare


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Stang

Will I have the same staf people take care o me rom day to day or do they change?

Does the nursing home post required inormation about the number o licensed andunlicensed nursing staf? Are they willing to show me i I ask to see it?

How many residents is a Certied Nursing Assistant (CNA) assigned to work withduring each shi (day and night) and during meals?

I I have a medical need, will the staf contact my doctor or me?

What type o therapy is available at this acility? Is therapy staf available?

Is there a social worker available? Can I meet him or her?

Religious and Cultural Preerences Does the nursing home ofer the religious or cultural support I need? I not, what type

o arrangements will they provide to meet my needs?

Do they provide special diet options that my aith practice may require?

Language

Is my primary language spoken by staf that will work directly with me and ellowresidents?

I not, is an interpreter available or another system in place to help me communicate myneeds?

Policies

Are there resident policies I must ollow?

Will I get a written copy o these policies?

Note: Policies are rules that all residents must ollow. For example, smoking may not beallowed in the nursing home.


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Security

Does the nursing home provide a sae environment?

Will my personal belongings be secure in my room? Is the nursing home locked at night?

Preventive care

Does the nursing home make sure residents get preventive care to help keep themhealthy? Are specialists, like eye doctors, ear doctors, dentists, and podiatrists, availableto see residents on a regular basis? Does the acility help make arrangement to see thesespecialists?

Does the nursing home have a screening program or vaccinations, such as u(inuenza) and pneumonia?

Hospitals

Does the nursing home have an arrangement with a nearby hospital or emergencies?

Can my doctor care or me at that hospital?

Licensing

Are the nursing home and current administrator licensed in my state?

Note: Tis means nursing homes have met certain standards set by a state or localgovernment agency.

Certication (certied)

Is the nursing home Medicare and/or Medicaid-certied?

Note: Certied means the nursing home meets Medicare and/or Medicaid regulationsand the nursing home has passed an inspection survey done by the State Survey Agency.

I theyre certied, make sure they havent recently lost their certication or are about tolose their certication. Also, some nursing homes may only have a certain part o theirbuilding or Medicare or Medicaid residents.


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Services

What services does the nursing home provide? Does the nursing home have the services

I need?

Charges and ees

Will the nursing home tell me in writing about their services, charges, and ees beore Imove into the home.

Note:Medicare and/or Medicaid-certied nursing homes must tell you thisinormation in writing. Get a copy o the ee schedule to nd out which services areavailable, which are included in your monthly ee, and which services cost extra. Ten,compare nursing home costs.

Is there a basic ee or room, meals, and personal care?

Are there extra charges or other services, such as beauty shop services?

Health inspection and re saety inspection reports

Does the nursing home have the most recent health and re inspection reports or meto look at?

Note: Ask the staf to provide these reports. Tey tell you how well the nursing homemeets Federal health and saety regulations. Te nursing home must have the report o

the most recent state or Federal survey o the acility available or you to look at.

Resident, amily, and staf satisaction

Can I talk to staf, residents, and amily members o residents? Will I be able to askthem i theyre satised with the nursing home and its services?

Note: Any resident or amily member o a resident has the right to reuse to talk to you.However, staf should be able to visit with you i theyre not involved in care or serviceduties at the time.


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Visit the nursing homes

Aer you consider whats important to you in a nursing home, visit the nursing homes.

Its best to visit the nursing homes that interest you beore you make a nal decision onwhich one meets your needs.

A visit gives you the chance to see the residents, staf, and the nursing home setting. Italso allows you to ask questions o the nursing home staf and talk with residents andtheir amily members.

I you cant visit the nursing home yoursel, you may want to get a amily member orriend to visit or you. I a amily member or riend cant visit or you, you can call orinormation. However, a visit can help you see the quality o care and lie o the actual

residents.

Important things to know when visiting a nursing home:

Beore you go, call and make an appointment to meet with someone on staf. Yourealso encouraged to visit the nursing home at other times without an appointment. I anursing home doesnt ofer a drop-in policy, this is another issue to think about whenmaking your nal decision.

Dont be araid to ask questions.

Ask the staf to explain anything you see and hear that you dont understand. For

example, i you hear a person calling out, it may be because theyre conused, notbecause theyre being hurt or neglected.

Ask who to call i you have urther questions and write down the name and phonenumber.

I a resident or a residents amily wishes, you may talk to them about the care and theirexperience.

Dont go into resident rooms or care areas without asking the resident and nursinghome staf rst. Residents have a right to privacy and can reuse to allow you to come

into their rooms. Aer your visit, write down any questions you still have about the nursing home or how

the nursing home will meet your needs.


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The Nursing Home Checklist

Use the Nursing Home Checklist when you visit a nursing home.

ake a copy o the Nursing Home Checklist when you visit to ask questions aboutresident lie, nursing home living spaces, staf, residents rooms, hallways, stairs, lounges,bathrooms, menus and ood, activities, saety, and care.

Use a new checklist or each nursing home you visit. You can photocopy the checklist or

print additional copies available at www.medicare.gov/NHCompare .

Name o Nursing Home: __________________________________________________

Address: _______________________________________________________________

Phone Number: _________________________________________________________

Date o Visit: ____________________________________________________________

Basic Inormation

Is the nursing home Medicare-certied?

Is the nursing home Medicaid-certied?

Does the nursing home have the level o care I need?

Does the nursing home have a bed available?

Does the nursing home ofer specialized services, such as a special unit or care or a

resident with dementia, ventilator care, or rehabilitation services?Is the nursing home located close enough or riends and amily to visit?

Resident Appearance

Are the residents clean, well groomed, and appropriately dressed or the season or time oday?
http://www.medicare.gov/NHComparehttp://www.medicare.gov/NHCompare


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Nursing Home Living Spaces

Is the nursing home ree rom overwhelming unpleasant odors?

Does the nursing home appear clean and well kept?Is the temperature in the nursing home comortable or residents?

Does the nursing home have good lighting?

Are the noise levels in the dining room and other common areas comortable?

Is smoking allowed? I so, is it restricted to certain areas o the nursing home?

Are the urnishings sturdy, yet comortable and attractive?

Staf

Does the relationship between the staf and residents appear to be warm, polite, andrespectul?

Does the staf wear name tags?

Does the staf knock on the door beore entering a residents room? Do they reer toresidents by name?

Does the nursing home ofer a training and continuing education program or all staf?

Does the nursing home check to make sure they dont hire staf members who have been

ound guilty o abuse, neglect or mistreatment o residents; or have a nding o abuse,neglect, or mistreatment o residents in the state nurse aid registry?

Is there a licensed nursing staf 24 hours a day, including a Registered Nurse (RN) presentat least 8 hours per day, 7 days a week?

Will a team o nurses and Certied Nursing Assistants (CNAs) work with me to meet myneeds?

Do CNAs help plan the care o residents?

Is there a person on staf that will be assigned to meet my social service needs?

I I have a medical need, will the staf contact my doctor or me?

Has there been a turnover in administration staf, such as the administrator or director onurses, in the past year?


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Residents Rooms

Can residents have personal belongings and urniture in their rooms?

Does each resident have storage space (closet and drawers) in his or her room?Does each resident have a window in his or her bedroom?

Do residents have access to a personal phone and television?

Do residents have a choice o roommates?

Are there policies and procedures to protect residents possessions, including lockablecabinets and closets?

Hallway, Stairs, Lounges, and Bathrooms

Are exits clearly marked?

Are there quiet areas where residents can visit with riends and amily?

Does the nursing home have smoke detectors and sprinklers?

Are all common areas, resident rooms, and doorways designed or wheelchair use?

Are handrails and grab bars appropriately placed in the hallways and bathrooms?

Menus and Food

Do residents have a choice o ood items at each meal? (Ask i your avorite oods are

served.)

Can the nursing home provide or special dietary needs (like low-salt or no-sugar-addeddiets)?

Are nutritious snacks available upon request?

Does the staf help residents eat and drink at mealtimes i help is needed?

Activities

Can residents, including those who are unable to leave their rooms, choose to take part ina variety o activities?

Do residents have a role in planning or choosing activities that are available?

Does the nursing home have outdoor areas or resident use? Is the staf available to helpresidents go outside?

Does the nursing home have an active volunteer program?


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Saety and Care

Does the nursing home have an emergency evacuation plan and hold regular re drills

(bed-bound residents included)?Do residents get preventive care, like a yearly u shot, to help keep them healthy? Doesthe acility assist in arranging hearing screenings or vision tests?

Can residents still see their personal doctors? Does the acility help in arrangingtransportation or this purpose?

Does the nursing home have an arrangement with a nearby hospital or emergencies?

Are care plan meetings held with residents and amily members at times that areconvenient and exible whenever possible?

Has the nursing home corrected all deciencies (ailure to meet one or more state orFederal requirements) on its last state inspection report?

Go to a resident council or amily council meeting

While youre visiting the nursing home, ask a member o the resident council i you canattend a resident council or amily council meeting. Tese councils are usually organizedand managed by the residents or the residents amilies to address concerns and improvethe quality o care and lie or the resident.

I youre able to go to a meeting, ask a council member the ollowing questions and takenotes:

What improvements were made to the quality o lie or residents in the last year?

What are the plans or uture improvements?

How has the nursing home responded to recommendations or improvement?

Who does the council report to?

How does membership on the council work?

Who sets the agendas or meetings?How are decisions made (or example, by voting, consensus, or one person makes them)?

Visit again

Its a good idea to visit the nursing home a second time. Its best to visit a nursing homeon a diferent day o the week and at a diferent time o day than your initial visit. Stangcan be diferent at diferent times o the day and on weekends.

ake notes on the second visit.


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Step 4: Choose the nursing home that meets your needs.

When you have all the inormation about the nursing homes youre interested in, talk

with people who understand your personal and health care needs. Tis might includeyour amily, riends, doctor, clergy, spiritual advisor, hospital discharge planner, or socialworker.

I you nd more than one nursing home you like with a bed available, use all theinormation you get to compare them. rust your senses. I you didnt like what you sawon a visit, or example, i the acility wasnt clean or i you werent comortable talking tothe nursing home staf, you may want to choose another nursing home. I you elt that theresidents were treated well, the acility was clean, and the staf was helpul, you might eel

better about choosing that nursing home.I youre helping someone, keep the person youre helping involved in making thedecision as much as possible. People who are involved rom the beginning are betterprepared when they move into a nursing home. I the person youre helping isnt alert orable to communicate well, keep his or her values and preerences in mind.

Important: I you visit a nursing home that you dont like, look at other options, iavailable. Quality care is important. I youre in a hospital, talk to the hospital dischargeplanner or your doctor beore you decide not to go to a nursing home that has an

available bed. Tey may be able to help you nd a more suitable nursing home or arrangeor other care, such as short-term homecare, until a bed is available at another nursinghome you choose. However, you may be responsible or paying the bill or any additionaldays you stay in the hospital.

Moving is dicult. However, an extra move may be better or you than choosing to stayat a acility that isnt right or you. Be sure to explain to your doctor or discharge plannerwhy you arent happy with a acility that they may be recommending.

Once in the nursing home, i you nd that you dont like the nursing home you chose,

you can move to another acility with an available bed. Te nursing home you leave mayrequire that you let them know ahead o time that youre planning to leave. alk to thenursing home staf about their rules or leaving. I you dont ollow the rules or leaving,you may have to pay extra ees.


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What inormation is needed?

Aer you choose a nursing home, you will need to make the arrangements or admission.

When you contact the nursing home oce, its helpul to have the ollowing inormationready:

Payment inormation or nursing home oce staf

Insurance inormation: Provide inormation about any health care coverage and long-term care insurance you have that pays or nursing home care, health care, or both. Tisincludes the name o the insurance company and the policy number.

Note: I nursing home care will be covered byMedicare or Medicaid, the nursinghome cant require you to pay a cash deposit. Tey may ask that you pay your Medicare

coinsurance amounts and other charges you would normally have to pay. Its best topay these charges when theyre billed, not in advance. You may have to pay a cashdeposit beore youre admitted to a nursing home i your care wont be covered by eitherMedicare or Medicaid.

Inormation or nursing home staf

Inormation on your medical history: Your doctor may give the staf some o thisinormation. Tis includes a list o any current or past health problems, any pastsurgeries or treatments, any shots youve had, and allergies you have to ood or

medicine. Inormation on your current health status: Your doctor should give the staf this

inormation, including a list o your current health problems, recent diagnostic testresults, and inormation about any activities o daily living that might be dicult oryou to do by yoursel.

A list o your current medicines: Include the dose, how oen you take it, and why youtake it.

A list o all your health care providers: Include names, addresses, and phone numbers.

A list o amily members to call in case o an emergency: Include names, addresses,and phone numbers.


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Health care advance directives

You may be asked i you have a health care advance directive. A health care advance

directive is a written document that says how you want medical decisions to be made iyou become unable to make decisions or yoursel. Tere are two common types o healthcare advance directives:

A Living Will: A written legal document that shows what type o treatments you wantor dont want in case you cant speak or yoursel. Usually, this document only comesinto efect i youre unconscious and cant speak or yoursel. A Living Will tells otherswhat medical care or treatment you want, such as whether you want lie support, like arespirator.

A durable power o attorney or health care: A legal document that names someone

else to make health care decisions or you. Tis is helpul i you become unable to makeyour own decisions.

I you dont have a health care advance directive and need help preparing one, or needmore inormation, talk to a social worker, discharge planner, your doctor, or the nursinghome staf. You can call your local Area Agency on Aging to nd out i your state has anylegal services that help with preparing these orms. [State phone numbers]

Personal needs accounts

You may want to open an account managed by the nursing home, although the nursinghome may not require you to. You can deposit money into the account or personal use.Check with the nursing home to see how they manage these accounts. You may onlyhave access to the account at certain times. See pages 5556 or inormation about yourresident rights and protections regarding money.

Inormation about Medicare and Medicaid benets

For people seeking admission to a nursing home, the nursing home must provide (orallyand in writing) and prominently display written inormation about how to apply or and

use Medicare and Medicaid benets. Tey must also provide inormation on how to getreunds or previous payments covered by such benets.


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5

SECTION 4: Paying or Nursing Home

Care and Other Health Care CostsOverview

Nursing home care can be very expensive. Tere are many ways you can pay or nursinghome care. For example, you can use your own money, you may be able to get help romyour state, or you may use long-term care insurance.

Most people who enter nursing homes begin by paying or their care out o their own

pocket. As you use your resources (like bank accounts, stocks, etc.) over a period o time,you may eventually become eligible or Medicaid.

I you have Medicare and need nursing home care

Medicare generallydoesnt cover long-term stays (room and board) in a nursing home.Also, nursing home care isnt covered by many types o health insurance. However, dontdrop your health care coverage (including Medicare) i youre in a nursing home. Even iit doesnt cover nursing home care, you will need health coverage or hospital care, doctorservices, and medical supplies while youre in the nursing home.

Medicare covers skilled nursing acility (SNF) care in a Medicare-certied skilled nursingacilityor a limited time aer a 3-day qualiying hospital stay. For more inormationon Medicare coverage o skilled nursing acility care, get a ree copy o the bookletMedicare Coverage o Skilled Nursing Facility Care. [more ino].

Tis section explains some o the ways you can pay or a long-term stay in a nursinghome, or get help with other health care costs.It includes inormation about the ollowing:

Personal resources [more ino]

Help rom your stateMedicaid [more ino] Long-term care insurance [more ino]

Coming soonTe Community Living Assistance Services and Supports (CLASS)Program [more ino]

Medicare [more ino]
http://-/?-http://-/?-


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6 Paying for Nursing Home Care and Other Health Care Costs

Personal resources

You can use your personal money and savings to pay or nursing home care. Someinsurance companies let you use your lie insurance policy to pay or long-term care. Askyour insurance agent how this works.

Important: Be sure to get help beore using either o these options. Tere are importantissues you need to understand.

Help rom your state (Medicaid)

Medicaid pays or care or about 7 out o every 10 nursing home residents. Medicaid is a

joint state and Federal program that pays or certain health services and nursing homecare or older people with limited income and resources. I you qualiy, you may be ableto get help to pay or nursing home care or other health care costs. I you qualiy orboth Medicare and Medicaid, most health care costs are covered. But remember not allnursing homes accept Medicaid payment.

Check with the nursing home to see i they accept people with Medicaid, and i they havea Medicaid bed available. Who is eligible or Medicaid and what services are covered

varies rom state to state. Most oen, eligibility is based on your income and personal

resources. You may be eligible or Medicaid coverage in a nursing home even i youhavent qualied or other Medicaid services in the past.

Sometimes you wont be eligible until you have spent some o your personal resources onmedical care. You may be moved to another room in the Medicaid-certied section o thenursing home when your care is paid by Medicaid. o get more inormation on Medicaideligibility requirements in your state, call your State Medical Assistance (Medicaid) oce.[State phone numbers]

Some important things to know about Medicaid

Your home: Te state cant put a lien on your home i there is a reasonable chance youllreturn home aer getting nursing home care or i you have a spouse or dependentsliving there. Tis means they cant take, sell, or hold your property to recover benetsthat are correctly paid or nursing home care while youre living in a nursing home inthis circumstance.


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In most cases, aer a person who gets Medicaid nursing home benets passes away,the state must try to get whatever benets it paid or that person back rom their estate.However, they cant recover on a lien against the persons home i its the residence o thepersons spouse, sibling (who has an equity interest and was residing in the home at leastone year prior to the nursing home admission), or a blind or disabled child or a childunder the age o 21 in the amily.

Your assets: Most people who are eligible or Medicaid have to reduce their assetsrst. Tere are rules about whats counted as an asset and what isnt when determiningMedicaid eligibility. Tere are also rules that require states to allow married couples toprotect a certain amount o assets and income when one o them is in an institution(like a nursing home) and one isnt.

A spouse who isnt in an institution may keep one hal o the couples joint assets, upto a maximum o $109,560 in 2011, as well as a monthly income allowance. For moreinormation, call your State Medical Assistance (Medicaid) oce. [State phone numbers]You can also call your local Area Agency on Aging to nd out i your state has any legalservices where you could get more inormation. You can also get ree health insurancecounseling rom your State Health Insurance Assistance Program (SHIP). [State phonenumbers]

Transerring your assets: You cant give your assets away to amily members or non-

amily members, rather than use your assets to pay or your nursing home care. I yougive assets away within 5 years beore the date you apply or Medicaid, or even aer youapply, the gi may be treated as a transer o assets or less than air market value.

ransers or less than air market value may subject you to a penalty, and the penalty isthat Medicaid wont pay or your nursing home care or a period o time. How long thatperiod is depends on the value o the assets you gave away. Tere are limited exceptionsto this, especially i you have a spouse, or a blind or disabled child. But as a general rule,giving away your assets can result in no payment or your nursing home care, possibly ormany months or even years.


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Note: Federal law protects spouses o nursing home residents rom losing all o theirincome and assets to pay or nursing home care or their spouse. When one member oa couple enters a nursing home and applies or Medicaid, his or her eligibility is deter-mined under spousal impoverishment rules.

Spousal impoverishment helps make sure that the spouse still at home will have themoney needed to pay or living expenses by protecting a certain amount o the couplesresources, as well as at least a portion o the nursing home residents income, or the useo the spouse who is still at home. For more inormation about this protection, call yourState Medical Assistance (Medicaid) oce. See pages 6365.

o apply or Medicaid, call your State Medical Assistance (Medicaid) oce. [State phone

numbers] Tey can tell you i you qualiy or the Medicaid nursing home benet orother programs, such as the Programs o All-Inclusive Care or the Elderly (PACE), orhome and community-based waiver programs. [more ino]

Long-term care insurance

Tis type o private insurance policy can help pay or many types o long-term care, in-cluding both skilled and nonskilled (custodial) care. Long-term care insurance can varywidely. Some policies may cover only nursing home care. Others may include coverage

or a whole range o services like adult day care, assisted living, medical equipment, andinormal home care.

I you have long-term care insurance, check your policy or call the insurance company tond out i the care you need is covered. I youre shopping or long-term care insurance,nd out which types o long-term care services and acilities the diferent policies cover.Also, check to see i your coverage could be limited because o a pre-existing condition.Make sure you buy rom a reliable company that is licensed in your state.

For more inormation about long-term care insurance, get a copy o A Shoppers Guide

to Long-erm Care Insurance rom the National Association o Insurance Commission-ers, by visiting www.naic.org/index_ltc_section.htm.

Federal employees, members o the Uniormed Services, retirees, their spouses, and otherqualied relatives may be able to buy long-term care insurance at discounted group rates.

For more inormation about long-term care insurance or Federal employees, visit www.opm.gov/insure/ltc.
http://www.naic.org/index_ltc_section.htmhttp://www.opm.gov/insure/ltchttp://www.opm.gov/insure/ltchttp://www.opm.gov/insure/ltchttp://www.opm.gov/insure/ltchttp://www.naic.org/index_ltc_section.htm


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NewThe Community Living Assistance Services and Supports

(CLASS) Program

Te CLASS Program will be a national, voluntary insurance program to help pay orservices and supports needed to live as independently as possible. CLASS is not yetavailable. Eligible working adults will be able to enroll in the CLASS program whenit begins. Following a 5-year vesting period, enrollees who meet certain eligibilityrequirements (such as needing assistance with activities o daily living) will have accessto the benet. Visit www.healthcare.govto learn more.

Medicare or your health care and prescription drugs

Medicare

Medicare is a health insurance program or people age 65 or older, under age 65 withcertain disabilities, and any age with End-Stage Renal Disease (ESRD) (permanentkidney ailure requiring dialysis or a kidney transplant).

People get Medicare health care in two ways:

1. Original Medicare

Original Medicaredoesnt pay or most nursing home care. Most nursing home care

is custodialcare to help with activities o daily living like bathing, dressing, and usingthe bathroom. Medicare covers very limited and medically-necessary skilled care orhome health care i you need skilled care or an illness or injury and you meet certainconditions.

For more inormation on Medicare coverage oskilled nursing acility (SNF) care orhome health care, visit www.medicare.gov/Publications to view or print a copy o thebooklet Medicare Coverage o Skilled Nursing Facility Care or Medicare and HomeHealth Care. You can also order a ree copy by calling 1-800-MEDICARE (1-800-

633-4227). Y users should call 1-877-486-2048.
http://www.healthcare.gov/http://www.medicare.gov/Publicationshttp://www.medicare.gov/Publicationshttp://www.healthcare.gov/


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2. Medicare Advantage Plans and Other Medicare Health Plans

I you belong to a Medicare Advantage Plan (Part C) (like an HMO or PPO) or other

Medicare health plan, check with your plan to see i it covers nursing home care.Usually, plans dont help pay or this care unless the nursing home has a contractwith the plan. Ask the health plan about nursing home coverage beore you makeany arrangements. I the nursing home has a contract with your health plan, ask thehealth plan i they check the home or quality o care.

Medicare Prescription Drug Coverage (Part D)

I you belong to a Medicare Prescription Drug Plan and live in a nursing home or otherinstitution, youll get your covered prescriptions rom a long-term care pharmacy that

works with your plan. (Note: Institutions dont include assisted living or adult livingacilities or residential homes, or any kind o nursing home not identied by Medicare.)Tis long-term care pharmacy usually contracts with (or is owned and operated by) yourinstitution.

Unless someone chooses a Medicare health plan with drug coverage or a stand-aloneMedicare Prescription Drug Plan, Medicare automatically enrolls people with bothMedicare and ull Medicaid coverage living in institutions into Medicare PrescriptionDrug Plans. I you live in a nursing home and have ull Medicaid coverage, you paynothing or your covered prescriptions aer Medicaid has paid or your stay or at least 1ull calendar month.

I you have Medicare and live in a nursing home or other institution, you should alsoknow the ollowing:

I you move into or move out o a nursing home or other institution, you can switchMedicare drug plans at that time.You can switch Medicare drug plans at any time while youre living in the institution.

I you arent able to join on your own, your authorized representative can enroll you in a

plan that meets your needs. I youre in a skilled nursing acilitygetting Medicare-covered skilled nursing care, your

prescriptions generally will be covered by Medicare Part A (Hospital Insurance).


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Hospital stays and Skilled Nursing Facility Care

I you have Original Medicare or a Medicare health plan, you should also know the

ollowing: I you need short-term care in a Skilled Nursing Facility aer a Medicare-covered

inpatient hospital stay o 3 days or more, the hospital staf should help you nd aMedicare-certied acility that gives the skilled care you need. For more inormation onMedicare coverage o skilled nursing acility care, view the booklet Medicare Coverageo Skilled Nursing Facility Care. [more ino]

I you think youre being asked to leave a hospital (discharged) too soon, you canask or a review rom your Quality Improvement Organization (QIO). Te QIO is anindependent reviewer who will give you a second opinion about whether youre ready

to leave the hospital. Your hospital services will continue to be paid during the review(except or charges like your coinsurance and deductibles). Visit www.medicare.gov/contacts or call 1-800-MEDICARE (1-800-633-4227) or the QIOs phone number. Yusers should call 1-877-486-2048.

I you think youre being asked to leave a skilled nursing acility too soon, you canask or a review rom your QIO. Te QIO, under most circumstances, will give youits decision beore Medicare coverage o your skilled nursing care ends. For the QIOsphone number, visit www.medicare.gov/contacts or call 1-800-MEDICARE.

For anyone being discharged rom a health care setting like a hospital or skillednursing acility: Use Medicares Your Discharge Planning Checklist to help make sureyou have all the inormation you need beore youre discharged. [more ino]
http://-/?-http://www.medicare.gov/contactshttp://www.medicare.gov/contactshttp://www.medicare.gov/contactshttp://-/?-http://-/?-http://www.medicare.gov/contactshttp://www.medicare.gov/contactshttp://www.medicare.gov/contactshttp://-/?-


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Get your personalized Medicare inormation

Register at www.MyMedicare.gov, Medicares secure online service or accessing your

personal Medicare inormation. Create and print an On the Go report that lists inormation you can share with your

providers.

Add or modiy sel-reported health management inormation, such as medicalconditions and allergies.

View or modiy your personal drug list and pharmacy inormation, and see yourprescription drug costs.

Search or and create a list o your avorite providers, and access quality inormation

about them. Complete your Initial Enrollment Questionnaire so your bills can get paid correctly.

rack your Original Medicare claims, and order a Medicare Summary Notice.

Check your Part B deductible status.

View your eligibility inormation.

Get notices about what services you will be eligible or in the coming year.
http://www.mymedicare.gov/http://www.mymedicare.gov/


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43

SECTION 5: Living in the Nursing Home

Care plans

Te nursing home staf will get your health inormation and review your health conditionto prepare your care plan. You (i youre able), your amily (with your permission), orsomeone acting on your behal has the right to take part in planning your care with thenursing home staf.

Your care plan is very important. A good care plan can help make sure that youre gettingthe care you need and help make your stay more pleasant. Your health assessment (a

review o your health condition) begins on the day youre admitted. A comprehensiveassessment must be completed within 14 days o admission. You should expect to get ahealth assessment at least every 90 days aer your rst review, and possibly more oen iyour medical status changes.

Te nursing home staf will assess your condition regularly to see i your health statushas changed. Tey will adjust your care plan as needed. Nursing homes are required tosubmit this inormation to the ederal government. Tis inormation is used or qualitymeasures, nursing home payment, and state inspections.

Depending on your needs, your care plan may include the ollowing: What kind o personal or health care services you need

What type o staf should give you these services

How oen you need the services

What kind o equipment or supplies you need (like a wheelchairor eeding tube)

What kind o diet you need (i you need a special one)

Your health goal (or goals)

How your care plan will help you reach your goals


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44 Living in the Nursing Home

Reporting and resolving problems

I you have a problem at the nursing home, talk to the staf involved. For example, i you

have a problem with your care, talk to the nurse or Certied Nurse Assistant (CNA). Testaf may not know there is a problem unless you tell them. I the problem isnt resolved,ask to talk with the supervisor, social worker, director o nursing, administrator, or yourdoctor.

Te Medicare and/or Medicaid-certied nursing home must have a grievance procedureor complaints. I your problem isnt resolved, ollow the acilitys grievance procedure.You may also want to bring the problem to the resident or amily council.

A Medicare and/or Medicaid-certied nursing home must post the name, address, and

phone number o state groups, such as the State Survey Agency, State Licensure Oce,State Ombudsman Program, Protection and Advocacy Network, and the Medicaid FraudControl Unit. I you eel you need outside help to resolve your problem, call the Long-erm Care Ombudsman or State Survey Agency or your area. [State phone numbers]


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Your resident rights and protections

What are my rights in Medicare and/or Medicaid-certied nursing homes?

As a resident in a Medicare and/or Medicaid-certied nursing home, you have certainrights and protections under Federal and state law that help ensure you get the care andservices you need. You have the right to be inormed, make your own decisions, and haveyour personal inormation kept private.

Te nursing home must tell you about these rights and explain them in writing in alanguage you understand. Tey must also explain in writing how you should act andwhat youre responsible or while youre in the nursing home. Tis must be done beore orat the time youre admitted, as well as during your stay. You must acknowledge in writing

that you got this inormation.At a minimum, Federal law species that a nursing home must protect and promote theollowing rights o each resident:

Be treated with respect: You have the right to be treated with dignity and respect, aswell as make your own schedule and participate in the activities you choose. You havethe right to decide when you go to bed, rise in the morning, and eat your meals.

Participate in activities: You have the right to participate in an activities programdesigned to meet your needs and the needs o the other residents.

Be ree rom discrimination: Nursing homes dont have to accept all applicants, butthey must comply with local, state, and Federal civil rights laws. I you believe you havebeen discriminated against, call the Department o Health and Human Services, Oceor Civil Rights at 1-800-368-1019 or visit www.hhs.gov/ocr. Y users should call1-800-537-7697.

Be ree rom abuse and neglect: You have the right to be ree rom verbal, sexual,physical, and mental abuse. Nursing homes cant keep you apart rom everyone elseagainst your will. I you eel you have been mistreated (abused) or the nursing homeisnt meeting your needs (neglect), report this to the nursing home, your amily, your

local Long-erm Care Ombudsman, or State Survey Agency. Te nursing home mustinvestigate and report all suspected violations and any injuries o unknown originwithin 5 working days o the incident to the proper authorities.
http://www.hhs.gov/ocrhttp://www.hhs.gov/ocr


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Be ree rom restraints: Nursing homes cant use any physical restraints (like side rails)or chemical restraints (like drugs) to discipline you or the staf s own convenience.

Make complaints: You have the right to make a complaint to the staf o the nursinghome or any other person without ear o being punished.Te nursing home must address the issue promptly.

Get proper medical care: You have the ollowing rights regarding your medical care:

o be ully inormed about your total health status in a language you understand.

o be ully inormed about your medical condition, prescription andover-the-counter drugs, vitamins, and supplements.

o be involved in the choice o your doctor.

o participate in the decisions that afect your care. o take part in developing your care plan. By law, nursing homes must develop a

care plan or each resident. You have the right to take part in this process. Familymembers can also help with your care plan with your permission.

o access all your records and reports, including clinical records (medical recordsand reports) promptly during weekdays. Your legal guardian has the right to lookat all your medical records and make important decisions on your behal.

o express any complaints (also called grievances) you have about your care or

treatment. o create advance directives (a health care proxy or power o attorney, a living will,

or aer-death wishes) in accordance with State law.

o reuse to participate in experimental treatment.

Have your representative notifed: Te nursing home must notiy your doctor and, iknown, your legal representative or an interested amily member when the ollowingoccurs:

Youre injured in an accident and/or need to see a doctor.

Your physical, mental, or psychosocial status starts to get worse.

You have a lie threatening condition.

You have medical complications.

Your treatment needs to change signicantly.

Te nursing home decides to transer or discharge you rom the nursing home.


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Get inormation on services and ees: You have the right to be told in writing about allnursing home services and ees (those that are charged and not charged to you) beoreyou move into the nursing home and at any time when services and ees change. Inaddition:

Te nursing home cant require a minimum entrance ee i your care is paid or byMedicare or Medicaid.

For people seeking admission to the nursing home, the nursing home must tell you(both orally and in writing) and display written inormation about how to applyor and use Medicare and Medicaid benets.

Te nursing home must also provide inormation on how to get a reund i youpaid or an item or service, but because o Medicare and Medicaid eligibility rules,

its now considered covered.

Manage your money: You have the right to manage your own money or choosesomeone you trust to do this or you. In addition:

I you deposit your money with the nursing home or ask them to hold or accountor your money, you must sign a written statement saying you want them to dothis.

Te nursing home must allow you access to your bank accounts, cash, and othernancial records.

Te nursing home must have a system that ensures ull accounting or your undsand cant combine your unds with the nursing homes unds.

Te nursing home must protect your unds rom any loss by providing anacceptable protection, such as buying a surety bond.

I a resident with a und passes away, the nursing home must return the unds witha nal accounting to the person or court handling the residents estate within 30days.


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Get proper privacy, property, and living arrangements: You have the ollowing rights:

o keep and use your personal belongings and property as long as they dont

interere with the rights, health, or saety o others. o have private visits.

o make and get private phone calls.

o have privacy in sending and getting mail and email.

o have the nursing home protect your property rom the.

o share a room with your spouse i you both live in the same nursing home (i youboth agree to do so).

Te nursing home has to notiy you beore your room or your roommate ischanged and should take your preerences into account.

o review the nursing homes health and re saety inspection results.

Spend time with visitors: You have the ollowing rights:

o spend private time with visitors.

o have visitors at any time, as long as you wish to see them, and as long as the visitdoesnt interere with the provision o care and privacy rights o other residents.

o see any person who gives you help with your health, social, legal, or other

services at any time. Tis includes your doctor, a representative rom the healthdepartment, and your Long-erm Care Ombudsman, among others.

Get social services: Te nursing home must provide you with any needed socialservices, including the ollowing:

Counseling

Help solving problems with other residents

Help in contacting legal and nancial proessionals

Discharge planning


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Leave the nursing home:

Leaving or visits: I your health allows, and your doctor agrees, you can spend

time away rom the nursing home visiting amily or riends during the day orovernight, called a leave o absence. alk to the nursing home staf a ew daysahead o time so the staf has time to prepare your medicines and write yourinstructions.Caution: I your nursing home care is covered by certain health insurance, youmay not be able to leave or visits without losing your coverage.

Moving out: Living in a nursing home is your choice.You can choose to move to another place. However, the nursing home may have apolicy that requires you to tell them beore you plan to leave. I you dont, you may

have to pay an extra ee. Have protections against unair transer or discharge: You cant be sent to another

nursing home or made to leave the nursing home, unless any o the ollowing are true:

Its necessary or the welare, health, or saety o you or others.

Your health has improved to the point that nursing home care is no longernecessary.

Te nursing home hasnt been paid or services you got.

Te nursing home closes.

You have the ollowing rights:

You have the right to appeal a transer or discharge to the State Survey Agency.[State phone numbers]

Te nursing home cant make you leave i youre waiting to get Medicaid.

Except in emergencies, nursing homes must give a 30-day written notice o theirplan and reason to discharge or transer you.

Te nursing home has to saely and orderly transer or discharge you and give you

proper notice o bed-hold and readmission requirements.


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Form or participate in resident groups: You have a right to orm or participate ina resident group to discuss issues and concerns about the nursing homes policiesand operations. Most homes have such groups, oen called resident councils. Tehome must give you meeting space and must listen to and act upon grievances andrecommendations o the group. [more ino]

Have your amily and riends involved: Family and r

medicare guide to choosing a nursing home 2011.pdf

Documents