GUIDE TO CHOOSING A NURSING HOME

* The importance of planning ahead

First Considerations

* Do you need a nursing home?
* Quality-of-life/quality-of-care issues

Beginning the Search

* Identifying important resources
* Understanding your needs and wants

Visiting a Nursing Home

* When to visit
* Who to talk to
* What to ask

Making the Selection

* Payment considerations
* Medicare/Medicaid coverage
* Long-term care insurance
* Reviewing the contract

Nursing Home Checklist

INTRODUCTION
Selecting a nursing home is one of the most important and
difficult decisions that you may be asked to make either for
yourself or for a member of your family. So it's important that
you base your decision on the most complete and timely
information available.
Ideally, you would have ample time to plan ahead: to examine
facilities; to talk to residents of nursing homes and their
families; and to find out about the costs of care and make some
financial plans to cover the cost of your nursing home care.
Planning ahead is one of the best ways to ease the stress that
accompanies choosing a nursing home, and it helps assure a good
choice of facility and location when the decision is made.
Unfortunately, such a decision often must be made during a
time of crisis -- frequently when a person is ready to leave the
hospital after a serious illness or operation.
When an individual can no longer live independently or
requires short-term care after a hospital stay, a decision must
he made about providing the best alternative arrangement to meet
the person's needs for care. Understandably, this can be a
bewildering task.
The task of finding the right kind of services in a
desirable, nurturing atmosphere is not easy. It is a time-
consuming effort to gather the many facts needed to help in the
decision-making process.
This booklet is designed as a first step to help you choose
a nursing home. We at the Health Care Financing Administration
(HCFA) want you to know some of the key resources that are
available to you now as you begin your search. This booklet is a
guide to some of the places to go, people to speak with, and some
of the questions you should ask when considering whether a
particular nursing home is right for you or someone in your
family.
Finding the right facility is all-important to you or your
loved one's well-being. The facility selected will be the home
and community for the duration of any stay often for the
remainder of a person's life.
Consequently, if you are helping a relative find a nursing
home, involve them as much as possible in the decision-making
process. If he or she is mentally alert, it is essential that the
person's wishes be considered and that the individual be involved
in the process of selecting the home every step of the way.
Many people know very little and don't like to think about
life in nursing homes. Therefore, if you or a family member is
likely to need nursing home care in the future, discuss the
subject well in advance of such a move and educate the family
about the realities of nursing home care.
By planning ahead, you will have more control of your life.
Even if others must make decisions for you, you will have
participated in making your preferences and needs known ahead of
time. There are people who can help you, however, as you begin
your search.

FIRST CONSIDERATIONS

DO YOU NEED NURSING HOME CARE?
Nursing homes are only one of a range of long-term,
comprehensive medical, personal, and social services designed to
meet the needs of chronically ill and disabled persons. Before
considering placement in a nursing home, therefore, you should
explore the possibility of using home- and community-based care.
What's important is that you discuss your needs and plans with
your physician or caregiver and your family to decide on the most
appropriate place in which you receive care. Your financial
ability to pay will also affect your decision (see "Payment
Considerations").
When a less intensive and less restrictive form of care is
called for, a mix of services and/or programs popularly called
"alternatives to institutional care" may be most appropriate.
While most long-term care is still provided at home by
relatives and friends, an increasing number and variety of
community based health and supportive services and specialized
living arrangements are now being created in communities
throughout the nation. Among the home- and community-based
services available:

* Home Health Care;
* Respite Care;
* Adult Day Care Centers;
* Foster Care;
* Residential care in a board and care home;
* Retirement Communities; and
* Hospice Care.

When an individual needs 24-hour nursing care and
supervision, however, a nursing home may be the best answer.
Once you decide that nursing home care is needed, you may
become overwhelmed. It is normal to be anxious, angry, guilty,
depressed, or scared at the thought of making such a big decision
for yourself or a family member. This book can help ease those
emotions by assisting you to make informed choices. By planning
ahead, you will be better prepared to make the appropriate choice
for care. By using this book, you will already be familiar with
the individuals and organizations to whom you can turn if you
need help.

WHY DO PEOPLE LIVE IN NURSING HOMES?
The great majority of nursing home residents are elderly.
Some are frail and unable to take care of themselves and live
safely on their own. Other residents, regardless of age, suffer
from chronic illnesses and need some medical attention, but do
not require hospital care. Still others have been transferred to
the nursing home from a hospital to convalesce after a serious
illness, accident or operation.
Forty percent to 45 percent of everyone turning age 65 in
1990 will stay in a nursing home at least once in their lifetime.
About one-half of those admitted to nursing homes stay less than
six months. However, one in five will stay a year or more, and
one in ten will stay three or more years.
Some nursing home residents have no families to care for
them at home. In other cases, the families are not able to supply
the kind of care the individual needs there may be no one home
during the day, or the care needed may be too specialized or too
expensive to provide at home. In still other cases, families may
decide that keeping the person at home would be too difficult.

FACTS ABOUT LONG-TERM CARE AND NURSING HOMES
During the past two decades, the number of people over age
65 has grown dramatically, more than 55 percent. While people are
living longer, the number of people with chronic illnesses or
disabilities that will require long-term care services is also
increasing. By the year 2000, almost 9 million older Americans
will need long-term care services, up from almost 7 million in
1988. Many of these people will require nursing home services.
Typically, these people are older women without spouses.
Almost 20,000 nursing homes in the United States now provide
care for about 5 percent of older Americans.

QUALITY-OF-LIFE ISSUES
When people enter nursing homes, they don't leave their
personalities at the door. Nor do they lose their basic human
rights and needs for respect, encouragement, and friendliness.
All individuals need to retain as much control over the events in
their daily lives as possible.
Consequently, nursing home residents should have the freedom
and privacy to attend to their personal needs. That means several
things: from managing their own financial affairs, if they are
able, to decorating their rooms with personal belongings. It also
means being able to participate in the planning of their
treatment and being assured of the confidentiality of their
medical records.
In the 1980s, several studies identified some problems with
the quality of care that the nation's nursing homes provided to
Medicare and Medicaid residents and recommended the
implementation of new and higher standards of care in nursing
facilities. In 1987, Congress enacted legislation to raise these
standards. In October of 1990, these important new nursing home
reforms took effect and are designed to strengthen both the
quality of life and quality of care for residents. The reforms
call for the provision and enforcement of certain rights of
residents to dignity, choice, self-determination, and quality
services and activities.
Knowing some of the key details of the law can help you make
a better decision about selecting a nursing home. It can also
better prepare you to be a resident, to know what to expect, and
what to ask for if you are not receiving the care and services to
which you are entitled. You will need to ask questions and
observe how a nursing home is performing.
Under the law, nursing homes must train their nurse aides.
Facilities must also conduct a comprehensive assessment of
resident needs within two weeks of admission. The law also
requires that nursing home residents have the right to choose
activities, schedules and health care that are consistent with
their interests and needs. Facilities are expected to provide a
safe, clean, comfortable homelike environment.
Residents must receive the necessary care and services that
enable them to reach and maintain their highest practicable level
of physical, mental, and social well-being.
For example, married residents should be assured privacy for
visits from spouses. If both husband and wife live in the home,
they should be able to share a room, if possible. All residents
should have freedom and opportunity to make friends and to
socialize.
Residents and their relatives must be able to talk to
administrators and staff about questions, problems and complaints
without fear of reprisal. Administrators should be courteous,
helpful and frank. They should treat residents and their requests
with respect. Staff members should respond quickly to calls for
assistance and treat residents with courtesy, respect and
affection. A long-term care facility may meet every known
standard, but that's not enough. Warm, professional relationships
between staff and residents are an essential ingredient to
quality care.
Residents should not be transferred or discharged
arbitrarily and should be given reasonable advance notice if they
must be moved.
Many of the specific items you should keep an eye out for
are part of the regulations concerning residents' rights a set of
rules that nursing homes certified by Medicaid and Medicare must
follow. The law applies to referrals, admissions, accommodations,
room assignments and transfers, policies regarding financial
matters, care services, physical facilities, residents'
privileges, and the assignments of medical staff and volunteers.
In addition, a civil rights law ensures equal access regardless
of race, color or national origin in all nursing homes.

BEGINNING THE SEARCH

SEEK REFERRALS
Before visiting nursing homes, get information about
available options from a variety of different people:
professionals in the long-term care field (such as the local
ombudsman, see below) to friends or acquaintances who have been
in a situation similar to yours. They can help focus your search
for a nursing home. In that way, you can save some time and avoid
needless frustration.
Once again, it is important to remember that choosing a
nursing home will require you to use critical judgment at a
variety of levels. That final judgment should also include your
intuitive "gut feeling." In addition, you should seek information
from a broad base of sources and not rely on any one source in
making your decision.

LONG-TERM CARE OMBUDSMAN PROGRAM
The Ombudsman program is a significant part of the nursing
home system. Federal law requires each State Agency on Aging to
have an Office of the Long-Term Care Ombudsman, and more than 500
local ombudsman programs now exist nationwide. These offices
provide help and information to older Americans, their families
and friends regarding long-term care facilities.
Ombudsmen visit nursing homes on a regular basis, and they
often have knowledge of what goes on in facilities in their
communities. In addition, they receive and investigate complaints
made by or on behalf of nursing home residents and work to
resolve the problems. If they are unable to resolve problems or
if they find serious violations of standards in the facility,
ombudsmen refer complaints to State Health Departments for
action.
Ombudsmen can also provide information on licensed long-term
care facilities in the state or local area, usually including
some descriptive information. They cannot advise you on any one
particular nursing home, but they will supply current information
regarding nursing homes near you. Ask the local ombudsman about:

* Information from the latest survey report on the facility;

* Any complaints against the nursing homes you plan to visit;

* The number and nature of complaints for the past year against
the facility;

* The results and conclusions of the investigation into these
complaints; and

* What to look for as tell-tale signs of good care in
facilities.

If there are local advocacy groups or support groups for the
aged and their families, they will also be good sources for
recommendations.

OTHER COMMUNITY RESOURCES
While the ombudsman program is a good place to begin your
search for a nursing home, there are many other valuable
community resources that you should consult before deciding which
nursing homes to visit. Among these resources:

* Hospital discharge planners or social workers;
* Your family physician;
* Religious organizations;
* Volunteer organizations such as Pets on Wheels;
* State nursing home associations; and
* Close friends or relatives.

In meeting with these resources, ask about the facility's
reputation in the community. Does the facility have a list of
references especially family members of current residents?

OTHER KEY FACTORS TO CONSIDER
As you set about deciding on a nursing home, it is also
important for you to distinguish between your wants and your
needs. To that end, you should ask yourself:

* What kind of care do you need; and

* What is the lifestyle you would like to lead in the facility?

Different kinds of nursing homes provide different types of
care; yet all must provide certain basic services. The key is to
match the home to the resident to ensure the nursing home
provides the person the kind of care and services needed.
Some people may want a safe and comfortable place to live
among pleasant companions. You may want a home that places
special emphasis on ethnic factors, such as special food or
foreign languages, while others may prefer similarity in
religious background.
On the other hand, other residents may require help with
grooming and occasional medical treatment. Still others may
require constant medical attention, therapy, and other skilled
nursing care.
Once you identify what you want and need in a home, simply
telephoning some of the nursing homes on your list may eliminate
the need to visit them. Some of the key questions that you may
ask over the phone to facilities are:

* Is the nursing home certified for participation in the
Medicare or Medicaid programs?

* What are the facility's admissions requirements for residents?

* What is the "typical profile" of a resident in the facility?
For example, if you require temporary rehabilitation services
and the nursing home specializes in Alzheimer's disease care,
it's probably not a good match.

* Does the nursing home require that a resident sign over
personal property or real estate in exchange for care?

* Does the facility have vacancies, or is there a waiting list?

LOCATION
As you develop your list of potential nursing homes to
visit, you should also consider the location of the facility. For
example, how close is it to family members and friends? How easy
is it for people to visit? How near is it to other community
contacts and resources that you hope to continue to see and use?

ENROLLMENT IN A MANAGED CARE PLAN
If you or your family member is enrolled in a health
maintenance organization (HMO) or competitive medical plan (CMP),
ask a representative of the plan about coordination of health
care services between the HMO/CMP and the nursing home. Ask which
nursing homes the HMO or health plan works with in the area. If
you are interested in a nursing home outside of the area served
by the HMO, discuss this with the plan representatives.

PUBLIC INFORMATION
Your State Health Department produces a yearly report on the
performance of each nursing home that is certified for Medicare
or Medicaid. You should review the latest report. It is required
to be posted at the nursing home and is also available through
your state health department or from the local ombudsman program.
You should talk to the nursing home administrator and long-term
care ombudsman about the results of the survey report. What did
the nursing home do to correct problems, if any, that were
identified in the report? The Health Care Financing
Administration, which administers the Medicare and Medicaid
programs, also produces an annual report on nursing home
information that allows consumers to compare performance of
different nursing homes on a variety of measures.

VISITING A NURSING HOME

TALK TO RESIDENTS AND STAFF
It is very important for you or a family member to visit a
nursing home before becoming a resident. A visit provides you an
opportunity to talk not only with people who work at the
facility, but more importantly, with the people who live and
receive care at the nursing home and their families.
Ask residents what they like about the home and what they do
when they need something to be different. Ask them what they like
about the staff. Ask visitors or volunteers the same questions.
If you see no volunteers, ask why none work in the home.
Take advantage of this opportunity. You can gain valuable
insight into the quality of life in the facility.

WHEN AND HOW OFTEN SHOULD YOU VISIT A HOME?
Ideally, you should visit a nursing home more than once and
during different times of the day. One visit should be during
late morning or midday so you can observe whether people are out
of bed, and, if possible, whether the noon meal is being served.
You should also plan to visit during the afternoon to observe
activities as well as during and after the evening meal and
evening hours.
The first time you visit a nursing home, make an appointment
to see the administrator or admissions director so that you can
fully explain the purpose of your visit. Mention that you would
like to watch the daily routine at the nursing home, including
staff preparing and serving a meal in the dining room and to
residents in their own rooms, and observe as many different
resident activities as possible, including therapy sessions.
Most nursing homes will gladly arrange for a guided tour of
the facility, and they should be able to direct you to the posted
Residents' Bill of Rights. You may ask for a copy of the
statement, which you can then review carefully at home. You may
also ask to see the posted results of the nursing home's most
recent Medicare and/or Medicaid survey of the facility and the
resulting plan of correction, if there were problems.
The administrator or admissions director can also arrange
for you to speak with any of the staff, including the nursing
home social worker. In fact, when you visit a nursing home, you
should carefully observe staff members at work. Once again, the
interactions among staff and between staff and residents should
be warm, but professional. You should also note the physical
condition of the nursing home.
Is the building clean, free from overwhelming odors, and
well-maintained?
Evaluate the quality of the care and concern for residents
you see. For example, do nursing assistants speak slowly and
clearly so the resident can hear and see them? How does the staff
react when a resident's behavior is inappropriate? How does the
staff respond to residents with Alzheimer's disease or residents
who seem to have some impairments in expressing themselves?
Overall, does the staff show an active interest in and affection
for individual residents? In addition, ask residents if there is
enough staff to meet their needs.

FORM YOUR OWN IMPRESSIONS
Although a formal tour is useful, it is important that you
talk to residents and observe conditions in the nursing home by
yourself, without facility staff assisting you. Make an
unscheduled visit.
Ask residents their opinion of the nursing home, and if they
will show you around the facility. In either case, be observant.
Notice whether the residents are dressed neatly and appropriately
for the time of day. Ask how often residents get a full bath or
shower. Do they appear to be contented and enjoying the
activities, and do residents interact with one another?
Remember, although some residents may prefer to watch rather
than participate in activities at the nursing home, if most
residents are passive, it may be a sign that the home has no
activity program or that residents are kept on medications.
Are residents eager to discuss their feelings about the
nursing home with you, or do they appear apathetic about their
surroundings? Ask residents whether the facility has a resident
council a committee of residents that helps advise the facility
about resident concerns, needs, wants, likes, and dislikes. The
law does not require nursing homes to have such councils.
And, if possible, meet with members of the family council at
the nursing home. Family councils, which are similar to resident
councils, are composed of family members of the facility's
residents. Even if the nursing home does not have a family
council, ask to speak with family members of residents of the
facility. Also note whether visiting hours are generous and set
for the convenience of residents and visitors.
In making these kinds of observations, trust your instincts
and perceptions. Be certain to bring a note pad and pen with you
to make notes about your impressions soon after you leave the
facility. Impressions become blurred with time.

MEDICAL SERVICES
Medical and nursing care are crucial to you or your
relative's welfare as a resident of the nursing home. Therefore,
you need to spend extra time to ensure your needs will be met in
this important area. In most cases, you can choose your own
physician, even for emergency care.
Nursing homes also have their own physician. You should
understand how often the physician visits the facility and
reviews medical records of the residents. Does the physician and
nursing staff meet with residents and their families to develop
plans for treatment? On average, how many residents is each nurse
aide or direct care nurse assigned to care for? Are licensed
nurses on duty around the clock? If not, is there 24-hour access
by telephone? In addition, will the confidentiality of your
medical records be assured? The importance of understanding the
answers to these questions in part depends on the needs of the
individual resident. Still, you need to know the answers in case
you need medical treatment.

RESTRAINTS
The law strictly limits circumstances under which facilities
can physically restrain residents in beds or chairs. Residents
can never be restrained simply for the convenience of staff. All
physical or chemical (medication) restraints must be ordered by a
physician. Many nursing homes are making progress in finding
other, safe ways to care for residents without restraining them.
If you see residents with restraints, you should carefully
question the staff about the nursing home's philosophy on the use
of restraints. Ask what kind of activities and rehabilitation are
used to keep residents restraint free.
When a medication is used, facility staff must check the
resident to make sure there are no adverse side-effects. When a
physical restraint is used, the resident should be monitored
frequently to see that all is well, and to take care of any
physical needs such as toileting.
Remember that federal law states that nursing home residents
have the right to be free from any restraints administered for
purposes of discipline or convenience, and not required to treat
medical conditions.
In addition, the law says you will have the right to be free
from any type of abuse-verbal, sexual, physical, and mental. That
includes corporal punishment and involuntary seclusion.

FOOD SERVICES
The preparation and serving of meals is one of the most
important services provided to nursing home residents each day.
On your visit to the nursing homes, take the time to watch
servers in action. Ask to sample the food. Are hot foods served
hot?
Ask the dietitian at the facility for a list of menus for
the month, and ask how special diets are handled. Among the
questions you should get answers to from both the dietitian and
residents are:

* How much time is allowed for eating each meal?

* Is food delivered to residents who are unable or unwilling to
eat in the dining room?

* Are snacks available?

* Are those residents in need of special equipment or assistance
at meal time provided with such equipment or assistance?

As you watch residents eat their meal, note whether they
seem to be enjoying the food. Talk to residents about the quality
and variety of their meals.

FIRE SAFETY
Although nursing home fires causing multiple deaths do not
occur often, fire safety is very important. It is often difficult
to evacuate residents quickly enough should a major fire erupt.
Therefore, review the facility's fire safety training program. Do
all staff know what to do? Are residents provided a supervised
place in which to smoke?

FOLLOW-UP OBSERVATIONS
When deciding on which nursing home to enter, one visit is
not enough. Ideally, you should plan on a second and, if time
permits, a third visit to a facility after reviewing your written
notes from the initial visit. Once again, you should make
unannounced visits to the nursing home.
On your follow-up visit, go back at a different time of the
day, preferably during the evening and/or weekend. There are
usually fewer staff on duty at that time, and the visit will give
you an indication of the types of evening or weekend activities,
if any, that are available for the residents. These visits will
also give you a way to compare the level of attention that staff
give to residents and whether the attitude of staff is the same
during the night and day and during weekdays and weekends.

MAKING THE SELECTION

PAYMENT CONSIDERATIONS
For most people, finding ways to finance nursing home care
is a major concern. There are four basic ways in which nursing
home costs may be financed:

* Personal Resources -- About one-half of all nursing facility
residents pay for costs out of personal resources. When many
people enter a nursing home, they first pay for their care out
of their own income and savings. Because of the high cost of
such care, however, some people deplete their resources and
apply for Medicaid.

* Private Insurance -- Some Medicare supplementary insurance
policies, often referred to as "Medigap" insurance, also can
provide a source of payment for nursing homes. There is also
private, long-term care insurance available.

* Medicaid -- State and federal coverage is available to eligible
low income individuals who need care at least above the level of
room and board. The nursing home must be Medicaid-certified.

* Medicare -- Under some limited circumstances, Medicare hospital
insurance (Part A) will pay for a fixed period of skilled
nursing home care. The nursing home must be Medicare-certified.

Many health maintenance organizations (HMOs) and other
coordinated care plans participate in the Medicare and Medicaid
programs. These health care plans often cover certain benefits in
addition to those required by Medicare and Medicaid and are
experienced in "coordinating" a member's health care. Some HMOs
may also offer more medical or supportive services; others may
not require a hospital stay before approving a nursing home
admission.

WHAT DO MEDICARE AND MEDICAID PAY FOR?
Medicare pays for at least some of nursing home costs for up
to 100 days per benefit period for those who meet coverage
requirements and require care in a skilled nursing facility
(SNF). The first through the 20th day carry no deductible or
coinsurance amounts for the resident; however, the 21st through
the 100th days carry a coinsurance amount. This amount is
calculated each year and is equal to one-eighth of the annual
hospital deductible. For example, in 1993 the coinsurance amount
is $84.50 per day.
Medicare only pays for care in SNFs following a hospital
stay of at least three days and when individuals require daily
skilled nursing or skilled rehabilitation (physical therapy,
speech therapy or occupational therapy) services that must be
performed or supervised by professionals.
Many nursing homes have both Medicare and non- Medicare
parts. Medicare law does not permit payment for residents in non-
Medicare parts of the facility, even if the care needed meets the
medical standards for coverage. Therefore, in order for Medicare
to pay, the resident must be placed in the section of the nursing
home that is certified under Medicare.
To help you avoid such problems, however, SNFs generally
work closely with hospital discharge planners and social workers
to ensure that only individuals requiring skilled services are
admitted to skilled parts of the nursing home. If the SNF
determines that the person does not meet skilled standards and
then admits the resident to a skilled part, it must provide the
individual with a Notice of Non Coverage. Nursing homes are
required to give residents the Notice of Non Coverage at time of
admission, or any time after admission, when skilled services are
no longer required.
You may appeal the nursing home's decision for non-
coverage. You should not be charged for services until you
receive a formal decision on your appeal from Medicare. However,
if as a result of the appeal, it is determined that Medicare will
not cover your stay, you are liable for the cost of care since
the start of your nursing home stay.
When you visit a nursing home, if you are eligible for
Medicare coverage, ask to see a copy of the facility's Notice of
Non-Coverage. Ask some of the residents in the facility if they
have had difficulties or misunderstandings with the facility over
payments and whether problems were satisfactorily and quickly
resolved.

MEDICAID ELIGIBILITY
Medicaid pays nursing home expenses for individuals who meet
income and resource eligibility requirements. Medicaid can pay
for nursing facility care that ranges from skilled nursing care
to care that is above the level of room and board, but less
intensive than "skilled" care.
It is important to contact the local State Medicaid Agency
for eligibility and program information as early in the placement
process as possible. Financial guidelines vary from State to
State and can be somewhat restrictive, but remember that
eligibility is retroactive to the date of application.
Moreover, if either spouse transfers resources, such as real
estate or bank accounts, for less than fair market value within
30 months before a spouse goes into a nursing home, this could
affect the extent to which the Medicaid program would pay for the
cost of care for the spouse in the nursing home and for certain
community services.
Recent changes in Medicaid law the "spousal impoverishment"
provisions provide some protection for a certain amount of income
and resources for a spouse still living at home when the other
partner needs nursing home placement.

LONG-TERM CARE FINANCING AND INSURANCE
Given the increasing likelihood of older Americans having to
use long-term care services at some point in their lives, an
important part of planning ahead is preparing for your financial
future. This is important because most home care and about half
of nursing home costs are paid directly by consumers and their
families.
There are a variety of financing mechanisms for long-term
care services, including continuing care retirement communities
and private long-term care insurance.
Medicare supplemental insurance (Medigap) policies generally
cover very little long-term care at home or in a nursing home,
usually covering only deductibles, coinsurance, and long hospital
stays. Medicaid covers nursing home care and some community care
benefits such as home health care or adult day care. Coverage
varies by State and is generally limited to people with low
income and assets.
One option that you might wish to consider is purchasing
long-term care insurance. This type of insurance policy covers
nursing home care and increasingly includes home care coverage as
well.
Because costs for long-term care policies can vary widely,
even for similar policies, shopping and price comparison is
important. Counseling services may help you select a policy most
appropriate to your needs.
People purchase long-term care insurance for several reasons.
If you are deciding whether and when to buy long-term care
insurance, you should consider the following questions:

* Will your income cover long-term care expenses, along with
other ongoing expenses?

* If you purchase such insurance, can you pay for the deductible
period and coinsurance?

* Can you pay the premiums now? Can you pay if the premiums rise?

* Will you be able to pay the premiums if your spouse dies?

* Will you be able to pay for upgrading benefits to meet
inflation?

* Would you become eligible for Medicaid if you had large medical
bills, or entered a nursing home where average yearly costs run
almost $30,000? Before signing a long-term care insurance
policy, you should also ask if you have a period during which to
cancel the policy and receive a refund for the first premium. As
you shop around:

* Be sure that the policy does not base coverage on medical
necessity, or require prior hospitalization before entering a
nursing home, or prior nursing home stays for home health care.

* Be sure that the insurer can cancel your policy only for reason
of nonpayment of premiums.

* Make certain you have realistic inflation protection.

* Check the length of time that preexisting conditions are
excluded.

* Check for permanent exclusions on certain conditions, such as
Alzheimer's disease.

Finally, if you decide to purchase long-term care insurance,
do some checking into the reputation and financial stability of
the company offering the insurance. Your state health insurance
commissioner and consumer affairs offices should be helpful in
identifying reliable companies.

REVIEWING THE CONTRACT
Before an individual is admitted to a nursing home, the
resident, or the person sponsoring the resident, will have to
sign a contract. Before you sign any contract with a nursing
home, stop, and carefully review the document. Remember: the
admissions contract is a legally binding document that spells out
the conditions under which the resident is accepted.

A comprehensive contract should:

* State your rights and obligations as a resident of the
facility, including safe guards for residents' rights and
grievance procedures;

* Specify how much money you must pay each day or month to live
in the nursing home;

* Detail the prices for items not included in the basic monthly
or daily charge;

* State the facility s policy on holding a bed if you temporarily
leave the home for reasons such as hospitalization or vacation;
and

* State whether the facility is Medicaid and/or Medicare
certified. If so, and if you desire, the facility must accept
Medicaid payments when your own funds run out, or accept Medic
repayments if you qualify for Medicare coverage. Private pay
admissions contracts are illegal and cannot be enforced.

Remember: discrimination against Medicaid recipients is
illegal.

ADDITIONAL TIPS BEFORE SIGNING A CONTRACT

* Ask the nursing home for a copy of a contract. In this way,
you will he able to review the document at your own pace, get
additional advice from a variety of outside sources, and compile
a list of questions that you might have about provisions in the
contract.

* Have the nursing home administrator, the home's social worker,
or the local ombudsman answer your questions.

* Because the admissions contract is a legally binding document,
you should talk to a lawyer, if possible, on terms of the
contract.

* Remember that you can change terms of the contract. But if you
make changes, each of them must be initialed by both you and the
nursing home representative.

* Be sure that the contract is complete and correct before you
sign it. There should be no blank spaces.

NURSING HOME CHECKLIST

When you visit a nursing home, you should carry this
checklist with you It will help you to compare one facility with
another, but remember to compare facilities certified in the same
category; for example, a skilled nursing facility with another
skilled nursing home Because nursing homes may be licensed in
more than one category, always compare similar types of service
among facilities. Home A_____ Home B_____

A B

LOOK AT DAILY LIFE Y N Y N

1.Do residents seem to enjoy [][][][]
being with staff?

2.Are most residents dressed [][][][]
for the season and time of day?

3.Does staff know the residents [][][][]
by name?

4.Does staff respond quickly to [][][][]
resident calls for assistance?

5.Are activities tailored to [][][][]
residents' individual needs and
interests?

6.Are residents involved in a [][][][]
variety of activities?

7.Does the home serve food [][][][]
attractively?

8.Does the home consider personal [][][][]
food likes and dislikes in
planning meals?

9.Does the home use care in [][][][]
selecting roommates?

10Does the nursing home have a [][][][]
resident's council? If it does,
does the council influence
decisions about resident life?

11Does the nursing home have a [][][][]
family council? If it does, does
the council influence decisions
about resident life?

12Does the facility have contact [][][][]
with community groups, such as
pet therapy programs and Scouts?

LOOK AT CARE RESIDENTS RECEIVE

1.Do various staff and [][][][]
professional experts
participate in evaluating
each resident's needs and
interests?

2.Does the resident or his or her [][][][]
family participate in developing
the resident's care plan?

3.Does the home offer programs to [][][][]
restore lost physical functioning
(for example, physical therapy,
occupational therapy, speech and
language therapy)?

4.Does the home have any special [][][][]
services that meet your needs?
For example, special care units
for residents with dementia or
with respiratory problems?

5.Does the nursing home have a [][][][]
program to restrict the use of
physical restraints?

6.Is a registered nurse available [][][][]
for nursing staff?

7.Does the nursing home have an [][][][]
arrangement with a nearby
hospital?

LOOK AT HOW THE NURSING HOME HANDLES PAYMENT

1.Is the facility certified for [][][][]
Medicare?

2.Is the facility certified for [][][][]
Medicaid?

3.Is the resident or the [][][][]
resident's family informed when
charges are increased?

LOOK AT THE ENVIRONMENT

1.Is the outside of the nursing [][][][]
home clean and in good repair?

2.Are there outdoor areas [][][][]
accessible for residents to use?

3.Is the inside of the nursing [][][][]
home clean and in good repair?

4.Does the nursing home have [][][][]
handrails in hallways and grab
bars in bathrooms?

5.When floors are being cleaned, [][][][]
are warning signs displayed, or
are areas blocked off to prevent
accidents?

6.Is the nursing home free from [][][][]
unpleasant odors?

7.Are toilets convenient to [][][][]
bedrooms?

8.Do noise levels fit the
activities that are going on? [][][][]

9.Is it easy for residents in [][][][]
wheelchairs to move around
the home?

10Is the lighting appropriate [][][][]
for what residents are doing?

11Are there private areas for [][][][]
residents to visit with family,
visitors, or physicians?

12Are residents' bedrooms [][][][]
furnished in a pleasant manner?

13Do the residents have some [][][][]
personal items in their bedrooms
(for example, family pictures,
souvenirs, a chair)?

14Do the residents' rooms have [][][][]
accessible storage areas for
residents' personal items?

OTHER THINGS TO LOOK FOR

1.Does the nursing home have a [][][][]
good reputation in the
community?

2.Does the nursing home have a [][][][]
list of references?

3.Is the nursing home convenient [][][][]
for family or friends to visit?

4.Does the local ombudsman visit [][][][]
the facility regularly

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