Deciding to enter a nursing home and then choosing the right one can be very difficult--both practically and emotionally. This pamphlet provides some suggestions for selecting the right nursing home for residents' specific needs and for making sure that residents receive good care once they have moved into the facility.
Tour the Facilities
Making visits to several nursing homes before you settle on one is a great way to figure out what type of facility will be the best fit for you. You would never buy a home without first taking a tour of it, and the same practical philosophy holds true for a nursing home. When making your visits, it is important to respect the privacy of the residents and to not interfere with the care being given by the staff.
When to visit
Dropping in unannounced during visiting hours and during different shifts of duties are good ways to get a feel for that particular facility. Typically, shifts of duty are from 7 a.m. to 3 p.m., 3 to 11 p.m. and 11 p.m. to 7 a.m. Visiting hours are not typically held during the third shift of the day. It is also a good idea to visit a nursing home during the week and on a weekend. If the home appears to be running smoothly on weekend days and in the evenings, as well as during business hours, that is usually a good sign. It is also helpful to visit during a meal time. That way, you can see how the residents are cared for as a group and you can see if they are happy with the food provided.
Activities and events
The activities schedule should be posted. Planned events and the activity level of the residents give an indication of how engaged the residents are and whether the staff encourages meaningful interaction. Keep in mind that residents can choose to abstain from participating in activities.
Staff and resident interactions
Carefully observe how the staff and the residents relate to each other. By paying attention to the way the workers interact with the residents, you can determine if the staff is caring, sensitive and responsive to the needs of the residents. Another indication of the relationship between the staff and the residents is the appearance of the residents. Just as the appearance of the home indicates whether it would be a nice place to live, the appearance of the residents shows whether they are well-groomed, dressed appropriately and cared for by the staff.
Talking to current residents
Residents can be an excellent source of information about life in the nursing home, if they are available and willing to talk. Also, visiting family members of residents can also offer their impressions of the facility and its staff.
If possible, you may also want to attend a resident council meeting. Nursing homes are required to allow residents to form resident councils to address issues that affect them. In some homes, resident councils include family members. The administrator or the social services director should be able to tell you how to get in touch with the resident council to determine if you may attend a meeting.
Meeting with the staff
After visiting unannounced, it would be wise to arrange a mutually convenient time to meet with some of the staff. Those at the nursing home with whom you want to meet are the administrator, the director of nursing and the social services director. These members of the staff should be willing to meet with you to go over the home's policies. The staff should also be willing to discuss the home's inspection reports openly and honestly.
Nursing Home Regulations
Georgia nursing homes are regulated by the government in two ways. First, nursing homes obtain their licenses from the Department of Human Resources' Office of Regulatory Services (ORS). Then, the Centers for Medicare and Medicaid Services (CMS) and the Georgia Department of Community Health certify and reimburse nursing homes participating in Medicare and/or Medicaid programs.
To be licensed or to receive Medicare or Medicaid reimbursements for services, nursing homes must meet and maintain certain minimum requirements found in federal and state regulations, which promote and protect the health, safety, welfare and rights of residents.
To ensure compliance with both federal and state regulations, the ORS staff inspects nursing homes. Generally, the ORS staff inspects a nursing home before it begins operation and then once every year. If violations or deficiencies are found, the ORS inspector makes a record of the infractions. The nursing home must then file a plan of correction demonstrating how it will correct each violation. After receiving the plan of correction, the ORS staff usually conducts a follow-up inspection to make sure the nursing home has remedied the deficiencies.
During an inspection, the ORS staff looks at the care given to a representative sample of residents at the home. They do not inspect the care given to every resident, but they do look at the physical condition of the home, they talk with residents and staff, they observe the activities at the home and they review medical records.
If the ORS staff inspector finds that a nursing home is not meeting regulatory requirements at any time, the government can revoke the home's license and reimbursement or impose another sanction, such as a fine. Any imposed sanctions against a nursing home are based upon the deficiencies recorded in the inspection reports.
The ORS makes and keeps three types of inspection reports that provide important summary information on how well nursing homes comply with regulatory requirements. These reports are the Medicare/Medicaid Statement of Deficiencies and Plan of Correction, the Report of Licensure Inspection and the Complaint Investigation Report.
The Medicare/Medicaid Statement of Deficiencies and Plan of Correction and the Report of Licensure Inspection identify each violated regulation as a deficiency. For every deficiency, a summary of the facts detailing how a particular regulation was violated is provided. The home's plan of correction is also detailed. If the facility disagrees with the cited deficiency, it may dispute the findings.
If a complaint is made against a nursing home, the ORS staff will investigate the allegations and make a Complaint Investigation Report. If no violations are found, a report is still made to reflect what steps were taken to investigate the complaint.
All inspection reports and cover letters accompanying them are public information. Any person may read these reports and obtain copies of them. These reports offer a great deal of insight to a person in the process of selecting a nursing home.
The ORS also provides lists of all nursing home facilities during the past month. The list should detail whether any deficiencies were found. Information on obtaining these documents are listed at the end of this pamphlet.
Interpreting Inspection Reports
The statement of deficiencies and plan of correction
For nursing home facilities receiving Medicare or Medicaid, the Statement of Deficiencies and the Plan of Correction form (2567) shows violations based on failures to meet certain regulations.
To read the form, start on the left side with the identification number used by inspectors (ID Prefix Tag Number). The federal regulation violated is cited next. Then, there is a summary of the topic of the regulation. Finally, the summary of facts supporting the deficiency finding appears under the citation to the regulation.
On the right side of the 2567 is the home's plan of correction for each deficiency. A statement disputing the deficiency may also be there as well.
The nursing home federal regulations are found in the Code of Federal Regulations (42 C.F.R. Part 483). The Code may be found in law school libraries, the State Law Library in Atlanta and online at the Government Printing Office website (www.gpo.gov).
The report of licensure inspection
This report has a format similar to that of the 2567. However, it also contains deficiencies based upon a facility's failure to meet state licensure regulations. These reports are made for every nursing home licensed in Georgia, regardless of whether they receive Medicare or Medicaid.
How to Use the Reported Information
To make good use of the inspection reports, be sure to look at several items. It is important to pay closest attention to those aspects of the report that deal with the health, safety and welfare of residents.
Seriousness of deficiencies
The severity of a deficiency or violation is an indication of the harm that could come to residents. Likewise, the number of deficiencies and the number of residents adversely affected by them give an indication of how widespread problems are in a particular home.
While all nursing home regulations are important, some are more directly related to health, safety and welfare of residents. For example, it would be of greater concern to find a problem with medication errors in a facility than one with failure to keep patient statistics properly, as administrative requirements are not directly related to patient care. Also, close attention should be paid to violations of regulations that are designed to protect patients' rights.
Further, if a nursing home facility has had fines or other sanctions imposed against it or if it has been threatened with license revocation or decertification by Medicare or Medicaid, you should carefully consider those infractions.
Plan of correction
A facility's plan of correction sheds light on its ability and willingness to solve its internal problems and provide good care for residents. If a nursing home has been cited repeatedly for the same or similar deficiencies in the past, its commitment to addressing and fixing its problems should be questioned. This is especially true if the facility files a similar plan of correction in response to the violation each time. If a facility is cited over and over for numerous or serious deficiencies, this may indicate real problems within the home.
Isolated events or widespread problems?
It is rare to find a nursing home with no deficiencies whatsoever. So, whether a deficiency is a one-time or a common occurrence is of particular importance. Isolated events that have been addressed through a well-thought plan of correction indicate a high level of responsiveness on the facility's part. Problems that present themselves repeatedly and problems that have the potential to become larger as time progresses are an indication of pervasive issues within the facility.
For example, if a facility is short staffed, improper care may be or may become widespread throughout the home. As another example, a medication error rate of 16 percent reflects a broad and potentially extremely serious problem that could affect a large population within the facility. However, while a medication error rate of 6 percent should not be ignored, it is important to note that this rate is just one percentage point over the allowable federal regulation error rate of 5 percent.
Obtaining Inspection Reports
A facility receives copies of every 2567 and Report of Licensure Inspection that the ORS makes. Each nursing home is required by law to post its latest 2567 in visible places and make it available upon request. If the last report is not posted in a readily visible place, this should raise questions about whether the facility is trying to hide its record.
The ORS keeps copies of all federal and state inspection reports for at least three years. Any interested person can review the reports and obtain copies from the ORS by sending a written request. The request should clearly state what records are sought. The ORS may charge a reasonable amount to cover copying costs. Similarly, the CMS keeps copies of 2567 reports and must make them readily available upon request. Before releasing any records, the ORS and CMS are required to delete information that would invade a person's privacy, such as names and medical conditions.
Additionally, the federal deficiencies cited in the most recent annual inspections are reported online at www.medicare.gov by selecting the "Compare Nursing Homes in Your Area" search option. Local Social Security Administration and Departments of Family and Children Services offices also have copies of reports.
After a Home is Selected
Once you have made the visits, talked with the staff, inspected the reports and selected your facility, it comes time to discuss any final questions or concerns you may have. Also, once you move in, it is important to have your family and friends visit as often as possible and at different times. By doing this, you and your loved ones will be able to see the kind of care you are receiving. Also, it will demonstrate that you, your family and your friends will notice should something go wrong.
Some residents may be afraid to voice concerns or questions for fear that they would be causing trouble. They may be worried about retaliation if they ask too many questions or complain too much. But, at all times remember that you should feel free to ask questions and express concerns to the administrator, the director of nurses or any other supervisory staff members. Nursing home facilities are prohibited by law from retaliating against residents. There are also outside resources available to look into concerns and complaints on behalf of a resident without revealing the identity of the person who made the complaint. These resources can also help with general questions. These outside resources are the Long-Term Care Ombudsman Program and the ORS.
The Long-Term Care Ombudsman
The Long-Term Care Community and State Ombudsmen take complaints, investigate the complaints and attempt to resolve the problems on behalf of the residents. Whenever possible, the ombudsmen use informal means in attempting to resolve complaints. Though the ombudsmen has no regulatory authority, they are very effective and helpful advocates for nursing home residents.
The Office of Regulatory Services (ORS)
The ORS is another useful resource for nursing home residents and their families. As discussed above, the ORS has a legal duty to investigate complaints and require facilities to take corrective actions to remedy deficiencies.
It is important to note that if ever you make a complaint with the ORS, you should follow up with the office to determine the outcome. You will want to know if the complaint was deemed valid. If so, it is beneficial to find out what action the ORS took to ensure that the facility corrected the identified problem. If the complaint was found to be invalid, it is still helpful to know what actions were taken by the ORS to investigate the complaint.
Before the ORS staff can discuss the findings of an investigation with anyone other than the resident involved or the resident's representative, they must have the resident's permission.
To find out more about your local Long-Term Care Ombudsman Program, contact the Georgia Long-Term Care Ombudsman Program, the Legal Services Developer or your local Georgia Legal Services Program. You may receive additional assistance by contacting your local Department of Family and Children Services office.
To assist you with any questions or concerns you may have regarding nursing home residency, please contact the resources listed below for assistance and information.
Georgia Long-Term Care Ombudsman Program
Division of Aging Services
2 Peachtree St. NW, Suite 9385
Atlanta, GA 30303-3142
Office of Regulatory Services
Long-Term Care Section
2 Peachtree St. NW, 31st Floor
Atlanta, GA 30303-3142
404-657-5850 or 1-888-454-5826
Centers for Medicare and Medicaid Services
Atlanta Federal Center
61 Forsyth St. SW, Suite 4T20
Atlanta, GA 30303-8909
This pamphlet was prepared by the Elder Law Committee of the Young Lawyers Division of the State Bar of Georgia as a public service. It is not intended to be a comprehensive statement of law. Its purpose is to inform, not to advise on any specific legal problem. If you have specific questions regarding any matter contained in this pamphlet, you are encouraged to consult an attorney.