Selecting a Nursing Home

Introduction
Making the decision to enter a nursing home and then choosing the right one can be difficult. This brochure gives some suggestions for selecting a nursing home and for seeing that residents receive good care once they have moved in.

It is important to know that nursing homes are regulated by the state and federal governments. Because regulatory records give objective information about how well nursing homes comply with legal requirements, this brochure concentrates on using those records as a tool in making an informed decision. It also points out some other easy and practical things to do before selecting a nursing home.

Before Selecting a Nursing Home, Visit It
It is a good idea to visit any nursing home under consideration. Make unannounced visits during visiting hours during the different shifts of duty. Typically, shifts are from 7 a.m. to 3 p.m., 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. (visiting hours usually are not observed during this last shift). It is also a good idea to visit the home on a weekend day as well as on a weekday. It usually is a good sign if the home appears to be running smoothly on weekend days and during evening shifts. It also might be helpful to visit during one of the meal times. This way you can see how the residents are cared for as a group and see if residents are happy with the food.

There are several things to look at during visits to nursing homes. The activities schedule should be posted. Planned activities and the activity level of the residents give an idea of whether residents are engaged in meaningful activities or just sitting around. Keep in mind, however, that residents are free to choose not to participate in any activity. By observing the interactions between staff and the residents, you can see whether the staff is caring, sensitive and responsive to the residents.
The appearance of the residents shows if they are well-groomed and appropriately dressed by the staff. The appearance of the home itself shows whether it would be a nice place to live.

If residents and their families or visitors are available and willing to talk, they can be a very good source of information about the home. Another way to find out what the residents and their families think about the home might be to attend a resident council meeting, if possible. Nursing homes are required to allow residents to form resident councils to address any issues that affect them. In some homes, resident councils include family members as well. The administrator or social services director of the nursing home should be able to tell you how to get in touch with the resident council to see if you can attend a meeting.

After visiting the home unannounced, it would be a good idea to arrange a mutually convenient time to meet with some of the staff. Some important staff at the home are the administrator, the director of nursing and the social services director. They should be willing to meet with you and go over the home's policies. The staff also should be willing to discuss the home's inspection reports (discussed below) openly and honestly.

When visiting a nursing home, it is important not to interfere with the care being given by the staff. It is also important to respect the residents' right to privacy.

Understanding How Regulation of Nursing Homes Works
The government regulates nursing homes in Georgia in two ways:

• The State Department of Human Resources' Office of Regulatory Services (ORS) licenses nursing homes; and
• The Centers for Medicare and Medicaid Services (CMS) and the Georgia Department of Community Health (DCH) certify and reimburse nursing homes that participate in the Medicare and/or Medicaid programs.

To be licensed or to receive Medicare or Medicaid reimbursement for services, nursing homes must meet and maintain certain minimum requirements found in federal and state regulations. These regulations are designed to promote and protect the health, safety, welfare and rights of nursing home residents.

To see whether nursing homes meet the requirements of both the federal and state regulations, ORS inspects them and makes records of its inspections. Typically, ORS inspects nursing homes before they begin operation and one time per year after that. If ORS staff find violations (also known as "deficiencies") during an inspection, they make a record of the violations found. The nursing home then must file a plan of correction (POC) to show how it will correct each violation. After receiving the POC, ORS staff usually will conduct a follow-up inspection to see if the nursing home made the corrections.

During an inspection, ORS staff look at the care given to a representative sample of the residents at the home. They do not look at the care given to each resident. ORS staff will look at the physical condition of the home, talk to residents and staff, observe activities at the home, review medical records, etc.

If ORS finds that a nursing home does not meet regulatory requirements at any time, the government can revoke the home's license and reimbursement, or impose another sanction, such as a fine. Any sanctions imposed against a nursing home are based upon the deficiencies shown in the inspection reports.

Inspection Reports
ORS makes and keeps three types of inspection reports that provide important summary information on how well nursing homes comply with regulatory requirements: the Medicare/Medicaid Statement of Deficiencies and Plan of Correction (also known as a 2567); the Report of Licensure Inspection; and Complaint Investigation Reports.

The first two reports vary in length depending upon the number of deficiencies cited in them. They identify each regulation violated as a deficiency. For each deficiency, a summary of the facts that show how the particular regulation was violated is given. In addition, the reports show the home's plan of correction. If the home does not agree with any deficiency cited, it may dispute the findings.

ORS staff also investigate complaints against nursing homes. If they find any violations, they will note them on the 2567 and Report of Licensure Inspection. Additionally, they will make a Complaint Investigation Report. If they do not find any violations, they will still make a Complaint Investigation Report showing what they did to investigate the complaint.

The inspection reports and cover letters accompanying them are public information. That means any person can look at them and get copies of them. The reports can be very valuable tools to assist in making a decision when selecting a nursing home.

Also, ORS will provide a list of all homes inspected during the past month. The list should show whether deficiencies were found. See page 9 of this brochure for information about where to get these documents.

Interpreting Inspection Reports
Statement of Deficiencies and Plan of Correction (2567)
For nursing homes that receive Medicare or Medicaid, the Statement of Deficiencies and Plan of Correction form (2567) shows deficiencies based on a home's failure to meet federal regulations. It starts on the left side with an identification number for use by inspectors (the ID Prefix Tag number). The citation to the federal regulation that was violated follows. Next is a summary phrase of the topic of regulation. (The federal regulations are in 42 C.F.R. Part 483. The C.F.R. can be found at law school libraries, at the State Law Library in the Judicial Building across the street from the Capitol in Atlanta and online at the Government Printing Office Web site, www.gpo.gov).

Finally, a summary of the facts supporting the deficiency finding appears under the citation to the regulation.

On the right side of the 2567 will be the home's POC for each deficiency. A statement disputing the deficiency also may appear here. An example from a page of a 2567 follows.
 

This example shows that the nursing home was cited for a deficiency related to serving food at improper temperatures. By serving food at tepid temperatures, the nursing home violated the federal regulation found at 42 C.F.R. Section 483(d)(2). This regulation requires that the home provide food that is palatable, attractive and at the proper temperature. ORS staff checked the food on ten plates and talked to residents before it concluded that tepid or cold food was a problem in the facility.

Report of Licensure Inspection
The Report of Licensure Inspection is similar in format to the 2567. However, it contains deficiencies based upon failure to meet state licensure regulations. These reports are made for all nursing homes licensed in Georgia, whether or not they receive Medicare or Medicaid.

Using the Information Contained in the Reports
To make good use of the inspection reports, it is important to look at several items. The seriousness of the deficiencies is an indication of the harm that could occur to residents. The number of deficiencies and the number of residents actually affected or that could be affected give an idea of how widespread problems in the home are.

Whether the plan of correction seems likely to bring about lasting correction of the problems indicates the home's ability and willingness to solve its problems and provide good care. If a nursing home has been cited for the same or similar deficiencies before, its ability or willingness to solve its problems should be questioned. This is especially true if it files a similar plan of correction each time. If the nursing home has been cited time and again for numerous or serious deficiencies, this may indicate real problems at the home.

While all of the regulations governing nursing homes are important, some are more directly related to the health, safety, welfare and rights of residents than others. For example, it would be of greater concern to find a problem with medication errors than one with failure to keep patient statistics (an administrative requirement that does not relate directly to patient care). Pay particular attention to whether regulations designed to protect resident's rights have been violated. Residents' rights deficiencies are indicated as such on the inspection reports.

Another important consideration is whether any particular deficiency is widespread or is an isolated event. In the example discussed, cold food was a problem in close to one third of the trays checked. It is important to keep in mind that only a representative sample was checked, however. Some deficiencies have the potential, by their very nature, to affect a large number of residents. For example, if a home is short staffed, improper care may be or become widespread. As another example, a medication error rate of 16 percent reflects a widespread and potentially very serious problem affecting a large number of residents in the nursing home. An error rate of six percent, although a problem that should not be ignored, barely makes it as a deficiency since federal regulations allow a five percent medication error rate.

You should be aware that it is not uncommon to see the same act or conduct on the part of a nursing home violating several different regulations. Therefore, the number of deficiencies or the number of pages of the report alone is not enough to make a conclusion about the care being given at a home. Also, it is rare to find a nursing home with no deficiencies whatsoever.

If a nursing home has had fines or other sanctions imposed against it or if it has been threatened with license revocation and/or Medicare or Medicaid decertification, you should consider those facts carefully.

Getting the Inspection Reports
The nursing home receives copies of each 2567 and Report of Licensure Inspection that ORS makes. The home is required by law to post its latest 2567 in visible places and make it available upon request. If its latest report is not posted in a readily visible place, you should question whether the home is trying to hide its record.

In addition, ORS keeps copies of all federal and state inspection reports for at least three years. Any person can look at the reports and get copies from ORS by making a written request. The request should make clear which records are sought. ORS may charge a reasonable amount to cover copying costs. CMS also keeps copies of the 2567 and must make them available to anyone who requests them. The federal deficiencies cited in the most recent annual inspection are reported on the Internet at www.medicare.gov by selecting "Nursing Home Compare." Reports are also available at the local Social Security Administration offices and at the local Department of Family and Children Services (where Medicaid applications are made). The addresses for ORS and CMS are found on page 9 of this brochure.
Before ORS or CMS can release any records, it must delete patient names, medical information and other information which would invade any person's privacy or that otherwise is required by law to be deleted.

Once You Select a Nursing Home, Follow Up With Any Concerns

Discuss Concerns with Staff
It is important for family, friends and others to visit as often as possible. It also is a good idea to visit at different times. By doing this, you are able to see for yourself the care being given. Also, you show the nursing home that you will notice if something goes wrong. You should feel free to ask questions and express concerns to the administrator, director of nurses or other supervisory staff.

Some people may be afraid to "cause trouble." They may fear retaliation if they ask too many questions or complain too much. Nursing homes are prohibited by law from retaliating against residents. There are outside resources that can look into concerns and complaints on behalf of residents without revealing the identity of the resident or the person who made the complaint. They also can help with questions of a general nature.

Discuss Concerns with an Ombudsman
One such resource is the long-term care community or state ombudsman. Ombudsmen take complaints, investigate them and try to resolve them on behalf of residents. Whenever possible, the ombudsmen use informal means in attempting to resolve complaints. Ombudsmen have no authority to require nursing homes to do anything, but they can be very helpful advocates for residents.
The address and telephone number of the state long-term care ombudsman is found at the end of this information.

File a Complaint with ORS
Another resource is ORS. As discussed above, ORS has a legal duty to investigate complaints and to require nursing homes to take action to correct deficiencies.

Follow Up with the ORS
If you make a complaint with the ORS, it is important to follow up to see whether the complaint was found valid. If the complaint was found valid, it is a good idea to find out what action ORS took to be sure that the home corrected the problems identified. If the complaint was not found valid by ORS, it still is a good idea to find out what ORS did to investigate the complaint. ORS should be responsive to any questions about its findings contained in any investigative report. Before ORS staff can discuss the findings of any complaint investigation with someone other than the resident involved, or the resident's representative, they will have to get permission from the resident.

The address and telephone number of the Complaint Unit of ORS is found at the end of this information.

Summary
When selecting a nursing home, there are a few things you can do to be sure you make the best choice possible. Visits to the home under consideration are an essential part of getting an idea about whether a particular nursing home would be a good place to live. It is also important to know how well the home has met state licensing, and if applicable, federal Medicare/Medicaid requirements. This information is available in inspection reports. These reports should be reviewed before selecting any home. Making an informed decision when selecting a nursing home is one of the best ways to see that good care will be received there.
Once a home is selected, it is important for family, friends and others to maintain a presence by visiting as often as possible. If you have any concerns about care or conditions at a nursing home, you should discuss them with the staff of the home, with the state or community ombudsman and/or with the Office of Regulatory Services. Once you raise a concern, it is important to follow up and make sure it is addressed adequately by both the home and the government agencies regulating it.


State Resources
Office of Regulatory Services
Department of Human Resources
Personal Care Home Program
2 Peachtree Street NW, 31st Floor
Atlanta, GA 30303-3167
(404) 657-4076
(404) 657-5726 (complaints)

Office of the State Long-Term Care Ombudsman
Department of Human Resources
2 Peachtree Street NW, 9th Floor
Atlanta, Ga 30303-3167
(888) 454-5826

Legal Services Developer
Division of Aging Services
Department of Human Resources
2 Peachtree Street NW, 9th Floor
Atlanta, GA 30303-3167
(404) 657-5328

Local Resources
Contact the local Long-Term Care Ombudsman Program or the Elderly Legal Assistance Program (for people over 60) by calling the Office of the State Long-Term Care Ombudsman or the Legal Services Developer.

Federal Resources
Centers for Medicare and Medicaid Services
Atlanta Federal Center
61 Forsyth Street SW, Suite 4T20
Atlanta, GA 30303-8909
(404) 562-7400
www.medicare.gov


This information 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.