CHECKLIST FOR EVALUATING SENIOR FACILITIES
Evaluating senior facilities can be daunting. It is best done before you need to move. Long before you need a nurse on staff or on call, you may need more care than can reasonably be provided at home.
Some facilities you visit may not offer all types of living arrangements or levels of care in this checklist. Continuing care retirement communities (“CCRCs”) offer multiple levels of care. They require an upfront deposit, part or none of which may be refundable, and may or may not have a benevolent fund, promising not to kick you out if you are reduced to applying for Medicaid. These questions and the financial stability of any CCRC must be examined carefully. Also be aware that while the CCRC may offer independent, assisted and skilled nursing, there is no guaranty that a bed in an assisted living or skilled nursing unit will be available when you need it. The CCRC may also require that you use its affiliated home health agency, which may not provide what you need.
Some facilities, regardless of the level of care they may provide, do not accept Medicaid. Some accept neither Medicare nor Medicaid. Some may not be approved by your private insurer. These are important considerations.
Download a copy of this checklist for each facility you visit. Take it with you.
LIFE AT ____________________
What services and assistance are provided?
Is any of this at an additional cost? If so, what are the costs?
Which of your doctors comes here?
Which do not?
How would you get to your doctors, your dentist, your ophthalmologist or other medical providers?
Would someone accompany you to take notes?
If so, who? How much would you pay? $_______________
Would they share information from and with this facility?
If so, how?
How would your doctor’s observations and recommendations be communicated?
Even very expensive Continuing Care Retirement Communities (“CCRCs”) may have an arrangement with one general practitioner or internist and perhaps a geriatric psychiatrist who come to the CCRC. All residents must see this person or make their own arrangements to see someone else, just as they must to see another specialist. Some doctors, nurse practitioners, dentists and lawyers do make house calls.
Will you be allowed to remain in independent living while receiving some help with medication management and “activities of daily living” (bathing, dressing, toileting, continence, moving from one position to another [“transferring”] getting sufficient nutrition and hydration)?
If so, which activities?
If so, who provides this help?
Is there a cost? If so, what? $_________________
Are you allowed to hire people from outside to help?
If so, who?
How much would it cost? $___________
What is the entrance fee? $_______________
What is the monthly charge? $_____________
What does it include?
Is the payment all inclusive, a la carte, based on service level? ____________________
How is it determined?
If this is part of a CRCC, are people living in Independent Living at the CRCC given a waiting list preference?
If this is part of a CCRC, what help could you receive in Independent Living while waiting for a place in assisted living?
What is the certified nurse’s assistant (“CNA”) : patient staffing ratio at different times of day?
How is medication dispensed?
When are R.N.s present? On call?
Is a physician on call? If so, when?
Can you hire whomever you want or are you restricted to the assisted living facility’s affiliated home health agency?
Will your bed/room/apartment be held if you enter a hospital, rehabilitation or nursing facility? If so, for how long?
What happens if you decide to enter a facility somewhere else?
If this is part of a CCRC, is there an additional entry or monthly fee? If so, how much?
What is the staffing at different times of day and on weekends?
What services are provided?
What is the physical layout like?
Are people moved from one room to another? If so, why?
What is the written policy on administering psychotropic drugs?
Most of us go directly to a nursing home from our own home. The average nursing home stay is two years; 20% of nursing home stays are for more than 5 years. Many of us die in a nursing home.
For those of us who go for “rehab” following a three night inpatient hospitalization, stays are generally about 30 days (21 at Green House nursing home “cottages.”) Most last no more than 90 days, too short to trigger payment under most long-term care insurance policies. For these stays, Medicare pays without a co-pay for the first 20 days (and with a $197.50/day co-pay for another 80 days).
Visit and talk with people who live there and with their families. Consider attending a meeting of the resident’s family committee. Also look at
If the nursing home is part of a CCRC, is there an additional entry, monthly or daily fee for the nursing home? If so, how much?
Are private rooms available? If so, are they only available if “medically necessary”? What is the additional cost?
What is the additional cost?
How many Medicare beds are available?
What is the turnover? How does that relate to Medicare payments?
How many Medicaid beds are available?
How long can you afford private pay at current rates?
How are nonprescription medicines, disposable items, communication and entertainment devices and other personal needs such as lotions and booties paid for?
Medicaid permits a person to keep only $75/month for these; the VA adds $90. Medicaid planning before or early in retirement is ideal. After entering a nursing home but before applying for Medicaid other, more limited planning can be done.
If there is no bed (or no Medicare or Medicaid bed) available, what arrangements are made?
If you enter a hospital or rehabilitative facility, how long will your bed be held?
How can you move between the nursing home, assisted and independent living?
What is the CNA/patient staffing ratio during the day? in the evenings? at night? on holidays?
How is medication dispensed?
What is the L.V.N./patient staffing ratio during the day? in the evenings? at night? on holidays?
Is there an R.N. present? When?
Is there an R.N. on call? When?
Is there a physician on call? When?
What is the staffing hierarchy?
Generally speaking, the fewer levels and more autonomy, the better and less expensive the facility.
What is the CNA absentee rate? What is the turnover rate?
Nursing homes typically have a high CNA absentee rate and a 100-170% turnover rate.
Are you permitted to hire a private duty nurse?
If so, how much would that cost?
Continuing Care Retirement Community
What is the provider’s background and experience? “Sponsorship” by a church or other nonprofit does not equate to legal control or financial responsibility.
Is the provider financially strong? Does the facility have sufficient financial reserves? Be sure to have a professional review the financial, actuarial and operating statements.
Are all levels of care state licensed?
How does the facility assure quality of care?
What is the entrance fee? What is the monthly fee? How can it be increased? What happens when you can no longer pay? Is there a benevolent fund? How does it operate?
What, specifically, is included? How might this change?
Is there a residents’ association? What are its powers?
Is there a Families’ Council? How does it operate? Talk with some members.
Is there a Residents’ Council? How does it operate? Attend a meeting.
How are complaints, disputes and requests for exceptions handled?
What choice do you have about your unit and how it is furnished or decorated?
Will your unit or payments change if you marry, divorce, become widowed or have a friend or family member move in?
What happens if you and your spouse require different levels of care?
Does hospice care involve additional costs? If so, what?
Are there facility requirements for receiving hospice care?
Previously Medicaid hospice services were only provided to a person whom a doctor certified could be expected to live no longer than six months. Now it is recognized that certain progressive diseases, such as ALS and Parkinson’s, have no clear progression timeline. Medicaid also no longer always requires giving up “cure” to receive pain management and related palliative care, including hospice.
What services does this hospice provide?
Some include companionship, a chaplain, and counseling for the family continuing for up to 13 months after the person’s death.
Do hospice workers come to you and follow you through various levels of care?
Long-Term Care Insurance
Is the facility currently licensed for the type of care covered by the policy in the bed and building in which you would reside? (check www.dads.state.tx.us)
Is it also licensed for the bed and building in which you might reside in the future?
Does it provide the R.N. availability required by the policy in the bed and building in which you would reside? (get this in writing)
In which you might reside in the future? (get this in writing)
If your policy covers home health care, does it include or exclude locations at the facility where you would reside now or might reside in the future? For example, does it limit home health care to “your own home” and exclude “assisted living”? What does the policy provide regarding “assisted living” or “independent living” or “facility?”
How does this fit with this facility’s rules?
Before signing any facility contract, get specific, written pre-approval from your long-term care insurer including a doctor-specified plan of care and the number of hours or visits and amount of money the insurer will reimburse, including payment terms. Make sure that it is just what the doctor ordered and that it can be easily and quickly changed to meet your changing needs.
The written contract governs, not what you are told. Read it carefully, twice.