The holiday season brings families together. Sometimes when family members arrive in Naples to see their aging parents, they are surprised to find their parents in need of critical medical care. Hospitalizations may lead to nursing home admissions. Family members should be knowledgeable about nursing home admission laws as well as nursing home discharge laws.
Medicare recipients admitted to the hospital for three nights who subsequently need rehabilitation will be able to receive Medicare services in a nursing facility.
Families should review the state survey results of the facilities when making a decision about appropriate placement. Facilities may be compared at the website for the Agency for Health Care Administrationregularly reviews and rates long-term care facilities. In addition family members should visit the proposed facilities and observe staff interact with patients, observe activity levels of the patients and interview the director of the facility.
The first twenty days in a nursing home (following a qualifying hospital stay) are covered 100 percent by Medicare. Subsequent days are subject to a co-pay. Therapy should be provided if the therapy improves the resident’s condition, maintains the resident’s condition, or slows the decline of the resident’s condition. Sometimes the facility will discontinue services prematurely out of fear that they will not be reimbursed by Medicare for the therapy. It is important that family members advocate for sufficient therapy pursuant to the rules for the patient in order to insure a maximum outcome. The family needs to be particularly watchful if the facility seems to be applying the wrong standard for discontinuing the therapy. An erroneous but often cited reason to discontinue therapy is that the “patient has plateaued.” The maximum Medicare benefit for nursing facilities services after a hospitalization is 100 days. Patients and their families should be aware that the decision to discontinue therapy under Medicare may be appealed.
Nursing homes cannot require that a family member personally guarantee a patient’s payment as a condition of admission, nor can they require that a patient waive his or her right to apply for Medicaid when eligible. Family members should be cautious about signing as “responsible party” as such designation may be deemed to be a personal guarantee.
Once a patient is admitted, Florida and Federal Law provides only five valid reasons for discharge:
• the patient’s health has improved such that the resident no longer needs the services provided by the facility
• the safety of other individuals is endangered
• the health of individuals in the facility would be otherwise endangered
• for non-payment after reasonable notice
• the facility ceases to operate.
Non-payment does not occur when a patient’s payor source changes as long as the patient has provided all written documentation needed for an alternate payor source (Medicaid) to approve payment and has paid all required co-pays under the program.
A nursing home must complete a full assessment of the resident’s condition within 14 days of admission and must hold the first care plan meeting within seven day of the full assessment. Every three months thereafter, the facility must hold a care plan meeting. The care plan is prepared by a team that includes the resident’s doctor, a registered nurse, and other nursing home staff members. The resident, the resident’s legal representative and/or am member of the resident’s family should be included at the care plan meeting. A meaningful care plan should address the individual needs and preferences of the resident. The family members should think creatively about what the resident may need or would appreciate. The family should assert the desires of the resident and to the extent that they are reasonable, the facility should comply. Once the care plan is in place, the family can use it as a guide to insuring appropriate care is given.
Having a good experience at a nursing home requires the family to be vigilant about advocacy and generous with communication about the needs and desires of the patient. Most of the staff in the facilities genuinely care for the well being of the patients but care is sometimes less than optimal when family members are not present to make the patient’s wishes known. Patients and families should not be afraid to be assertive in their quest for good care.