Delaware County Office of Services for the Aging

Long Term Care Facilities

Long-term care facilities can be thought of as housing with integrated supportive services. The level of service varies with the type of facility. This section outlines important aspects of the most common types: nursing homes, assisted living facilities and Continuing Care Retirement Communities. For lists of these facilities in Delaware County, contact Delaware County Office of Services for the Aging (COSA) at 610-490-1300.

Nursing Homes

A nursing home is a facility where residents receive round-the-clock nursing care designed to help an individual with the activities and needs of daily living and health care. These residents do not need the kind of acute health care provided in a hospital. A person usually enters a nursing home after all other long-term care options, such as an assisted living facility or living at home with supportive services, are found to be inadequate.

Medicare does not provide substantial coverage for long term nursing home care. Medicare may pay for a portion of the cost for the first 100 days of a nursing home stay, under very limited circumstances. Those circumstances are:

Skilled nursing or rehabilitation services are provided within 30 days of a Medicare- covered hospital stay of more than 3 days;
A doctor certifies the resident’s need for skilled care on a daily basis;
Skilled care is actually received on a daily basis;
The facility is Medicare-approved.

If these requirements are met, Medicare will fully cover the first 20 days of skilled care and a portion of the cost for the next 80 days of skilled care. Note that Medicare does not cover custodial care.

Medicaid is the only public benefit program that covers intermediate or skilled care provided in a nursing home after Medicare benefits are exhausted. See the chapter on Medicaid in this handbook (page 36) for information pertaining to eligibility rights.

Nursing Home Residents’ Rights

Upon admission to a nursing home, a resident or his/her family will be required to sign an admission contract. Entering into a nursing home can thrust a family into emotional turmoil. A prospective resident or the family member or members responsible for the resident might feel pressure under emergency circumstances to sign a nursing home admission contract without a careful review of its terms. Do not be pressured. Read the contract and have it reviewed by an attorney before signing. Federal and state laws have been enacted to protect individuals entering nursing homes and an experienced advisor can make sure that you get the benefit of these protections. For example:

A nursing home cannot require a resident to waive his/her right to apply for Medicaid. Furthermore, a nursing home cannot discriminate against a resident who is receiving Medicaid. Nursing homes must establish and maintain identical policies and practices regarding transfer, discharge and covered services for all residents regardless of source of payment.
A nursing home cannot require a third party guaranty of payment as a condition of admission or continued stay. A nursing home is allowed to require that an individual having legal access to a resident’s income and assets, such as an agent under a power of attorney, sign a contract, without the agent incurring any personal liability, promising only to pay for a resident’s care only from the resident’s funds.
A nursing home cannot require a resident to agree to pay privately for a specified period of time before the nursing home will “allow” the resident to convert to Medicaid. Once admitted to a nursing home, a resident enjoys certain rights mandated by both federal and Pennsylvania law.
For example:
A nursing home must conduct a comprehensive assessment of every resident’s functional capacity within 14 days of admission. This assessment must be used to develop, review and periodically revise, as necessary, an individualized plan of care for each resident. The resident, the resident’s family and, if desired, the resident’s legal representative, must be given full opportunity to participate in the development of the plan of care.
A resident has the right to choose a personal attending physician and to be kept fully informed about care and treatment.
A resident has the right to remain free of physical and chemical restraints which are not required to treat the resident’s medical condition.
A resident has the right to privacy with regard to communications in writing and by telephone and with regard to visits of family and meetings of resident groups. A resident must be provided with reasonable access to the use of a telephone where calls can be made without being overheard.
A resident has the right to access to clinical records upon request by the resident or the resident’s legal representative.
A resident has the right to voice grievances with respect to treatment or care without fear of reprisal.
A resident can only be transferred or discharged from a nursing home under limited circumstances which are spelled out in the law, upon 30 days advance written notice.

A nursing home must inform every resident of his/her legal rights, orally and in writing, at the time of admission. Pennsylvania maintains an ombudsman program to investigate and resolve complaints made by or on behalf of residents of nursing homes and other long-term care facilities. COSA contracts with Horizons Unlimited in Delaware County to be the local providers of these ombudsman services. Your Long Term Care Ombudsman can be contacted 610-566-6248.

Assisted Living Facilities & Personal Care Boarding Homes

An assisted living facility or personal care boarding home is housing for older individuals who need some assistance with the activities and needs of daily living and perhaps some medical help, but who do not need the degree of care provided in a nursing home. The goal of an assisted living facility is to help people live as independently as possible. However, some assisted living facilities are licensed to provide care for residents with severe dementia (Alzheimer’s, for example) in locked units. An important benefit of residency in an assisted living facility is help with medication. A resident can be reminded when to take medication and a nurse can assist the resident in taking medications.

Payment for residency in an assisted living facility is almost exclusively through private arrangements with the resident. Neither Medicare nor Medicaid covers residency in an assisted living facility. If a resident needs some sort of skilled medical or nursing care, Medicare may cover such care under the same rules that would apply to home health care in general. Long term care insurance will pay benefits for residency in an assisted living facility if the policy’s “benefit triggers” requirements are met by a resident’s need for assistance with activities of daily living or by a resident’s cognitive impairment. Most long term care insurance policies define “activities of daily living” as including dressing, eating, bathing, toileting and transferring from a bed to a chair, and usually require that an individual needs assistance with a certain number of these activities of daily living.

Contract Questions

Upon entrance to an assisted living facility, a prospective resident should carefully review the admission contract. Significant issues to consider in evaluating an admission contract include:

What personal care services are to be provided? Who delivers these services? Is the service provider licensed or certified?
What are the monthly or other charges for such services? Are housekeeping services included? How can fees be increased and what happens if fees are increased and a resident cannot afford the higher fee?
In the case of a married couple, what happens upon the death of a spouse? Is a change of living unit required? How would fees be affected?
What recreational or cultural activities are available and are they included with the monthly fee?
Is transportation provided to such things as doctor appointments, shopping and community activities? Is a separate fee charged?
Are nursing services available at the site? What happens if a resident’s health declines? Is the facility responsible for coordinating medical care?
How does the facility determine the point at which a resident cannot be served by the facility? What recourse does a resident have to challenge the facility’s decision? Is there a grievance process?
How does the facility determine the point at which a resident cannot be served by the facility? What recourse does a resident have to challenge the facility’s decision? Is there a grievance process?

Assisted Living Facilities/Personal Care Homes: Residents’ Rights

Under Pennsylvania law, residents of an assisted living facility have many rights, including:

to be treated with dignity and respect;
privacy, including the right to have access in reasonable privacy to a telephone and the right to have uncensored access to the mail;
to receive visitors;
to leave and return to the home;
to participate in religious activities;
to exercise the rights of a citizen and to voice grievances;
to be provided with 30 days advance written notice of the facility’s intent to terminate a resident’s stay and the reason for termination;
to be free of chemical and physical restraints;
freedom from discrimination.

Continuing Care Retirement Communities (CCRC)

Continuing Care Retirement Communities provide different levels of care based on the particular needs of the individual resident. New residents usually move into independent living units. As they age and become physically disabled and need assistance with the activities and needs of daily living, residents move to an assisted living facility located on the grounds of the continuing care retirement community. Some CCRC provide assisted living services in the independent living units so that a resident does not have to move. If physical decline continues and more intensive care is needed, nursing home care is also available within the premises of the Continuing care retirement community. Upon entrance into a CCRC, a resident enters into a contract whereby the continuing care retirement community agrees to provide housing, a certain level of activities and health care support as needed in return for the resident’s payment of an entrance fee and monthly occupancy fees. In most cases, residents do not own their living unit. The services offered can vary; most provide house cleaning, laundry facilities and at least some meals. The monthly fee for residents who move into the assisted living or nursing home facilities may be higher than if they had remained in an independent living unit.

Some Continuing Care Retirement Communities provide in their contract for a refund of all or part of the initial payment when the resident leaves or dies. In these instances there are usually higher charges if assisted living or nursing care becomes necessary. (These costs may be covered by long-term care insurance.)

A careful review of the contract, preferably by an attorney, is advised to make sure the resident understands what they are buying. Some Continuing Care Retirement Communities offer unlimited health services in exchange for the entrance fee, while others provide that residents pay an additional fee for health care services as they are needed. Still others offer a combination of the two. The fee-for-services arrangement is becoming increasingly more common. Other important issues to be reviewed in a Continuing Care Retirement Community contract are:

Who determines when a resident must change living arrangements due to a decline in health?
What are a resident’s rights and responsibilities with regard to furnishing and altering his/her living unit?
Under what circumstances would the entrance fee be refundable?
Under what circumstances can the monthly service fee be increased?
What services are not covered by the monthly service fee?
Pennsylvania law mandates that all Continuing Care Retirement Community contracts:
provide for continuing care;
specify all services to be provided and provide that a resident cannot be liable to a health care provider for services that the continuing care retirement community promises to furnish;
describe any exclusions or limitations on coverage for pre-existing conditions;
provide for termination by either party upon 30 days written notice and the terms for refund upon termination;
contain notice of rescission rights before moving in.
The advantages of living in a continuing care retirement community are:
An individual whose health declines can move into an assisted living unit or, if necessary, to a nursing home within the same residential community.
Payment of the entrance fee locks in a fixed price for continuing care at an amount that is usually less than the market rate for nursing home care. For this reason, some people consider a continuing care retirement community as a form of long term care insurance. However, if there will be a substantial increase in the monthly service fee upon moving into the assisted living or the nursing home portion of the continuing care retirement community, there could still be a need for long term care insurance.
A couple that moves into a continuing care retirement community ensures that, if one spouse must enter the nursing home, the other spouse will be living on-site and can easily visit.

Because a continuing care retirement community comprises both assisted living and nursing home care, different activities within the continuing care retirement community can be governed by different laws and regulations. Residents would be protected by the laws that apply to assisted living facilities while they are receiving assisted living services and they would be protected by the laws that apply to nursing homes when residing in the nursing home component of the continuing care retirement community. See previous sections covering assisted living facilities and nursing homes for a description of these protections.

When you apply to a Continuing Care Retirement Community, the CCRC is required to give you a disclosure statement. Besides the contract terms, etc., described above, the disclosure statement contains a financial report on the CCRC. This also must be reviewed. Your future security depends on the financial stability of the CCRC. For this, too, you should have professional assistance.

A caveat is that Continuing Care Retirement Communities usually require a health review for admission. This is because they offer higher levels of care when needed at below market cost. Therefore, if you plan to move to one of these communities you should act while you are free of major impairments.

Nursing Home Licenses: Problems, Sanctions and Revocations

Although nursing home placement is a difficult decision, there are people to help you to verify that you are placing your loved one in a secure environment. One contact person is the Horizon’s Unlimited Ombudsperson who responds to care issues in all licensed facilities in your county. The telephone number is 610-566-6248. Family members and friends can call the ombudsman on behalf of the nursing home or assisted living home resident.

Any employee or administrator of a licensed facility who has reasonable cause to believe that a resident of the facility is a victim of abuse is required under Pennsylvania law to report the abuse immediately. The law does not require that the reporter be a direct eye witness; having more than a suspicion obligates them to make an oral report at once, followed up by a written report to law enforcement officials. This reporting requirement protects a care-dependent person and applies to all caretakers. Civil and criminal fines and imprisonment for up to one year can be imposed upon the person or facility that commits the violation or abuse.

Pennsylvania law protects nursing home residents by requiring criminal history background checks by the Pennsylvania State Police of all employees of public or private nursing homes, personal care facilities, adult daycare and home healthcare providers. Employees with certain felony and misdemeanor convictions are precluded from working in these facilities.

The final sanction under Pennsylvania state law is that a facility can have its license revoked or its licensing withheld in the first place for any one of the following reasons: gross incompetence, negligence, misconduct in operating the facility or mistreating or abusing an individual cared for in the facility. This sanction applies to both physical and mental abuse of a patient. This law serves as a deterrent to such abuse since the facility cannot do business without a license. Court cases in Pennsylvania have upheld the decision to revoke the license of homes for abuse of patients.

To investigate licensed personal care homes, contact your county’s Department of Public Welfare. To find out about nursing homes, check with your county’s Department of Health. For home health care agencies, call COSA at (610) 496-1300 or 800-416-6248. For nursing home complaints you may call 800-254-5164.

The Pennsylvania Department of Health website, http://www.health.state.pa.us, is another resource that reports the results of surveys and on-site inspections of all long term care facilities in the state. The website contains valuable factual public information. Survey results of complaints and deficiencies are reported for the last 18 months to two years. Constant vigilance and checking of the website is recommended, especially in the event of a change in administration at the facility, which is a frequent occurrence.

Resources

“How To Select Long Term Care in Pennsylvania;” “Benefits and Rights for Older Pennsylvanians”, “Know Your Rights as a Personal Care Home Resident” and “Know Your Rights as a Nursing Home Resident;” Pennsylvania Department of Aging, 717-783-7247. Long Term Care Hotline information on long term care 1-866-286-3636 or gain more information by visiting the Pennsylvania Department of Aging
“Assisted Living: Asking the Right Questions”, “Navigating Your Way to a Quality Assisted Living Facility”, “Family Conversations that Help Parents Stay Independent” and 7 more publications are available from AARP, 888-687-2277. Information is also available on www.aarp.org.
“Finding the Assisted Living Program For You;” Institute for Health Policy, Heller School, Brandeis University, www.brandeis.edu.