elder-helper

How do I research a facility's reputation?

Ok, you think you have found a facility for your mom. (I use the word mom to keep things simple) The hospital has provided
the Nursing home with all of the information it needs to make a decision and the good news is, they are willing to take your
mom into their facility. The next step is to determine if the facility is a quality facility that you would be willing to place your
mom. We got past the 'may we' and now we are to the 'should we?' The 2 most common ways to determine if this home is
worth your time is to take a personal tour and to use the government website nursing home compare.

Let's start with a tour. Personal tours are awesome. I have personally conducted tours and they are actually fun. This is a
process that you do not want to rush. If you follow my insider secrets to nursing homes during your inspection, you will feel
empowered to make the right decision! Tours are usually given by the admissions director, a social worker or a variety of
different staff members, it doesn't really matter who gives the tour as long as they can answer your tough questions. They may
be baffled to see how thorough your questions are!

1. Schedule a tour or show up unannounced? This doesn't matter too much. They are NOT going to tidy up and fix all of their
mistakes just because you are coming in for a tour. Tours happen all the time. Most facilities just wing it. If you want to tour
with a specific staff person, you may want to call ahead but it isn't necessary.

2. Before you arrive, obtain a clip board, printed check list and a good pen. This might sound like I'm going overboard but
this is your mom we're talking about. You can't possibly memorize every question and know everywhere to look. You will
end up missing something. There are good, free check lists available on the web, one example is created by the Federal
government themselves, click here to download a free check list. Points to remember during the tour.
- Speak to other residents during the tour. Get their opinion on the food, room temperatures, staff, etc.
- When you ask questions during the tour, never accept "I'm not sure", "maybe" or "I can tell you later". Get your questions
answered before you leave.
- Ask to see their most recent state inspection survey results. They probably wont let you have a copy but they msut allow
you to read a copy in private. Also, ask if they are currently in 'compliance' after their most recent survey. If not, when do
they plan on being in compliance? Click here to downlaod and print your free nursing home check list.

3. During the tour, pay close attention to the interaction of the staff with the other residents. Do the staff appear caring but
overworked? Do they appear hurried or well organized? Does it appear that there are enough staff?

4. After the tour is finished but before you leave, go over the check list one last time and make sure all of your questions have
been answered. If not, politely say, "I have a few unanswered questions, who should I speak to and what is their phone
extension?" Your check list and questions should be as complete as possible to make the best informed decision.

5. After the tour, go home and read over your check list. What is your gut feeling about the facility? Keep in mind that no
facility is perfect and it definitely is not home. Would you feel comfortable placing your mom there? Do you think she would
be happy there? If yes, give them a call and tell them you wish to place your mom in their facility. If you are unsure, it may
help to tour another facility or speak to friends or relatives that have experience with other, nearby facilities. If you feel it is a
definite 'no' then don't feel bad. There are other facilities. Don't feel rushed. This is not a process that you want to take lightly.

The next option is to use the free government website from CMS called "Nursing Home Compare." Before you follow the
link to the site, a little background information first. CMS stands for "Centers for Medicare & Medicaid services". It is a
division of the U.S. Department of Health and Human Services. It's previous name was HCFA or "Health Care and Finance
Administration." The CMS website is huge. It's beyond huge, it's a monster. You will literally get lost attempting to navigate all
of the menus, submenus, etc. I have made it easy for you by providing quick links and no-nonsense instructions. If you are
interested in the history behind the Nursing Home Compare service and knowing why it may not be as useful as you might
think, click the menu button on the left, "Nursing Home Compare." The CMS website can be buggy at times. If you are
having difficulty connecting, try again in a few hours.

1. Click this link to access Nursing Home Compare.

2. A new window will open to the CMS website. Click the gray button that says 'find and compare nursing homes' in the
middle of the page.

3. On the next screen you will choose your criteria on how you want to search for particular nursing homes. I recommend
searching by zip code.

4. On the next screen is step 2, comparing the actual homes. You can select up to 3 at a time to do a side by side
comparison. Check the 3 that you want to compare and then click the "compare" gray button

5. Under the category "Overall ranking" you will see 4 areas, "health inspections, nursing home staffing, quality measures, fire
safety inspections." Under this you will see the heading, "nursing home characteristics". That area is self explanatory.

6. Health inspections - Click "show information" to uncover the dirt! (notice the date of the inspection, it may be quite old).
Next click "view health inspection details". This report may be disappointing as it does not give specific details. It does
provide some interesting information. Pay close attention to the area to the right entitled, "level of harm" and "residents
affected". This report is different than the one that is given to the Nursing home. The report the nursing home receives uses
terminology that is related more to "potential harm vs. actual harm" and how wide spread the problem is. If you notice levels
of harm in the 1-2 range this could be anything from food that was served cold to paper work issues that have little affect on
the resident's quality of life or safety. If the level of harm is in the 3-4 range and the residents affected is "many", that is a
serious problem. (few usually means 1 resident, some means more than 1 but fewer than 10%, many usually means 10% or
more). Unfortunately, the deficiencies can be very vague like, "Be administered in a way that leads to the highest possible
level of well being for each resident." What the heck does that mean? It could mean 100 different things. The only way to
really know would be for you to schedule a meeting with the Director of Nursing or Nursing home administrator and ask for
specific details in person. Don't bother asking over the phone, they are quite reluctant to give details to just anyone who calls.
If you are sincere and polite, they should have no issue with telling you details of a particular deficiency.

7. Nursing home staffing - click the "show information" button. Here you will find information on the ratio of different staffing
hours to the number of residents. Some things to keep in mind. The number of RN hours includes all the RNs that work at
that facility. Not all RNs provide direct patient care. Most are managers who work behind the scenes. This report does not
differentiate how many RNs work as floor nurses and how many are managers. "total number of residents", this is a snap shot
of a 2 week time period. If the facilities census drops during this period and they do not adjust staffing (as most don't), it may
give the appearance that they are staffed very well but when the census goes back up, the staffing may stay the same and the
ratio is no longer as good as it appears on this report. "CNA hours per resident per day", this may be the most useful and eye
opening statistic. A CNA is a "certified nursing assistant". They provide the most care to the residents. Sadly they receive the
least pay but perform the most difficult work. The time given here, for example "1 hour 29 minutes" is the average amount of
time a CNA spends with each resident per day. The more time obviously, the higher the rating. This does not take into
account the acuity level of the residents. The time may appear average or even good and receive a decent rating. But if the
resident acuity is very high, the quality of care may be low due to the higher acuity level which makes it more difficult to care
for the resident. This is known as a "false positive". If the hours are low, that is a facility you will want to avoid. Low CNA
hours is never good.

8. Quality measures - Click the "show information" button. Boy, I could make a career on this one. Actually, I am! I am a
Registered Nurse Manager in the area of Medicare reimbursement and I am highly involved in generating and using this very
report (quality measures). But enough about me. I will briefly add my 2 cents to some of the categories. On a side note, if you
are a visual person and would like to compare any of these individual measures to other nursing homes in your state and for
the nation, check one measure and then click the gray button "view graphs".
" Percentage of long stay residents that receive the flu and pneumonia vaccination" - the reason this is never 100%
= residents have the right to refuse, and do. Also, some are allergic and are not eligible to take it
" Percentage who's needs have increased" - if this is zero, run the other way. I find it hard to believe that this could ever
be zero.
" Moderate to severe pain" - this does not take into account hospice residents, residents that have cancer, etc. Also, the
resident need only have complained of their pain at a severe level one time in a 7 day period to qualify as severe. Regardless,
this % should be low
" Low risk/high risk who have pressure sores" - unfortunately this does not tell you the severity of the bed sore, stage 1
- 4 with 4 being the worst. It also doesn't indicate for how long they have had one. A bed sore for 48 days is much more
dangerous than 6 days for example.
" Percentage who were physically restrained" - easy for a facility to manipulate this number. A zero does NOT mean
that restraints are not being used. It simply means that it's use is not defined as a restraint by the facility. See my FAQ section
for an explanation.
" Percentage of low risk residents that are incontinent" - this is completely unfair. The criteria for this measure is
unrealistic. You will usually see high numbers in this area. Reasons for incontinence are many; bladder infections,
disorientation, recently removed indwelling catheter, staff slow to answer a call for help, etc. I could go on and on. According
to the Quality measures report, supposed Low risk is defined as "1. do not have a severe cognitive impairment, 2. are able to
participate in any way, whether assisted or not, with bed mobility, transfers and locomotion on the unit." This pretty much
includes just about everyone. Residents are excluded if they are comatose, have an indwelling catheter in their bladder or
have an ostomy." Bladder incontinence includes any time the resident's skin is wet from urine, even if the resident dribbles a
few drops of urine. As you can see, this percentage will always be high. Bowel incontinence can be due to a temporary
illness, reaction to antibiotics or even if an ostomy leaks.
" Percentage of residents who spend most of their time in bed or in a chair" - "in a chair" refers to a chair or recliner
in their room. It doesn't explain it very well but this measure is for residents who spend the majority of their time in their room.
" Percentage of residents who lose too much weight" - again, the report does not take into account residents who are
actively dying (unless hospice is coded), on a weight reduction program, have had a recent amputation, etc. The implication is
that the nursing home is neglecting it's duties and allowing a resident to lose weight.
" Short stay residents with moderate to severe pain" - short stay residents are usually rehab residents who have
typically just had surgery a few days prior to admission to the nursing home and are very likely to have pain. Too much pain
medication will put the resident at higher risk for falls. Too little pain management is not good either, it's a delicate balance. A
high number in this area is not uncommon.
" Short stay residents who have a pressure sore" - this should not happen but it does. This number should be low. This
number excludes residents that are admitted with a pressure sore and only counts those who develop one after admission to
the home.

9. Fire safety inspections - pretty self explanatory, nothing earth shattering here. Just remember that this process can be
subjective from one fire marshal to the next.

10. Nursing home characteristics - some useful information.

If a facility you were considering has a 'one' star rating, you may want to reconsider. Let me offer this disclaimer. The Nursing
home compare website is a good way to see a facilities state survey inspection results. Even if there might not be a lot of
detail, it still will give you some idea where a facility might be lacking. But, in my opinion, don't be turned off to a facility just
because it received only 2 or 3 stars out of 5. To really know if the facility is a place that you would want a loved one to
receive care, you need to tour the facility in person. Ask to see the most 'current' state survey results (they are required to
have a copy handy), ask if they are currently in 'substantial compliance' and if not, what do they plan to do about it and when?
Ask them if they are aware of their 5 star rating and do they feel it accurately reflects their performance? Your gut instinct and
what you witness during a tour are your most valuable tools.

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