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Suggested Minimal Guidelines for Nursing Homes or Other Long-Term Care Facilities

by Linda D. Pershall

By Linda D. Pershall. E-mail:

This is a list of guidelines and suggestions for selecting a quality nursing home or other long-term care facility as compiled by medical professionals at L D H P Medical Review Services Corp. This is not a federal or a specific state's standard, but rather a composite of many standards and the experiences of our medical professionals. These suggestions were designed for the public to use in making their personal evaluations of a specific facility. This list was compiled to assist individuals with the process of selecting a long-term care facility. We believe these items should be met before considering any long-term care facility. There are many excellent long-term care facilities, however there are a few that need to be avoided. Please do not be intimidated about "looking" carefully at a facility. Your loved one deserves the best of care. Use this list to assist in the evaluation of a long-term care facility to your personal standards and satisfaction.

The first step in the selection process of a facility is deciding the level of care that is necessary for the person’s needs. The individual’s personal physician would be an excellent resource to assist in making this decision. Other resources that may be helpful are hospital discharge planners, hospital social workers and visiting nurses.

Most facilities describe their care as skilled vs. non-skilled care. This is not a reflection on the level of skill of the staff, but rather a classification of licensed vs. non-licensed staff (licensed practical/vocational or registered nurses vs. non-licensed certified nursing assistants). A non-skilled facility may be supervised by a licensed nurse who is available for emergencies and the care be provided by certified health care workers such as nursing assistants. For someone needing moderate assistance with meals and dressing but not intensive nursing care, this can be quite appropriate as well as cost effective. Before selecting any facility, be sure the individual’s physician agrees that the facility will be able to meet their care needs.

Our suggestions are geared toward skilled facilities but many of these guidelines will also apply and be very appropriate for facilities of a lesser level of licensing.

Our first suggestion is that the facility have valid and current licenses from all state and local licensing agencies regardless of the level of skilled care. Your state health care licensing agency will be able to advise you on this.

Secondarily, does the facility accept Medicare as a payer source? This is important even if this is not your personal payer source as this creates a minimum standard of care that must be met by the facility. This applies primarily to skilled care facilities as non-skilled facilities are usually private pay.

Some basic standards for a facility to follow would be: Does the facility maintain liability and malpractice insurance, regardless of the level of skilled care being provided? Does the facility have a satisfactory referral from local hospitals? Does the facility have a satisfactory referral from local physicians? Does the facility have a satisfactory record with the local health inspectors and government licensing agencies? Ask the facility you are considering if they have a copy of their state inspection on file for you to read. Are there any lawsuits pending, prior malpractice suits or suits for unpaid debts? Are there any mechanic liens or any other types of liens or judgements against the owners of the facility or the facility itself? Check with the local county clerk’s office. Any of these could indicate a management problem or financial problem. Management and financial problems may make the incidence of negligence more likely due to under-staffing and the inability to maintain the facility.

Emergency care provisions need to be addressed: Is there a physician on staff or on call? Is there access to a physician 24 hours a day for emergencies? Is there physician back-up coverage if the first physician is not available? Does the physician maintain regularly scheduled visits at frequent intervals for all residents? All residents should be seen by the physician at least twice a year, even if they are medically stable. If the individual is not medically stable, the frequency of physician visits would need to be increased. Physicians visits may be within the institution or the person may be seen in the physician's office. This would be appropriate for any level of care, skilled or non-skilled.

An equally important emergency question is, are all staff members trained in basic first aid and C. P. R. (Cardiopulmonary Resuscitation) regardless of the level of staffing or licensing? Also, is there an emergency equipment cart in plain view and easily accessible if it is a skilled care facility?

Is there a licensed nurse on duty at all times (RN/LPN/LVN)? Ideally, one RN per shift and one or more LPN/LVNs per shift depending upon the size of the facility. Does the licensed nurse do direct patient care? A licensed nurse doing some direct patient care makes for better supervision of all residents. This applies only to skilled Nursing Home facilities. (see the above explanation).

Some basic questions/areas to investigate in general care would be: Is the facility free of any strong or unpleasant odor? Please, give it the old "take a deep breath and sniff test." You will know if it passes! If it does not pass, suspect a lack of staff to keep the residents clean and/or a lack of appropriate janitorial services. A strong odor is a strong clue to investigate further.

Are the residents clean and dressed in street attire when you tour the facility? Residents need a home-like environment. This is "their home" and not a hospital.

Also tour during a meal. Are the residents well nourished? Is there a staff member present to assist the residents who need help cutting up food, opening containers, etc.? Is the food appealing? Is the amount of food appropriate? Is the meal served in a manner in which you would want your meal served? Are residents who need to be fed receiving assistance in a relaxed and pleasant manner? If the manner is rushed, the residents are at risk of choking or not receiving adequate nutrition. Walk down the halls. Are the bed-bound residents being assisted? Is there sufficient staff to assist all of the residents before their meal is cold?

Other safety issues would include: Are all medications and emergency equipment locked to prevent disoriented persons from gaining access to them? Are there alarms on the exit doors to alert the staff if a disoriented resident wanders off? Are fire and safety codes met? Is there easy emergency escape access and plenty of fire extinguishers, smoke detectors, sprinkler systems, etc.? Also, are the halls reasonably free of clutter in case of an emergency? If the building is multi-level, are there fire escapes for the upper level? Check with the state licensing boards and local fire Marshall to see if safety standards are met.

Another important question is family visitation. Are families permitted to visit freely, including children? Are areas set aside for family visitations in a private setting which would be safe for small children as well as not creating a disturbance to other residents? Are small children welcome and able to visit their elderly relatives (unless medically unwise in a particular situation)? Are families encouraged to visit during and participate in activities such as Bingo night? An excellent way to assess the quality of care is to visit at an unexpected time to "catch" any irregularities. Visitations that need prior arrangements are a "red flag" that the institution’s quality is questionable. We stress that frequent, random family/friends visitations are an important safeguard for quality care.

Does your loved one have a diagnosis of Alzheimer's disease? The facility under consideration should be set up specifically for that disorder. The facility should have staff members familiar with the unique needs of the Alzheimer's patient. The setting should have specific physical safeguards in place, alarms on exits, locked supply areas, locked medication cabinets, etc. The physical environment needs to be more simplified for Alzheimer's patients as well. There also needs to be an increased ratio of staff members to residents to allow for more personalized supervision. Is the facility you are considering familiar with recent Alzheimer’s developments and treatments? There are unique therapies geared specifically to the needs of the Alzheimer’s patient and their family.

If this list is satisfactory, there is a supplementary list to utilize in your selection process as well as a list of alternatives to nursing home placement available on our Internet site at