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Finding A Nursing Home - The Guide Part 2 - Seniors Long Term Care & Nursing Home Issues - SeniorSite.com
Finding A Nursing Home - The Guide Part 2 - Seniors Long Term Care & Nursing Home Issues - SeniorSite.com
Finding A Nursing Home
The Guide Part 2

Finding A Nursing Home - The Guide - Seniors Long Term Care & Nursing Home Issues - SeniorSite.com Finding A Nursing Home - Nursing Home Information

Public nursing homes are owned by state/local governments.

Note: Voluntary nursing homes are not-for-profit businesses. Proprietary nursing homes are businesses operated for profit.

Advance Directives

A verbal or written instruction plan in advance of incapacitating illness or injury, which ensures that the resident's wishes about treatment will be followed. This includes but is not limited to a health care proxy, a do-not-resuscitate (DNR) order recorded in the resident's medical record and a living will.

Basic Services

Those services included in the daily rate. At the time of admission, a written copy of the following basic services must be made available to all residents:

- the daily, weekly or monthly rate;
- board, including therapeutic or modified diets, as prescribed by a doctor;
- lodging -- a clean, healthful, sheltered environment, properly outfitted;
- 24-hour-per-day nursing care;
- the use of all equipment, medical supplies and modalities used in the care of nursing home residents, including but not limited to catheters, hypodermic syringes and needles, irrigation outfits, dressings and pads, etc.;
- fresh bed linen, as required, changed at least twice weekly, including sufficient quantities of necessary bed linen or appropriate substitutes changed as often as required for incontinent residents;
- hospital gowns or pajamas as required by the clinical condition of the resident, unless the resident, family member or designated representative elects to furnish them, and laundry services for these and other launderable personal clothing items;
- general household medicine cabinet supplies, including but not limited to nonprescription medications, materials for routine skin care, dental hygiene, care of hair, etc., except when specific items are medically indicated and prescribed for exceptional use for a specific resident;
- assistance and/or supervision, when required, with activities of daily living, including but not limited to toileting, bathing, feeding and assistance with getting from place to place;
- services, in the daily performance of their assigned duties, by members of the nursing home staff assigned to resident care;
- use of customarily stocked equipment, including but not limited to crutches, walkers, wheelchairs or other supportive equipment, including training in their use when necessary, unless such items are prescribed by a doctor for regular and sole use by a specific resident;
- activities program, including but not limited to a planned schedule of recreational, motivational, social and other activities together with the necessary materials and supplies to make the resident's life more meaningful; - social services as needed;
- physical therapy, occupational therapy, speech pathology services, audiology services and dental services, on either a staff or fee-for-services basis, as prescribed by a doctor, administered by or under the direct supervision of a licensed and currently registered physical therapist, occupational therapist, speech pathologist, qualified audiologist or registered dentist.

Designated Representative

The individual or individuals designated to receive information and to assist and/or act on behalf of a particular resident to the extent permitted by State law. The representation occurs by a court of law if sought; by the resident if he or she has the capacity to make such a designation; or by family members and others who have an interest in the well-being of the resident. The name of the designated representative must be noted in the residents clinical record at the facility.

The designated representative:

(1) receives any written and verbal information required to be provided to the resident if the resident lacks the capacity to understand or make use of the information, and receives any information required to be provided to both the resident and the designated representative;

(2) participates (to the extent authorized by State law) in decisions and choices regarding the care, treatment and well-being of the resident if such resident lacks the capacity to make decisions and choices. These decisions are not the same as those made by a health care agent unless the same person has been appointed both the designated representative and the health care agent.

Governing Body

The policymaking body of the facility, the board of directors or trustees of the facility or the owner or owners of the facility.

Health Care Agent

Someone appointed by the resident to decide about treatment if the resident becomes incapable of making decisions for himself or herself. The resident has the right to appoint someone by filling out a form called a Health Care Proxy. These forms should be available at the facility, should be kept at the facility and made known to the medical staff.

Health Care Proxy

A document that delegates the authority to another individual known as a Health Care Agent to make health care decisions on behalf of the resident when that resident is incapacitated.

Nursing Home

A facility (subject to State Public Health Law) providing lodging for 24 or more consecutive hours to three or more nursing home residents who are not related to the facility operator by marriage or by blood, who need regular nursing services or other professional services, but who do not need the services of a general hospital.

Resident

An individual who has been admitted to and who resides in a long term care facility (nursing home) and is entitled to receive care, treatment and services required by State law.

Finding A Nursing Home - Nursing Home Inspections

The U. S. Department of Health and Human Services has developed a national process for nursing home inspections to ensure quality care.

This is carried out by the Department of Health.

The state's survey team most often includes a nurse, dietitian, sanitarian and social worker, but other health professionals such as physicians, physical therapists and pharmacists may also participate.

Surveyors spend most of their time evaluating the care and services residents receive.

Surveyors observe meals, drug administration and recreational activities and also speak with residents and their families regarding the treatment they receive and their opinions about the nursing home.

The inspection survey includes the following steps:

- touring the nursing home;
- meeting with staff and administrators;
- meeting with members of the resident council and/or other residents;
- assessing the safety of the building;
- watching medications being given to ensure that the dosage goes to the right person at the right time;
- observing meals to assure that residents' nutritional needs are being met;
- interviewing nursing home residents, examining residents' medical records and observing clinical procedures; and
- summarizing the results of the survey and reporting findings to the nursing home administrator.

Every nursing home receives a copy of the Department of Health's most recent survey report and federal law guarantees the report be made available for inspection by the public.

Finding A Nursing Home - State Agencies That Oversee Care

Following is a list of state agencies that oversee and monitor care.

Housekeeping/Chore Services
Department of Labor

Homemaker Services
Department of Labor

Personal Care Services
Department of Social Services

Home Health Aide Assistance
Department of Health

Certified Home Health Care (CHHA)
Department of Health - non-skilled nursing services

Adult Day Health Care
Department of Health

Enriched Housing
Department of Social Services/State Office for the Aging

Adult Home Services
Department of Social Services/State Office for the Aging

Assisted Living Program (ALP)
Department of Social Services/Department of Health

Certified Home Health Care (CHHA)
Department of Health - skilled nursing services

Long Term Home Health Care
Department of Health Program (LTHHCP)

Long Term Care Facility
(Nursing Department of Health/State Home) Services 0ffice for the Aging

Hospice
Department of Health.

Finding A Nursing Home - Appointing Your Health Care Agent

Proxy Law

A new law called the Health care proxy law allows you to appoint someone you trust - a family member or close friend, to decide about treatment if you lose the ability to decide for yourself.

You can do this by using a Health Care Proxy form like the one presented here, to appoint your " health care agent. " This law gives you the power to make sure that health care professionals follow your wishes. Your agent can also decide how your wishes apply as your medical condition changes. Hospitals, doctors and other health care providers must follow your agents decisions as if they were your own. You can give the person you select, your health care agent, as little or as much authority as you want. You can allow your agent to decide about all health care or only certain treatments. You may also give your agent instructions that he or she has to follow.

Why should I choose a health care agent?

If you become too sick to make health care decisions, someone else must decide for you. Health care professionals often look to family members for guidance. But family members are not allowed to decide to stop treatment, even when they believe that is what you would choose or what is best for you under the circumstances.

Appointing an agent lets you control your medical treatment by:

- allowing your agent to stop treatment when he or she decides that is what you would want or what is best for you under the circumstances;
- choosing one family member to decide about treatment because you think that person would make the best decisions or because you want to avoid conflict or confusion about who should decide; and
- choosing someone outside your family to decide about treatment because no one in your family is available or because you prefer that someone other than a family member decide about your health care.

How can I appoint a health care agent?

All competent adults can appoint a health care agent by signing a form called a Health Care Proxy. You don't need a lawyer, just two adult witnesses. You can use the form printed here, but you don't have to.

When would my health care agent begin to make treatment decisions for me?

Your health care agent would begin to make treatment decisions after doctors decide that you are not able to make health care decisions. As long as you are able to make treatment decisions for yourself, you will have the right to do so.

What decisions can my health care agent make?

Unless you limit your health care agent's authority, your agent will be able to make any treatment decision that you could have made if you were able to decide for yourself. Your agent can agree that you should receive treatment, choose among different treatments and decide that treatments should not be provided, in accord with your wishes and interests. If your health care agent is not aware of your wishes about artificial nutrition and hydration (nourishment and water provided by feeding tubes), he or she will not be able to make decisions about these measures. Artificial nutrition and hydration are used in many circumstances, and are often used to continue the life of patients who are in a permanent coma.

How will my health care agent make decisions?

You can write instructions on the proxy form. Your agent must follow your oral and written instructions, as well as your moral and religious beliefs. If your agent does not know your wishes or beliefs, your agent is legally required to act in your best interests.

Who will pay attention to my agent?

All hospitals, doctors and other health care facilities are legally required to honor the decisions by your agent. If a hospital objects to some treatment options (such as removing certain treatment) they must tell you or your agent IN ADVANCE.

What if my health care agent is not available when decisions must be made?

You can appoint an alternate agent to decide for you if your health care agent is not available or able to act when decisions must be made. Otherwise, health care providers will make treatment decisions for you that follow instructions you gave while you were still able to do so. Any instructions that you write on your Health Care Proxy form will guide health care providers under these circumstances.

What if I change my mind?

It is easy to cancel the proxy, to change the person you have chosen as your health care agent or to change any treatment instructions you have written on your Health Care Proxy form. Just fill out a new form. In addition, you can require that the Health Care Proxy expire on a specified date or if certain events occur. Otherwise, the Health Care Proxy will be valid indefinitely. If you choose your spouse as your health care agent and you get divorced or legally separated, the appointment is automatically cancelled.

Can my health care agent be legally liable for decisions made on my behalf?

No. Your health care agent will not be liable for treatment decisions made in good faith on your behalf. Also, he or she cannot be held liable for costs of your care, just because he or she is your agent.

Is a health care proxy the same as a living will?

No. A living will is a document that provides specific instructions about health care treatment. It is generally used to declare wishes to refuse life-sustaining treatment under certain circumstances. In contrast, the health care proxy allows you to choose someone you trust to make treatment decisions on your behalf. Unlike a living will, a health care proxy does not require that you know in advance all the decisions that may arise. Instead, your health care agent can interpret your wishes as medical circumstances change and can make decisions you could not have known would have to be made. The health care proxy is just as useful for decisions to receive treatment as it is for decisions to stop treatment. If you complete a Health Care Proxy form, but also have a living will, the living will provides instructions for your health care agent, and will guide his or her decisions.

Where should I keep the proxy form after it is signed?

Give a copy to your agent, your doctor and any other family members or close friends you want. You can also keep a copy in your wallet or purse or with other important papers.

APPOINTING A HEALTH CARE AGENT IS A SERIOUS DECISION. MAKE SURE YOU TALK ABOUT IT WITH YOUR FAMILY, CLOSE FRIENDS AND YOUR DOCTOR.

DO IT IN ADVANCE, NOT JUST WHEN YOU ARE PLANNING TO ENTER THE HOSPITAL.

FILLING OUT A HEALTH CARE PROXY IS VOLUNTARY. NO ONE CAN REQUIRE YOU TO DO SO.


About the Health Care Proxy Form

This is an important legal form. Before signing this form, you should understand the following facts:

1. This form gives the person you choose as your agent the authority to make all health care decisions for you, except to the extent you say otherwise in this form. "Health care" means any treatment, service or procedure to diagnose or treat your physical or mental condition.

2. Unless you say otherwise, your agent will be allowed to make all health care decisions for you, including decisions to remove or provide life-sustaining treatment.

3. Unless your agent knows your wishes about artificial nutrition and hydration (nourishment and water provided by a feeding tube), he or she will not be allowed to refuse or consent to those measures for you.

4. Your agent will start making decisions for you when doctors decide that you are not able to make health care decisions for yourself.

You may write on this form any information about treatment that you do not desire and/or those treatments that you want to make sure you receive. Your agent must follow your instructions (oral and written) when making decisions for you.

If you want to give your agent written instructions, do so right on the form. For example, you could say:

If I become terminally ill, I do/don't want to receive the following treatments:...........
If I am in a coma or unconscious, with no hope of recovery, then I do/don't want............
If I have brain damage or a brain disease that makes me unable to recognize people or speak and there is no hope that my condition will improve, I do/don't want..........
I have discussed with my agent my wishes about_________________ and I want my agent to make all decisions about these measures.

Examples of medical treatments about which you may wish to give your agent special instructions are listed below. This is not a complete list of the treatments about which you may leave instructions.

- artificial respiration - artificial nutrition and hydration (nourishment and water provided by feeding tube)
- cardiopulmonary resuscitation (CPR)
- antipsychotic medication
- electric shock therapy
- antibiotics
- psychosurgery
- dialysis
- transplantation
- blood transfusions
- abortion
- sterilization

Talk about choosing an agent with your family and/or close friends. You should discuss this form with a doctor or another health care professional, such as a nurse or social worker, before you sign it to make sure that you understand the types of decisions that may be made for you. You may also wish to give your doctor a signed copy. You do not need a lawyer to fill out this form.

You can choose any adult (over 18), including a family member, or close friend, to be your agent. If you select a doctor as your agent, he or she may have to choose between acting as your agent or as your attending doctor; a physician cannot do both at the same time. Also, if you are a patient or resident of a hospital, nursing home or mental hygiene facility, there are special restrictions about naming someone who works for that facility as your agent. You should ask staff at the facility to explain those restrictions.

You should tell the person you choose that he or she will be your health care agent. You should discuss your health care wishes and this form with your agent. Be sure to give him or her a signed copy. Your agent cannot be sued for health care decisions made in good faith.

Even after you have signed this form, you have the right to make health care decisions for yourself as long as you are able to do so, and treatment cannot be given to you or stopped if you object. You can cancel the control given to your agent by telling him or her or your health care provider orally or in writing. 

Filling Out the Proxy Form

Item (1) Write your name and the name, home address and telephone number of the person you are selecting as your agent.

Item (2) If you have special instructions for your agent, you-should write them here. Also, if you wish to limit-your agent's authority in any way, you should say-so here. If you do not state any limitations, your-agent will be allowed to make all health care-decisions that you could have made, including the-decision to consent to or refuse life-sustaining-treatment.

Item (3) You may write the name, home address and telephone number of an alternate agent.

Item (4) This form will remain valid indefinitely unless you set an expiration date or condition for its-expiration. This section is optional and should be filled in only if you want the health care proxy to-expire.

Item (5) You must date and sign the proxy. If you are unable-to sign yourself, you may direct someone else to-sign in your presence. Be sure to include your address.

Two witnesses at least 18 years of age must sign your proxy. The person who is appointed agent or alternate agent cannot sign as a witness.

Health Care Proxy Form

Click here for a printable version.

Finding A Nursing Home - Deciding about CPR: Do-Not-Resuscitate (DNR) Orders - A Guide for Patients and Families

What do CPR and DNR orders mean?

A new law called the Health care proxy law allows you to appoint someone you trust - a family member or close friend, to decide about treatment if you lose the ability to decide for yourself.

CPR --cardiopulmonary resuscitation --refers to the medical procedures used to restart a patient's heart and breathing when the patient suffers heart failure. CPR may involve simple efforts such as mouth-to-mouth resuscitation and external chest compression. Advanced CPR may involve electric shock, insertion of a tube to open the patient's airway, injection of medication into the heart and in extreme cases, open chest heart massage.

A do-not-resuscitate (DNR) order tells medical professionals not to perform CPR. This means that doctors, nurses and emergency medical personnel will not attempt emergency CPR if the patient's breathing or heartbeat stops.

DNR orders may be written for patients in a hospital or nursing home, or for patients at home. Hospital DNR orders tell the medical staff not to revive the patient if cardiac arrest occurs. If the patient is in a nursing home or at home, a DNR order tells the staff and emergency medical personnel not to perform emergency resuscitation and not to transfer the patient to a hospital for CPR.

Why are DNR orders issued?

CPR, when successful, restores heartbeat and breathing and allows patients to resume their previous lifestyle. The success of CPR depends on the patients overall medical condition. Age alone does not determine whether CPR will be successful, although illnesses and frailties that go along with age often make CPR less successful.

When patients are seriously ill or terminally ill, CPR may not work or may only partially work, leaving the patient brain-damaged or in a worse medical state than before the heart stopped. In these cases, some patients prefer to be cared for without aggressive efforts at resuscitation upon their death.

Can I request a DNR order?

Yes. All adult patients can request a DNR order. If you are sick and unable to tell your doctor that you want a DNR order written, a family member or close friend can decide for you.

Is my right to request or receive other treatment affected by a DNR order?

No. A DNR order is only a decision about CPR and does not relate to any other treatment.

Are DNR orders ethically acceptable?

It is widely recognized by health care professionals, clergy, lawyers and others that DNR orders are medically and ethically appropriate under certain circumstances. For some patients, CPR offers more burdens than benefits, and may be against the patient's wishes.

Is my consent required for a DNR order?

Your doctor must speak to you before entering a DNR order if you are able to decide, unless your doctor believes that discussing CPR with you would cause you severe harm. In an emergency, it is assumed that all patients would consent to CPR. However, if a doctor decides that CPR will not work, it is not provided.

How can I make my wishes about DNR known?

An adult patient may consent to a DNR order orally by informing a physician, or in writing, such as a living will, if two witnesses are present. In addition, the Health Care Proxy Law allows you to appoint someone you trust to make decisions about CPR and other treatments if you become unable to decide for yourself.

Before deciding about CPR, you should speak with your doctor about your overall health and the benefits and burdens CPR would provide for you. A full and early discussion between you and your doctor will assure that your wishes will be known.

If I request a DNR order, must my doctor honor my wishes?

If you don't want CPR and you request a DNR order, your doctor must follow your wishes or:

- transfer your care to another doctor who will follow your wishes; or
- begin a process to settle the dispute if you are in a hospital or nursing home.
If the dispute is not resolved within 72 hours, your doctor must enter the order or transfer you to the care of another doctor.
If l am not able to decide about CPR for myself, who will decide?
First, two doctors must determine that you are unable to decide about CPR. You will be told of this determination and have the right to object.
If you become unable to decide about CPR, and you did not tell your doctor or others about your wishes in advance, a DNR order can be written with the consent of someone chosen by you, by a family member or by a close friend. The person highest on the following list will decide about CPR for you:
- the person chosen by you to make health care decisions under the State Health Care Proxy Law;
- a court appointed guardian (if there is one);
- your closest relative (spouse, child, parent, sibling);
- a close friend.

How can I select someone to decide for me?

The Health Care Proxy Law allows adults to select someone they trust to make all health care decisions for them when they are no longer able to do so themselves, including decisions about CPR. You can name someone by filling out a health care proxy form, which you can get from your physician or other health care professionals.

Under what circumstances can a family member or close friend decide that a DNR order should be written?

A family member or close friend can consent to a DNR order only when you are unable to decide for yourself and you have not appointed someone to decide for you. Your family member or friend can consent to a DNR order when:

- you are terminally ill; or
- you are permanently unconscious; or
- CPR will not work (would be medically futile); or
- CPR would impose an extraordinary burden on you given your medical condition and the expected outcome of CPR.

Anyone deciding for you must base the decision on your wishes, including your religious and moral beliefs, or if your wishes are not known, on your best interests.

What if members of my family disagree?

In a hospital or nursing home, your family can ask that the disagreement be mediated. Your doctor can request mediation if he or she is aware of any disagreement among your family members.

What if I lose the ability to make decisions about CPR and do not have anyone who can decide for me?

A DNR order can be written if two doctors decide that CPR would not work or if a court approves of the DNR order. It would be best if you discussed your wishes about CPR with your doctor in advance.

Who can consent to a DNR order for children?

A DNR order can be entered for a child with the consent of the child's parent or guardian. If the child is old enough to understand and decide about CPR, the child's consent is also required for a DNR order.

What happens if I change my mind after a DNR order has been written?

You or anyone who consents to a DNR order for you can remove the order by telling your doctor, nurses or others of the decision.

What happens to a DNR order if I am transferred from a nursing home to a hospital or vice versa?

The DNR order will continue until a doctor examines you and decides whether the order should remain or be canceled. If the doctor decides to cancel the DNR order, you or anyone who decided for you will be told and can ask that the DNR order be entered again.

If I am at home with a DNR order, what happens if a family member or friend panics and calls an ambulance to resuscitate me?

If you have a DNR order and family members show it to emergency personnel, they will not try to resuscitate you or take you to a hospital emergency room for CPR.

What happens to my DNR order if I am transferred from a hospital or nursing home to home care?

The order issued for you in a hospital or nursing home will not apply at home. You, your health care agent or family member must specifically consent to a home DNR order. If you leave a hospital or nursing home without a home DNR order, a DNR order can be issued by a doctor for you at home.

Finding A Nursing Home - Planning In Advance For Your Medical Treatment

Your Right to Decide About Treatment

Adults have the right to accept or refuse medical treatment, including life-sustaining treatment. Our Constitution and state laws protect this right. This means that you have the right to request or consent to treatment, to refuse treatment before it has started and to have treatment stopped once it has begun.

Planning In Advance

Sometimes because of illness or injury people are unable to talk to a doctor and decide about treatment for themselves. You may wish to plan in advance to make sure that your wishes about treatment will be followed if you become unable to decide for yourself for a short or long time period. If you don't plan ahead, family members or other people close to you may not be allowed to make decisions for you and follow your wishes.

Appointing someone you can trust to decide about treatment if you become unable to decide for yourself is the best way to protect your treatment wishes and concerns. You have the right to appoint someone by filling out a form called a Health Care Proxy. A copy of the form and information about the Health Care Proxy are available from your health care provider.

If you have no one you can appoint to decide for you, or do not want to appoint someone, you can also give specific instructions about treatment in advance. Those instructions can be written, and are often referred to as a Living Will.

You should understand that general instructions about refusing treatment, even if written down, may not be effective. Your instructions must clearly cover the treatment decisions that must be made. For example, if you just write down that you do not want "heroic measures, " the instructions may not be specific enough. You should say the kind of treatment that you do not want, such as a respirator or chemotherapy, and describe the medical condition when you would refuse the treatment, such as when you are terminally ill or permanently unconscious with no hope of recovering. You can also give instructions orally by discussing your treatment wishes with your doctor, family members or others close to you.

Putting things in writing is safer than simply speaking to people, but neither method is as effective as appointing someone to decide for you. It is often hard for people to know in advance what will happen to them or what their medical needs will be in the future. If you choose someone to make decisions for you, that person can talk to your doctor and make decisions that they believe you would have wanted or that are best for you, when needed. If you appoint someone and also leave instructions about treatment in a Living Will, in the space provided on the Health Care Proxy form itself, or in some other manner, the person you select can use these instructions as guidance to make the right decision for you.

Deciding About Cardiopulmonary Resuscitation

Your right to decide about treatment also includes the right to decide about cardiopulmonary resuscitation (CPR). CPR is emergency treatment to restart the heart and lungs when your breathing or circulation stops.

Sometimes doctors and patients decide in advance that CPR should not be provided, and the doctor gives the medical staff an order not to resuscitate (DNR) order. If your physical or mental condition prevents you from deciding about CPR, someone you appoint, your family members or others close to you can decide.

A brochure on CPR and your rights under State law is available from your health care provider.

Finding A Nursing Home - The Guide Part 2 - Seniors Long Term Care & Nursing Home Issues - SeniorSite.com
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