Levels of Nursing Home Care

Nursing homes provide around-the-clock professional medical care for patients with chronic illnesses or patients recovering from acute illnesses who need skilled nursing care but do not need to be hospitalized. Also known as long-term care facilities, nursing homes vary by the level of care provided. Nursing homes provide three levels of care: Skilled care, Intermediate care, and Custodial care.

Skilled care is nursing and rehabilitative care that is prescribed by a physician and is delivered on a daily basis by skilled medical personnel such as nurses or therapists. Skilled care is generally provided to assist patients during recovery following hospitalization for treatment of acute conditions.

Intermediate care is provided intermittently, or periodically, for patients who are recovering from acute conditions but do not need continuous care or daily therapeutic services. Intermediate care is provided by skilled professionals such as registered or licensed practical nurses, and therapists, under the supervision of a physician.

Custodial care provides assistance to patients in daily activities such as bathing, dressing, toileting, and eating. Custodial care is often needed as a result of chronic illnesses that decreases an individual's ability to remain independent. While custodial care must be supervised by a physician, not all custodial care must be delivered by skilled professionals and is frequently provided by nurse's aides.

Federal Regulation

Nursing homes are extensively regulated and operate under federal, state, and local laws and regulations. In response to a study commissioned by Congress to examine the state of nursing home care in America, additional laws were enacted in 1987 establishing comprehensive standards for nursing homes. The federal Nursing Home Reform Act (NHRA), part of the Omnibus Reconciliation Act of 1987, applies to all nursing facilities and their owners and operators who receive Medicare or Medicaid funds.

The NHRA covers a number of areas defining the nursing home's obligation to its residents.

• The NHRA requires all Medicare and Medicaid certified nursing homes to care for residents "in such a manner and in such an environment as will promote maintenance or enhancement of the quality of life of each resident."
• The NHRA also accords residents basic human rights of choice, privacy, and autonomy. Federal regulations promulgated under the NHRA require that nursing homes must protect and promote the rights of each resident to a dignified existence and self-determination.

Federal regulations also establish the following rights:

• to be free of interference, coercion, discrimination, and reprisal
• to be free from any physical or chemical restraints not required to treat the resident's medical symptoms
• to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion
• to have access to all records pertaining to one's self, including current clinical records within 24 hours
• a written statement of fees, charges, and services
• to manage one's own financial affairs
• to participate in resident and family groups
• to express grievances

Federal regulations also require nursing home facilities to conduct a comprehensive assessment of each resident's ability to function and perform activities of daily living. The assessment serves the basis for a plan of care that provides goals and strategies to meet a resident's medical, nursing, and psychosocial needs. Each resident must be assessed by the nursing home staff within 14 days of admission, and then periodically thereafter.

The NHRA outlaws discrimination against residents who are, or may become, Medicaid recipients. A nursing home cannot:

• require that a resident agree not to apply for Medicaid benefits
• solicit or receive any gift, money, or donation as a precondition of admission
• require that a friend or family member guarantee payment

Transfers and Discharges

Under the law, residents cannot be transferred or discharged from a nursing home arbitrarily. Conditions where the involuntary transfer or discharge of a patient is allowed include:

• to meet the resident's welfare, where the resident's welfare cannot be met in the facility
• if the resident's health has improved, making a nursing home stay inappropriate
• if the resident presents a risk to the safety or health of others
• if the resident fails to pay
• if the facility ceases to operate

In addition, the resident must be provided with a 30 day advance notice of a transfer or discharge and has the right to appeal the decision.

Bed-Hold Policies

Nursing homes have bed-hold and bed reservation policies in the event that a resident must be hospitalized. Nursing homes generally hold beds for as long as the private paying resident or the resident's insurance pays for it. Medicaid regulations generally cover a minimum number of days. Medicaid recipients, whose hospitalization exceeds the minimum number of days, are entitled to be readmitted to the nursing home as soon as a bed becomes available. Bed-hold policies are also regulated by some states. For example, Florida requires private-pay beds to be held for 30 days.

State Regulation

State laws also regulate nursing homes. In addition to federal regulations, states require yearly reviews and quality of care surveys of nursing homes. Every state provides an ombudsman program to investigate complaints made by a resident or on behalf of a resident, and to monitor deficient nursing homes. States also have laws similar to the federal NHRA establishing standards for nursing homes and setting forth basic human rights due to all nursing home residents.