A variety of state and federal requirements must be satisfied by the nursing facility prior to admission or shortly thereafter. For example, a Medicaid pre-admission evaluation (PAE), to determine medical eligibility, typically will be conducted before admission. A comprehensive patient assessment, to determine a plan of care, is also completed for each patient. The formal care plan is then prepared by the attending physician, a registered nurse and other staff members who will be involved with the patient’s care. This care plan is updated every three months, or more frequently if the patient’s condition changes.
Other requirements must be met at admission to determine the suitability of the environment for patients and to preserve patients’ rights after they are admitted and receiving medical care.
Federal law mandates that nursing homes determine prior to admission whether a patient has any mental illness or mental retardation. This rule applies to all patients in facilities that participate in the Medicare and Medicaid programs. The screening is referred to as PASARR, which stands for Pre-Admission Screening and Annual Resident Review.
A PASARR is conducted for the benefit of both patient and facility, as it determines whether the facility is the best source of treatment for the patient. If the initial evaluation demonstrates the patient has any degree of mental illness or mental retardation, a more involved evaluation follows to determine whether the patient needs special services that cannot be provided in a nursing home.
If the second evaluation indicates a need for special services, the patient and family will be assisted in finding an alternative setting for the required care. Patients whose mental conditions change during their stay in the facility will be retested.
All patients have the moral and legal right to make decisions regarding their care and treatment in a nursing home, hospital or other health care facility. The value and risks of medications and procedures must be explained clearly to patients, and their rights include the right to refuse treatment.
Sometimes, of course, patients are unable to make their own health care decisions due to illnesses or other reasons. If possible, patients can make their treatment wishes known in advance through the use of advance directives.
Over the last few years, Tennessee has taken significant steps to simplify the health care decision making process for its citizens by changing advance directives laws and rules.
In 2004, members of the state Legislature passed the Health Care Decisions Act, which was carefully designed to make it easier for Tennesseans to express their end-of-life wishes through advance directives and for health care providers to honor those wishes. The Health Care Decisions Act not only updated living wills and durable powers of attorney for health care (DPAHC), it also broadened the spectrum of forms individuals can use.
Any existing forms already completed such as living wills and DPAHCs, remain valid under the Health Care Decisions Act and can be used to follow a patient's health care wishes; however, new forms have been adopted by the state of Tennessee. These include the Advance Care Plan form, the Appointment of Health Care Agent form and the Physician Orders for Scope of Treatment (POST) form.
The two-page Advance Care Plan form serves a similar function as the former living will. It allows individuals to tell their doctors how they want to be treated if they are terminally ill or permanently unconscious. Advance Care Plans may also be used to tell doctors to avoid life-prolonging interventions, such as cardiopulmonary resuscitation (CPR), kidney dialysis or breathing machines. Other special instructions or limitations may also be included in the form.
The Appointment of Health Care Agent form, on the other hand, is similar to the former durable power of attorney for health care (DPAHC). It allows individuals to name one individual and one alternate to make health care decisions for them should they become unable to make decisions for themselves.
Both the Advance Care Plan and Appointment of Health Care Agent forms are completed by individuals while they have the capacity to make health care decisions. Ideally, this happens in advance of an illness or disability.
The Physician Orders for Scope of Treatment or POST form replaces the old do-not-resuscitate (DNR) form and represents the most noteworthy change resulting from the new law and new forms. It is more comprehensive than either the old in-facility or state Emergency Medical Service (EMS) DNR forms.
The POST form is completed by an individual’s physician or, at the physician’s direction, by another health care provider, such as facility staff. The patient or his representative does, however, sign the POST form. It includes a section to record a patient’s choice on cardiopulmonary resuscitation, i.e., “Resuscitate (CPR)” or “Do Not Attempt Resuscitate (DNR/no CPR).” It also includes sections to record preferences when a patient is not in cardiopulmonary arrest such as medical interventions, antibiotics and medically-administered fluids and nutrition. Since this form is approved by the state, EMS will accept the new POST form as a replacement for the old EMS DNR form.
Written advance directives can still be notarized, but individuals may choose simply to have the documents signed by two witnesses, one of whom is not a relative or entitled to any part of the individual’s estate. Once advance directives are created, individuals are urged to keep copies of the document in a safe location and give other copies to family members, health care agents and physicians.
During the nursing facility selection process, you are likely to discover a policy unique to Tennessee – patient wait lists. In fact, you will find wait lists at most Tennessee facilities that accept Medicaid. The practice of maintaining prospective patient wait lists originates from a 1990 court case, Linton v. Commissioner, which resulted in a federal court ruling mandating Medicaid-participating facilities admit patients on a first-come, first-served basis.
As the name implies, wait lists mean beds may not always be immediately available for patient admission. When a bed is vacant, facilities must consult the wait list to determine who is next in line to be admitted. Wait list size varies greatly among facilities and changes daily. It is important to understand that whether the list has two or 200 names, it is not an accurate reflection of when any patient will be admitted primarily because many people on the wait lists simply are not yet in need of nursing home care or they have been placed in another facility. There may be 200 names on the waiting list, but there also may be 10 empty beds that can’t be filled from the list.
In addition, the regulations include instances when a patient may be admitted according to circumstances beyond first-come, first-served. The most common example of this is admission to the nursing facility directly from the hospital due to medical need. Also, because nursing facilities place only patients of the same gender together in each room, admission may depend on whether the patient is male or female. Admission preference also may be given in cases requiring intervention by the Department of Human Services Adult Protective Services; in limited instances of patient transfer from another facility; as well as when a nursing facility patient has been in the hospital.
Although having to place your name on a wait list may seem discouraging, Linton regulations exist to protect consumer rights and help individuals plan ahead for when long-term care services will be needed. If you are told by facility staff that your admission may be delayed by the wait list, please remember the facility has no choice in complying with the law.