|Senior Citizens Handbook - Nursing Homes||
Last updated: March 2009
Choosing a nursing home can be a difficult decision, but help is available. Medicare and Medicaid may provide financial assistance. This section also explains the Illinois Nursing Home Care Act, and the federal Nursing Home Reform Law which protect the rights of nursing home residents to receive humane care and govern the procedures by which a person may be involuntarily discharged from a nursing home. This section also explains how the Illinois Department of Public Health (IDPH) and the Nursing Home Ombudsmen Program protect nursing home residents.
The decision to enter a nursing home is often one of the most difficult decisions an individual and his/her family can face. The question of whether long term nursing home placement is appropriate comes at a time when a person’s health situation is fragile and very often after it has taken a turn for the worse.
When going through the process of selecting a nursing home for skilled nursing care, intermediate care, or merely “bed and board,” it is important for family and friends to remain calm and objective. It is also helpful to maintain a healthy consumer skepticism while “shopping.” Choosing a nursing home that will suit your needs or the needs of a loved one deserves much care and caution.
Before choosing a nursing home, first consider whether any less restrictive alternative is more appropriate for the individual in need of care. In-home health care may allow more independence. In-home services such as homemakers, meal programs, visiting nurses programs and chore services may allow the individual to remain in his or her home. See the section of this Chapter titled “Community Care Program.”
There are other long-term care alternatives, such as assisted living establishments and supportive living facilities. These alternatives are for elderly persons at risk of living alone but who do not require nursing care. In these types of facilities, residents live in their own apartments, but are provided certain services, such as housekeeping, meals and laundry, and are given assistance with activities of daily living. See the following sections of this Chapter titled, “Assisted Living and Shared Housing” and “Supportive Living Program.”
Hospice care may be more appropriate for a terminally ill person. Congregate living arrangements, where several adults pool their strengths and resources, may be available in your community. Ask your Area Agency on Aging for more suggestions.
If you or your representative decide a nursing home is the most appropriate placement, the Illinois Department of Public Health publishes an excellent guide online on how to choose a nursing home. If you have Internet access, you can download the guide including a checklist to use when shopping for a nursing home by visiting the Illinois Department of Public Health's website. In the alternative, you can request that the Department mail a copy to you by calling 217-782-4977.
In addition, the Department publishes a directory of facilities. It is available at each of the Department's regional offices.
The "directory" must provide, at a minimum, the following information:
You should always check to see whether a nursing home you are considering has violated safety and other regulations. Your local ombudsman can tell you about any problem nursing homes in your area. Call the Illinois Department of Aging at 800-252-8966 to locate the ombudsman in your area. The Department of Public Health inspects nursing homes, which are required to post the results of their last inspection. When you visit a nursing home, ask the staff to show you the inspection report.
The Illinois Department of Public Health prepares a quarterly list of all nursing homes that it has cited for serious violations of the residents’ rights. The report can be obtained, free of charge, by calling the Department at 217-782-4977. You also may obtain the list from the Department’s web page listed on this page.
You may also want to call 800-MEDICARE (800-633-4227 toll free) or (877-486-2048 TTY/TDD) and request the publication Your Guide to Choosing a Nursing Home.
The federal government has resources available for comparing nursing homes at their website www.medicare.gov. This information can be found in the search tools section and is titled "compare Nursing Homes in Your Area."
Before beginning to look at homes, take time to determine the medical and physical needs and financial resources of the prospective nursing home resident. If possible, friends, clergy, and the family doctor should participate in identifying needs and resources. Consider most seriously those homes that are located near the people who will be visiting most frequently. Visits are very important in maintaining a resident’s morale and well-being.
Once you have prepared a list of prospective nursing homes, call them to obtain information about their basic charges and services. Determine which “extras” cost more or are not included.
Example: The family may be expected to do the resident's laundry.
If you are still interested, schedule a visit. Arrange a guided tour with the administrator or director of the facility. Return unannounced for a second, closer look.
To see the various ways you might have a “representative” make decisions for you, see Chapter 3 of this Handbook.
Do not be afraid to ask questions. Here is a list of some good questions to ask.
License: The home is required to be licensed. Is the license in danger of being, revoked, suspended or not renewed? Ask to see the most recent inspection report. Find out if the faults mentioned in the report have been remedied.
Nursing Service: What level of care is provided? Does it meet the needs of the prospective resident?
Physician Service: Is there a staff physician or medical director who helps set policies and provides for emergency calls? What provisions does the home have for follow-up by a family physician? What hospitals are nearby?
Activities: Are there organized activities? What are they? Is there a regular schedule? What religious services are available?
Rehabilitation and Physical Therapy: What facilities and staff are available for these services? Do they meet the prescribed needs of the patient?
Visiting Hours: What are they?
In-Service Education: Does the home have continuous in-service education programs for its staff? Is the staff up to date on rehabilitation techniques?
Dietary Service: Does the home serve attractive, nutritious meals that are planned by a registered dietitian. Are special diets available? Ask to see a copy of the planned menus, and sample a meal, if possible.
Safety: Are there handrails in the hallways and grab bars next to bathtubs, showers and toilets? Is there an adequate fire safety system that includes at least smoke and heat detectors and sprinklers? Is there a posted fire evacuation plan? How often does the staff train in fire safety? Ask to see the home’s last fire inspection report.
Roommates: Are rooms shared? If so, by how many residents? How does the home choose roommates? Husbands and wives should be roomed together, unless there is a medical reason to do otherwise.
Costs and Charges: What services are included in the "basic daily charge" of the nursing home? Get this information in writing from the administrator. What services are provided for an extra charge? Do these extra charges include all of the supply costs that are necessary for the service?
Deposit: What, if anything, is required in advance? How will the deposit be returned? If a deposit is received from a potential Medicaid eligible resident, the deposit must be returned within 30 days of establishing Medicaid eligibility.
Medication: How will medications be obtained? The home may require you to purchase all medication through the home. This is convenient, but it also may be more costly than purchasing medicine elsewhere. If you choose to purchase your own medicine, be sure to reach a clear agreement with the nursing home that the home can supply its own medicine in an emergency.
Third Party Payment: What third party payments will the nursing home accept? Does it take Medicare and Medicaid patients? Will it allow you to shift to Medicaid payment if, after being admitted as a private pay or Medicare patient, you then become eligible for Medicaid? If so, does the facility have a limit on the number of Medicaid certified beds? What is the nursing home’s policy when a Medicare or private pay patient’s resources run out?
Once you have chosen a nursing home, the home is required to provide a written contract. The contract should include:
The nursing home must also state whether it accepts Medicaid residents. If it does, attempt to get in writing a statement that the nursing home will retain the resident when and if his or her source of funding changes to Medicaid.
Because the resident is not able to sign the admission agreement, the facility may ask a family member to sign. If that family member is the agent pursuant to a Power of Attorney, the family member should sign in that capacity.
Example: John Doe, agent for Jane Doe.
Advocacy Tip: Be careful not to assume liability for payment.
Under limited circumstances, Medicare (Part A) may pay up to 100 days of care in a skilled nursing home per spell of illness.
A “spell of illness” begins on the first day you receive hospital level of care and continues until 60 consecutive days have elapsed without either hospital or skilled nursing level of care. Coverage under a new “spell of illness” can begin any time after that.
You will be responsible for paying deductible and coinsurance amounts. Medicare pays for skilled nursing home care only after a patient has spent at least three consecutive days in the hospital. Medicare’s definition of skilled care is very strict when it comes to nursing home coverage. In general this term refers to a level of care that includes services which can be performed safely and correctly only by a licensed nurse.
Medicare does not pay for custodial care, only for care that meets the definition of skilled care. Be sure the nursing home is Medicare-eligible before entry if you expect Medicare to pay. Medigap policies may pay deductible or extended coverage, but only if the facility is Medicare-eligible.
If you are denied Medicare coverage, you can appeal the decision. For more information or assistance, you may contact the Medicare hotline at 800-633-4227 or 877-486-2048 (TTY/TTD), or call the Senior Health Insurance Program (SHIP) at 800-548-9034.
Medicaid is a joint State and Federal program, administered by the Illinois Department of Healthcare and Family Services (HFS), which pays for care in skilled nursing homes and intermediate care facilities. A physician must certify the need for this level of care, and the patient must be income eligible for Medicaid benefits. See the Section of this Handbook titled "Medicaid."
Many facilities are certified to accept Medicaid patients. Other nursing homes choose not to accept Medicaid patients because the amount HFS pays a facility per day for care of Medicaid patients is very low. This may become very important when a resident’s Medicare coverage ends or the resident’s private funds run out, and Medicaid becomes the only way to pay for nursing care. It is important that you make sure the nursing home will retain a patient whose funding source may switch from private or Medicare funds to Medicaid funds.
Although state and federal laws prohibit discrimination against Medicaid recipients, a nursing home that accepts Medicaid recipients can limit the number of such recipients. The nursing home can limit the number of Medicaid eligible beds, meaning that there may not be a Medicaid bed available when the patient’s Medicare or other funds are depleted.
If you think you may need to rely on Medicaid to pay your nursing home bills, get a guarantee in writing from the nursing home that a Medicaid bed will be available when you need it. If there are only a limited number of Medicaid beds available at a facility, do not rely on just a spoken promise that a Medicaid bed will be available when you need one.
If a resident receives Medicaid, HFS pays for many expenses related to the resident's care. The resident or her family should not be charged by the nursing home for Medicaid-covered items. Some of those items for which there should not be a charge appear on the following list.
If a resident receives Medicaid, there should not be a charge for these items:
This is not a complete list of covered items. Ask your HFS caseworker for the complete list.
If HFS denies you Medicaid, or if an expense is not covered by Medicaid, do not assume that HFS made the right decision. You may appeal any denial of Medicaid by filing an appeal with your HFS caseworker, or by calling 800-435-0774.
The Nursing Home Care Act (Act) is an Illinois law that protects the rights of residents of long term care facilities. The Illinois Department of Public Health (IDPH) is the state agency given the authority to enforce this law. The Act applies only to those facilities which meet the definition of a long term care facility.
A "Long-Term Care Facility" means a private home, institution, building, residence, or any other place which provides personal care, sheltered care or nursing for three or more persons, not related to the facility owner by blood or marriage. This includes skilled nursing facilities, intermediate care facilities and shelter care facilities.
The Nursing Home Care Act guarantees the following rights to all nursing home residents:
The Nursing Home Care Act does not apply to the following:
A federal law known as the Nursing Home Reform Law provides residents with additional rights beyond those provided under state law:
No Discrimination Against Medicaid-Eligible Residents
The nursing home is prohibited from discriminating against you based on your Medicaid eligibility. If you are a Medicaid-eligible resident, the nursing home must use the same policies and practices regarding services and regarding transfer and discharge that it uses for other residents.
You and your family have the right to participate in developing your care plan. The nursing home staff is required to schedule care plan meetings at a time that allows your family to attend.
Advocacy Tip: You can also ask the Ombudsman to come to a care plan conference to help make sure you receive an appropriate plan.
Honoring Resident Preferences
The nursing home must make reasonable adjustments to honor your needs and preferences. You have the right to choose activities, schedules and health care consistent with your interests and with your care plan.
Example: You do not have to be woken up at 6 a.m. just because that suits the nursing home's schedule.
Providing Necessary Services
The nursing home must provide the necessary care that you need to reach the highest practicable level of functioning.
Example: A nursing home violates that rule if it expects you to hire your own private-duty aide.
Use of Feeding Tubes
The nursing home cannot compel you to use a feeding tube, except as a last resort. The nursing home must help you to eat, as needed, such as by prompting you to eat, providing therapy to improve swallowing skills, providing assistive devices such as easy-to-grip utensils or simply feeding you by hand.
Your family members can visit you at any time of the day or night. The nursing home cannot limit visiting hours for immediate family or other relatives. For a late-night visit, the visit may take place in a common area to avoid disturbing other residents’ sleep.
“Responsible Party” Provisions in Admission Agreements
The nursing home cannot require a family member or friend to be financially responsible for your nursing home expenses.
Advocacy Tip: Some nursing homes use "Responsible Party" signatures as a way of tricking a family member or friend into becoming financially liable. Family members and friends may think that signing as a "Responsible Party" means only that they are a contact person. They should make sure they are not also agreeing to pay.
There is no need for you or your representative to sign an arbitration agreement at the time of admission. In this type of agreement, the nursing home and resident agree that future disputes between them will not go to court, but will be handled by a private judge called an arbitrator. This is usually not a good option for the resident.
Determining Eligibility for Medicare Reimbursement
You have the right to insist that the nursing home bill Medicare even when the nursing home determines that you need custodial care only. The nursing home does not have the last word as to whether or not your condition qualifies for Medicare reimbursement.
Continuation of Therapy After Medicare Reimbursement Has Ended
The nursing home must continue to provide medically necessary therapy and services, even when your Medicare reimbursement has expired. The nursing home must provide therapy services even if the nursing home is entitled to no more than the typical Medicaid rate.
Continued Stay in Medicare-Certified Bed
You do not have to leave a Medicare-certified bed just because your care is no longer being reimbursed through the Medicare program. You have the right to veto a transfer within the nursing home if the purpose of the transfer is to move you out of Medicare-certified bed.
Readmission from the Hospital
If you are eligible for Medicaid, and you have left the nursing home to be hospitalized, the nursing home is required by state law to hold the bed for you for a short period of time. During that time, the Medicaid program will pay for the bed hold. However, after that time, you have the right to be re-admitted to the next available bed at the nursing home, no matter how long you were in the hospital.
A nursing home can assess extra charges only if those charges were authorized in the admission agreement.
Example: Separate charges for catheter supplies, diapers or other products and wound dressings are not permitted if they were not authorized in the admission agreement.
Moreover, if your care is covered by Medicare or Medicaid, additional charges are always inappropriate because the nursing home must accept payment from Medicare or Medicaid as payment in full. The resident’s only financial obligation is to pay the deductibles and co-payments authorized by law.
You cannot be transferred or discharged from a nursing home against your will, except for one of these reasons:
If the nursing home wants to move you, it must give you written notice of the proposed move at least 21 days in advance. The notice must tell you why the nursing home wants to move you, and it must tell you of your right to appeal the home’s decision. You must make your appeal in writing and file it with IDPH within 10 days of receiving the notice.
If you file a timely appeal, the facility cannot discharge or transfer you while the appeal is pending. If there is an emergency which threatens your safety or the safety of others, the facility may discharge you right away. In this case, you may be returned to the facility if you win your appeal.
You can contact Prairie State Legal Services or a private attorney for help appealing the decision to make you move. You may also call the Long Term Care Ombudsmen for help filing an appeal or to file a Complaint against a nursing home for violating any of your rights. Call 866-800-1409 (toll free) or 888-206-1327 (TTY). If you have a disability or mental illness, you may call Equip for Equality at 800-537-2632 OR 800-610-2779 (TTY) for help.
If you appeal a decision to remove you from the nursing home, a Department of Public Health hearing officer will conduct a hearing at the facility. You are entitled to be present at the hearing, to testify, and present witnesses and other evidence in support of your case as to why you think you should stay. IDPH will issue a written decision within 14 days after the hearing. If IDPH rules against you, the facility cannot discharge you within 34 days after the date you received the discharge notice. If you must go, the nursing home is required to develop a discharge plan to place you in a suitable facility.
If the decision of the IDPH hearing is not satisfactory, you may file a written complaint in the Illinois circuit court. You must file your Complaint in court within 35 days of the IDPH decision.
You and your fellow residents have the right to organize. Every nursing home is required to establish a residents’ advisory council to make recommendations to the administrators and to safeguard residents’ rights. The Council is intended to provide an opportunity for residents and family members to do the following:
If the council identifies problems with the facility or staff, or if it has suggestions for improvements, the council can inform the facility director about these matters. The council also may present complaints on behalf of a resident to the Illinois Department of Public Health or to any other person or agency that the council considers appropriate.
Employees of the facility cannot be members of the council. However, the facility must designate an employee as a liaison with the group. The nursing home also must provide the council group with a private meeting space.
All Residents’ Advisory Council meetings must meet at least once each month with the staff coordinator who provides assistance to the council, by reporting on the council meetings. That report must be available to all residents and facility staff.
If a facility violates your rights, you have several options. You can do one of the following:
The Residents' Advisory Council also has the authority to file a complaint with IDPH or the Ombudsman on behalf of facility residents. However, only you or your legal representative may file a private lawsuit concerning a violation of your rights. Each of these options is discussed in detail below.
The Long Term Care Ombudsman Program is operated by the Illinois Department on Aging. The Ombudsman has the legal duty to investigate and resolve complaints made by residents (60 years and older) or their representatives. The Ombudsman can advocate for your rights and seek to have the facility voluntarily comply with the requirements of the Act. If the facility will not correct the violation, the Ombudsman can assist you with a complaint to IDPH. To find the Long Term Care Ombudsman program for your area, call the Illinois Department on Aging at 866-800-1409 (toll free) or 888-206-1327 (TTY).
If you believe that a facility is violating the Act, you may file a complaint with the Illinois Department of Public Health (IDPH). It is a crime to intentionally file a false complaint.
You may contact the IDPH and file a complaint at:
Illinois Dept. of Public Health
Attn: Central Complaint Registry
535 W. Jefferson St.
Springfield, IL 62761
To file a complaint by phone, contact the IDPH Central Complaint Registry at 1-800-252-4343.
Upon receiving your complaint, IDPH will conduct an investigation. IDPH must complete the investigation of complaints involving abuse and neglect within 7 days. They must complete other investigations within 30 days. If the investigation shows that the facility is in violation of the Act, IDPH will send a notice of the violation to the facility.
IDPH will not require you to give your name when you file a complaint. But if you do not give your name, IDPH will be unable to notify you of the outcome of their investigation. IDPH will not reveal your identity as the person who filed the complaint without your written permission, unless IDPH needs to file a court case against the facility or it is essential to the investigation.
The facility cannot transfer, discharge, evict, harass or retaliate against you because you make a complaint or provide information in connection with an IDPH investigation.
Upon completing the investigation, IDPH will notify you and the facility of the results of their investigation. If IDPH decides that the facility has violated the Nursing Home Care Act, IDPH can impose fines and other penalties on the facility. In extreme cases, IDPH also can revoke the facility's license and force them to shut down.
If IDPH determines that the facility did not violate the Nursing Home Act, you are entitled to file an appeal and get a hearing. You must make the appeal in writing, and you must file it with IDPH within 30 days of the notice of the investigation findings.
IDPH will hold a hearing within 30 days of your appeal. You are entitled to appear and testify at the hearing. The hearing officer can issue subpoenas to force other people to appear and testify or provide other evidence. You can be represented by a lawyer at the hearing. Following the hearing, the Director of IDPH will send you a written decision.
If you disagree with the Director’s decision, you are entitled to file a complaint in Illinois Circuit Court. You must file this Complaint within 35 days of the IDPH decision.
In addition to or instead of filing a complaint with IDPH, you are entitled to file a lawsuit against a facility if it violates your rights under the Nursing Home Care Act. You also may file a lawsuit if you are injured as a result of a wrongful action by the facility or its staff.
If you file a lawsuit and the judge or jury decides that the facility violated your rights, the judge can require the facility to pay you compensation for your losses. If it is determined that the facility violated your rights protected by the Act, the judge also will order the facility to pay your court costs and attorney’s fees. The judge also can enter an injunction, which is a court order requiring the facility to stop violating the Act.
The facility cannot transfer, discharge, evict, harass, or retaliate against you for filing a lawsuit or for providing testimony in connection with a lawsuit filed by someone else.
Long Term Care Ombudsman Program
Equip for Equality, Inc.
Illinois Department of Public Health
Legal Information and forms are available.
For a list of organizations in your area that may be able to help you, enter your zip code.
User Survey - Please take a moment to fill out our User Survey to help us to provide better service.