1) Find out how important care and service is at every level—from the owner to the maintenance person. Do everything you can do prior to deciding on a residence to discover what level of care your loved-one will be receiving. This includes the bricks-and-mortar facility, a sense of community (like a neighborhood without fences) where true relationships are encouraged among residents and staff, and a sense of FAMILY—the highest level that functions like a good family where everyone cares and looks after your loved-one. If you are not convinced that care and service are the top priority at every level, RUN!!!
Talk to people in all levels of the care chain, including residents, about how they feel about the care at the facility. Don’t simply depend on a marketer/salesperson or the Administrator to tell you how good they are. Their primary job, in most companies, is to “fill beds,” to make money for the people that own the building. If they don’t make money for the owner/operator, often nothing else matters. Talk to other residents —alone. Have the administrator introduce you around and have her/him tell you something about each resident. Then the administrator should LEAVE. And if she/he won’t do this, you should LEAVE.
And as you search for the information you need throughout this process, do not let the staff use HIPAA (generally, among other things, the federal privacy law applicable to health care providers) or any other confidentiality concern as an excuse to not let you obtain the information you need. Yes, residents all have confidentially rights and they must be protected. But if residents are willing to talk to you, they certainly can. And you are not asking the facility staff to give you access to their confidential records—which you should NEVER do —the rest is fair game for the well-informed decision-maker -- YOU.
Talk to staff in every department -- from activities to dietary to maintenance—all shifts. If the staff is unhappy, it directly affects the care they give. Now why would I suggest a maintenance person? Not because you care about his lawnmower, but because this person will maintain many things in your apartment. Often they are part-time, untrained and overworked. My Dad was killed when 100-pound door fell on him. It was in place though an architectural error, improperly installed by the construction company and, in my firm opinion, not maintained properly by the half-day a week maintenance man for a facility with 47 rooms.
Look at turnover statistics, but go beyond the statistics because they become stale quite quickly. For example, with a change in the Administrator, staffing usually changes—sometimes turnover increases and sometimes that’s an improvement. However, a turnover rate of 50% or more—meaning on average half the staff is new and has to learn medications, dietary habits, ADL needs and resident preferences, etc.—can and usually does diminish the level of care. Elders need and certainly deserve continuity in their “family” to feel safe and comfortable. Ask the staff and residents, “Is staffing adequate ALL the time and is the staff really clear and focused on its mission of caring?” High turnover—100%, 200% or worse means no family and probably no community either—and it is a lead indicator that almost everything else can and will be a problem for your loved-one.
2) Review and authenticate the administrator’s (and other key staff members’) qualifications and track records. Find out how the staff feels about him or her. As the “administrator goes, so goes the care and service, period. Is she trustworthy? Is she respected? Is she an advocate for the caregivers? Does she hire the best staff? How does she go about doing that? What do her key lieutenants think of her—her Director of Nursing (in a Skilled Nursing or in a “step-up” Assisted Living facility or Memory Care facility), her Activities Director, her Dietary Chief, etc? If an administrator does not have the trust and respect of the staff, this is a bad sign indeed. If she has little experience as an administrator, or has lots of experience but changes jobs often, that will directly and adversely affect care. Beware.
Here is another tip—use your contacts (clergy, friends, family, physicians and other healthcare workers you may know) to obtain information on the facility and its history and reputation. Find the names of former employees if you can. Call them and ask some of these questions. Former employees can provide invaluable information that you need to know and that the facility staff probably does not want you to know. Never expect the facility staff to provide you with these names of former associates that’s work you have to do—see Tab D for my Checklist.
3) Look at the record-keeping practices of the administrator -- and her time in the building generally and with residents particularly. Look at his or her policies and procedures and ask the staff about their training and how important these procedures really are to them. Ask the administrator about his training in them. Do the policies and procedures really drive care and services -- or are they merely window-dressing that care providers don’t even know about let alone follow? How are breaches of policies and procedures handled? How often is the administrator out of the building for business-related meetings? Who is in charge when she is not there, and what are the qualifications of that person? Is the Administrator trustworthy and is he an advocate for the care staff? Listen to residents; they and their caregivers can be your best source of information that will not appear on a website or in a report.
4) Talk to the owner or a senior manager above the administrator if you can. Find out why he or she is in the business. How often does he come to the building; what does he do when he’s there? Does she accept responsibility for anything and everything that happens there or is she simply a delegator? Is he on the quality committee? Most states require one, but I have met a number of owners who do not even know that. Is she on the Governing Board? Again, most states require them for accountability purposes, and yet I have met a number of owners and many administrators who do not know they are required or what they are supposed to do. Does he ever sit in on resident’s meetings? If he does not, that is an obviously bad sign.
5) Find out everything you are getting for your money and trust no promises of “extra care” that are not in writing. Learn about the operator’s systems—such as the call-light monitoring systems. Establish a history of call-light response times. Many if not most facilities have call-light monitoring systems for training and quality purposes. Among other things, they contain a computer-generated written history to help ensure a process whereby call-lights are answered on a timely basis. Regrettably, I did not discover that in my Mother’s case until the week before trial, and both the facility owner and the state just pleaded ignorance of the fact that there even was such a system. Every operator should know its systems and share the monitoring results for your loved-one as part of his JOB. And, when you move your loved-one into their new home, review these systems, care plans, and resident progress notes regularly to ensure that these plans are being followed and that resident progress/problems are documented and resolved quickly.
Ignore promises of extra care that are not in the contract you will sign. For example, if you have long-term care insurance, it may very well require that the facility have an RN on duty some or all of the time. Yet, the facility may not be required to provide one by law or regulation. But, you may be told, that the administrator is an RN or that they will “look into it for you.” If they don’t deliver the RN, your coverage under your long-term care insurance could be lost. If it is not in writing, the facility will only do it if it helps them. Get it in writing or do not risk anything important if it is not.
6) Be “hyper-vigilant.” Once you are in the facility---hopefully it is a family environment of great people, care, and service based on your diligence and hard work --stay vigilant. It is worth every moment of your time and effort. Be kind and respectful to the staff, but document everything and follow-up with proper personnel until the issue(s) are resolved and the results are documented to your satisfaction -- and then permanently placed in the resident file.
7) Do NOT depend upon the state to enforce any of your loved-one’s rights. Their “investigators” are of uneven competence, over-worked, underpaid and are almost entirely dependent on what is in the resident’s/facility’s records, which may be little or nothing depending on the administrator’s record keeping practices. Know the state regulations governing your facility and get contact numbers for key state staffers involved in regulating the industry. Communicate with them when you believe you should. But they simply are not a substitute for your own vigilance.
8) Make sure you know your loved-one’s rights, which are usually in the resident agreement and often are established by law. Do NOT let these rights be curtailed. This is your loved-one’s home and because they may be old and are often impaired in one way or another, they should not lose ANY rights because of age or infirmities. While you may want to involve the state Ombudsman at the local level, for the same reasons just listed in Tip 7, do not depend on them as the final say.
Do not discount your loved-one’s complaints—listen to them and investigate their concerns until you are satisfied. My Mother complained about call lights long before I recognized a problem and brought it to the attention of the facility and the state. They ignored her complaints. I hired caregivers to sit with her two-plus shifts a day, and I tried to hire a previous caregiver for the night shift. The facility would not let that caregiver back at the facility, but for no stated reason. My Mother had an absolute right to have anybody she wanted in her home. I failed to enforce that right though God knows I tried. My Mother’s fatal accident was on the shift that would have been covered by the former employee not allowed on the premises, but for my failure to force the facility to respect her clear and absolute right that any “homeowner” has.
9) Knowing when to leave is hard, but don’t ignore the signs that suggest it may be time. The decision to leave a care facility can be as tough as or tougher than the decision to move your loved-one in. However, things change—in the facility (what used to be good staff, low turnover, good care and service may change for the worse), with other residents and with your own loved-one who may be declining such that the facility may no longer be equipped to adequately care for her. Maybe you feel your loved-one would be better off, perhaps safer, somewhere else – even though it is their home and the staff is their family. So, if possible, you may want to involve your loved-one in the decision to move. What is easiest for the family is not the be-all and end-all. And sometimes there is just no simple/ right answer, so just try to ensure that the process is one that is as fair as possible for all.
10) Avoid threats -- and avoid like the plague lawyers and lawsuits. They are the ultimate last resort and only for those who are willing to lose it all in the pursuit of some ideal result, which rarely comes. Whatever happens, my advice is that the only sustaining justification for a lawsuit is IF there is a higher purpose than money and/or revenge. As a plaintiff, be ready to be vilified and demonized. And be ready to see, as I did TWICE, the point when the suit becomes about you or anything BUT the people who suffered the most. Be ready when your efforts to bring accountability take you down roads you wish you had never known existed. Remember, many plaintiff lawyers pursue the blameless, while many defense lawyers defend the indefensible. In either case, in an industry so critical, every dime wasted on needless litigation costs is inexcusable!
Good luck on this journey of dealing with your loved-one in the elder care system—a journey that no one really ever asks for or wants. But, it is a noble journey and you will meet good people—HEROES in fact—along the way who can and will if you let them make you and your loved-one better for the journey. Finally, please see Tab D on this site for a one-page Checklist you can print and take with you as you visit potential homes for yourself or a loved-one.
For the sake of our loved-ones and the people that care for them—paid and unpaid family—please make any postings to this site respectful and informative for all those involved in caring for our elders. At the very least, our elders deserve that from us. Thank you.