Nursing Home Requirements for Seniors

The moment you realize your family member likely needs nursing home care is often overwhelming. Whether your senior loved one is currently in the hospital or at home, understanding the process and requirements for nursing home care placement is a good first step.

“The process is not always simple and it can be tedious,” says senior care professional Mark Pavlovich, owner of Yardstik Behavioral Analytics and member of the workforce and customer experience committees at the American Health Care Association. “But it can be easier if you know who you need to talk to and are aware of the documents needed beforehand.”

Learn more about nursing home requirements, documents to bring, and who to talk to when filling out paperwork for government programs, like Medicare or Medicaid.

How can my loved one qualify for a nursing home?

Qualifying for nursing home care generally depends on your state’s assessment test. Although the federal Centers for Medicare and Medicaid (CMS) requires states to follow some guidelines, it offers flexibility and does not enforce standardized tests.

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Therefore, it’s possible for a senior to meet nursing home requirements in Iowa or Kansas, but not in California or New York. Be sure to contact your local Medicaid or government county agency to learn more about your state’s specific nursing home testing standards and guidelines.

Some states like Maryland, for example, may provide free health care assessments for seniors. Their Adult Evaluation and Review Service (AERS) is performed by a nurse or social worker and can identify whether a senior qualifies for nursing home care or other long-term care options.

In general, nursing home services are intended for seniors with debilitating health issues or serious chronic diseases. Any medical conditions must be documented and signed off by a physician.

Nursing home qualifications are different in each state, but seniors may qualify if they require some or all of the following:

• Skilled nursing or rehabilitative services
• Assistance with activities of daily living, such as bathing, dressing, or grooming
• Continuous supervision
• Assistance with managing daily health care needs
• Medication management

Your loved one’s doctor can also assess their health and evaluate their long-term care needs. If your loved one requires day-to-day care, but does not qualify for a nursing home, they may be a good candidate for an assisted living community.

Medicare requirements for nursing home placement

Medicare doesn’t cover custodial care, or long-term help with activities of daily living or personal needs in a nursing home. However, it may provide coverage for up to 100 days for short-term rehabilitation following a stroke, hip replacement, or another health event that resulted in a hospital stay of three days or more.

Regardless of whether Medicare pays for your nursing home stay, it will likely cover doctor services, medical supplies, and prescription drugs while you’re there, though the exact coverage depends on your Medicare plan. Learn more about the services, items, and tests covered by Medicare.

Medicaid requirements for nursing home placement

To qualify for nursing home care covered by Medicaid, your senior loved one must have a medical need. This requirement is consistent across the country, however, each state defines “medical need” in its own way. Contact your state’s Medicaid agency to learn more about which health conditions are required to qualify. Admissions staff at Medicaid-certified nursing homes will also have information about the process.

An elder law attorney or social worker can be helpful partners in the Medicaid application process and determining eligibility. The entire application can be rejected and sent back if any information is missing, says Pavlovich.

To learn more, CMS created a Nursing Home Toolkit to explain nursing home Medicaid benefits to providers and beneficiaries.

Nursing home admission requirements: What’s the process like?

Most nursing homes are certified by Medicare and Medicaid, which include strict documentation and care rules and requirements. These are meant to protect residents and help them receive proper care.

If your loved one is currently in the hospital, the first five items on this checklist will be taken care of by hospital staff.  Otherwise, you’ll need to make an appointment with their primary care physician to discuss the following requirements:

1. Physician’s order for admission to a skilled nursing facility. This order is similar to writing out a prescription. A doctor needs to confirm the patient needs to enter a nursing home for care.
   
2. Physician’s order for medications and treatment. Your loved one will have a new physician and caregivers at the nursing home. In order to provide care, they’ll need orders from a primary care physician or hospital staff.
   
3. Medical history and physical. The nursing home’s attending physicians need up-to-date information about your loved one. The primary care physician should perform a physical and report to provide current medical history.
   
4. State-required form. Every state has a required form for nursing home admittance. It certifies that a patient meets state nursing home criteria. It also means the person’s medical needs can be fulfilled by a skilled nursing facility. Either the hospital or the primary care physician will fill out and sign this form. It can be obtained at any nursing home in the state where your loved one will be receiving care. Because financial assistance is only granted if the individual meets state criteria for nursing home care, this form meets the first requirement for funding, before monetary need is ascertained.
   
5. Health care tests. Nursing homes are required to offer flu shots, pneumonia vaccines, and tuberculosis (TB) tests within three days of admission. If newly admitted patients have had these services recently, the nursing home may ask for proof. 
   
6. Completed admissions paperwork. Paperwork can usually be filled out prior to or on the day of admission. Although nursing homes have different rules, it’s common for these forms to be filled out at the facility with a staff member. The patient (or agent) will sign their name several times after learning about nursing home policies, responsibilities, legal certificates, and the cost and care provided. Because nursing homes are regulated by state and federal laws, the community needs written proof the patient learned this information. Part of the paperwork gives the patient’s consent to be treated.

As part of the application process you may need to bring your loved one’s Social Security card, documentation related to Medicare or Medicaid, and insurance cards.

Nursing home financial assessment: What questions will I be asked?

Nursing homes are obligated to determine if incoming residents meet the criteria for any state or federal funding. This process is similar to someone providing financial information to get a mortgage.

This step ensures each patient has the means to pay for nursing home care. The patient and their family will need to disclose financial information and paperwork and answer questions such as:

• Is the patient currently enrolled in Medicare (Part A or B) or Medicaid? Do they plan to apply?
• Does the patient have supplemental insurance?
• Does the patient receive VA benefits, railroad retirement, SSI funds, or a private or government pension?
• What are the patient’s assets, including cash, checking and savings accounts, stocks, bonds, CDs, trust funds, and real estate holdings?
• Does the patient have any paid-up life insurance policies or paid-up burial insurance or long-term care insurance?
• Has the patient transferred assets in the last 3-5 years?
• What’s the patient’s current living situation?
• What’s the amount of rent paid per month or mortgage payment?

Additional documents for nursing homes

The process of admitting a loved one into a nursing home can take several hours or more, says Pavlovich. There can be a lot of personal information and essential documents for seniors and families to provide, such as advanced directives and more.

Nursing homes may also ask for:

• Power of Attorney (POA) papers
• Do not resuscitate (DNR) paperwork
• End-of-life care wishes
• Dietary requirements
• Medical orders for life-sustaining treatment (MOLST)
• Living will