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Nursing Facilities And Skilled Nursing Facilities

When A Nursing Facility Is Appropriate

For the purposes of this guide and in general consumer usage, all 24-hour licensed nursing facilities are considered skilled care facilities. However, the federal government refers to:

  • non-Medicare-certified facilities as nursing facilities and to
  • Medicare-certified facilities as skilled nursing facilities or SNFs.

The Virginia Department of Health recognizes those facilities that do not participate in Medicaid or Medicare as non-participating facilities.

Unless otherwise noted, this section focuses on licensed nursing facilities.

Most nursing facility admissions--more than 70% of them--come as the result of an acute care hospitalization for injury or illness.

Nursing facility care may be needed to:

  • continue the recovery process
  • provide hospice services for the terminally ill
  • facilitate rehabilitation or
  • maintain nursing care for a chronic set of medical needs.

Nursing facilities are to be considered when:

  • the required period of care is longer than acute care facilities provide
  • alternatives to institutional care are not sufficient for proper medical care
  • 24-hour licensed/registered nursing care is medically necessary and/or
  • short-term or long-term rehabilitative services for injured, disabled or ill persons are needed.

An entire facility or portion of a facility can be licensed as a nursing facility. For example, continuing care retirement communities offer skilled nursing facility services for their residents. Those services can be fulfilled in a special section of their CCRC or in a special section of a hospital that provides long-term care services under contract to the CCRC. Hospitals may also provide skilled nursing care in a long-term care unit--LTCU.

Whether a nursing facility admission follows hospitalization or is the result of a determination by medical professionals that full-time nursing care must be provided, the first requirement for entrance is the admission assessment.

With their 100-year-old history, nursing homes, now called nursing facilities and skilled nursing facilities are one of the most recognized long-term care providers.

A Quick Look Back

Nursing homes were started by a physician in France in 1881. They created little impact in the U.S. until the early 1900s when the Nurses Act of 1919 stipulated new licensing parameters for nurses. America's nursing associations expanded these licensing boundaries by detailing the capabilities level--the education necessary plus the responsibility and accountability that came with it--for carrying out a physician's orders over an extended period of time.

With the advancements in the professional recognition of nurses' capabilities, the door was opened to the development of places specific to around-the-clock nursing care and day-to-day medical care for the ill and disabled. Nurses could now take care of their patients under the orders of--but not constantly watchful eye of--a physician.

Building on this beginning, the National League for Nursing introduced the accreditation of nurses' educational programs. It was this growth of the professional credentialing of the nursing profession and the early findings of geriatric physician specialists and other medical professionals that came together to form the foundation for what we know today as nursing facilities.


Nursing Facility Assessments

By law, except for a clinical (medical) debilitation, nursing facilities are responsible for preventing a patient's condition and abilities from diminishing. To uphold this commitment, periodic reassessments are necessary to provide any 'then and now' changes that might take place.

Therefore, all licensed nursing facilities must conduct and complete a comprehensive assessment of each resident within 14 days of admission. A significant change in the resident's condition requires additional assessments and care plan changes.

The medical and functional portions of the assessment form the foundation for the resident's care plan. A physician must write all orders for the resident's care including orders for :

  • medications
  • diet
  • treatments and
  • any changes to standing medical orders.

The facility's administrator or designated supervisor must review and approve all care plan changes before they can be instituted.


Staffing

A nursing facility is required to maintain interdisciplinary staffing at several levels including

  • licensed nursing facility administrator
  • physician medical directors as well as directors of nursing services
  • nurses trained to provide skilled nursing care and
  • social workers and activities directors.
They are also required to staff or have as consultants :
  • a pharmacist
  • therapists that may include physical, occupational and speech therapists
  • food service personnel including a dietary supervisor (minimally a consulting dietician) and
  • an interdisciplinary assessment and assurance committee.
And, like hospitals they never close. Service is continuous--24 hours a day, 365 days a year with trained, licensed nursing staff always present.

Nursing Care

Today's nursing facilities provide a mix of training levels in their nursing staffs. This allows patient care needs to be matched to the most appropriate levels of training.

However, to be licensed in Virginia,

  • a nursing facility must provide around-the-clock licensed nursing care and
  • a Registered Nurse (RN) must be on duty for at least one eight-hour shift of every day, seven days a week.

Licensed nursing care is nursing care provided by any of the following state licensed nursing levels:

  • Licensed Practical Nurse--LPN
  • Registered Nurse--RN
  • Clinical Nurse Specialist--CNS/is also registered
  • Registered Nurse Practitioner--RNP

Skilled nursing care (for example, a Medicare-certified SNF) is appropriate for those whose day-to-day condition is not acute or chronic but who still need 24-hour nursing services. When acute episodes require treatment and care, the nursing facility, with a physician's orders, will move the patient to an acute care hospital.

Certified Nurse Aides provide basic services but are not licensed or registered (degreed) nurses. However, in Virginia, CNAs must :

  • complete a certified 120-hour training program
  • pass a competency test within four months of being hired to work in a licensed nursing facility and
  • be registered with the Virginia Nurse Aide Registry.
CNAs may provide assistance with Activities of Daily Living--ADLs:
  • bathing, dressing and eating
  • toileting, transferring and bowel/bladder continence and assistance with Instrumental ADLs (IADLs)
  • changing linens or performing other housekeeping duties
  • laundry and meal preparation


Physician Care And Attendance

Even though a nursing facility runs to a physician's orders, nursing facility licensing in Virginia requires that each resident be seen by a physician at least once every 30 days for the first 90 days of care. Thereafter, a physician visit is required every 60 days. In a Medicare-certified skilled nursing facility, physician visits are required upon admission--no later than the 14th day--and every 30 days thereafter. Interim physician visits in both nursing and skilled nursing facilities would be driven by residents' needs.

If you need to see your own physician on a more regular basis and/or it is medically necessary, this is your right but the request should go through appropriate channels at the facility in which you are receiving care.


Socialization

Many nursing facility residents enjoy social activities and the nursing facility is responsible for supplying various levels of social activity that meet the capabilities of all patients. Community agencies also provide out-of-home activities for those who are able. Activities in and out of the home can include:

  • social
  • recreational
  • intellectual and
  • religious activities and may even include
  • opportunities for volunteer service.

Summing Up--Virginia has many nursing facilities that provide much needed services. Statewide monitoring and consumer response systems have been put in place to ensure that good service and quality care continue.

  • Long-term care ombudsmen who can help with special patient and family concerns and issues are becoming more plentiful.
  • Nursing facilities' compliance with state and federal licensing and certification measures continue to be reviewed and enforced by Virginia authorities.
  • Many nursing facilities participate in voluntary accreditation organizations.
  • And, federal guidelines have been strengthened and enforcement improved.
If you are a family member who is responsible for making a nursing facility decision for a member of your family, there are things you can do that can improve your comfort level with your final choice, enhance the overall satisfaction of your choice and improve the care your loved one receives.