The Admissions Process
A sound EHR software system can play a valuable part in residents’ journeys, from the beginning of their entry into a long term care facility to the conclusion of their stay, whether via discharge or transfer. The most important piece of admissions is a robust Admit, Discharge, and Transfer system.
Patient Referral Sources
The admission process can involve referrals from a variety of sources such as
- Hospitals and geropsychiatric hospitals
- Hospice agencies
- Home care agencies
- Senior care referral companies
- Family or friend inquiries
- Another long term care facility that requests transfer due to additional care needs or the resident’s personal request
- Other sources such as senior community centers, medical clinics, Adult Protective Services (program for elders with potential welfare concerns), and medical supplies outlets
The admission process can involve referrals from a variety of sources such as hospitals and hospice agencies
The Referral Process
When a family member is looking to move their elderly parent or relative to a long term care facility, they will consider several factors that include:
- The level of specialized care provided
- Available payment options
- Proximity to home
- The facility’s reputation
Management then receives the referral through referral management software or fax and carefully reviews it.
What Information Should a Referral Include?
Referrals should “tell a story” about the person, where they are currently located—like at home, in a hospital, geropsychiatric hospital, or another facility—family contacts, and a payor source. If more information is needed, one might have to contact their current location for up-to-date progress notes and clarification regarding any upcoming medical procedures. All this information is then imported into the long term care EHR used by the facility.
Determining Whether a Referral Should Be Accepted
Management then discusses the referral with the patient case manager to determine if the facility is the best fit. There may be valid reasons for which the facility cannot accept the referral, such as the inability to accept certain healthcare coverage or provide the service needed. For example, a nursing home is a skilled facility that can offer enteral tube feeding for eligible residents, whereas assisted living facilities cannot.
Payor Sources as an Acceptance Factor
Every facility must establish the payor source during its referral research and determine whether or not it can accept that payment option. Assisted living facilities, for instance, are not as likely as nursing homes to accept Medicare or Medicaid. Further, not all facilities accept the same types of insurance coverage. Some will accept Medicare/Medicaid, while others will not. This information about payor source must be entered into an insurance verification system, like ABILITY or a state website.
If a referral mentions Medicare as the primary payor, then “the three-day rule” applies. This means that the person had a medically necessary inpatient hospital stay of three consecutive days. It is important to note that these three days do not include the time spent in the emergency room prior to admission , the day of discharge, or any outpatient care.
Assessing Residents For Continuing Care or Discharge
An MDS nurse will then assess the resident before the first 100 days come to an end to determine whether they should be discharged or remain in long term care. Ultimately though, the final decision on whether to discharge is made by the Medical Director in charge of the resident’s care.
Medicare Part A can cover up to 100 days for skilled nursing facility placement. This includes 100 percent of the costs for the first 20 days . From day 21 of their stay, a significant amount should be covered by a supplemental policy. In 2021, the copay was $185.50 a day. After 100 days, expenses are usually out of pocket unless an extension of care has been applied for and approved. These costs can be covered by the resident’s long term care insurance or Medicaid if they have a low income. Additional services, like therapy, can be covered by Medicare Part B .
The facility may invite the family to meet or experience a facility tour before any commitments are made. However, staff members must inform the family about any current protocols that may be in place (e.g., COVID-19 protocols) before a scheduled visit.
Once a facility has decided to accept the referral, the staff must then begin to prepare for the new resident’s arrival. That means filling out admission forms, which can be easier with an intuitive long term care EHR system.
Communication, Events, and Education
Facilities can also educate families on all the services they provide and inform them of any upcoming events that involve family members. In addition, many facilities have social directors, life enrichment directors, and even activities directors, who can make regular visits to help the new resident feel comfortable and address any questions or concerns.
Facilities can educate families on all the services they provide and inform them of any upcoming events that involve family members.
Preparing For a New Resident’s Arrival
Next comes cleaning the room or apartment. The resident and their family may wish to move personal belongings into the room prior to the resident’s arrival. This can be particularly helpful, especially for residents who have dementia.
Other arrangements may need to be made, such as transport to medical appointments or placing an order to begin physical therapy. Many facilities like to provide new residents with a welcome basket containing helpful information about the facility with a few gifts or snacks that the resident may enjoy.
Assessing the New Resident During Admission
There are several steps to assessing a new resident during admission to a nursing home and these steps require multiple staff members to participate. The accuracy of the initial assessment is crucial as it affects the financial success of the facility.
The Daily Rate At Time Of Admission
The initial daily rate for a resident could be impacted by a few dollars per day by something as simple as not documenting certain medications or a patient receiving a bag of fluid in the hospital. When such an opportunity is missed during the initial assessment, you can not return to the resident’s profile and document what was missed.
The daily rate determined during the admissions process will remain the same for the first week or two that a resident is first admitted. After this initial period, reimbursement is based on services provided, which is determined by the charting of Activities of Daily Living (ADLs), therapy, and modalities conducted by CNAs.
Accurately Assessing the Resident’s Initial Condition
The initial assessment sets the stage for the resident’s care and reflects on the care provided. For instance, a facility will want to show upward progress with the goal of the resident being discharged or making progress and requiring less therapy. Meanwhile, the facility will not want the resident’s condition to appear to have become more complex or suffer a rapid decline. Thus, a complete picture of the resident must be painted from the start and documented in the facility’s long term care software.
Who Is Responsible for Assessing New Referrals?
It is important that nurses and administrators work in tandem to get the information needed to provide an accurate profile for new residents. First, the MDS nurse will look to pick apart a newly-admitted resident’s medical history. To do so, the admissions coordinator must supply the MDS nurse with the information necessary. The MDS nurse will then review the admission information forwarded to the facility from the hospital. This includes the most recent documentation, as well as the results of testing and searching for areas tied to reimbursement and comorbidities that result in higher daily rates.
What Role Does Each Staff Member Play in The Admissions Process?
Admitting a new resident requires input from multiple staff members. Here are some examples of how various employees play a part in the admissions process.
LPNs will document the admission in the long term care software system to ensure that correct medications have arrived for the resident, are administered according to the physician orders and that of the resident care plan. An RN should also conduct an initial assessment within 30 days of admission.
Dietary management staff
Dietary management should meet the resident to establish diet and food preferences. This information must then be documented in the long term care software system. Food allergies must be disclosed for safety reasons, and food preferences noted to ensure cooperative behavior from residents. For instance, if a resident has already told someone that she does not like carrots twice this week, she may grow upset upon seeing them on her plate again.
Other dietary restrictions issued by a physician order must be followed as well. These may include low salt, reduced-size portions, religious considerations, and diabetes management.
Nurses from an outside entity
Nurses who do not work directly for the facility may be part of the admission process if the resident is under hospice care or will still be receiving services from another care agency.
Nurse aides or Certified Nursing Assistants (CNAs)
Nurse aides or Certified Nursing Assistants (CNAs) will provide personal care, including arranging the next meal after a diet is established and assistance to consume a meal. They may obtain vital signs and conduct an inventory of belongings as well. In addition, they will document their monitoring, including ADLs, in their long term care software and report any concerns directly to the nurses.
Management should get to know new residents. They may assist in areas as needed during the admission period and can address any questions the resident or their family may have. Facilities that have an admissions coordinator can oversee the process and take leadership.
Activities Directors/Life Enrichment Directors
Activities Directors or Life Enrichment Directors should meet with the new resident and obtain a social history with activity preferences. This information can help all staff get to know the new resident’s preferences and routines and should also include discussions with the family.
For example, if a resident does not like bingo but enjoys arts and crafts, staff should inform the resident when arts and crafts activities occur to encourage participation and socialization. Of course, staff should continue to offer all activity choices, as residents may decide to participate in an event they usually decline.
Other staff such as housekeepers, laundry assistants, and maintenance should also familiarize themselves with residents after admission. They will interact with residents regularly and can be another source of resident monitoring.
Current residents should also be requested to welcome new residents and help them settle in. Staff and other residents can encourage the new resident to participate in activities, attend facility resident council meetings (usually a monthly event), and offer to escort new residents to and from communal dining areas.
Identifying a Care Plan
An appropriate care plan will identify appropriate care needs and goals. It will contain user-defined assessments – a series of questions under various headings within a long term care software system – like activities of daily living (ADLs), physician orders, progress notes, and a list of diagnoses with noted medication allergies.
The physician orders will refer to treatments that must be followed and correctly documented in the long term care software system such as prescribed medications, medical devices needed, and therapy referrals.
Activities of Daily Living (ADLs)
ADLs and progress notes track daily aspects of the resident’s life, such as
- Food intake
- Activity participation
- Sleep pattern
- Bathing schedule
- Vital signs
- Cognitive abilities
ADLs and progress notes track daily aspects of the resident’s life, such as mood, food intake, and activity participation
Due to their efficiency and cost savings, more and more facilities are turning to long term care EMR software to log and store this information.
The Importance of Resident Preferences and Routines
Facilities that familiarize themselves with each resident’s preferences and routines provide better care and run a smoother operation. Failure to observe a resident’s preferences often leads to dissatisfaction on the part of the resident and wastes the time and energy of the resident’s family as well as the staff.
Discharging a Resident
There are many reasons a resident may be discharged from a facility. Anytime a resident leaves a facility there are several important steps that need to be taken by the nursing home staff.
Why Do Residents Get Discharged?
Residents can be discharged from a facility at their request or due to their ability to return to the general community (for instance if the stay was known to be temporary from the beginning), being transferred to another facility, or even being asked to vacate the property (the resident has a right to appeal this notice). This information must be documented in a progress note and should include how the residents’ belongings and medications were handled when the resident leaves the premises.
What Happens When a Resident is Discharged?
When a resident leaves, staff should handle the process with dignity and be aware of the different discharge circumstances. A date should be scheduled for the discharge, and a planning meeting held before that date. The meeting can involve key staff, family members, and anyone assisting the resident once they return home. This meeting can offer the family information on local resources, such as assistance with medical devices, and offer the facility services if needed in the future.
In addition, the facility can arrange assistance in gathering all belongings and distributing medications as per facility policy and procedure. A leaving basket with memories of their stay, a few gifts, and facility contact details can also be given to the resident.
The resident may need a transfer to another facility. This can be a sister facility they selected to be closer to family members, a different type of facility due to their declining health, or special placement due to worsening behavioral issues that need more one-to-one staff attention.
Management can hold a meeting with the resident and their family to formulate a plan according to their needs and document this as a progress note to be included in discharge planning or the care plan of the nursing home EHR
What makes a smooth transfer?
Leaders at the facility should also work with the receiving facility to ensure that the transfer is as smooth as possible. The discharging facility should provide the receiving facility with as much information as possible regarding the resident. Both facilities should also confirm the transportation requirements of the resident. The following questions should be asked before transport:
- Does the resident need a wheelchair?
- Will they need a meal on the way to the receiving facility?
- Do they need to take medication before or during the transport?
- Are there designated or available staff members assigned for the transport if needed?
- Is all relevant documentation—like current medications, the discharging facility’s factsheet, contact information, and recent progress notes—ready to be handed over to the receiving facility?
- Is the receiving facility prepared to receive and welcome the resident?
The answers will then be included in the discharge planning note for which the social services coordinator is responsible.
When a Resident Passes Away
Unfortunately, many residents will never be discharged and will rather pass away in the facility. The facility should offer support to the family and staff members involved in the resident’s care. The resident’s belongings left behind must be documented in the LTC software, and any resident medications must be either destroyed or moved as appropriate. This information must be entered in a progress note that will be signed by the responsible party.
Once the resident’s living quarters are vacated, the facility must clean and sanitize the area. The room, once vacated, will show up as being available in the long term care software as soon as the patient is discharged in the system. Staff must also follow any other protocols in place for COVID-19 or other infection control policies. These measures help maintain a safer environment and better prepare the living quarters for the next new admission as the cycle is ready to begin once again.
Long Term Care State Surveys
Surveys are conducted by the government to ensure that facilities are in compliance with required federal regulations and state laws and, thus, providing appropriate care for residents. These surveys rate long term care facilities on a 1-5 star scale. Facilities in each state are rated against one another as well.
Consequences of Low Survey Scores
If a post-acute care facility gets a poor survey rating it could mean
- They are no longer eligible for Medicare or Medicaid
- Their reimbursement level drops
- They are subject to additional monitoring and further surveys
- They can be penalized with a monetary fine
Who is Responsible For Survey Preparedness?
SNFs need to be prepared to provide accurate and complete data that will be submitted to surveyorsupon request. Often it is the responsibility of the MDS coordinator to provide requested data to the director of nursing, who will then hand those reports and medical records over to surveyors.
Though the MDS coordinator may be the one providing data to the surveyor, all facility staff must be knowledgeable about the survey process. Survey readiness is essential for staff to have a clear understanding of the importance of striving for better care and be motivated to care for their residents in a professional manner.
Minimum Data Set (MDS)
Surveyors use a Minimum Data Set (MDS) which is part of a federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. The MDS includes an assessment of residents’ health needs and functional capabilities.
The current version, MDS 3.0, includes additional information such as residents’
- Physical, psychological, and psychosocial functioning
How Do Surveyors Get The Data For an MDS-Focused Survey?
It is the LTC facility’s responsibility to complete survey forms by pulling information from reports, such as
- A list of current residents in the building on the day of a survey
- The number of available and occupied beds
- Resident location by payor type
- Items required for entrance
Because these reports and others required by surveyors must be produced quickly and accurately, it is important to have an MDS software system that is capable of generating the necessary reports by importing data from other areas of the LTC software.
Types of Surveys
There are several types of surveys all SNF staff members should be aware of. It’s important to always be prepared for any type of survey since they are usually unannounced so as to capture the facility in its normal operating state
Annual surveys occur every nine to fifteen months. (Though the COVID-19 pandemic has disrupted this timeline for many states and may continue to do so.)
A survey team will look at various areas of the facility including:
- Documentation reviews
- Care observations
- Observations of food preparations
- Environment checks
Annual surveys occur every nine to fifteen months.
What Happens During an Annual Survey?
The survey team conducts an overview of all residents within the facility before picking a case mix of residents to review in more detail. The survey team has specific assignments to complete which may include
- Observing residents consuming a meal
- Looking to see if daily activities are taking place
- Observing specific care performed by staff
- Conducting resident interviews for their feedback
The survey team will also look at how residents and staff interact together. Surveyors gather a lot of information to then determine if there are any deficient practices. They will discuss all information as a team to decide outcomes.
Complaint surveys occur when a concern has been reported. A survey team will then visit the facility to investigate the complaint. Surveyors usually stay focused on the nature of the complaint but if something else occurs during this survey then that area will also be investigated.
Depending on the nature of the complaint, surveyors may decide to enter the facility after normal working hours or on holidays or weekends. The CMS has requirements for conducting a percentage of surveys during irregular hours. Surveyors may ask staff specific questions or request to review specific documentation. A complaint survey will determine that a claim is substantiated, unsubstantiated, or that some parts are substantiated while others are unsubstantiated.
A follow-up survey will occur after a survey has been conducted and deficiencies were cited. Deficiencies are categorized into F-Tags, which can be minor or severe. Surveyors again should stay focused on the areas found deficient and will expect to see where corrections or improvements have been made. The facility can expect a follow-up visit and must make time to implement the necessary changes.
The facility and the survey team will both look to clear the deficiencies, which may also contain monetary fines. Some fines run on a daily basis until deficiencies are cleared, while others are a set amount. There may be occasions where the number of deficiencies is few or very minor, in these cases CMS may conduct a desk review as the follow up. A desk review usually means a survey team does not have to return to the facility.
Life Safety Surveys
A life safety survey assesses the safety of a facility itself. These surveys will review the facility structure, conduct a facility tour to check systems in place, and review inspections documentation. Deficiencies can occur if concerns are identified and documentation is not present or current. Systems such as the fire alarm, sprinkler, and fire extinguishers in place will be reviewed, and the fire alarm may be tested as part of this survey.
COVID-19 surveys allow surveyors to review current protocols in place to determine whether or not the facility is safe for its residents and what preventative measures are in place to reduce the spread. Even before the pandemic, surveyors occasionally conducted infection control surveys when required. It is simply a more pressing issue now. A long term care facility, thus, needs to stay updated, as guidelines and/or regulations can be subject to further change during the pandemic.
Survey Results and Their Repercussions
A satisfactory survey means the facility is operating as it should be and the residents are happy. Such a facility will earn a good reputation as reflected in the score it receives in a five-star rating system made accessible to the public.
Penalties for Deficiencies
A facility that continually receives many deficiencies or the same deficiencies repeatedly may encounter penalties including
- Reduced or suspended reimbursements
- Regular facility walkthrough surveys
- The suspension of onsite CNA training classes
- Loss of pay raises for staff, as that money must now go elsewhere
- Increased stress for staff members, who must deal with the added pressure of regular visits from surveyors
If surveyors observe any potentially harmful situations for residents, those have to be addressed and resolved whilst surveyors remain in the facility to ensure the harm or potential harm is removed. Further, the facility has a duty to prevent such harmful situations from reoccurring and must document how they plan to do so.
What Surveyors Are and Are Not Looking For
Surveyors may document direct statements from staff, which may or may not cite a deficiency. Surveyors may also document direct quotes from residents and their families. Surveyors regard the residents as their priority, and their job is to ensure the residents are safe.
Surveyors are not looking for perfection, but they are looking to see that the facility is making every attempt to take care of its residents. It is normal to be a little nervous if observed, but staff should still be able to perform their job if they have received suitable training.
Surveyors can look back on the facility’s previous surveys to see if there are any patterns that may be focus areas to keep in mind for a future survey and to see how many complaint surveys were completed.
How Facility Policies and Procedures Can Lead To Better Surveys
Staff must be informed about the importance of following facility policies and procedures. Surveyors will review these facility policies and procedures, and, in this process, they may identify deficiencies if the facility’s rules are not correctly followed or are not current. For example, a surveyor may review the facility policy and procedure for incontinence care. If this document is dated some years back and contains verbiage referring to products no longer used in long term care, then they will immediately recognize that the policy and procedure are outdated. This, alone, can create a deficiency. Accurate, consistent documentation shows the facility is making real attempts to operate efficiently and to maintain current protocols.
The Role Of The Staff In The Survey Process
Staff who are educated and caring will become familiar with the survey processes. This, in turn, results in better care quality for residents and makes the survey itself proceed more smoothly.
It is important to notify your team that staff members may be observed performing their work during the survey process. Surveyors may ask them questions. Staff should respond politely and stay on topic. If a surveyor asks a question, and the staff member is unsure of the answer, they should get clarification from management and get back to the surveyor with a response in a timely manner. It is best not to guess an answer but rather take the time to obtain accurate information in giving a surveyor a response.
Better Surveys Means More Money and Better Staff
Since good survey scores lead to higher reimbursements, facilities that perform well on surveys have more financial resources to work with as a result. Doing well on surveys can increase an LTC organization’s ability to make the best possible hires, and to have the number of staff members needed to run smoothly every shift making subsequent surveys even better.
How Staff Can Positively Impact Surveys
An emphasis on Professional, well-trained staff are more likely to
- Complete accurate and regular documentation helps to ensure surveyors have what they need
- Understand and follow the facility’s procedures and processes
- Conduct their tasks in a safe, courteous, and standardized fashion
- Consider their work to be a direct representation of the facility’s values
An emphasis on professional, well-trained staff are more likely to complete accurate documentation to ensure surveyors have what they need.
How Staff Can Negatively Impact Surveys
Nursing homes with high staff turnover rates, overworked employees, and undertrained staff run into issues that can have a negative influence on surveys like
- Lack of adherence to policies and procedures
- Understaffed shifts
- Documentation mistakes or missing documentation
- A lack of knowledge on how to use important systems and equipment
- Employees not feeling a sense of pride in their work
- Employees not considering how they are representing the facility
- Too many new faces can be concerning or confusing to residents
Staff members need to understand why they are required to follow facility regulations as well as the need to perform work duties appropriately. Staff will be far more inspired to complete tasks correctly if they have an understanding of the purpose as well as a love of the job that they do. Explaining the “whys” as well as the procedure itself shows that the facility cares about its staff members.
How Management Can Create A Better Survey Experience
Facility leaders can facilitate a more successful survey outcome. Strong management will encourage all staff to be properly trained and to strive for the best practices every shift. Surveyors watch to see that residents are treated with respect, dignity, and as the unique individuals that they are, which should be reflected in the facility’s PDPM score.
Facilities can combine strategic training, on-the-job training, team-building activities, and mentoring to promote good working relationships that ultimately lead to better care. It is also important that facilities and their staff members prepare for surveys in advance so as to know how to provide accurate answers and act in accordance with the legal obligations of the industry.
Long Term Care Roles Defined
Owner or Owner-Operator
All long term care facilities have leaders in upper management roles, though the titles may vary. Leaders in long term care must be effective communicators, capable of resolving conflict, skilled in people management, and adaptable. They must also be able to make important decisions, including when and how to make the move to electronic documentation and which long term care software to implement. Leadership will be first determined by the owner or operator of the facility. This person or people are also known as proprietors or partners.
For-profit ownership organizations usually structure a facility’s operations with an eye toward maximizing profits, as they view a facility as a lucrative real estate business. They tend to maximize the occupancy of rooms and charge for additional services and amenities like cable TV packages, alternative dining options, on-site entertainment events, and specialized care.
Non-profit ownership organizations, meanwhile, tend to prioritize the resident’s quality of life and staff’s general well-being. They invariably provide better service, as for-profit, investor-owned facilities are more likely to produce poorer resident outcomes due to fewer resources and reduced budgets. It is important for residents and their families to research the ownership of a facility to get a good idea of the care provided.
CEO (Chief Executive Officer)
CEO can sometimes refer to an administrator, like in the case of a CCRC, where the CEO manages both matters related to skilled nursing and assisted living. The CEO is the highest-ranked position within the company and is the overall chief decision-maker, meaning it will be his or her decision to move to electronic health records and then choose a long term care software system.
COO (Chief Operations Officer)
The COO is typically the second highest-ranked position within the company and oversees the daily operations of the facility. The COO reports directly to the CEO and is responsible for ensuring the overall direction is in line with the facility’s mission and core directive.
CIO (Chief Information Officer)
This position oversees a company’s Information Technology (IT) or computer software system. Companies that engage in research and technology development may employ a CTO (Chief Technology Officer), who may, in turn, oversee the CIO and the technology team. In addition, the CIO will work alongside the CEO to promote business growth and success.
Other duties may include:
- Developing computer systems and strategies to stay competitive and profitable
- Choosing options to be added to their long term care software system
- Integrating systems and creating websites
- Analyzing relevant technologies that may benefit the company
CNO (Chief Nursing Officer)
The Chief Nursing Officer, another common role, can serve as the highest-ranking clinical resource within the corporate structure. The CNO will operate in a similar capacity as the CMO or, Chief Medical Director, to ensure clinical compliance. This role is served by a Registered Nurse with advanced training through a Master’s degree, or higher, and is considered an authority in long term care. Traditionally speaking, this individual directly manages the clinical regional directors to propagate policy, training, and adherence to governmental regulation.
Administrator/Executive Director/Facility Manager
This is a qualified and licensed position that usually requires a bachelor’s degree in business management, facilities management, or a related field. Administrators usually have a minimum of five years experience in a supervisory role, and come with a wide number of skills necessary to enable the successful running of a facility.
A nursing home administrator or facility manager will need to have:
- Problem-solving and analytical skills
- Time-management skills
- Familiarity with building upkeep, structural issues, and grounds maintenance
- Budgeting skills
- Interpersonal and communication skills
Administrators usually have a minimum of five years experience in a supervisory role, and come with a variety of skills.
The administrator oversees all facility departments by communicating with each department head on a regular basis to ensure facility compliance. He or she must utilize the facility’s care plan software by tracking facility activities and making sure all planning, coordinating, and supervising is carried out effectively.
Larger facilities may also have an assistant administrator who is trained in the same duties. When the administrator is absent due to other work commitments, illness, emergencies or vacation, an assistant administrator will step in to ensure the facility continues running efficiently.
- Leadership role/ first point of contact for the facility between the residents, families, nurses, health care staff, and the general public
- Oversee all departments including care services, marketing/community outreach, and staff retention. The administrator must ensure all departments are complying with the most up-to-date federal regulations, state regulations, and local regulations.
- Monitor staffing, financial and payroll duties using the facility’s assisted living software
- Resolve complaints and grievances between residents, families and staff members
- Plan, coordinate, and supervise health care delivery across the facility
- Research new ways to keep patients and residents happy, healthy, and safe
It is essential an administrator is familiar with using the nursing home EMR because they are tasked with overseeing the day-to-day activities in a facility. They can only perform their role effectively through using long term care EMR to keep track of all facility details, from resident care plans to scheduling equipment maintenance to hiring and training staff.
For more information about the role and responsibilities of an administrator, read about one person’s journey to becoming a nursing home administrator.
A medical director is a qualified physician who provides medical guidance to the facility and may be responsible for multiple facilities. MDs will provide the documentation that facilities need, which can then be scanned and entered into their long term care software system. Further, MDs also coordinate with other agencies by way of the software.
The functions of a medical director include:
- Coordination of facility staff and outside resources (hospitals, clinics, etc.) to promote quality of residents’ care
- Scientific activities, such as research and publication
- Participating in an on-call system outside of regular work hours
- Patient care audits, which can be documented in the long term care software system
Larger organizations may employ Regional Directors to oversee and manage different departments such as therapy, nursing, medicine, information technology, dietary management, human resources, marketing, and consulting services.
Facility Level Management
An Administrator/Executive Director, or nursing home administrator, is responsible for maintaining all operations in a nursing home. A day in the life of a nursing home executive director typically consists of:
- Hiring and supervision of nursing home staff
- Implements and oversees quality assurance protocols
- Ensures the compliance of the nursing home with all local, state, and federal regulations
- Acts as a liaison between families, staff, and residents.
This helpful guide covers the steps required to become a nursing home administrator. Administrators are trained in fields like public health or administration and have the knowledge necessary to manage the entire facility. The administrator will oversee all departments and communicate with department heads on a regular basis to ensure facility compliance.
Director of Nursing (DON)
This position is occupied by a registered nurse (R.N.) who manages and oversees all care services provided by the facility personnel. A DON must hold a degree in nursing or a dual degree in nursing and healthcare or business administration. Larger facilities may also have an assistant DON who can assume the role when required, usually when the DON is otherwise absent or in need of assistance.
A DON acts as the head of the other nurses. They are responsible for overseeing the quality of care provided and act as a liaison between the team at a hospital or other facilities. They are required to use the nursing home software to keep track of the facility’s finances, medical records, and purchases.
They are also responsible for maintaining good relations between the residents and their families, therefore it is important for a DON to coordinate between all relevant people including the nursing team, the medical team, and management.
A DON’s responsibilities also include providing sufficient training and support to the nurses and other staff within the facility. This incorporates clinical training and administrative training in using the nursing home management software. Therefore, it is essential for a DON to fully understand how to use the facility’s long term care software, along with all its features.
Many DONs report that an efficient long term care EHR system can revolutionize a facility’s care by improving their POC reporting and providing more accurate resident data. On a daily basis, a DON must monitor resident care within the facility, ensuring high standards are maintained and adequate care is given.
A DON manages and oversees all care services provided by the facility personnel.
LTC software systems ultimately facilitate more efficient and effective work, therefore enabling a DON to correlate data better, with improved procedures to prioritize tasks.
A DON is a leadership/management role. The position requires a high degree of patience, perseverance, empathy, and a passion for providing care.
- Tracking resident data and health records via the facility’s care plan software (updating relevant information when required)
- Participating in the creation of resident care plans
- Establishing a standard of high-quality care complying with federal, state, and national rules and regulations
- Ensuring new and existing policies and procedures are updated and improved, providing a high quality of care
- Using the nursing home charting software, DONs must ensure resident admissions, transfers and discharges are processed appropriately and according to protocol
- Keeping accurate records through the SNF software of department and management budgets, including monitoring expenses, finances, and accounting
- Overseeing the hiring, firing, training, and development of nursing staff. All records must be clearly labeled and recorded in the nursing software programs, for future or past reference.
- Consistently engaging with physicians, patients, residents, and the family members to convey the care provided
- Conducting work performance evaluations
- Helping to manage the department budget
A DON plays an integral role in long term care, being one of the pillars of every hospital and long term care facility. While the role assumes many responsibilities, it is an enriching position, full of positive reinforcement. Read more about the role and responsibilities of becoming a DON here .
Licensed Practical Nurse (L.P.N.)
A licensed practical nurse provides care services under the supervision of the DON. Nurses are involved with directly treating and caring for residents, therefore it is common for nurses to specialize in a particular field such as a charge nurse, treatment nurse, or wound care nurse
A licensed nurse is therefore responsible for regularly updating and recording any changes to a residents’ condition through the nursing home software. It is of utmost importance that licensed nurses understand the full features of the nursing home charting software so they can record accurate resident data.
- Resident Medication Administration
- Shift charting and reporting using the nursing home EHR
- Nursing care such as bandage changes, specimen collections, physician telephone orders and vital signs tasks
- Supervising of direct care staff
Minimum Data Set (MDS) Coordinator
The MDS nurse is the driver of PDPM, or, the reimbursement model that is now the standard in long term care. This means that the MDS nurse is the one to enter important information into the long term care software. Still, he or she must get strong support from other team members, including management, to get the information he/she needs. Sometimes, the MDS nurse will have to approach physicians about potential diagnoses or nudge them in other ways to ensure that nothing is missed. To read more about the attributes of an outstanding MDS nurse, click here .
This position is usually filled by a nurse but it can also be filled by someone with relevant experience or qualifications as determined by the facility. The MDS coordinator is responsible for the gathering of information for all residents’ health conditions. The information gathered forms the basis of a resident’s care plan, which is then submitted and entered into the nursing computer software system. Once the data is inputted into the nursing home management software, a comprehensive resident care plan is developed. It is important that the collected data is accurate as this information is then passed onto Medicare and Medicaid to calculate a facility’s reimbursement payment.
- Resident assessments
- Reviewing potential new residents during the admissions process
- Monitoring case mix index (CMI) scores to ensure the facility is fully reimbursed
- Checking Medicare assessment schedules to ensure that submissions are accurate and timely
- Inputting and completion of data coding and submissions and ensuring its accuracy
- Coding corrections, additions, and adjustments (when required)
Social Services Director
This position requires a qualified professional in social work or a related field. They will identify and assist residents who are eligible for specific services or available programs. All records and services are stored in the assisted living software which is regularly updated to maintain accurate records.
- Visiting residents to determine their wellbeing and eligibility
- Communicating with outside organizations to assist facility residents
- Using the assisted living software to monitoring the department’s budget including raising funds for activities
Nursing homes need to attract residents to their facilities. Hence, they need marketing managers to promote the organization and bring in new residents. Their responsibility will often be relationship building in order to gain more referrals.
Some of the duties of a marketing director include:
- Hiring junior marketers and managing the performance of the marketing team
- Research and analysis of market trends and competitors
- Creation of the business marketing plan
- Managing the marketing budget and ensuring a return on investments
- Educating the community about the facility and its services
- Arranging and improving facility tours
- Obtaining referrals and improving the admissions process (when required)
- Traveling to meet with families or businesses
The role of marketing director tends to be filled by a person with relevant marketing experience or a marketing qualification. It is helpful for the marketing director to be familiar with both the facility and the local demographics, so they can create better marketing plans. If the facility is part of a holding company, then it is common for the marketing director to be responsible for multiple facilities.
Marketing directors tend to use a mixture of digital and traditional marketing ideas to build brand awareness.
Marketing managers help to promote the organization and bring in new residents.
Some tried and tested marketing ideas include:
- Revamping the facility website and building a strong online presence. Using visually-appealing images, providing valuable information, and creating an easy-to-navigate website will allow website visitors to gain a better understanding about the facility’s mission, what amenities and services are available, and how the staff can improve the lives of seniors.
- Targeting adult children of seniors in ad campaigns. Adult children are often the decision-makers when choosing a senior nursing facility. Therefore, facility’s need to alleviate the adult children’s fears by addressing the most commonly asked questions through a FAQs page on the website. This will also help to foster trust and open communication with the adult children, thus giving the facility a higher chance of gaining a new resident.
- Gaining a presence in local search results. Being atop the local search results is very advantageous, as the Google algorithm is designed to show local businesses. Facilities need to make the most of the Google my business listing page in order to appear in the local search results more.
- Building positive online reviews. Reading online reviews is a key part of a customer’s decision-making process. Therefore, facilities should ask residents or their families to leave online reviews about their experiences at the facility.
- Providing virtual tours. With the impact of the COVID-19 pandemic, there are now fewer prospective residents wanting to take in-person tours of a nursing home. One highly effective marketing idea for facilities is to create video tours allowing prospective residents and their families to see what amenities a facility has to offer.
Read this blog for more effective marketing strategies in long term care.
Business Office Manager
A nursing home business manage oversees financial operations, such as payroll and accounts payable and receivable. Other additional responsibilities include:
- Assuming responsibility for residents’ trust accounts
- Assisting in the planning, development, organization, and implementation of administrative policies and procedures
- Ensuring regulatory compliance in a nursing home
- Setting standards for administrative personnel
Activities Director or Life Enrichment Coordinator
The activities director is responsible for creating a meaningful activities program for all residents. Long term care facilities are places that foster a culture of care and a strong community. The culture in a facility should have a zero tolerance policy toward negative behaviors, while encouraging positivity, fostering collaboration between residents, engaging in open discussions about what improvements can be made, and providing appropriate training for staff.
Residents are also encouraged to participate in the organized activities to enhance their overall experience and to improve their quality of life. There are many innovative ways an activities director can increase a resident’s happiness within a facility. Creative programs and activities like karaoke nights and virtual reality experiences give residents more opportunities to socialize while giving them new experiences they otherwise would not experience.
Meanwhile, there are also several ideas an activities director can explore to foster community relationships with local partnerships, such as:
- Developing an on-site bank branch. Not only is this more convenient for residents, but it also provides an opportunity for banks to widen their footprint by entering into new areas.
- Forming a partnership with a local pharmacy. It is common practice for residents to fill their prescriptions at an offsite pharmacy from which the medication will then be couriered to the nursing home. This, though, poses security and safety problems, as prescriptions are often left in unsecured delivery sites. To combat this problem, facilities can open a satellite branch (a full drug store but without a pharmacist) so prescriptions can be delivered and securely held in the satellite branch, thus providing a more convenient and secure way for residents to access their medication.
- Connecting with local learning institutions. Partnering with universities and colleges is a great way to provide non-credit classes for adult learners. Not only will the local institutions allow residents to continue to pursue their educations, but it also gives the residents the opportunity to teach some courses.
For more community outreach ideas, read this blog.
It is useful for an activities director to be familiar with the facility’s assisted living software so they can better organize and implement programs that are within the capabilities of the residents.
This position requires a qualification in Education or a similar field. Some facilities will also have an activities assistant who may be working towards their qualification but are not yet fully qualified. They will assist the activities director with planning and implementation.
- Designing and coordinating activities and programs for residents>
- Ensuring activity programs follow the facility’s activity calendar.
- Including one-to-one resident activity programs (when necessary)
- Documenting and inputting all activities into the nursing home software to prevent schedule conflicts
- Fundraising for activity programs
- Maintaining an activities fund budget in the assisted living software program
- Assisting residents with basic functions, like standing and walking
- Assisting with meal preparation and serving food as needed
If a long term care facility has a limited budget, there are many cost-effective ideas and events a facility can implement to improve residents’ quality of life. Read this blog to learn more innovative ideas in long term care.
Dietary managers oversee the kitchen team who prepares and distributes all meals and food to residents. They generally have a bachelor’s degree in either nutrition, food service management, or the culinary arts.
All resident dietary requirements are stored in the nursing home charting software where dietary managers can access when preparing resident meals. It is important for nursing software programs to have accurate data as dietary managers will need to adapt and cater resident meals according to their preferences, allergies, or intolerances.
- Hiring and training kitchen staff
- Kitchen inventory management
- Maintaining and following current menus and instructions
- Following resident diet preferences and requirements as outlined in the nursing home software
- Ensuring the safe storage and preparation of food
- Checking to see that the correct food orders are processed
- Provide adequate training and scheduling for dietary staff
- Resolving food complaints and discrepancies
A dietary manager oversees the kitchen team who prepares and distributes all meals and food to residents.
Depending on the facility, some facilities require the maintenance director to hold a bachelor’s degree in facility management or business administration, as well as have a minimum of two years industry experience.
The maintenance director is responsible for maintaining the facility in good operating condition. He or she will also set overall goals, strategies, and objectives for their department and individual team members.
A maintenance director will use the nursing software programs to identify and resolve issues that arise, and may be contacted outside of their regular working hours. Some facilities also employ a maintenance assistant if there are a lot of unresolved problems and issues.
- Ensuring health and safety protocols are followed
- Conducting facility checks when required (e.g. fire alarm tests/drills, water pressure checks, elopement drills)
- Keeping day-to-day operations running smoothly by checking to see all tools and equipment are functioning properly
- Maintaining orderly documentation using the assisted living software program for the required inspections
- Resolving appliance issues and dealing with facility maintenance emergencies, including technical maintenance
- Providing adequate staff training to include staff orientation and safety training
- Facility upkeep (painting/touch up work, replacing non-working apparatus, trash removal)
- Overseeing the various operations of the maintenance staff
A housekeeping manager oversees a nursing home and ensures a clean and safe environment for residents.The responsibilities of a housekeeping manager include:
- Monitoring all daily cleaning operations, such as cleaning of resident rooms and the cleaning of common rooms and other shared spaces
- Hiring and training the cleaning staff
- Overseeing the cleaning budget, taking inventory of cleaning essentials, and ensuring there is a stock of cleaning supplies
- Documenting all cleaning activities and documents and reporting any cleaning issues such as door damage or floor tile damage
Housekeeping staff are responsible for maintaining a clean and hazard free environment. Accidents should be logged in the nursing home EHR so the housekeeper can clean any hazards quickly and efficiently.
- Housekeeping in the assigned daily resident areas, which include trash removal, vacuuming and dusting
- Daily cleaning of areas, such as offices, break rooms, nurses stations, and laundry departments
- Sanitizing all high traffic areas regularly
- Immediate clean up of spillages
- Reporting any hazards or repairs to the designated point of contact area
Laundry staff wash, dry, and maintain the residents’ clean clothing, bedding and bathing materials. Facilities usually offer laundry services as an additional service as some families prefer to do the laundry themselves.
- Ensuring all residents assigned for facility laundry service are scheduled and following the laundry schedule
- Collecting and returning laundry to the appropriate residents
- Retaining a current resident log to include new admissions and discharges
- Maintaining all laundry equipment is in working condition
Staffing Supervisor/CNA (certified nurse assistant) Supervisor
This position is usually occupied by an LPN or sometimes by a very experienced CNA. Duties can vary depending on the facility’s needs, therefore it is important for the staffing supervisor to be familiar with the nursing home software, as they will need to use it on a daily basis.
- Staff orientation, including training and mentoring
- Staff scheduling
- Providing staff inservices
- Assisting cover shifts if other coverage cannot be found
CNA (Certified Nurse Assistant/Aide) / DCA (Direct Care Aide)
Staff are often considered “frontline” as they build close relationships with the residents who they care and provide very personal care for.
CNAs need to complete a state-approved CNA training program to be certified in their profession. There are different specialities a CNA can train in, as a transport aide, restorative aide, certified medical assistant or a receptionist. ALl of which will require the CNA to use the nursing home software to maintain accurate resident records.
In contrast, DCAs are not required to hold the same certification as a CNA, however, they often provide a similar level of service and care. Some facilities do not have a requirement for all direct care staff, in which case, DCAs can be employed even if they are uncertified. Both positions require staff training in using SNF software to ensure accurate resident records are maintained and kept.
- Providing assistance to residents for bathing, dressing and transfers
- Monitoring and documenting residents’ activities of daily living (ADLs)
- Taking vital signs
- Reporting concerns to a nurse or other relevant management
- Assisting with social and activity events
CNAs build close relationships with the residents who they care and provide very personal care for.
Physicians provide routine visits to a facility’s patients (monthly or as required). They will also pay additional visits when required and help to prescribe, adjust and recommend different medication (when applicable). They will access the facility’s long term care EMR when necessary to check the resident’s condition hasn’t worsened.
Nurse Practitioner/APRN (Advanced Practitioner Registered Nurse)
A nurse practitioner provides assistance to the MD and the facility. They can also prescribe medication, diagnose diseases and review laboratory results when required. This information is recorded through the facility’s nursing home management software, so all relevant people are informed about a resident’s medication.Some larger facilities will also employ a nursing assistant.
A registered dietitian advises the inhouse dietary manager regarding residents’ diets, menus and best practices. They often cover multiple facility visits across multiple locations, therefore it is important for facilities to use efficient nursing home charting software so they can accurately track resident’s diets.
Physical/Occupational Therapy (PT/OT) /Speech Therapy (Speech Language Pathologist SLP)
These are specially-trained therapists who provide both inhouse or clinic appointments to eligible residents. Their aim is to focus on a resident’s problem area giving them the tools to fully recover and reach their full potential. All records are stored on the resident’s nursing computer software, along with any changes in condition and ongoing problems.
Hospice staff work alongside the facility team to support the residents who are under their care. Staff can include RNs, CNAs, social services directors and chaplains. When applicable, resident data will be passed from the facility’s senior living software to inform the hospice staff of any potential problems and issues.
Hospices tend to offer a range of services including bathing supplies and end-of-life resident care. They also offer sufficient training to their staff, educating them about their services on offer. Therefore it is useful for the hospice staff to be trained in using the senior housing software so they can keep accurate resident records.
Dentist and Podiatrist
Both mobile dental and podiatry teams can schedule visits to the facility for residents requesting service. The costs, however, vary on the services rendered and on the resident’s insurance coverage.
Home Health Services
Residents in assisted living facilities can enlist some services from offsite agencies. These may be covered by Medicare, providing the service is not already available in the facility.
Home Health services can also include wound care, medication management, physical therapy and personal care. It is important to maintain accurate resident records using an efficient nursing home charting software so office agencies can provide adequate care.
The facility may employ or enlist the services of a hair stylist/beautician for the residents. These services may include hair styling, manicures and makeovers.
The facility may invite a pastor or religious personnel into the facility to conduct church services. Residents may also request a visit from their church or religious organization.
An Ombudsman is a resident advocate who is not employed by the long term care facility. The Ombudsman makes facility visits and deals with resident or family complaints and concerns. Some larger locations also provide an assistant Ombudsman to help.
It is important to address any elder abuse that may be taking place in a facility. Therefore, learning the signs and preventative measures, will allow the facility and Ombudsman to take immediate action should elder abuse the facility.
The main forms of abuse to look out for include:
- Physical abuse
- Emotional abuse
- Financial exploitation
- Sexual abuse
Should elder abuse occur within a facility, the abuse must be evaluated with the facility adjusting their policies accordingly to prevent any future incidences. There are also several resources available to residents and their families, such as the state-run Ombudsman program that assists with problems related to the health, safety, welfare, and rights of residents living in long term care facilities
Other services include the local Adult Protective Services (APS) that ensures the safety and well-being of elders and adults with disabilities, and Nursing Home Abuse Justice , which receives reports of abuse. For more information about elder abuse, read this blog.
Additional support for the facility may include:
- Volunteers – for activities (reading to residents, chair exercises, assisting residents to complete an activity), one-to-one social visits
- Entertainers – for various music events (local bands, choir groups, Elvis Presley impersonators are popular with residents)
- Pet therapy – certified personnel and animals for social visits
- Mobile libraries – can visit facilities on a scheduled basis if the service is available in the local area
- Local clubs and organizations – may provide seasonal activity visits, entertainment or donations
- Other services – such as a visiting mobile clothing and accessories company or mobile catering events
The community can play a very positive role in supporting the facility and its residents.
The facility should welcome this participation in the continuous strive for quality in care.