Admission Policy

Policy: The admission process is intended to obtain all the information possible about the resident, for the development of comprehensive plans of care, and to assist the resident in becoming comfortable in the facility. Residents are admitted to the facility under orders of the attending physician.

Policy Explanation and Compliance Guidelines:

• The admission process has several phases:
  • Pre-Admission Preparation:
    • The social service designee or other designated staff member may meet with prospective residents/families while they are first touring the facility.  Information about facility services should be provided.
    • Once the resident/family has selected the facility, pre-admission information should be gathered.  As much social background information as possible should be obtained prior to or upon admission, to help the resident adjust to the facility. Information should be shared with the nursing department, so the resident may be greeted promptly, and made comfortable in their room.
    • A Resident Handbook and/or Facility orientation material should be provided to the resident/family prior to or upon admission, so they understand what to bring to the facility. 
    • The social service designee or other designated staff member may be needed to assist in the admission process, in the gathering of information such as MR/MI screening forms, mental health diagnoses and background information, etc.
  • Performing a Social Service Assessment of the Resident:
    • Numerous social service assessments should be completed upon admission of a resident:
      • Minimum Data Set; Social Service completes designated sections within 14 days of admission.
      • Mental Status Testing, as appropriate. 
  • Develop Comprehensive Plan of Care:
    • The comprehensive, interdisciplinary plan of care should be developed within 21 days of admission, using the social service assessments as part of the basis for the plan of care.
  • Making the Resident Comfortable:
    • The social service designee should greet the resident as soon after admission as possible. 
    • The resident should be introduced to roommates, and the nursing department should provide needed equipment.
    • Within the first week of admission, the social service designee should arrange for an orientation to the facility, including all areas of the facility the resident will access (e.g., activities room, therapy room, dining areas, lounges, etc.).
    • The social service designee should determine any needs for the use of outside resources, such as psychosocial services, equipment, clothing, money, etc., and make attempts to arrange for the goods or services as soon as possible.
  • Special characteristics or service limitations of Grandview Nursing & Rehabilitation Center that are disclosed to a resident or potential resident prior to time of admission:
    • Skilled Unit and Long Term Care Unit
    • Hospice Services
    • No dialysis
    • No secured unit
    • No tracheostomies
    • No ventilators
    • No personal pets
    • No severe psychiatric conditions, such as a history of suicide
    • No bariatric (weight in excess of 350lbs.)
    • No Total Parenteral Nutrition and Peripheral Parenteral Nutrition (PPN)
    • No scooter chairs, electric wheelchairs, etc.

Nursing Facility Non-Discrimination Admission Policy

Policy Statement
The facility is committed to providing equal access to services and shall not discriminate in admission, transfer, discharge, or the provision of care based on:

• Race
• Color
• National origin
• Religion
• Sex
• Sexual orientation
• Gender identity
• Age
• Disability
• Marital status
• Veteran status
• Source of payment, including Medicare or Medicaid, when applicable
• Any other characteristic protected by federal, state, or local law

Admission decisions are based solely on:

• The individual’s clinical needs.
• The facility’s ability to meet those needs.
• Bed availability.
• Compliance with applicable admission criteria.

The facility will provide reasonable accommodations to qualified individuals with disabilities and will provide language assistance services, including qualified interpreters and translated materials, when necessary to ensure meaningful access.
No employee, contractor, or representative of the facility shall discourage, delay, or deny admission based on any protected characteristic.
Any individual who believes they have been subjected to discrimination may file a complaint with the facility administrator. Complaints will be investigated promptly and confidentially, and retaliation against anyone filing a complaint in good faith is prohibited.

Responsibility
The Administrator and Admissions Coordinator are responsible for ensuring compliance with this policy. All staff involved in admissions shall receive training on the facility’s non-discrimination requirements.

Regulatory References

• Section 1557 of the Affordable Care Act
• Title VI of the Civil Rights Act of 1964
• Americans with Disabilities Act
• Section 504 of the Rehabilitation Act of 1973
• Applicable federal, state, and local laws governing nursing facilities.

Discharge Planning Starts Early
Discharge isn’t something that just happens at the end—it usually begins soon after admission.

• A care team is involved: doctor, nurses, social worker
  • They assess:
    • Progress toward goals
    • Safety at home
    • Support system (family, caregivers)

Ongoing Evaluation
Throughout the stay, They’re asking:

• Is the patient improving?
• Are the safe to function outside this setting?
• What level of care is needed next?

In physical rehab, this might include:

• Walking safely
• Bathing/dressing independently
• Managing medications

Discharge Decision
A discharge is typically decided when:

• Goals are met or
• Progress plateaus or
• Insurance coverage ends

The physician signs off, but it’s usually a team recommendation.

Discharge Planning Meeting (Care Plans)
Often includes the patient and family. This is where details are finalized:

• Where the patient is going:
  • Home (with or without help)
  • Home with home health services
  • Assisted living
  • Another facility (like long-term care)
  • What’s needed:
  • Equipment (walker, hospital bed, etc.)
  • Medications
  • Follow-up appointments

Discharge Instructions
You’ll get a detailed plan, usually written and explained:

• Medication list (what to take, when, and why)
• Therapy instructions or exercises
• Wound care (if needed)
• Diet recommendations
• Warning signs (when to call a doctor or go to ER)

Services Set Up Before Leaving
The facility typically arranges:

• Home Health (nursing, PT/OT)
• Outpatient therapy
• Medical equipment delivery
• Transportation (if needed)

Day of Discharge

• Final paperwork is signed
• Medications may be sent to a pharmacy
• Staff reviews instructions again
• Patient leaves with caregiver or transport

After Discharge (Very Important)
This is where a lot of people struggle, so planning matters:

• Follow-up appointments (often within 1-2 weeks)
• Continued therapy
• Monitoring for complications or setbacks

*** A Few Real-World Notes ***

• Insurance (especially Medicare) plays a big role in timing
• Families sometimes feel discharge is “too soon” – you can appeal if safety is a concern
• Social workers are your biggest ally-lean on them for resources

The length of stay in a skilled nursing facility (SNF) varies a lot depending on the reason for admission, overall health, and how quickly rehabilitation progresses.
Some general ranges:

• Short-term rehabilitation after a hospitalization (such as a hip fracture, joint replacement, stroke, or severe illness): often a few days to several weeks.
• More complex recovery needs: sometimes several weeks to a few months.
• Long-term care needs: some people transition from a skilled nursing stay to longer-term nursing home care if they cannot safely return home.

Factors that influence the stay include:

• Ability to perform daily activities (walking, dressing, bathing, eating)
• Progress with physical, occupational, or speech therapy
• Medical stability
• Availability of caregivers and support at home
• Home environment and safety considerations
• Insurance coverage and authorization requirements

A person is generally ready to leave a skilled nursing facility (SNF) when the care team determines that they can be cared for safely in a less intensive setting, such as at home, with family, with home health services, or in another type of facility.
Common factors that determine readiness for discharge include:

Functional abilities
The person can perform enough daily activities safely, such as:

• Getting in and out of bed
• Walking or transferring safely (for example, from bed to chair)
• Using the bathroom
• Dressing and bathing
• Eating and managing basic self-care

The exact level of independence needed depends on what support will be available at home.

Medical stability
The person’s condition is stable enough that they no longer need daily skilled nursing services, such as:

• Complex wound care
• Frequent medication adjustments
• Intensive monitoring
• IV therapies or other specialized treatments that cannot easily be provided elsewhere

Therapy progress
Physical, occupational, and speech therapists assess whether:

• Rehabilitation goals have been met
• Progress has plateaued
• The person can continue therapy safely in an outpatient setting or through home health services

Safety
The team evaluates whether the person can function safely in their expected living environment, including:

• Risk of falls
• Cognitive status and judgment
• Ability to take medications correctly
• Ability to respond to emergencies

Home support system
Discharge planning includes assessing:

• Whether family or caregivers are available
• Whether needed equipment is in place (walker, wheelchair, hospital bed, grab bars, etc.)
• Whether home health services have been arranged if needed

Patient and family education
Before discharge, the person and caregivers are often taught:

• Medication management
• Exercise programs
• Wound care or other medical tasks
• Warning signs that require medical attention

Insurance and coverage considerations
Insurance coverage can affect how long a stay is approved, but coverage alone does not determine medical readiness. The key question is whether the person still requires skilled services and whether discharge can be done safely.

A useful question to ask the care team is:
“What specific goals or milestones still need to be met before discharge, and what is the estimated discharge date?”
That often provides the clearest picture of what is keeping someone in the SNF and what remains before they can go home.

If you don’t think you’re ready to be discharged from a skilled nursing facility (SNF), it’s important to raise your concerns as soon as possible with the care team.

Talk to the care team
Ask for a meeting with:

• The attending practitioner
• The nursing staff
• Your therapists (physical, occupational, or speech)
• The social worker

Be specific about your concerns. For example:

• “I still can’t get safely from bed to the bathroom.”
• “I don’t have anyone to help me at home.”
• “I’m still having severe pain.”
• “I don’t understand how to manage my medications.”
• “I am worried about falling.”

Specific examples can help the team assess whether additional services or a different discharge plan are needed.

Ask for the discharge criteria
Request that the team explain:

• Why they believe you are ready for discharge?
• What goals you have met.
• What support they expect you to have after discharge.
• What services will be arranged (such as home health care, equipment, or outpatient therapy).

Discuss alternatives
If returning home does not seem safe, ask whether other options are available, such as:

• Additional home health services
• Caregiver support
• Assisted living
• Another level of rehabilitation or long-term care, depending on your needs

If you have Medicare
If your stay is covered by Medicare and you receive notice that your covered services are ending, you generally have the right to request a fast appeal (sometimes called an expedited appeal) of the discharge or termination of coverage decision.
You can ask the facility for:

• The discharge notice
• Information about how to request an appeal
• The contact information for the designated quality improvement organization (QIO) handling Medicare appeals

The notice should explain the deadlines, which are often very short, so act promptly.

If you have concerns about care in a skilled nursing facility (SNF), there are several ways to file a complaint, depending on the issue and how urgently it needs attention.

Report the concern to the facility
Many issues can be addressed by speaking with:

• The Charge Nurse
• Director of Nursing
• Administrator
• Social worker

Ask for a written response if possible, and keep notes of dates, times, and who you spoke with.

Contact the Long-Term Care Ombudsman 1-800-252-2412
Every state has a Long-Term Care Ombudsman Program that advocates for residents of nursing homes and skilled nursing facilities. An ombudsman can:

• Investigate complaints
• Help resolve disputes
• Explain residents’ rights
• Assist residents and families

File a complaint with the state survey agency 1-800-458-9858
State survey agencies license and inspect nursing homes and investigate complaints about:

• Quality of care
• Safety issues
• Abuse, neglect, or mistreatment
• Staffing concerns
• Violations of residents’ rights

Report suspected of abuse or neglect immediately
If you believe a resident is in immediate danger or has experienced abuse, neglect, exploitation, or serious injury:

• Notify facility Administrator immediately.

In Texas, there is no single statewide ombudsman. Instead, the state uses specialized ombudsman programs for different sectors, all under the Texas Health and Human Services (HHS) Office of the Ombudsman.

What an Ombudsman Does
An ombudsman is an impartial official who investigates complaints about government services, advocates for consumers, and helps resolve disputes without the power to enforce penalties.

 They can:

• Review complaints about policy, quality of care, or rights violations.
• Mediate between you and the agency.
• Recommend corrective actions to the agency, which must respond in writing.

They do not have the authority to fine agencies or reverse court decisions.

Main Ombudsman Offices in Texas

• HHS Office of the Ombudsman
  • Handles complaints about state-administered programs like Medicaid, SNAP (food stamps), TANF, and other HHS benefits.
  • Phone: 877‑787‑8999 (Mon–Fri, 8 a.m.–5 p.m. CT)
  • Fax: 888‑780‑8099
  • Mail: P.O. Box 13247, Austin, TX 78711‑3247

• Long‑Term Care (LTC) Ombudsman
  • Advocates for residents in nursing homes and assisted living facilities.
  • Phone: 800‑252‑2412
  • Website: ltco.texas.gov 

How to File a Complaint

• First, try to resolve the issue directly with the agency or provider.
• If unresolved, contact the ombudsman office for your situation. 
• You can call, fax, mail, or use the online form on the HHS Ombudsman site.
• Expect to provide accurate details, cooperate with staff, and be treated with courtesy.

When to Call

• HHS Ombudsman: Medicaid, SNAP, TANF, or other HHS benefit issues.
• LTC Ombudsman: Quality of care, rights violations, or abuse/neglect in long‑term care.

Home health care is a range of medical and supportive services provided in a person’s home rather than in a hospital or nursing facility. It is designed for people who are recovering from an illness, injury, surgery, managing a chronic condition, or need assistance to remain safely at home.
Common home health care services include:

• Skilled nursing care – wound care, medication management, injections, monitoring health conditions.
• Physical therapy – helping patients regain strength, mobility, and balance.
• Occupational therapy – helping people perform daily activities such as dressing, bathing, and cooking.
• Speech therapy – assistance with communication or swallowing difficulties.
• Medical social services – counseling and connecting patients with community resources.

Home health care is typically prescribed by a doctor and provided by licensed healthcare professionals. It differs from non-medical home care, which focuses mainly on companionship, housekeeping, and personal assistance rather than medical treatment.

The main difference between home health therapy and outpatient therapy is where the therapy is provided and the patient’s ability to leave home safely.

Example
After a stroke:

• A patient who struggles to leave home may receive home health physical therapy, where the therapist works on walking safely through the house, navigating stairs, and preventing falls.
• Once the patient improves and can travel, they may transition to outpatient physical therapy, where they can use specialized rehabilitation equipment and participate in more advanced exercises.

Insurance Considerations
Many insurance plans, including Medicare, generally cover home health services only when specific eligibility requirements are met, while outpatient therapy is covered under a different set of benefits and billing rules.

Which Is Better?
Neither is inherently better—it depends on the patient’s condition:

• Home health therapy is often best for people who are recently discharged from the hospital, medically fragile, or unable to travel safely.
• Outpatient therapy is often best for people who are mobile enough to leave home and need more intensive or specialized rehabilitation.

A care plan meeting is a scheduled discussion between a patient, family members or caregivers, and members of the healthcare team to review the patient’s health status, goals, needs, and treatment plan.
The purpose is to make sure everyone involved in the patient’s care understands:

• The patient’s current condition
• Treatment goals and expected outcomes
• Medications and therapies being provided
• Safety concerns and risk factors
• Progress toward recovery or health goals
• Any changes needed in the care plan
• Discharge planning or long-term care needs

Who attends?
Depending on the setting, participants may include:

• The patient
• Family members or designated caregivers
• A nurse 
• A social worker

Why it matters
Care plan meetings help ensure that care is coordinated, patient-centered, and aligned with the patient’s preferences and goals. They also give patients and families an opportunity to ask questions, express concerns, and participate in healthcare decisions.
If you’re preparing for a care plan meeting, it can be helpful to bring a list of questions about medications, therapy progress, safety concerns, future care needs, and expected timelines for recovery.

Long-term care can be paid for through several sources, and the payer often depends on the person’s income, assets, age, health condition, and the type of care needed.

Common Ways Long-Term Care Is Paid For

1. Personal Funds (Private Pay)
Many people pay for long-term care using:

• Nursing home care
• Assisted living
• Adult day care
• Home care services

This is one of the most common payment methods, especially at the beginning of a long-term care need.

2. Medicaid
Medicaid is the largest payer of long-term care services in the United States.
To qualify, a person generally must meet income and asset limits, although rules vary by state.

3. Long-Term Care Insurance
Some people purchase long-term care insurance policies that help pay for:

• Nursing home care
• Assisted living
• Adult day care
• Home care services

Coverage varies by policy and benefits typically begin after meeting certain eligibility requirements.

If you’re being admitted to a skilled nursing facility (SNF), it’s helpful to bring items that will support your care, comfort, and identification.

Important Documents

• Photo ID (driver’s license, state ID, passport)
• Insurance cards, including Medicare, Medicaid, or supplemental insurance cards
• Any admission paperwork provided by the hospital or facility
• Advance directives, such as a living will or healthcare power of attorney, if you have them
• Contact information for family members, caregivers, and healthcare providers

Medical Information

• A current list of medications, including dosages
• Information about allergies
• Recent medical records, if requested
• Glasses, hearing aids, dentures, CPAP machine, or other personal medical equipment you use regularly

Clothing and Personal Items

• Comfortable, loose-fitting clothes
• Non-slip shoes or slippers
• Socks and undergarments
• Pajamas or sleepwear
• A light robe or sweater

Toiletries
Check with the facility, as many provide basic supplies. You may want to bring:

• Toothbrush and toothpaste
• Hairbrush or comb
• Deodorant
• Shampoo and soap (if preferred)
• Electric razor or shaving supplies

Personal Comfort Items

• Cell phone and charger
• Books, magazines, puzzles, or hobbies
• Family photos
• Small comfort items such as a favorite blanket or pillow

What Not to Bring

• Large amounts of cash
• Expensive jewelry
• Valuable electronics that aren’t necessary
• Irreplaceable personal items
• Extension cords/power strips/multi-plugs
• Aerosol cans (hairspray, deodorant, room freshener, etc.)
• Personal medications (over the counter, prescription or supplements)
• Electric blankets
• Heating pads
• Firearms
• We are a non-smoking facility this does include vapes
• Alcohol of any kind
• Electric Wheelchairs or Scooters

Before You Go
Contact the facility and ask if you have an item you want to bring but are not sure if it is allowed. We will be happy to answer any questions.
If you’re moving from a hospital to a skilled nursing facility, the hospital typically sends your medical records, physician orders, and much of the clinical information directly to the facility, but it’s still a good idea to confirm that everything has been arranged.