Nursing Home Admission Agreement Review Checklist

Nursing Home Admission Agreement Review Checklist

Purpose

This checklist provides a comprehensive framework for reviewing nursing home admission agreements to identify problematic provisions, ensure compliance with federal regulations, and protect resident rights.

Important Notice

CMS Regulatory Updates Effective 2025:

• Effective March 24, 2025, nursing homes may NOT include language imposing liability on third parties without legal access to resident's funds
• Prohibition on third-party payment guarantees reinforced
• Stricter oversight on discharges and transfers
• Enhanced requirements for nurse staffing and payroll reporting

Always have an elder law attorney review the agreement before signing.

Part 1: Basic Agreement Information

Facility Information

Resident Information

Agreement Details

Part 2: Federal Law Compliance Check

Third-Party Guarantee Prohibition (42 CFR §483.15(a)(3))

CRITICAL: Facilities CANNOT require third-party guarantee of payment

☐ Agreement does NOT require family member to personally guarantee payment
☐ Agreement does NOT require co-signer to be personally liable for charges
☐ Agreement does NOT condition admission on third-party guarantee
☐ Agreement does NOT condition continued stay on third-party guarantee

2025 Update: Even for persons with legal access to resident's funds (spouse, POA, joint account holder), liability must be LIMITED to the extent of their access to the resident's resources - NOT personal liability.

Red Flag Language to Watch For:

☐ "Responsible party agrees to pay..."
☐ "Family member guarantees payment..."
☐ "Co-signer is personally liable..."
☐ "Joint and several liability..."

If found, circle the provision and note: _________________________________

Medicaid/Medicare Non-Discrimination

☐ Agreement does NOT require private pay as condition of admission
☐ Agreement does NOT require deposit for Medicare/Medicaid recipients
☐ Agreement confirms equal care regardless of payment source
☐ No "duration of stay" requirements for Medicaid conversion

California Note (SB 1354 effective January 1, 2025): Medi-Cal participating facilities cannot discriminate based on payment source.

Part 3: Payment Terms Review

Daily/Monthly Rates

What Is Included in Base Rate

Review what the base rate covers:

☐ Room and board
☐ Nursing services
☐ Meals and snacks
☐ Housekeeping
☐ Laundry (personal)
☐ Activities program
☐ Basic supplies
☐ Other: _________________

Additional Charges (Not Included)

☐ All additional charges are clearly listed
☐ No hidden fees or vague "miscellaneous" charges
☐ Rate increase procedures are explained

Deposit Requirements

☐ No deposit required (if Medicare/Medicaid paying)
☐ Deposit amount (private pay): $______________
☐ Deposit terms are clear
☐ Deposit refund policy is stated
☐ Interest on deposit addressed

Note: Nursing homes CANNOT require a deposit if Medicare or Medicaid is paying.

Part 4: Billing and Payment Procedures

Billing Practices

☐ Billing frequency stated (☐ Monthly ☐ Other: _______)
☐ Payment due date specified
☐ Acceptable payment methods listed
☐ Late payment fees disclosed (Amount: $_________)
☐ Procedure for billing disputes explained

Insurance and Benefits Coordination

☐ Medicare billing procedures explained
☐ Medicaid billing procedures explained
☐ Private insurance coordination addressed
☐ VA benefits coordination addressed (if applicable)
☐ Resident's obligation to apply for benefits stated

Bed-Hold Policy

☐ Hospital bed-hold policy stated
☐ Number of bed-hold days: _______
☐ Daily bed-hold rate: $__________
☐ Therapeutic leave policy stated
☐ Payment responsibility during bed-hold clear

Part 5: Resident Rights Protection

Federal Resident Rights (42 CFR §483.10)

The agreement should affirm these rights:

☐ Right to be treated with dignity and respect
☐ Right to be free from abuse, neglect, and exploitation
☐ Right to be free from physical and chemical restraints
☐ Right to privacy
☐ Right to confidentiality of records
☐ Right to voice grievances without retaliation
☐ Right to participate in care planning
☐ Right to refuse treatment
☐ Right to manage own finances (or designate someone)
☐ Right to personal property
☐ Right to visitors
☐ Right to information about facility policies
☐ Right to review own medical records

Rights Documentation

☐ Separate Resident Rights document provided
☐ Rights explained in understandable language
☐ Copy of rights given to resident/representative

Part 6: Transfer and Discharge Provisions

Permitted Reasons for Transfer/Discharge

Federal law allows transfer/discharge only for:

☐ Resident's welfare cannot be met at facility
☐ Resident's health has improved; no longer needs services
☐ Safety of others is endangered
☐ Health of others is endangered
☐ Nonpayment (after reasonable notice and opportunity to pay)
☐ Facility ceases to operate

Required Notice

☐ 30-day written notice required (except emergencies)
☐ Notice requirements explained in agreement
☐ Appeal rights explained
☐ Assistance with transfer/discharge planning addressed

Prohibited Discharge Reasons

Watch for provisions allowing discharge for:

☐ Not permitted: Conversion from private pay to Medicaid
☐ Not permitted: Challenging care or filing complaints
☐ Not permitted: Family member disputes
☐ Not permitted: Need for increased level of care

Part 7: Care and Services

Level of Care

☐ Current level of care assessment documented
☐ Services included are clearly described
☐ Process for reassessment explained
☐ Procedure for requesting additional services stated

Care Planning

☐ Resident participation in care planning affirmed
☐ Family participation addressed
☐ Care conference schedule explained
☐ Procedure for requesting care plan changes stated

Staffing

☐ Nursing staff ratios disclosed (or available upon request)
☐ Physician services explained
☐ Specialist access addressed
☐ Therapy services (PT/OT/Speech) explained

Part 8: Problematic Clauses to Flag

Arbitration Clauses

☐ Arbitration clause present? ☐ Yes ☐ No

If yes, review carefully:
☐ Arbitration is OPTIONAL (cannot be required)
☐ Resident can opt out without affecting admission
☐ Location of arbitration is reasonable
☐ Cost-sharing for arbitration is fair
☐ Right to bring claims in court is preserved

Recommendation: Consider opting out of arbitration clauses.

Waiver of Liability/Hold Harmless Clauses

☐ Waiver of liability clause present? ☐ Yes ☐ No

Red Flags:
☐ Facility not liable for negligence
☐ Resident waives right to sue
☐ Broad indemnification requirements
☐ Release from "any and all claims"

Note: These provisions may be unenforceable but should be struck or negotiated.

Consent to Treatment Clauses

☐ Blanket consent for any treatment? ☐ Yes ☐ No
☐ Consent to psychotropic medications? ☐ Yes ☐ No
☐ Consent to restraints? ☐ Yes ☐ No

2025 Update: Stronger restrictions on psychotropic medication use - explicit consent required.

Personal Property Clauses

☐ Facility disclaims responsibility for belongings? ☐ Yes ☐ No
☐ Valuables policy explained
☐ Property inventory required at admission
☐ Insurance requirements for personal items

Part 9: Financial Responsibility Provisions

Who Signs the Agreement

☐ Resident signs (if capable)
☐ Representative signs (with proper authority)

Representative Capacity Statement

The agreement should clearly state representative's capacity:

☐ Signing as agent under Power of Attorney
☐ Signing as guardian/conservator
☐ Signing on behalf of resident (not personally liable)

Required Language (2025):
"Representative is signing solely in their capacity as [POA/Guardian] and not in their individual capacity. Representative's liability is limited to the resident's resources to which they have legal access."

☐ This language is present
☐ This language is NOT present (request addition)

Financial Authority Documentation

☐ Power of Attorney attached/on file
☐ Guardianship/Conservatorship papers attached/on file
☐ Representative's legal authority verified

Part 10: Insurance Requirements

Facility's Insurance

☐ Facility maintains liability insurance
☐ Coverage amounts disclosed (or available on request)

Resident's Insurance

☐ Resident's insurance information collected
☐ Medicare information provided
☐ Medicaid application status documented
☐ Private insurance coordination explained

Part 11: Signature Review

Before Signing

☐ Read entire agreement (all pages and attachments)
☐ Asked questions about unclear provisions
☐ Received satisfactory answers to questions
☐ Requested copies of all documents
☐ Attorney review completed (recommended)

Modifications Requested

Provisions to Strike

☐ Third-party guarantee clause
☐ Mandatory arbitration (if preferred)
☐ Broad liability waivers
☐ Other: _________________________________

Note: Cross out objectionable provisions, initial, date, and have facility representative initial.

Part 12: Documents to Obtain

Before Admission

☐ Copy of admission agreement (take time to review)
☐ Rate schedule/fee disclosure
☐ Resident Rights document
☐ Facility rules and policies
☐ Grievance procedures
☐ Bed-hold policy
☐ Transfer/discharge policy
☐ Visiting hours and policies

At Admission

☐ Signed copy of admission agreement
☐ Property inventory form
☐ Advance directive forms
☐ HIPAA authorization forms
☐ Emergency contact form
☐ Room assignment confirmation

For Reference

☐ State Long-Term Care Ombudsman contact
☐ State licensing agency contact
☐ Medicare/Medicaid contact information

Part 13: Post-Signing Checklist

Immediate Actions

☐ Received fully executed copy of agreement
☐ All attachments and exhibits received
☐ Property inventory completed and signed
☐ Advance directives provided to facility
☐ Insurance cards copied
☐ Emergency contacts listed

Ongoing Monitoring

☐ Review monthly statements for accuracy
☐ Compare charges to agreement terms
☐ Document any service issues
☐ Attend care conferences
☐ Communicate concerns promptly in writing

Part 14: Resources and Contacts

Long-Term Care Ombudsman

State Licensing Agency

Legal Resources

Summary Assessment

Overall Agreement Evaluation

Recommendation

☐ Proceed with signing
☐ Proceed after modifications
☐ Seek attorney review before signing
☐ Consider other facilities

Signatures

Reviewer:

Name: _________________________________ Date: _______________

Relationship to Resident: _________________________________

Attorney (if reviewed):

Name: _________________________________ Date: _______________

This checklist is for informational purposes only and does not constitute legal advice. Have an elder law attorney review any nursing home admission agreement before signing.