Finding a place which implements person-directed care can be difficult. Here is a set of questions that we have developed to help families determine whether or not a nursing home is engaged in person-directed care.
Person-directed care allows the elder to make their own choices, continue familiar routines and maintain their dignity after moving into the new setting — or in other words, be at home wherever home may be. Below are some questions you should ask when visiting a nursing home or an assisted living care community. Just click on the down arrow to the left of each question to read the answer.
Key Questions to Ask the Staff in Nursing Homes to Find Out If They Provide Person Directed Care
How is your nursing home involved in culture change?
Listen for: “We have a committee that works on making our place a home for individuals who live here. Individuals and families serve on the committee. Staff members attend the state coalition meetings and go to conferences to learn more. Several of our staff (including direct care workers) have visited other places involved in culture change. We have consistent assignment so that our staff can get to know the individuals they are caring for including their individual needs and wishes.”
How will you get to know my family member?
Listen for: “It is very important for us to really get to know each person who lives here. We have a questionnaire for your family member to fill out that helps us get started. If they are not able to do this (because of dementia, for example), we want you to help us get to know them. Then we will talk with them and spend time together. We will learn about their preferences, their past, what they enjoy doing now, and their goals and wishes for the future. Everyone on the staff will get to know your family member.”
Do the care partners take care of the same group of individuals each time they work, or do you rotate the assignments after a period of time?
Listen for: “Consistent Assignment.” “With few exceptions, our care partners care for the same group of individuals each time they come to work.”
Will my loved one be awakened at a set time in the morning or will she have a choice?
Listen for: “Individuals may choose to sleep as long as they want without being awakened.”
What is your policy regarding food choices and alternatives?
Listen for: “Let me show you a list of the alternatives we always have on hand if someone does not like the main entree being offered. Do you think your loved one would be satisfied with these? If not, we can usually accommodate their wishes.”
Can my loved one be given a shower/bath when he or she chooses?
Listen for: “Yes. We can accommodate a person’s lifelong pattern of bathing. Plus, we understand about the special needs of persons with dementia. We have many creative ways to keep people bathe, so we can adapt to their preferences and comfort and still maintain cleanliness.
What type of recreational activities are offered here?
Listen for: “We offer a wide variety of meaningful and purposeful activities, planned by trained activity directors. Individuals have input into what is offered. Many of our activities are also spontaneous. Our staff do activities with individuals based on what the individuals like to do, including at night for those who are awake. We also have someone here in the evenings and on weekends to engage individuals.”
How do you build a sense of community, and give those who live here a voice in the decisions about how things are done?
Listen for: “Individuals are part of the home team. We have an active Resident Council. Discussion groups, neighborhood, or household meetings are held weekly with individuals, staff and invited family members. Individuals have a say in who cares for them.”
How do you meet the special needs of people who have some type of dementia?
Listen for: “We educate our staff on how to best communicate with people with dementia. Because we have consistent assignments, staff know the individuals well and can anticipate and meet their needs in flexible, creative ways. We also support and teach staff how to problem-solve difficult situations. Our staff has in-person training and continuing education in best practices in dementia care.”
What is the role of family members? Do you have a Family Council?
Listen for: “Family members may visit here any time, volunteer, and participate in our Family Council. Let me provide you with a Family Council meeting schedule. Family members can always speak to any member of our staff to discuss their loved one’s needs and preferences.”
Do you have a rehabilitation team and access to therapists such as speech pathologists, physical therapists and occupational therapists?
Listen for: “We have licensed therapists on staff. We can provide one-to-one therapy, and our therapists also advise us on such things as how to adapt a room or bathroom to best meet individual needs, and how to transfer a resident from chair to bed in the most comfortable way.”
Do you measure the turnover of your staff (defined as the average percentage of staff who stop working at the home each year)? If so, what is the turnover rate for your direct care workers?
Listen for: Any number under 40 percent. (The national average is 70 percent.)
Do you measure the turnover rate of your licensed nursing staff? If so, what is your turnover rate of licensed nurses?
Listen for: Any number under 30 percent. (The national average is 50 percent.)
Do you measure staff satisfaction? If yes, what do you do with the satisfaction survey results?
Listen for: “Yes. We measure the morale and satisfaction of our staff with a survey and by meeting with them in small groups. We know that if our staff feels respected and supported, they give better care to individuals. We use what we learn from the survey to make improvements.” Ask for a recent example.
Do you also measure resident satisfaction each year?
Listen for: “Yes. We measure the satisfaction of our individuals by using a survey and by meeting with them in small groups. We use what we learn to make improvements.” Ask for a recent example. Ask individuals about this.
Do you measure family satisfaction?
Listen for: “We do. Family opinions are important. However, we understand that our “customer” is the person living here.”
What is your organization's policy regarding the use of agency nurses and agency nursing assistants (people who are brought in from the outside who are not your regular staff)?
Listen for: “Only our own nurses and care partners work here. Only in a dire short-staffing emergency do we bring in people from an outside agency.”
What is your mission statement? Is staff able to share the mission in their own words and indicate that it is meaningful to their work?
Listen for: “Our mission statement is….We try very hard to make our mission not just words but part of daily life for people who live and work here.”
Download a copy of Key Questions to Ask Nursing Home Staff.
What should I look for on a tour?
To get a feel of the tone of the nursing home during your “walk-about,” look at the colors (furniture, walls, floors), lighting, real or artificial plants, bird cages and fish tanks, other animals, smells, lighting, signs, elements of privacy, options for sitting alone, conversation areas, and individuals’ facial expressions. Are staff and individuals interacting in what looks like interest and kindness?
How can I assess activities, services, and quality of care?
Look at the types of activities that are posted. Check to see if Resident Council and Family Council materials, and ombudsman contact information, are posted in obvious places and at a level where a person in a wheelchair could read them. The last report of the state survey should be available for you to review. Talk to individuals and families when you are visiting. Ask them how they feel about the place and if they would recommend it. Remember that if you ask this in the presence of a staff person, individuals may fear sharing negative comments and so may give you an inaccurate impression.
Key Questions to Ask the Staff in Assisted Living to Find Out If They Provide Person Directed Care
There is a need to ask more specific questions about person-directed care and what the assisted living community is doing, if anything, with person-directed care. Listed below are some general and specific things to ask and to listen for in the response. These are not the only “correct” responses, but they will give you a general idea of what you might hear that indicates work toward creating home for individuals.
How do you welcome a new resident?
Listen for: “We have a welcoming committee made up of individuals and staff that makes a new resident feel special – that everyone is so glad he or she is there. For the first few weeks, a welcoming committee „buddy‟ stays in close contact with the new resident making sure that he or she is adjusting well, meeting new people, etc.”
How will you get to know me/my loved one? (or whoever is the potential resident)
Listen for: “It is very important for us to really get to know each person who lives here. We have a questionnaire for the resident to fill out that helps us get started. If he or she is not able to do this (because of memory loss, for example), we want you to help us get to know them. Then we will talk with them and spend time together. We learn about their preferences, their past, what they enjoy doing now and their goals and wishes for the future. Everyone on the staff will get to know them when they move in and on an ongoing basis.”
Do you provide training for your staff on how to provide person-directed care?
Listen for: “Yes, when we hire staff, our philosophy and practice of person-directed care is emphasized in their orientation and we provide training for our staff on person-directed care and other topics. Staff are evaluated on their ability to provide this level of care and attention.”
Are individuals involved in developing their individualized service plan so it is based on their needs and preferences?
Listen for: “Each resident (and/or family member if appropriate) participates in the development of the resident‟s service plan to ensure that the specific choices and preferences of the resident form the basis for the plan.”
For those individuals needing personal care, is the same caregiver consistently assigned to them?
Listen for: “With few exceptions, our caregivers care for the same group of individuals each time they come to work.” This is called “consistent assignment”.
How are a resident's sleep and wake times chosen?
Listen for: “Each resident wakes up and goes to bed whenever he or she wants. Breakfast is available for individuals whenever they are ready in the morning.”
How and when does a resident receive bathing assistance if she or he needs it?
Listen for: We can accommodate a person’s lifelong pattern of bathing. For example, if a resident prefers to shower at night before she goes to sleep, we will assist her in doing so. Plus, we understand about the special needs of person with dementia. We have many creative ways to keep people clean, so we can adapt to their preferences and comfort and still maintain cleanliness.”
What kind of meal service do you offer and do individuals have many choices as to what to eat?
Listen for: “A variety of dining choices exist including restaurant, buffet and family style, according to resident preference. Multiple menu items are available at every meal. There is a monthly meeting to discuss menus and meal planning, which is open to all individuals. People with eating difficulty will be provided proper utensils needed for issues such as tremors or failing dexterity. Those who may have swallowing difficulties will have food prepared for and fed to them in a respectful and safe manner.”
Can individuals have a snack or unscheduled meal 24 hours a day?
Listen for: “Yes, snacks are available 24 hours a day; there is a refrigerator and cupboards in the dining room/common area that individuals can access.” In small homes this may be direct kitchen access with assistance as needed.
What types of recreational activities are offered here? What if a resident prefers an activity that hasn't been offered in the past?
Listen for: “Here is this month’s activities calendar. It is important to us that are activities are meaningful and enjoyable to the individuals who live here. As you can see we have a wide variety of activities and consult our individuals regularly to find out what group activities they would like to have and we find out from individual individuals what they would like to do whether by themselves or in a group.” Look at the types of activities that are on the calendar. Activities should be diverse. Look for opportunities for individuals to be: intellectually thoughtful, physically engaged, involved in the local community, intergenerational, looking into politics, learning something new, engaged in conversation, spiritual, etc. Look for activities that provide assistance to do some things that may have become too hard such as sewing club, model train club, gardening.
How do you build a sense of community?
Listen for: “Individuals and staff are encouraged to get to know each other and develop relationships. This happens one on one and in groups. There are informal and formal opportunities for individuals to get together with other individuals, as well as individuals and staff to spend time together. Individuals are encouraged to maintain ties with the community outside the assisted living community. Family members and friends are welcome to visit and join in on meals, events, celebrations, etc.”
How do you give those who live here a voice in the decisions about how things are done?
Listen for: “Individuals are part of the team. We have an active Resident Council (Listen for how the council is used) The Resident Council runs their meetings and agenda- staff support them as needed. Town hall meetings and small Neighborhood Council meetings are held with all individuals, staff and family members on a weekly basis. In small homes there is a weekly “kitchen chat” or some such event where anything can be brought up (birthdays, events in the community, etc.) so no aspect of life is overlooked.”
What is the role of family members?
Listen for: “Family members may visit here any time, volunteer and participate in our activities. Family members can always speak to any member of our staff to discuss their loved one‟s needs and preferences.” Some assisted living communities may have Family Councils in which families come together to share ideas and concerns with individuals and staff.
How do you meet the special needs of people who have some type of memory loss?
Listen for: “We educate our staff on how to best communicate with people with memory loss. Because we have consistent assignments, staff knows the individuals well and can anticipate and meet their needs in flexible, creative ways. We also support and teach staff how to problem-solve difficult situations and how to notice subtle changes in individuals’ responses and function.”
Do you measure resident satisfaction each year?
Listen for: “Yes. We measure the satisfaction of our individuals by using a survey and by meeting with them in small groups. We use what we learn to make improvements.” Ask to see the survey form and ask individuals about this.
Do you measure family satisfaction each year?
Listen for: “We measure the satisfaction of our families by using a survey. However, we understand that our “customer” is the person living here.” Ask to see the survey form.
Download a copy of Key Questions to Ask Assisted Living Staff.
What should I do on a tour?
Show up 10 minutes early for the tour and sit and wait patiently and observe general feel of place and environment. Talk to individuals and families when you are visiting. Ask them how they feel about the home and if they would recommend it. Remember that if you ask in the presence of a staff person, individuals may fear sharing negative comments and so may give you an inaccurate impression. Ask to see the assisted living community’s most recent state survey–even if you have already seen it online.
What should I look for in a surprise visit?
If after the tour, you are sincerely interested in the home, return for an unannounced visit preferably during a meal or scheduled activity. How does the staff handle your surprise visit? Do things look different than they did during the tour? Talk to individuals and family members without staff present to find out how they like the home.
Developed through the support of the Picker Institute, adapted with permission from the work of David Farrell and the California Culture Change Coalition.
