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

• non-Medicare-certified facilities as nursing facilities
• medicare-certified facilities as skilled nursing facilities or SNFs

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

Unless otherwise noted, this section focuses on licensed nursing facilities. Most nursing facility admissions, more than 70% of them, come as the result of an acute care hospitalization for injury or illness.

Nursing facility care may be needed to:

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

Nursing facilities are to be considered when:

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

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

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

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

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

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

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

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

• licensed nursing facility administrator
• physician medical directors as well as directors of nursing services
• nurses trained to provide skilled nursing care
• social workers and activities directors

They are also required to staff or have as consultants:

• a pharmacist
• therapists that may include physical, occupational and speech therapists
• food service personnel including a dietary supervisor (minimally a consulting dietician)
• an interdisciplinary assessment and assurance committee

And, like hospitals they never close. Service is continuous--24 hours a day, 365 days a year with trained, licensed nursing staff always present.

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

However, to be licensed in Virginia,

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

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

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

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

• complete a certified 120-hour training program
• pass a competency test within four months of being hired to work in a licensed nursing facility and
• be registered with the Virginia Nurse Aide Registry

CNAs may provide assistance with Activities of Daily Living (ADLs):

• bathing, dressing and eating
• toileting, transferring and bowel/bladder continence and assistance with Instrumental ADLs (IADLs)
• changing linens or performing other housekeeping duties
• laundry and meal preparation

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

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

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

• social
• recreational
• intellectual and
• religious activities
• opportunities for volunteer service