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1. Skilled nursing deficiencies/and or compliance issues are available through the Department of Health.
2. Assisted living , small care home or dementia care facility are not rating by the Department of Social Services.
3. In California to determine if a facility has any serious deficiencies or compliances issues – you must contact the local CCL office and schedule an appointment to review the provider file. Download this PDF file
4. Contact the local county Ombudsman and check to see if they can provide any insight regarding the facility in question.
5. Ask the provider to provide you with references of current or past client and/or families to contact for a reference.

An Advance Health Care Directive (AHCD) is a document; giving someone else the power to make health and medical decisions if an individual is unable to speak or make decisions.

The AHCD allows an individual to appoint a health care agent (also known as “Durable Power of Attorney for Health Care” or “attorney-in-fact”), who will have the legal authority to make health care decisions if that individual is unable to speak for themselves. This is typically a spouse, but can be another family member, close friend, or anyone else that will assure that the indivduals wishes and expectations are met. The individual named will have authority to make decisions regarding artificial nutrition and hydration and any other measures that prolong life—or not.

Everyone needs such a document because we never know when or if we will become incapacitated.  The Advance Health Care Directive provides a clear statement of wishes about a persons choice to prolong their life or to withhold or withdraw treatment.   A standard advance directive form provides room to state additional wishes and directions and allows a person to leave instructions about organ donations.

 Advance Health Care Directive forms are available via:

• Community and senior services organizations,
• State healthcare association websites
• Attorneys handling wills, estates, probate and Elderlaw matters,
• Geriatric care managers, and
• Hospitals or hospice programs. 

 Assistance to complete an AHCD can be found at senior centers; from social service agencies, or from an elder law attorney.

The term “legal guardian” has different meanings in different states. I’ll take it to mean that your question applies to the duties of a person who was appointed guardian over an incompetent elder by a court. A guardianship is also called a conservatorship in some places. The guardianship can cover either the aging person’s money; or the person’s safety and welfare, or both.

The duties of a guardian; generally speaking; are to oversee the welfare and safety the aging person under guardianship, and to attend to the financial needs of the individual; using his or her assets wisely. A guardian has a legal duty; called a “fiduciary duty”; to act in the best interests of the individual.  A guardian has total control over the aging person they are appointed to serve.

They can decide how to spend the elder’s money, where the elder will live; what medical care the elder will receive; and how much freedom the elder or aging parent has in his or her life. The powers can be total. An elder under guardianship loses the freedom to make decisions for himself or herself about all important aspects of life.

The guardian also has a duty to protect the aging elder from abuse; to keep complete records of all expenditures; and to report regularly to the court which appointed the guardian; as to the elder’s finances and status.  The requirements vary somewhat from state to state; but generally, the court decides how often the guardian must return to court to report to the court how money is spent and what the status is of the elder.  Being a guardian is a very heavy responsibility.  It is formal; public and supervised.

Your Mom lives alone. She has friends, but gets lonely sometimes. She likes to talk on the phone. Dad is a widower, and seems lost since your mother passed away. He is a little confused, but can take care of himself all right with a little help. What do they have in common? Both are exactly the kind of victim identity thieves prey upon.

Identity thieves love older aging parents and persons for the reason that they are so vulnerable. Social isolation, loss of a spouse, early dementia, general memory loss or confusion make our elders and aging parents an easy mark. Add to that that seniors tend to be friendly and trusting, and you have a combination that can make your aging parent a sitting duck.

How can we help them protect themselves? There are an estimated 6 people a minute having their identities stolen, according to a television report on the Today Show in 2007. We need to educate our aging parents that trusting strangers on the phone is very dangerous. We need to warn our aging parents that even their own children can rip them off if they are desperate. Drug and alcohol abuse, serious financial trouble and mental illness can lead an adult child to steal account numbers when visiting and later raid his own parents’ bank account and steal from the ones most likely to trust him or her. Our elders must be educated to be alert to dangers in their own families. If you have a “black sheep” in the family who has serious money or substance abuse problems, consider it a risk to your parents.

Can we thwart the attempts at stealing our aging parents’ identities? We can at least take protective measures. Some of the simplest protections are the best.

• 1. First, buy a crosscut shredder. Shred or have your aging parents shred sensitive mail, credit card solicitations, and outdated personal documents such as bank statements, rather than throwing them in the trash. Thieves go through the trash looking for anything they can use to steal.

• 2. Guard credit cards. Watch sales people, wait staff in restaurants, and anyone who asks for your credit card. Thieves use tiny scanning devices to steal the numbers and then use the cards. Get rid of any rarely used or unused cards. The fewer your parent has, the better. Don’t give out the numbers unless you are absolutely sure you need to.

• 3. Mail letters at a mail box or the post office, rather than leaving outgoing mail in the mail box in front of the home. Thieves steal checks and payments slips, taking the information and using it to attempt to steal the entire identity. They take out new credit cards in the victim’s name and rob them of everything they can.

• 4. One should never, ever give out personal information or financial account information over the telephone. Telephone solicitors offer prizes and rewards to trick the person into telling the solicitor his bank account number, social security number, and mother’s maiden name. With that, the thief can wipe out a bank account in minutes.

• 5. Don’t let anyone copy your aging parents’ driver’s license. Anyone doing this can get access to bank accounts, personal data, and anything else you would want to protect. Getting the license number to verify a check is one thing. Letting someone take the entire license and have the other information on it is never necessary.

A Do Not Resuscitate Order is a legally binding physician’s order for a senior patient; which is signed by the treating doctor; that no steps will be taken to restart a person’s heart when it stops or to get a person breathing again if the patient stops breathing.

A DNR order is normally a result of a person’s healthcare directive; which says that he or she does not want measures to be taken to keep the person alive. The decision to not resuscitate a person must be made by the individual; if competent to do so; or by the person’s agent for healthcare; on a “living will’” or healthcare directive; if the person is not competent to do so.  The patient or agent must ask for such an order.

The signed DNR order is placed in the patient’s hospital chart. The family of the patient who does not want to be resuscitated often must remind the doctors and staff in a hospital about the order; because the first thing doctors and nurses want to do is to save someone’s life if their patient does stop breathing or their heart ceases to beat.

The DNR order only works if the patient or the patient’s family is clear with the doctors about it; and is able to be the patient’s advocate in a setting where it is almost automatic that resuscitation will take place.  In other settings; such as hospice care (care designed to keep someone comfortable in their last days for a dignified death; rather than trying to fix or save them during their last days);

DNR orders are fully respected without coaching or advocacy by family.

Possibly; depending on your situation.  If no one in your family is in disagreement with the arrangement; it is perfectly legal for your mother to pay you for getting care she would otherwise have to pay someone else to provide if you didn’t.

The clearest way to handle this is with a caregiver contract between you and your mother; so that your duties and her expectations; as well as the rate of pay you are to receive are spelled out in writing.  An elder law attorney can prepare such a contract for you.

Be aware that payment of a salary carries with it tax obligations on your part; and contribution for you to Social Security; disability and unemployment insurance on your mother’s part; in the form of deductions from your paycheck.  You may need a bookkeeper to advise you.

Difficulties sometimes arise with getting paid for care giving; as it may cause conflict with siblings or others in the family who want to inherit the funds your mother is paying for your care taking.  Before arranging such compensation; it is wise to seek the advice of an elder law attorney; to be sure there is not a problem with doing so.  Such factors as available long-term care insurance; if your mother has such a policy; trying to become eligible for Medicaid; and other factors can complicate the arrangement of your mother paying you for caregiving.  Her competence to decide to pay you out of her assets is also a consideration to discuss with the elder law attorney.

Mediation is a way to resolve disputes by discussion and negotiation; using the help of a neutral person; the mediator.  It is usually voluntary.  Disputing parties agree to use mediation to avoid continued conflict; to avoid or end lawsuits by settlement of the dispute; or to "clear the air" of ongoing disagreement which has reached the point of stalemate.

Arbitration is a process somewhat like a trial.  A neutral party; the arbitrator; sits and listens to the facts and evidence presented by both sides or all sides to a dispute; considers the law; and makes a decision as to what the outcome of the dispute is going to be.  The power to decide the outcome is entirely in the hands of one person: the arbitrator.  The arbitrator can take the place of judge and jury in making a decision about a conflict.  The parties to the conflict can only present the facts and evidence.  They do not have any choice about what the arbitrator decides.  They leave the decision up to the arbitrator.  Courts can use arbitrations as a way to lighten the load on the courts.  Parties to a dispute can agree to arbitration; or a judge can assign a matter to arbitration. Arbitrations take place outside the courts.

Mediations also take place outside the courts; but they are not "ordered" by judges.  Mediation is chosen by the parties to a dispute as a way to try to resolve it informally; through guided discussion.  The mediator does not decide what is going to happen.  How the dispute turns out is up to the parties; with the help of the mediator urging them; and guiding them toward settlement. Mediation involves choices.  Arbitration does not.  Mediation can be creative; and can go in any direction.  Arbitration goes in the direction of presenting evidence before an arbitrator; and the parties do not control what happens with the arbitrator`s decision. Arbitration is usually binding if it is the result of a requirement to use arbitration; such as a contract.  Mediation; on the other hand may or may not resolve a dispute.  No result is forced on the parties; and no one decides how the conflict will turn out except the parties to the dispute.

As the hidden consumers, what do the adult children of aging parents need to understand about these facilities? Very simply: what the facility can’t do. Invariably, the sales pitch tells you what the facility can do; which is fine, and to be expected. But as a consumer; you must understand the difference between assisted living and nursing care. First; an assisted living facility is not a nursing home with fancy furniture. Assisted living is not licensed to give nursing care. Typically; assisted living facilities are places where elders live in a supervised community; with some personal care services available. Meals; social activity; and help with the activities of daily living such as bathing and dressing are all usually offered at such facilities. The focus is on providing a healthy social environment and preventing social isolation. It is a worthy focus; as isolation is dangerous; and widespread among elders whose independence is declining.

If your parent is in fragile health and seems to be steadily declining physically or mentally; be cautious about choosing an assisted living facility over a nursing home (also known as a skilled nursing facility). No one chooses a nursing home first. Nursing homes are more like hospitals; which they must be to deliver skilled care to frail seniors. But if your aging parent needs nursing care; and must be watched day and night; or you believe that he or she is likely to need such supervision in the near future, it is the only choice. Assisted living facilities are not licensed by Medicare or Medicaid to give skilled care. Some have a separate skilled nursing facility on-site or nearby; but it will have its own license to deliver skilled nursing care. That license does not apply to the assisted living component; even the two facilities are located on the same campus or are operated by the same parent company.

Doctors & Nurses Not Required

Many assisted living facilities do not have any licensed nurse on staff; and may have no nurse connected to them at all. Because they are considered nonmedical facilities; having a licensed nurse is not required by law. Even if a nurse is employed by the assisted living facility; the nurse cannot give hands-on care in the form of dressing a wound; administering around-the-clock insulin; administering oxygen; or other tasks that are defined by the federal and state governments as “skilled nursing care.”

Skilled nursing care may only be administered within a facility that is licensed to do so. Legally; it is called a skilled nursing facility; though it may have a different business name by which a consumer finds it; such as “extended care” or “long-term care”. Medicare and Medicaid designate these homes as skilled nursing facilities. Because skilled nursing facilities bill Medicare and/or Medicaid for this type of patient care; they must comply with many complex legal regulations and requirements. Assisted living facilities are regulated by the state Department of Social Services; not the Department of Health; which regulates nursing homes. Assisted living facilities do not have the same safety or administrative requirements as a skilled nursing facility; and they are prohibited from giving care they are not licensed to give.

Coping with caregiver grief is truly a very lonely place to be. We often don’t age or die gracefully. So how do we deal with the challenges of being a caregiver of our aging parents when the final relief of suffering won't just come soon enough? We can't just do it alone, we need help, and must force ourselves to reach out to others. It is clear that you have reached your own personal emotional limit, when you no longer have the inner resources to offer hope and are felling quite helpless. This is a very important sign that our spirit is revealing to us that our personal responsibility and burden is clearly reducing the quality of our own lives.

So, now it's time ask for the help and support you need as a caregiver. The grieving process is quite different for everyone. Often grieving becomes protracted, and when that happens we are challenged to do everything in our power to take better care of our mental and emotional needs. Sometimes caring for your aging parent requires that you get professional support to ensure that you don't get stuck by your own hopeless and helplessness. Please don't wait to contact your family doctor and get a referral to a professional psychologist or mental health practitioner who has traveled the grieving road. For mental health links and resources contact your local mental health association.

I hope my words help you move forward to both better help yourself deal with your guilty feelings and manage the grief.  Mom would truly want you to do that for her. For additional resources on caregiving, see The Boomer’s Guide to Aging Parents, available at AgingParents.com and at Amazon.