Long-Term Care: Admission and Medicare Documentation

Admission to a long-term care facility is a major life change for individuals. For some, this is a relief as they now have assistance with activities of daily living and medical assistance. In contrast, this can be an overwhelming change of routine and environment for others. Healthcare providers have important roles and responsibilities during the admission process, including orienting the resident to the facility, gathering important information, completing an admission assessment, and fostering an environment of independence and support. Thorough, accurate, and complete documentation of resident assessments, status, medications, and care is a critical aspect of care. Medicare covers the medical treatment in skilled nursing facilities for those who meet particular eligibility requirements. It is important to understand what information, assessments, and forms must be completed to adequately document according to Medicare requirements. Medicare required assessments in long-term care support patient care, provide means for establishing care plans, reflect a need for skilled medical care, and aid in financial reimbursement. This course will cover important aspects of long-term care admission and Medicare documentation requirements.

Members of different multidisciplinary teams work together to admit a new resident to a long-term care facility and play a vital role in the admission process, facilitating a safe and smooth transition to long-term care. Upon admission, establish a good rapport, create a comfortable and supportive environment, and gather important personal information through assessments and asking appropriate questions. Admission information includes (Benedictine, 2022):

1. A physician’s order for the individual to be admitted to the facility
2. A state-required form that documents that the individual meets the criteria for the facility
3. Physician orders for treatment and therapy
4. Personal information such as name, birthdate, and social security number
5. Consent to treat forms so that medical attention can be given
6. List of current medications
7. Medical history and physical assessment
8. Contact information for family members, emergency contacts, and members of the individual’s healthcare team
9. Information about the individual’s routine, preferences, and ability to perform activities of daily living
10. A negative Tuberculosis (TB) test or chest x-ray
11. Financial information and insurance documents. Nursing facilities must establish how the treatment and care will be paid for. 
12. Medical power of attorney and advance directive paperwork

The admission assessment is a critical aspect of admitting a new resident to a long-term care setting. This assessment serves as a baseline of the resident’s status, helps the care team determine what assistance and medical therapies are needed, assesses the resident’s ability to perform activities of daily living (feeding, bathing, toileting, mobility, etc.), and helps to develop a personalized care plan for the resident. The admission assessment entails gathering past medical history, current medical conditions and medications, and assessing the individual's physical, mental, and emotional health. Proper assessment involves asking the resident questions, making observations, auscultation, percussion, palpation, and inspection.

Obtaining a thorough medical history for the resident helps depict a picture of the individual's overall health and acknowledges information that can impact future treatment and care. This is done by interviewing the resident and their family members as needed. Medical records may need to be obtained for specific information. A thorough medical history includes (Nichol et al., 2024):

• Medical History: Inquire about past medical diagnoses and conditions, including those that have resolved or are no longer considered unstable because of medication or surgery. Does the individual have a history of a myocardial infarction that requires continued cardiac care? Have they had a stroke in the past that explains their abnormal gait? Does the resident have any history of suicidal ideation or attempts? Has the individual had cancer in the past? You may have to ask residents specific questions to help them recall their medical history. It is also helpful to ask questions about each body system to obtain a thorough report.
• Surgical History: Asking about surgeries and medications can prompt individuals to remember past medical conditions and help healthcare providers understand the resident’s current health. Has the individual had any joint replacements or operations to remove organs, such as gallbladder removal or a hysterectomy? Have there been any surgeries about a past cancer diagnosis? Has the resident had a hernia repair or surgery for kidney stones? Collect a record of all past surgeries and dates of the operations.
• Family History: Understanding family history helps recognize medical conditions for which the individual may be at higher risk due to genetic predisposition. These can include cancer, myocardial infarction, heart disease, neurological diseases, or psychiatric conditions.
• Social History: This includes inquiring about substance or alcohol use or abuse, nutrition, and any risks for sexually transmitted diseases. Does the resident have a history of smoking? Does the individual have a history of alcoholism that has caused liver cirrhosis or other complications?
• Allergies and Medications: Allergies and reactions to the allergens should be documented clearly in the individual’s chart. Individuals can have allergies to foods, medications, the environment, or animals. Some facilities may use wrist bands or other forms of labeling to alert healthcare workers to allergies. Having warnings in the resident chart can help avoid exposure to the allergen and promote resident safety. For anaphylactic reactions, epinephrine must be available for emergency treatment.
• Reproductive History: Gather information about cancers or conditions related to reproductive organs. Has the resident had a hysterectomy? Is there any history of reproductive organ cancer? It is also beneficial to know if the individual has any children and their level of involvement with the resident's care.
• Immunization Status: It is important to know what vaccines the resident has had and when. By gathering this information, the healthcare team can help determine which boosters or vaccines they may need and when.

Gathering a complete medical history is critical as it can impact medical care or decisions. Knowing the dates of recent preventative or diagnostic procedures, including cancer screenings, and any abnormal findings, is also beneficial. A detailed medical history can help healthcare providers fully understand the individual’s health and support the development of future care plans.

Understanding current medical conditions and diagnoses is necessary for appropriate treatment while in long-term care. Inquire about current conditions, including physical, emotional, and mental conditions, the symptoms they experience, the duration of the condition, severity, and current therapies or medications they require. Are these conditions chronic or acute? Are they being treated appropriately? Is the condition stable or unstable? Is the current illness contagious, and are any isolation precautions needed? Prescribing providers need a complete understanding of the individual's health to ensure proper treatment. Care plans must be established based on current medical conditions and illnesses, and help support the resident's well-being and safety.

Gathering a list of current medications is an important part of the admission process. This includes prescription medications, as well as over-the-counter medications and supplements. Medication information should include:

• Medication name.
• Indication for the medication.
• Dose.
• Route.
• Concentration if applicable.
• Duration: How long has the resident been taking the medication?
• Time and Frequency: When is the medication to be taken, and how often should the medication be administered?
• Prescriptions as applicable.
• Testing requirements: Does the medication require testing to maintain a therapeutic level?

How much assistance the resident requires to take the medications must be determined. Does the individual have a difficult time swallowing pills and need an alternative option, such as liquid or crushed medications? Does the individual have a history of memory issues that have caused missed doses? Is the individual compliant with taking medications? Medications are a critical part of resident safety, and some medications are required for life-threatening conditions. It is also important to be aware of side effects or warnings accompanying the resident's medications. Drug interactions are also possible, so understanding what medications the resident takes can help decrease the risk of drug interactions with food, other medications, supplements, or conditions.

The head-to-toe assessment is critical to admission to long-term care because it provides a baseline understanding of a resident’s physical, mental, and emotional status. Healthcare professionals can notice changes, improvements, or declines in patient condition from this assessment. Many of the components of the head-to-toe assessment are completed by nursing staff, but a physical or occupational therapist might assess some.

Many beneficial scales and tests help determine the severity of conditions and risk factors for particular issues. A standardized scale helps healthcare providers recognize areas that need attention and treatment, aids in creating care plan goals, and serves as a standard, often numerical measurement tool, to portray the severity or status of the present condition. It eliminates room for interpretation and ensures that charting can be consistent, and any changes, improvements, or declines can be recognized. Let’s discuss some of the useful scales that are often used in long-term care nursing.

Amy is a nurse admitting a new resident, Mr. Hansen, to the long-term care facility. She gathers pertinent information from Mr. Hansen and completes a head-to-toe assessment. As part of the admission process, she administers the Geriatric Depression Scale self-questionnaire to Mr. Hansen to assess for any signs of depression. Mr. Hansen has never had a diagnosis of depression in the past, but Amy wants to be thorough when assessing his mental health. Upon scoring the assessment, he had several responses that were indicative of depression. His calculated score was 20, indicating that severe depression was likely. Upon administering and interpreting this assessment, Amy recognizes the mental health concerns for Mr. Hansen and is able to address them with him. He acknowledges the need for further treatment. Amy documents the assessment, findings, and the discussion with Mr. Hansen and notifies his physician. His physician is able to help treat his depression in a timely manner. Had Amy not administered the Geriatric Depression Scale, Mr. Hansen’s depression may have been left undiagnosed, and he could have been at risk for worsening depression and potential self-harm.

Care plans are an important aspect of patient care and are used in long-term care facilities to help outline the treatment and the required progress. Healthcare providers are trained to create care plans based on assessment findings and establish goals for the resident to promote safe and healthy living. Residents and their families are included in the creation and execution of care plans. With changes in condition, care plans may need to be adapted to meet the certain capabilities and needs of the individual. They serve as a blueprint for meeting resident goals and outcomes, and provide a means of attaining those goals.

A care plan may include (Medicare, 2025):

• What kind of services or therapies are needed
• What type of health care professionals should provide the services
• How often and for how long services are needed
• What kind of equipment or supplies are needed, such as a wheelchair, urinary catheter, nasal canula, or feeding tube
• Dietary or feeding considerations, and if a special diet is required 
• Health goals and how the care plan will help reach the goals

When creating a care plan for a resident upon admission, it is important to recognize the five components of a care plan. They are (University of St. Augustine for Health Sciences, 2025):

1. Assessment: Subject (verbal findings) and objective (measured findings) assess the resident's current physical, mental, and emotional status. This includes vital signs, medical conditions, medical history, and functional ability.
2. Diagnosis: Develop a nursing diagnosis using the information you have gathered. A nursing diagnosis is a judgment regarding a health condition, life process, or vulnerability. Based on this diagnosis, nursing actions can be determined to help improve the individual’s situation or outcome. These diagnoses are based on Maslow’s Hierarchy of Needs, through which nurses can then prioritize the needs of the individual.
3. Outcomes and Planning: During this phase of care plan creation, you determine the outcomes or goals to be met and the means of achieving them. Ensure that the goals meet the SMART criteria, which include specific, measurable, achievable, realistic, and time-bound goals.
4. Implementation: This phase is when steps and processes are implemented to help achieve the care plan outcomes and goals. Nursing interventions must follow the doctor's orders as necessary and utilize evidence-based practice guidelines.
5. Evaluation: This final phase includes evaluating the situation to determine whether specific outcomes or goals were attained based on the nursing interventions and actions implemented. If the desired goal has not been met, adjustments can be made to help the resident attain it.

Care plans are an important tool used in long-term care to establish an individual's goals and provide a means for attaining those goals. They help to improve each resident’s current state and support continued progress regarding health, independence, or overall well-being. Utilizing effective communication can help providers support residents and promote effective patient care. Interdisciplinary teams, including respiratory therapy, doctors, nurses, technicians, dieticians, physical therapy, and occupational therapy, are often needed for the successful completion of care plans.

Sean, the admitting physical therapist at the skilled nursing facility, welcomed a new resident, Mrs. Cook, a 72-year-old female with a history of an ischemic stroke. Since her stroke, she has experienced significant left-sided weakness and an impaired gait, requiring the use of a walker for mobility. She also needs assistance with transfers from bed and with showering.

Sean began his evaluation with a comprehensive physical therapy assessment, including a review of her medical history, a neurological examination, and a musculoskeletal assessment to determine her current functional abilities. He performed a gait analysis, balance testing, and a standardized fall risk assessment using the Morse Fall Scale, which confirmed that Mrs. Cook is at high risk for falling.

Based on his findings, Sean developed a physical therapy plan of care to improve her mobility, maximize her independence, and reduce her fall risk. The objectives included: ensuring she remains fall-free during her stay, demonstrating safe and consistent use of her walker, and effectively using the call light to request assistance when needed.

Sean implemented targeted therapeutic exercises to strengthen her lower extremities, improve postural stability, and enhance weight-shifting ability on her affected side to achieve these goals. He incorporated gait training to reinforce proper walker use and provided repeated practice with safe transfer techniques. He also coordinated with nursing staff to ensure environmental safety—keeping the call light and personal items within reach, encouraging the use of non-slip footwear, and ensuring fall risk signage was in place. Additionally, Sean trained Mrs. Cook in safe bathroom mobility strategies, including using handrails and requesting staff assistance for showering and toileting.

Over the following weeks, Mrs. Cook demonstrated steady progress. She consistently used her walker safely, requested assistance for transfers through the call light system, and maintained a fall-free record. The collaborative efforts between therapy and nursing, along with her active participation, allowed her to improve her confidence and mobility while reducing her fall risk. Mrs. Cook expressed satisfaction with her care and felt supported and secure in her environment.

Through his thorough assessment, individualized therapy interventions, and interdisciplinary collaboration, Sean was able to help Mrs. Cook remain safe, mobile, and engaged in her rehabilitation process.

Advance directives or planning forms are legal documents that tell healthcare providers what type of treatment an individual wants to receive if they cannot communicate their desires, or who they want to make medical decisions on their behalf if they cannot do so. Advance directives include (National Institute on Aging, 2022):

• Living Will: This document tells healthcare providers how the individual wants to be treated, what medical procedures they do or do not want, and under what conditions.
• Durable power of attorney for health care: This document details who an individual wants to make decisions on their behalf if they are unable to do so. Individuals should select someone they trust and feel would have their best interests in mind.
• Do not Resuscitate order (DNR): This directive means that if the individual stops breathing and does not have a heartbeat, they do not want to be resuscitated, including CPR or other life-supportive measures. It is also referred to as a natural death order.
• Do not intubate order (DNI): This order means that the individual does not want to be intubated and placed on a ventilator for respiratory assistance.
• Do not hospitalize order (DNH): This order informs the healthcare team that the individual does not want to be transferred to a hospital for treatment.
• Out-of-hospital DNR order: This order informs emergency medical providers of the individual’s wishes regarding resuscitation outside the hospital.
• Physician orders for life-sustaining treatment (POLST) and medical orders for life-sustaining treatment (MOLST) forms: These forms serve as a medical order as well as an advance directive and give instructions about an individual’s medical care that health care professionals can act on immediately.

It is important that advance directives are included in the resident’s chart and that it is obvious in the resident’s chart if they have a DNR or DNI, which can quickly be seen in an emergency. It is also helpful to familiarize yourself with these directives for each resident at the start of the shift. The resident's wishes must be respected and followed. At times, it can be difficult to stand back and not intervene, but it is very important that the resident’s desires are honored and that appropriate care is given at the end of an individual’s life.

Obtaining information regarding cultural and religious preferences allows healthcare providers to foster an environment of cultural and religious sensitivity. For example, some cultures prefer a healthcare provider of a specific gender. Knowing the resident’s primary language is important so interpreters can utilize it as necessary. Some religious beliefs may prohibit specific medical treatments or interventions, such as blood transfusions or specific medications. In maintaining religious sensitivity, it is appropriate to be aware of significant or sacred days of particular religions, and to be aware of specific times set aside for religious worship. For example, does the individual have particular times of the day that are dedicated to prayer? If so, it is respectful to try to plan resident care outside of these time frames so that they can worship as they desire. Is Saturday or Sunday considered a day of worship, and is it important to them to attend religious services on those days? It is also important to gather the contact information for any spiritual leaders if the resident wants them to be contacted in the future. Does the individual have a pastor, bishop, or other individual they want contacted for religious reasons, such as prayers, blessings, or end-of-life support? Document any cultural or religious preferences in the resident’s chart to incorporate these important aspects into the resident’s care.

Safety is the top priority in any healthcare setting, including long-term care. Assessing the resident’s safety and acknowledging risk factors for injury allows proper safety measures to be implemented. Resident safety assessments include gathering information and observing physical and mental health, including mobility and the use of ambulatory aides, history of family violence or domestic violence, history of elder abuse, fall risks, and suicidal ideation. Is the resident at risk of falling? Do they require ambulatory or transfer assistance? (Toney-Butler & Unison-Pace, 2023). Is the individual confused or disoriented? Are they agitated and at risk of harming themselves or others? Do they require orders for restraints or pharmaceutical intervention when necessary? Are they confused about living in the long-term care facility and considered a flight risk? It is also important to use the Braden Scale, the Morse Fall Scale, the Glasgow Coma Scale, and the Geriatric Depression Scale to assess risk factors that could lead to patient harm, such as pressure injuries, falls, self-harm, or suicide.

Transitioning to long-term care can be an overwhelming time for individuals who feel that they are losing a sense of dignity and independence. As a healthcare provider, it is your job to help facilitate continued dignity and independence while being in an environment that provides medical assistance and help with activities of daily living. Encourage the individual to actively participate in their daily activities and care. Residents should be supported as members of their healthcare team and encouraged to ask questions. Assess gaps in knowledge or understanding and ensure that you provide informed care. Remember to always provide information about the care and interventions that are provided. Ask permission before assisting a resident, and be sensitive when assisting with vulnerable activities of daily living such as toileting, dressing, or showering. Encouraging residents to socialize with other residents, eat in the dining room, and attend activities helps to promote relationships and friendships with others who live in the long-term care facility. As an important aspect of resident independence, recognize that residents have the right to deny care, procedures, and medications. If this is the case, always thoroughly document the refusal. In some long-term care settings, individuals may have memory or cognitive issues that prevent them from properly making decisions. In this case, it is best to follow facility guidelines and have the residents have legal documentation of the power of attorney or other medical permission forms. Be sensitive to each individual’s circumstances to foster a safe and healthy environment supporting independence and dignity.

Long-term care, typically classified as custodial care, includes medical and non-medical care for those with a disability or chronic medical condition (Mills, 2023). Residents in long-term care may or may not qualify for Medicare coverage for their care in a skilled nursing facility. Medicare does cover the cost of a long-term care stay in a skilled nursing facility if preceded by an inpatient hospital stay of at least three days. Medicare covers up to 100 days of care in a skilled nursing facility during a single benefit period, but the individual must be eligible (Medicare, 2025).

Proper documentation of care and assessments is crucial because Medicare payment decisions are based on the details and information gathered from clinical records portraying the care the resident needs and receives. Thorough and accurate documentation shows the individual’s needs and treatments (Larkey, n.d.).

Medicare charting is required for the following skilled nursing services (Whitehurst, 2019):

1. Care Plan Management and Evaluation
   • The development, management, and evaluation of a resident’s care plan, based on the physician’s orders.
   • Healthcare providers must adequately document the services and assistance the individual needs that require medical personnel in a skilled nursing facility.
2. Patient Condition
   • Healthcare providers must document assessments and observations of the individual’s condition. This includes documentation of a change, improvement, or decline of the resident’s current condition.
3. Teaching and Training
   • Healthcare providers must document any education, teaching, or training provided to the resident. They must also remember to document the resident's response to the training.
   • Examples of resident education and training may include wound care, colostomy care, insulin administration, dos and don’ts while on oxygen, prosthesis management, catheter care, and G-tube feedings.
4. Direct Skilled Nursing Services
   • There are certain skills or care that require a licensed medical professional. Documenting such care demonstrates the need for assistance that can be obtained in a skilled nursing facility.
   • Examples of direct skilled nursing services may include: IV feedings such as TPN and lipids, IV medications, suctioning, tracheostomy care, rehabilitation nursing procedures, ulcer care, tube feedings, care for surgical wounds, and diabetes management with injections.

The documentation must be comprehensive and complete when documenting any medical care or patient status. Medicare requires that documentation in the clinical records must include (Larkey, n.d.):

• Enough information to identify the resident
• A record of the resident’s assessments
• A plan of care for the resident and the services provided
• The results of any preadmission screening that is conducted by the state
• Progress notes

For those in a skilled nursing facility (SNF), Medicare requires assessment documentation initially and periodically to show the resident’s need for skilled nursing care. An initial assessment is to be completed within 8 days of admission. This assessment will help care providers determine the care the resident needs, and Medicare uses it to determine the correct payment to the facility (Medicare, 2025). This assessment involves multidisciplinary teams, and nurses, physical therapists, occupational therapists, and respiratory therapists have an important role in this assessment and proper documentation of findings. Any other assessments about a change in condition must also be recorded.

The initial assessment must portray the resident’s functional ability. The assessment must include (Center for Medicare and Medicaid Services [CMS], 2024a):

• Identification and demographic information
• Customary routine
• Cognitive patterns
• Communication
• Vision
• Mood and behavior patterns
• Psychosocial well-being
• Physical functioning and structural problems
• Continence
• Disease diagnoses and health conditions
• Dental and nutritional status
• Skin condition
• Activity pursuit
• Medications
• Special treatments and procedures
• Discharge planning
• Documentation of summary information about the other assessments done on the care areas triggered by the completion of the Minimum Data Set (MDS)

Periodic assessments must show the resident’s need for skilled nursing care for Medicare to reimburse the costs. Documentation in a resident’s chart must demonstrate (CMS, 2024a):

• The patient’s medical history and physical exams, including responses or changes in behavior
• Skilled services provided
• The patient’s response to skilled services during a visit
• A plan for future care based on prior results
• A detailed rationale explaining the need for skilled service
• The complexity of service
• Other patient characteristics
• Certification that the resident needed daily skilled care, only provided in a skilled nursing facility setting
• An authenticated plan of care
• Time (in minutes) for therapy services provided

Documentation is a crucial part of healthcare. It is necessary to determine patient status, changes in conditions, procedures performed, and medications given, and it serves as a narrative of patient interactions and care. Medicare requires specific assessments for those in long-term care, and documentation must meet specific standards to support the individual’s need for care in a skilled nursing facility.

Medicare documentation requires that the required assessments be performed to verify that the individual meets the requirements for Medicare-covered skilled nursing facilities and care. Nursing facilities that are Medicare-certified require completion of the Resident Assessment Instrument (RAI), which includes the Minimum Data Set (MDS) 3,0 as well as Care Area Assessments (CAAs) and the RAI Utilization Guidelines. These assessments must be completed initially, periodically, when there is a significant change in resident status, and upon discharge. Accurate, thorough, and complete documentation is necessary to prevent Medicare denials (Larkey, n.d.). Thorough, accurate documentation and attention to required assessments foster a smooth collaboration with Medicare to provide safe, necessary care.

The Resident Assessment Instrument (RAI) Process is a federal requirement from the Centers for Medicare and Medicaid Services. It includes three basic components: The Minimum Data Set (MDS) Version 3.0, the Care Area Assessment (CAA) process, and the RAI Utilization Guidelines (CMS, 2024b). This tool is used to evaluate the level of care required, create an individualized care plan for each resident, and assess the individual's functional capacity. Comprehensive assessments are completed quarterly, and with a significant change of status (Underwood, 2023).

The RAI process includes (Underwood, 2023):

• Admission physician orders for immediate care: Physician orders must be present at admission for care, medications, dietary needs, and other care to support the individual’s needs.
• Comprehensive assessment and timing: Comprehensive assessments are required initially and at required time frames to determine needs, preferences, strengths, goals, and life history.
• Significant change in status assessment (SCSA): This assessment is required within 14 days of a major change in status, whether it is a significant decline or improvement, that would not resolve itself without intervention. This pertains to physical and mental conditions.
• Quarterly assessment at least every 3 months
• Maintain 15 months of resident assessments: Assessments within the previous 15 months are kept in the resident’s active record and are revised as appropriate.
• Encoding/transmitting resident assessment: Assessments must be formatted and transmitted appropriately.
• Accuracy of assessments: Assessments capture the resident’s current status, including medical, functional, and psychosocial factors. 
• Coordination/certification of assessment: Nurses must coordinate assessments with interdisciplinary teams and sign and certify the aspects of assessment that they complete.
• Coordination of Preadmission Screening and Resident Review (PASARR) and assessments: The skilled nursing facility must coordinate assessments with the pre-admission screening and resident review program. This will avoid duplicate efforts and testing.
• PASARR Screening for MD and ID: Screenings for those with mental disorders (MD) and intellectual disabilities (ID) are required.
• MD/ID significant change notification: State mental health authority or state intellectual disability authority must be notified promptly if a resident who has a mental illness or intellectual disability experiences a significant change in mental or physical condition.

Understanding and feeling confident in the necessary steps of admission to long-term care is critical to patient care. This course discussed gathering important information from residents and their families upon admission, making thorough observations and completing detailed admission assessments, providing assessment scales to identify risk factors, and explaining Medicare documentation requirements, all of which are vital components of the long-term care admission process. Documentation must always be thorough, accurate, and complete. Completing Medicare assessments and adhering to documentation requirements support resident care, document the resident’s status, create individualized care plans, and are necessary for financial reimbursement of the skilled medical assistance provided in long-term care.

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