Can a skilled nursing facility demand that our private caregiver be hired through an agency?


My mom is in skilled nursing for rehab. She has a long time caregiver she has used in the past which we hired to stay with her in the skilled nursing facility to help her eat and just motivate her. The skilled nursing center first stated the caregiver must have a TB test, which she had but is now saying we can only use a caregiver if we go through a caregiver agency.

I looked up Medicare rules and found the following. It states any person who gives you help with your health may see you at any reasonable time. Can a skilled nursing center demand that a caregiver you hire has to go through some agency. The problem is the agencies charge twice as much and mom would not be able to afford that.


"You have the right to spend private time with visitors at any reasonable hour. The SNF must permit your family to visit you at any time, as long as you want to see them. You don't have to see any visitor you don't want to see. Any person who gives you help with your health or legal services may see you at any reasonable time. This includes your doctor, representative from the health department, and your Long-Term Care Ombudsman, among others."



AARP has plan F to help supplemental to Medicare for Rehab after surgery in a nursing home. If you don’t have the additional supplemental at time your in Nursing Home for rehab only they will most likely deny coverage . You would have to get it later after a certain amount of time after leaving rehab and not being in a hospital for a period of time. Our family member had this happen after surgery they thought they had the right plan for years that they paid on but to their surprise after the 21 days the daily rate the patient had to pay at that time was in this rehab was $157.50 daily and that was to the 100th day and a few days after it was higher plus cost of supplies while waiting for an Assisted Living. If you have a Caregiver at home that’s experienced and let’s just say a Low RATE of $10.00 an hr for 24 hours is $240 daily multiply that by 31 days is $7,440.00. So you may want to get an assisted living which would be less. But you still need to check on your loved one in all areas that give care to them & how they are treated and on a timely manner or the meds that are given to them are given correctly and watch when time given!
Most assisted livings do not take Medicare to help pay bill it is self pay!!
what are we going to do is my question? Things are so expensive!
Helpful Answer (0)
Reply to wwhelp2017

Let me ask you this . What about an assisted living? Why can’t family visit their parent anytime or sit with them as a caregiver besides an agency ? Or just visit them any time to see how they are being taken care of instead of being told there are only certain times allowed to be there? I don’t think that is right! I think the POA of the resident should be able to stay or visit when they feel they should or ok someone else if a care giver can come in to be with the resident in an assisted living . Or even if the resident did not have a POA the person who is helping pay bills there should be able to check on them anytime like a nursing home .
Helpful Answer (1)
Reply to wwhelp2017
Isthisrealyreal Sep 10, 2018
I never had visiting hours with my dad, 24/7 access was allowed with courtesy rules, ie after 10pm, BE QUIET.
See 1 more reply
IMHO, this question should be asked to the Ombudsman of the SNF.
Helpful Answer (0)
Reply to Llamalover47

Ok...this is my experience with rehab and Mom was only there to get her strength back. She was in the later stages of Dementia and a fall risk so she was put in a wheelchair with an alarm. Prior, she had walked all over her AL with a walker.

Pt, OT are only done an hour or so in the morning, same for the afternoon maybe 7 days a week? I know Mom was given it on Sunday. The rest of the time my Mom was in a wheelchair. The only time she walked was from her room to the therapy room, I was told by a CNA. So, I don't see where her aide would get in the way. Actually, I think its a good idea to have her there making sure Mom gets the therapy she needs and being the families eyes. And I mean just being in the room, not helping with the therapy. I was invited to watch a therapy session.

So, what I am saying is the woman is a companion. Someone to be with Mom when family can't be. Play cards, games etc. She just doesn't do any hands on. The facility doesn't need to know she is being paid or not. Actually, the facility probably sees the aide as a spy. But what is the difference if a family member is there all day or a friend/companion. Just have her report to you any odd things she sees but not to confront anyone.
Helpful Answer (2)
Reply to JoAnn29

It is a exposure to risk issue for them.
Sure, your private caregiver can be considered just a 'visitor', but if the staff sees that she's handing your mom in a way that's beyond what a visitor would do, they could be held liable if they didn't address that. What if the private caregiver injured your mom? The SNF could be held accountable for letting an unlicensed, uninsured person care for your mom under their roof.
Helpful Answer (5)
Reply to IsntEasy

We ran into this restriction when my spouse was transferred to sub-acute rehab after a stroke six years ago. I wanted to hire a home health aide whom I'd known out in the community to monitor his well-being. The facility objected, saying that we had to use an aide from one of the agencies with whom the facility contracted. Technically, I can see their wish to have control over the 'care' that is delivered within their facility. I believe it is a liability issue. However, if so, this is somewhat ironic considering the low quality of the 'care' that their directly-hired staff provided. I was so glad to get my spouse out of there and to a skilled nursing facility that provided him excellent care, so the choice of caregivers there was never an issue.
Helpful Answer (3)
Reply to con3ill

Yes, they can and do.
Helpful Answer (1)
Reply to Mapotter

Frank - I’m going to go in a different direction to your question..... as I see red flags in the near distance..... so your mom is in a MediCARE paid benefit post hospitalization rehab at a SNF with a rehab center, that’s it right?
2 issues from that:
- This can be a grey area as she’s not truly a resident in skilled nursing but rather transient there for limited time in rehab. So what nursing duties they do for SNF residents may not be required for her
- She has to be “progressing” on her own in rehab by whatever measurements the ICD -10 codes in her health chart require as the rehab was prescribed to a series of therapies based on the codes. And every day or every other day her progress is written in her chart. IF the “aide” has been at her side most of the time it has screwed the pooch on her rehab. The 100 days rehab is a maximum and rare for the advanced elderly to get that benefit. They “plateau” out and often before the standard 20/21 days.

SO Where is your mom at for # of days?
& What is her status for rehab “progress” or “plateau”?
Try to find this out ASAP. As once discharged from rehab, she (you) need to make a decision ASAP...... does she stay at this NH as a skilled nursing resident (will this NH take her); Or go back home (with the aide)? Or go somewhere else like move in with you? Or to an AL?
The current facility can do a needs assessment and that aide really should NOT be there at all when the assessment is done. There needs to be a reality check on what her ability is and a needs assessment does this. Assessments nowadays produce a report with abilities done on a point system. IL, AL, NH can use the points system to determine if they can meet their needs AND fees for services beyond the usual for private pay residents. There’s like 2 recent posts on this site about points system and serious $$ costs above the basic AL monthly rate.

You wrote your thinking of AL for her. I’m going to guess it’s not going to be AL as AL expects them to be pretty good on their ADLs and be able to transfer on thier own using a walker or footed cane & i bet that’s not her on her own. The AL may take her IF services needed are done by their staff or outside vendors that you can select from a list of vetted ones with liability insurance, etc. No facility is going to want an aide not within their purview there being a shadow & doing duties (transfer for bathing / bathroom, medication management) that has liability.
If they are actually just a “sitter” and say come in every afternoon to read them the paper, watch a movie and share a snack, do knitting, thats different. But it sounds like this person is doing “aide” stuff and that’s not gonna fly.

It may be that it’s time for a NH. If so please please take a hard look at her assets to see what is affordable and for how long. If she has a home and car, start to think what to do with these starting this weekend. If Her 20/21 days is fast approaching & she’s not progressing sufficiently doing this now keeps it from being a crisis decision.

Oh and if your thinking that you’ll fight the discharge from rehab & will do an appeal to Medicare, it’s imo a waste of time and energy. Her health chart has in detail what’s what on her. Hard to refute. And every day she stays there during the appeal she will be racking up a private pay bill. Medicare insurance will not pay as rehab is over.
Helpful Answer (9)
Reply to igloo572
Compassionate5 Aug 31, 2018
Per usual Igloo, you are spot on. You seem to simplify complicated issues so
it's easily understood. Your work experience allows realistic expectations about the success rate of appeals. And the frosting on the cake is your humor. (screw the dog). Thanks!!!
I think it is a liability issue.
The people that you mentioned in the rules, Doctor, rep from the Health Department, Long Term Care Ombudsman do not provide direct, hands on care, (Other than the doctor but presumably they are trained and are greatly insured) So if the patient were to sustain an injury it presents a problem. Is the caregiver insured? And if the caregiver herself gets injured anywhere on the property who would be liable there for her to file for workman's comp?
The facility should be providing someone that will help your Mom eat, bathe, dress and help her to activities.

A side note here...
IF this caregiver came in for a few hours a day to "motivate" Mom to play games with her, take her for a walk, sit and chat BUT she did no OBVIOUS care-giving tasks, changing a brief, helping Mom toilet, feeding Mom...and you paid her privately how would the facility know she was being paid? The caregiver would just be another visitor for Mom. You would not even have to let Mom know she is being paid just so Mom wouldn't "let the cat out of the bag"
Helpful Answer (5)
Reply to Grandma1954

If your mom is in a snf, they should be providing ALL care. You're paying for that.
I think they want the aid to be thru an agency because there is insurance in case your mom falls or something happens. Their butts have to be covered. It is very easy for a person to fall and break something. The elderly are extremely frail. It can be a complete accident, but that doesn't stop family from saying everyone's negligent! Their going to sue. They also have to write a lot of paperwork and document these things. There are protocols in place for these things. It is a big deal.
Agencies charge double for carers because your paying for insurance on the carer, and the agencies fees for their building, electric, taxes, as well as help paying the salaries of secretaries and management. They also have to be up to date on all vaccinations, hepatitis and perhaps meningitis vacinations too. Some people don't believe in vaccinations or vaccinate differently in other countries. It's for the safety of the elderly. Their immune systems are no longer as strong. Illnesses run thru the facility like wildfire.

Perhaps the care giver can just come in and sit with her and keep her company? Not do transfers, or work that the cna's already assigned are doing. They let family feed their loved ones. I know when I went in to visit my dad, they always wanted me to feed him. It gave them a break.

The PTs don't want the carer helping with ambulation training because they are not insured by the facility. They are also not qualified. The facility has properly trained Pts, pta's and aids.
The snf has staff that are assigned to your mom. They are all insured and trained. Unless the carer is there to make sure your mom doesn't wander because she is not in the lock down facility part of the building. There is no need to have her there.

If she just goes to visit and doesn't help with dressing, bathing, adls that should be ok. You can say she is a friend of the family. The facility has every right to demand that she is insured. Everyone at the site has to be.
I have seen carers come in to sit and visit with the clients to help with morale. That should be fine. That is very uplifting for them.
Just tell them she is a friend of the family. Your carer can't get her hours in working at the facility. She can only visit and chat. She has to wait till your mom comes home. Good luck.
Helpful Answer (2)
Reply to Jasmina