FACILITY AGREES TO:

1. Furnish room, board, linens, bedding and certain equipment, nursing care and such personal services as may be required for the health, safety, grooming and well-being of the resident.
2. Assist in obtaining the services of a licensed physician of the resident's choice whenever necessary, or the service of another licensed physician, if a personal physician has not been designated or is not available.
3. The facility will assist the resident in designating a pharmacist to obtain any medications the physician may order. Payment of any charges for the services, medications, durable medical equipment or other products provided by the Pharmacist (except as included in the State Plan, if resident is qualified for Medicaid benefits) not covered by third party payers, or governmenal payors, shall be the responsibility of the resident, except as otherwise provided by law.
4. Arrange for transfer of the resident to the hospital of the resident's choice, when this is ordered by the attending physician, or in case of an emergency, and immediately attempt to notify the designated party of such transfer.
5. Make refunds for over payment in accordance with established policy of the facility.

RESIDENT OR DESIGNATED PARTY AGREES TO:

1. Provide such personal clothing and effects as needed or desired by the resident.
2. Provide such spending money as needed by the resident for personal items.
3. Be responsible for hospital charges, if hospitalization of the resident becomes necessary and transportation to and from the hospital.
4. Be responsible for physicians fees, dentist fees, medications, ambulance service and other treatments ordered by the physician which are not covered by Medicaid, Medicare, Veteran Administration, or other agency.
5. Pay each month the charge agreed upon with facility for resident's care, or set forth herein on Attachment A.
6. Abide by the facility's policies and procedures, rules and regulations relating to the safety and welfare of the facility's clients, staff, visitors, or any other individual.
7. Hold the facility harmless from any claims for the loss or damage of any money (not deposited in the resident trust fund), jewelry, documents or any personal property. All articles retained in the resident's possession including eyeglasses, hearing aids, dentures, clothing, etc., shall be entirely the responsibility and liability of the resident UNLESS IT IS PROVEN THROUGH THE INVESTIGATIVE PROCESS THAT THE LOSS OR DAMAGE HAS OCCURRED AS A RESULT OF AN ACTION BY A FACILITY EMPLOYEE OR CONTRACTED VENDOR.

• The facility shall not transfer or discharge a resident unless one of the following conditions is present:
  1. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
  2. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
  3. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
  4. The health of individuals in the facility would otherwise be endangered;
  5. Nonpayment by the resident or appropriate third party has occurred after reasonable and appropriate notice;
  6. The facility ceases to operate;
  7. The resident requests a transfer or discharge.
• Before this facility transfers or discharges a resident, the facility shall provide the following notice:
  1. The facility shall notify the resident and, the resident's representative(s) of the transfer or discharge and the reason there of; in writing and in a manner they can understand;
  2. The facility shall record the reason for said transfer or discharge in the resident's clinical record.
• The timing of such notice shall be thirty (30) days prior to the time the resident is transferred or discharged unless one of the following conditions is present:
  1. The safety of individuals in the facility is endangered;
  2. The health of individuals in the facility is endangered;
  3. The resident's health improves sufficiently to allow a more immediate transfer or discharge;
  4. An immediate transfer or discharge is required by the resident's urgent medical needs;
  5. A resident has not resided in the facility for thirty (30) days.
  In the event one of the above conditions is present, notice shall be as soon as practicable before transfer or discharge.
• The facility shall dispose of personal items not claimed within 30 days of discharge unless other arrangements are made with the facility at time of discharge.

1. The resident and designated party must complete this agreement or make satisfactory arrangements for its completion prior to admission to the facility.
2. If the resident and/or designated party is unable to meet the terms of this agreement, the facility reserves the right to require the removal of the resident per the terms set forth in the TRANSFER or DISCHARGE section of this Agreement.
3. The term of this agreement is for one year with automatic renewal.

1. CONSENT FOR TREATMENT: The undersigned, knowing that the resident is in a condition requiring health care, diagnosis and medical treatment, does hereby voluntarily agree to such diagnostic and health care services, to such medical treatment, nursing care, intravenous feedings, injections, etc. which may be administered to or performed on the resident while residing at the facility under the general supervision of a physician in accordance with the resident's right to make treatment decisions and accept or refuse medical treatment according to the laws of the state.
2. PHYSICIAN SERVICES: The undersigned understands that the resident's care in the facility must be under the control and direction of the resident's physician. The undersigned further understands that the facility provides general nursing care and does not have the services of a physician available through its staff. The resident shall be responsible for payment of all physician charges.
3. PHYSICIAN ASSIGNMENT: The resident has a right to select his/her own attending physician. The physician responsible for the provision of care for the undersigned resident and the means to contact same are set out as follows:
   Name

   Specialty

   Telephone

   Address
   
   In the event that your designated physician does not provide timely physician services as required by federal regulation, you agree to designate a substitute physician to provide your physician services.
4. AUTHORIZATION FOR EMERGENCY TREATMENT: If, in the opinion of the nurse in charge at the time, emergency medical treatment is necessary for the health, safety, or general welfare of the resident, and the resident is unable to give written or verbal consent to treatment because of his condition, the facility is hereby authorized to provide such emergency treatment and care as may be required in the best judgment of the nurse in charge. Further, the resident hereby consents to the facility to obtain the services of a physician other than the resident's physician in the event said physician is unavailable for an emergency matter involving the resident.
5. RELEASE OF INFORMATION: The undersigned authorizes the facility to disclose all or any part of the resident's personal and/or clinical records in the event the resident is transferred to another health care institution or should such record release be required by law or third party payment contract. The undersigned further acknowledges, by signature attached, that they have received a copy of the facility's Notice of Privacy Practices and that they have had an opportunity to review the Notice and to opt out of any such practices in which they do not agree.
6. CARE PROVISION: The facility reserves the right to determine room assignments, menu planning and the establishment of service times. Any such provisions will be established with the needs and desires of each resident taken into consideration.
7. PHYSICIAN CONSENT TO RESIDENT ABSENCE: It is expressly understood and agreed that the facility must have authorization from the resident's physician prior to the resident being released from the facility for activities, for temporary leaves and for discharge.
8. VOLUNTARY ABSENCE FROM NURSING HOME: Resident hereby releases the facility from any liability for the resident's care during times that the resident may leave the facility alone or in the company of a friend or a family member for temporary leaves.
9. RELEASE OF RESPONSIBILITY FOR LEAVING WITHOUT APPROVAL: I, the undersigned, do hereby certify that the resident is being admitted to the admitting facility on his or her own volition and the facility, its personnel and the attending physician is absolved and released of any responsibility if the resident should leave the premises of the facility for any reason whatsoever without the consent of the attending physician and notice to the facility management.
10. PHARMACEUTICAL SERVICE POLICY: I have had the Pharmaceutical Policy used at the facility explained to me. I here by consent to the use of said system in connection with medications prescribed for me by my physician. Unless revoked by me in writing I also hereby consent to the use of the pharmacy selected by the facility as the pharmacy for filling my prescription orders. If I do not select facility pharmacy, I hereby select.
    Pharmacy Name:
11. ASSESSMENTS: The resident acknowledges that upon admission and periodically thereafter a comprehensive reproducible assessment of the resident's functional capacity shall be performed and then there shall be developed a comprehensive care plan for the resident. I further understand that I have both the right and the opportunity to participate in the development of my comprehensive plan of care.
12. ACKNOWLEDGEMENT OF ELECTRONIC TRANSMISSION OF ASSESSMENT: Resident acknowledges being informed that it is a requirement for Medicare/Medicaid participating facilities to electronically transmit required assessments to the state. The assessment is referred to as the Minimum Data Set (MDS). Electronically transmitted MDS information will be used to track changes in residents over time for purposes of evaluating and improving the quality of care and for Medicare billing purposes. The state is then required to transmit the assessment to the Centers for Medicaid and Medicare Services, which is responsible for Medicare and Medicaid nursing home requirements. If a nursing home does not submit the required data, reimbursement under the Medicare and Medicaid programs will be denied. Confidentiality of the submitted assessment information is protected under the Federal Privacy Act of 1974 and the MDS Long Term Care System of Records.
13. CONSENT TO PHOTOGRAPH: The resident agrees to allow the facility to photograph the resident while under the care of the above facility, and agrees that they may use the negatives or prints therefrom for such purposes as identification or medical purposes, unless the resident notifies the facility they do not want to participate.
14. AUTHORIZATION FOR RELEASE OF BODY: I, the undersigned, do hereby certify that in the event the resident expires, the admitting facility is hereby authorized to release the body to the mortuary specified on the admission face sheet.
15. ACKNOWLEDGEMENT OF FACILITY NOTIFICATION: Resident hereby acknowledges that he/she has been informed of:

    • Financial Agreement (Attachment A);

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      I have reviewed Section A1: Attachment A for this policy
      
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    • List of Services and Charges;

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      Non-Covered Items and Services

      
      

      Policy Statement

      Our facility provides, explains, and reviews charges for all services available to the resident which are not covered in the Medicare/Medicaid payment rate.

      Policy Interpretation and Implementation

      1. Our facility will review and explain charges for items and services requested by the resident that are not covered by the Medicare/Medicaid payment rate or as part of the facility per diem rate.
      2. We will only charge residents for items and services that are:
         • Specifically requested by the resident or representative;
         • NOT required to achieve the goals stated in the resident’s care plan;
         • Reviewed with the resident and charges approved in advance; and
         • Not already covered in the Medicare or Medicaid payment rate.
      3. The list of and charges for non-covered items and services is provided orally and in writing to the resident prior to or upon admission and when requests for non-covered items or services occur.
      4. Should a resident request an item or service not covered in the Medicare/Medicaid payment rate, a representative of the business office will inform the resident of the charges for the requested item or service.
      5. The following list is an example of some non-covered items and services:
         • Telephone, including a cellular phone;
         • Television/radio, personal computer or other electronic device for personal use;
         • Personal comfort items, including smoking materials, notions and novelties, and confections;
         • Cosmetic and grooming items and services in excess of those for which payment is made under Medicaid or Medicare;
         • Personal clothing;
         • Personal reading matter;
         • Gifts purchased on behalf of a resident;
         • Flowers and plants;
         • Cost to participate in social events and entertainment outside the scope of the activities program;
         • Non-covered special care services such as privately hired nurses or aides;
         • Private room, except when therapeutically required (for example, isolation for infection control);
         • Specially prepared or alternative food requested instead of the food and meals generally prepared by the facility, with the exception of:
           1. special foods and meals, including medically prescribed dietary supplements, ordered by the resident’s physician, physician assistant, nurse practitioner, or clinical nurse specialist; and
           2. the consideration of the resident’s food needs and preferences, as well as the overall cultural and religious make-up of the facility population.
         • Residents are not required to request any item or service as a condition of admission or continued stay.

      
      

      References

      OBRA Regulatory Reference Numbers	§483.10(f)(11) The facility must not impose a charge against the personal funds of a resident for any item or service for which payment is made under Medicaid or Medicare (except for applicable deductible and coinsurance amounts).
      Survey Tag Numbers	F571
      Other References
      Related Documents
      Version	1.1 (H5MAPL0541)

      
      
      

      Covered Items and Services

      
      

      Policy Statement

      Residents are provided with information regarding covered and non-covered items and services provided by the facility.

      Policy Interpretation and Implementation

      1. Services and items provided in our facility’s Medicare/Medicaid payment include the following items and services:
         • Nursing services;
         • Food and nutrition services;
         • Activities program;
         • Room/bed maintenance services;
         • Routine personal hygiene items and services as required to meet the resident’s needs, including but not limited to:
           1. hair hygiene supplies, comb and brush;
           2. bath soap, disinfecting soaps or specialized cleansing agents when indicated to treat special skin problems or to fight infection;
           3. razor, shaving cream;
           4. toothbrush, toothpaste, denture adhesive, denture cleaner, dental floss;
           5. moisturizing lotion;
           6. tissues, cotton balls, cotton swabs;
           7. deodorant;
           8. incontinence care and supplies;
           9. sanitary napkins and related supplies;
           10. towels, washcloths, hospital gowns;
           11. over the counter drugs;
           12. hair and nail hygiene services; and
           13. bathing assistance.
         • Medically-related social services;
         • Hospice services elected by the resident and paid for under the Medicaid Hospice Benefit or by the State Medicaid Plan; and
         • Basic personal laundry.
      2. Our facility will not impose a charge against the personal funds of a resident for any item or service for which payment is made under Medicaid or Medicare (except for applicable deductible and coinsurance amounts).
      3. Our facility may charge the resident for requested services that are more expensive than or in excess of covered services.
      4. Should the list of covered items and services change, residents will be informed in writing as soon as possible.

      References

      OBRA Regulatory Reference Numbers	§483.10(f)(11) The facility must not impose a charge against the personal funds of a resident for any item or service for which payment is made under Medicaid or Medicare (except for applicable deductible and coinsurance amounts).
      Survey Tag Numbers	F571
      Other References
      Related Documents
      Version	1.1 (H5MAPL0165)

      
      
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    • Residents Rights (Attachment B);

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      I have reviewed Section A3: Attachment B for this policy
      
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    • Residents Legal Rights (Attachment C);

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      I have reviewed Section A4: Attachment C for this policy
      
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    • Advance Directive Notification (Attachment E);

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      I have reviewed Section A6: Attachment E for this policy
      
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    • Notice of Privacy Practices;

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      NOTICE OF PRIVACY PRACTICES

      
      

      THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

      
      

      We respect the privacy of your protected health information (“PHI”) and are committed to maintaining such information in a confidential manner. This Notice applies to all information and records related to your care that our facility receives or creates. It extends to information received or created by our employees, staff, volunteers and physicians. This Notice informs you about the possible uses and disclosures of your PHI. It also describes your rights and our obligations regarding your PHI.

      We are required by law to:
      • maintain the privacy of your PHI;
      • provide to you this detailed Notice of our legal duties and privacy practices relating to your PHI; and
      • abide by the terms of this Notice that are currently in effect.

      
      

      For purposes of the HIPAA Privacy Rules, our facility is considered an affiliated covered entity and is covered by a HIPAA compliance plan

      • WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS
        

        We may use and disclose your PHI for purposes treatment, payment and health care operations. We have described these uses and disclosures below and provide examples of the types of uses and disclosures that we may make in each of these categories.

        • For Treatment. We will use and disclose your PHI in providing you with treatment and services. We may disclose your PHI to facility and non-facility personnel who may be involved in your care, such as physicians, nurses, nurse aides, and physical therapists. For example, a nurse caring for you will report any change in your condition to your physician. We also may disclose PHI to individuals who will be involved in your care after you leave the facility.
        • For Payment. We may use and disclose your PHI so that we can bill and receive payment for treatment and services you receive at the facility. For billing and payment purposes, we may disclose your PHI to your representative, an insurance or managed care company, Medicare, or another third party payer. For example, we may contact Medicare or your health plan to confirm your coverage or to request coverage information for a proposed treatment or service.
        • For Health Care Operations. We may use and disclose your PHI for facility operations. These uses and disclosures are necessary to manage the facility and to monitor our quality of care. For example, we may use PHI to evaluate our facility’s services, including the performance of our staff or to determine the most effective and efficient manner of providing services to our residents.
        
        

        We may also provide certain services by contracting with third parties, referred to as Business Associates. In some cases, we will need to disclose your PHI to a Business Associate in order for them to provide the appropriate services to you and/or the facility. We will only disclose your PHI to a Business Associate after we have received adequate contractual assurances from them that they will safeguard and keep confidential your PHI.

      • WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU FOR OTHER SPECIFIC PURPOSES (with the opportunity for you to object)
        

        In some circumstances, we may disclose a limited amount of your PHI if we provide you with notice of our practices, and the opportunity to object to such release. In an emergency situation, where you are unable to object, we may disclose your PHI provided such disclosure is consistent with any prior expressed intentions and deemed by us to be in your best interest. When you are able to respond, you will be given an opportunity to object to further uses or disclosures.

        • Facility Directory and Newsletter. Unless you object, we will include certain limited information about you in our facility directory and newsletter. This information may include your name, your location in the facility, your general condition and your religious affiliation. Your religious affiliation may be given to a member of the clergy even if they do not ask for you by name. The facility directory information may be released to people who ask for you by name. Your name may appear in the facility newsletter related to special activities, such as your birthday.
        • Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may disclose your PHI to a family member or close personal friend, including clergy, who is involved in your care. We may also disclose your PHI to a disaster relief organization for the purposes of notifying your family or friends about your general condition, location or status.
        • Uses and Disclosures Related to Treatment Alternatives, Reminders and Other Health Related Benefits. We may use or disclose PHI to remind you about appointments. We may also use or disclose PHI to inform you about treatment alternatives that may be of interest to you or to inform you about health-related benefits and services that may be of interest to you.
      • WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU FOR OTHER SPECIFIC PURPOSES (without obtaining your additional consent or authorization)
        • As Required By Law. We will disclose your PHI when required by federal, state or local law to do so.
        • Public Health Activities. We may disclose your PHI for public health activities. These activities may include, for example:
          • reporting to a public health or other government authority for preventing or controlling disease, injury or disability, or reporting abuse or neglect;
          • reporting to the federal Food and Drug Administration (FDA) concerning adverse events or problems with products for tracking products in certain circumstances, to enable product recalls or to comply with other FDA requirements;
          • to notify a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition or
          • for certain purposes involving workplace illness or injuries.
        • Reporting Victims of Abuse, Neglect or Domestic Violence. If we believe that you have been a victim of abuse, neglect or domestic violence, we may use and disclose your PHI to notify a government authority if required or authorized by law, or if you agree to the report.
        • Health Oversight Activities. We may disclose your PHI to a health oversight agency for oversight activities authorized by law. These may include, for example, audits, investigations, inspections and licensure actions or other legal proceedings. These activities are necessary for government oversight of the health care system, government payment or regulatory programs, and compliance with civil rights laws.
        • Judicial and Administrative Proceedings. We may disclose your PHI in response to a court or administrative law. We also may disclose information in response to a subpoena, discovery request, or other lawful process.
        • Law Enforcement. We may disclose your PHI for certain law enforcement purposes, including:
          • as required by law to comply with reporting requirements;
          • to comply with a court order, warrant, subpoena, summons, or similar legal process;
          • to identify or locate a suspect, fugitive, material witness, or missing person;
          • when information is requested about the victim of a crime if the individual agrees or under other limited circumstances;
          • to report information about a suspicious death;
          • to provide information about criminal conduct occurring at the facility;
          • to report information in emergency circumstances about a crime; or
          • where necessary to identify or apprehend an individual in relation to a violent crime or an escape from lawful custody.
        • Research. We may disclose PHI of residents from our facility who choose to participate in research studies. Your PHI may be used for research purposes only if the privacy aspects of the research have been reviewed and approved by a special Privacy Board of Institutional Review Board, if the researcher is collecting information in preparing a research proposal, if the research occurs after your death, or if you authorize the use or disclosure.
        • Coroners, Medical Examiners, Funeral Directors, Organ ProcurementOrganizations. We may release your PHI to a coroner, medical examiner, funeral director or, if you are an organ donor, to an organization involved in the donation of organs and tissue.
        • To Avert a Serious Threat to Health or Safety. We may use and disclose your PHI when necessary to prevent a serious threat to your health or safety or the health or safety of the public or another person. However, any disclosure would be made only to someone able to help prevent the threat.
        • Military and Veterans. If you are a member or former member of the armed forces, we may use and disclose your PHI as required by military command authorities. We may also use and disclose PHI when requested by appropriate federal authorities for the purposes of intelligence and other natural security activities, or to correctional facilities.
        • Workers’ Compensation. We may use or disclose your PHI to comply with laws relating to workers’ compensation or similar programs.
      • YOUR AUTHORIZATION IS REQUIRED FOR OTHER USES OF PROTECTED HEALTH INFORMATION
        

        We will use and disclose PHI (other than as described in this Notice or required by law) only with your written Authorization. You may revoke your Authorization to use or disclose PHI in writing, at any time. If you revoke your Authorization, we will no longer use or disclose your PHI for the purposes covered by the Authorization, except where we have already relied on the Authorization.

      • YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
        

        You have the following rights regarding your protected health information at the facility:

        • You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of your PHI, including both medical and billing information for as long as we maintain the PHI. In order to inspect and/or copy your PHI you must submit a written request to us. We may charge you a SNS/HIPAA/4/03 Privacy Notice5reasonable fee for the cost of such copies. Under federal law, however, your access to inspect or copy the following records may be limited: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and PHI that is subject to law that prohibits access to PHI. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Administrator if you have questions about access to your medical record.
        • You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your PHI for the purposes of treatment, payment or healthcare operations. You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must be in writing and must state the specific restriction requested and to whom you want the restriction to apply. The Facility is not required to agree to a restriction that you may request. If the Facility believes it is in your best interest to permit use and disclosure of your PHI, your PHI will not be restricted. If the Facility does agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment. You may request a restriction by sending your written request for additional restrictions to the Administrator.
        • You have the right to request confidential communications from us. You have the right to request to receive communications from us in alternate forms or locations, or that we not provide such information to certain people. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Administrator.
        • You may have the right to have your protected health information amended. This means that if you have reason to believe certain PHI is incomplete or incorrect, you may request an amendment of your PHI, for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Administrator if you have questions about amending your medical record.
        • You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you or pursuant to a written authorization signed by you, for a facility directory, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations.
        • You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.
      • COMPLAINTS
        

        If you believe that your privacy rights have been violated, you may file a complaint in writing with the facility or with the Office of Civil Rights in the U.S. Department of Health and Human Services. To file a complaint with the facility, contact the Administrator of the Facility who also serves as the HIPAA Compliance Officer. We will not retaliate against you if you file a complaint.

      • CHANGES TO THIS NOTICE
        

        We will promptly revise and distribute this Notice whenever there is a material change to the uses or disclosures, your individual rights, our legal duties, or other privacy practices stated in this Notice. We reserve the right to change this Notice and to make the revised or new Notice provisions effective for all PHI already received and maintained by the facility as well as for all PHI we receive in the future. We will post a copy of the current Notice in the facility. In addition, we will provide a copy of the revised Notice to all residents at the time of admission, via U.S. mail or in-house distribution.

      • FOR FURTHER INFORMATION
        

        If you have any questions about this Notice please contact the Facility Administrator.

        
        Effective as of April 14, 2003

      
      
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    • Resident Rules and Regulations;

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      I have reviewed Section A3: Attachment B for this policy
      
      Close section

    • Facility Personal Possession Policy;

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      Personal Property

      
      

      Policy Statement

      Residents are permitted to retain and use personal possessions and appropriate clothing, as space permits.

      Policy Interpretation and Implementation

      1. Each resident’s room is equipped with private closet space that includes clothes racks and shelving and that permits easy access to the resident’s clothing.
      2. The resident is encouraged to maintain his/her room in a home-like environment by bringing personal items (i.e., photographs, knickknacks, etc.) to place on nightstands, televisions, etc.
      3. The resident is permitted to bring room furnishings if:
         • The room is large enough to accommodate the furniture;
         • The furniture does not infringe upon the rights of others; and
         • The furniture does not violate current life safety code requirements.
      4. A representative of the admitting office will advise the resident, prior to or upon admission, as to the types and amount of personal clothing and possessions that the resident may keep in his or her room.
      5. The resident’s personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished.
      6. The facility will promptly investigate any complaints of misappropriation or mistreatment of resident property.

      
      

      References

      OBRA Regulatory Reference Numbers	§483.10(e) Respect and Dignity.
      Survey Tag Numbers	F557
      Other References
      Related Documents	Inventory of Personal Effects (MP5413)
      Version	1.1 (H5MAPL0618)

      
      
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    • Facility Physical Restraint Policy;

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      Use of Restraints

      
      

      Policy Statement

      Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident’s medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls.

      Policy Interpretation and Implementation

      1. “Physical Restraints” are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident’s body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one’s body.
      2. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident’s physical condition (i.e., side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint.
      3. Examples of devices that are/may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, geri-chairs, and lap cushions and trays that the resident cannot remove.
      4. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including:
         • Using bedrails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed;
         • Tucking sheets so tightly that a bed-bound resident cannot move;
         • Placing a resident in a chair that prevents the resident from rising; and
         • Placing a resident who uses a wheelchair so close to the wall that the wall prevents the resident from rising.
      5. Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention AND a restrain is required to:
         • Treat the medical symptom;
         • Protect the resident’s safety; and
         • Help the resident attain the highest level of his/her physical or psychological well-being.
      6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms.
      7. Emergency use of restraints is permitted if their use is immediately necessary to prevent the resident from injuring himself/herself or others and/or to prevent the resident from interfering with life-sustaining treatment, and no other less-restrictive interventions are feasible.
         • The Director of Nursing Services has the authority to order the use of emergency restraints. The Attending Physician must be notified of such use and the reason for the order.
         • Orders for emergency restraints may be received by telephone, and shall be signed by the physician within forty eight 48) hours.
         • The emergency use of restraints must not extend beyond the immediate episode.
      8. Treatment restraints may be used for the protection of the resident during treatment and diagnostic procedures if the resident and/or representative has consented to the treatment or procedure and the use of treatment restraints. Treatment restraints shall be applied for no longer than the time required to complete the treatment.
      9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following:
         • The specific reason for the restraint (as it relates to the resident’s medical symptom);
         • How the restraint will be used to benefit the resident’s medical symptom; and
         • The type of restraint, and period of time for the use of the restraint.
      10. Orders for restraints will not be enforced for longer than twelve (12) hours, unless the resident’s condition requires continued treatment.
      11. Reorders are issued only after a review of the resident’s condition by his or her physician.
      12. The following safety guidelines shall be implemented and documented while a resident is in restraints:
          • Restraints shall be used in such a way as not to cause physical injury to the resident and to insure the least possible discomfort to the resident.
          • Physical restraints shall be applied in such a manner that they can be speedily removed in case of fire or other emergency. Restraints with locking devices shall not be used.
          • A resident placed in a restraint will be observed at least every thirty (30) minutes by nursing personnel and an account of the resident’s condition shall be recorded in the resident’s medical record.
          • The opportunity for motion and exercise is provided for a period of not less than ten (10) minutes during each two (2) hours in which restraints are employed.
          • Restrained residents must be repositioned at least every two (2) hours on all shifts.
      13. Seclusion, which is defined as the placement of a resident alone in a room, shall not be employed.
      14. Residents and/or surrogate/sponsor shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use.
      15. Should a resident not be capable of making a decision, the surrogate or sponsor may exercise the right of the use or non-use of a restraint. (Note: The surrogate/sponsor may not give permission to use restraints for the sake of discipline or staff convenience or when the restraint is not necessary to treat the resident’s medical symptoms.)
      16. Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination.
      17. Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptom(s).
      18. Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use.
      19. Documentation regarding the use of restraints shall include:
          • Full documentation of the episode leading to the use of the physical restraint. This includes not only the resident symptoms but also the conditions, circumstances, and environment associated with the episode;
          • A description of the resident’s medical symptoms (i.e., an indication or a characteristic of a physical or psychological condition) that warranted the use of restraints;
          • How the restraint use benefits the resident by addressing the medical symptom;
          • The type of the physical restraint used;
          • The length of effectiveness of the restraint time; and
          • Observation, range of motion and repositioning flow sheets.

      
      

      References

      OBRA Regulatory Reference Numbers	483.13(a)
      Survey Tag Numbers	F221
      Other References
      Related Documents	24-Hour Restraint Observation RecordPhysical Restraints – Record of Informed ConsentRestraint Evaluation WorksheetRisk-Benefit Acknowledgement Form (MP5540)
      Version	1.2 (H5MAPL0919)

      
      
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    • Facility Resuscitate/Do Not Resuscitate Policy;

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      CARDIOPULMONARY RESUSCITATION (CPR)

      
      

      Policy Statement

      Cardiopulmonary Resuscitation (CPR) will be provided to residents who suddenly cease to have spontaneous pulse and respirations unless there is a physician’s order for no CPR, Do Not Attempt Resuscitation (DNAR), or a do not resuscitate (DNR) order, Out of Hospital Do Not Resuscitate (OHDNR), or allow natural death (AND).

      All licensed nurses will maintain current CPR Certification to assure qualified staff are available on each shift.

      Introductory Information

      Cardiopulmonary resuscitation is a technique that attempts to restore oxygen to the body and to restore a coordinated heartbeat. The keys to a successful outcome are:
      1. Early Access – Activate Emergency Medical System (EMS)
      2. Early CPR
      3. Maintaining a constant rhythm-push hard and fast: compress at a rate of 100-120 times/minute.
      4. Continuing resuscitation until the person revives or is pronounced dead.

      
      

      Inflation of the lungs and massaging of the heart must both be performed in cardiopulmonary resuscitation. Mask-to-mouth (or ambu bag) resuscitation provides oxygen to the body and closed chest massage circulates this oxygen throughout the body.

      The 2015 American Heart Association (AHA) Guidelines for CPR deemphasize breathing and pulse check. There is no evidence, however, that checking for breathing, coughing, or movement is superior for detection of circulation. Because delays in chest compressions should be minimized, the healthcare provider should take no more than 10 seconds to check for a pulse and respirations; and if the rescuer does not definitely feel a pulse within that time period, the rescuer should start chest compressions.

      Studies have shown cardiopulmonary resuscitation must be initiated within 4 – 5 minutes after cessation of breathing and heartbeat for successful recovery. Nevertheless, if a resident does NOT have a DNR, OHDNR, DNAR or AND order, the resident MUST receive CPR.

      
      
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    • Room Reservation Policy;

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      Admissions – Room Assignments

      
      

      Policy Statement

      A resident will be admitted to the first available room that meets his/her medical needs. Room assignments are made without regard to race, color, creed, national origin, or payment source.

      Policy Interpretation and Implementation

      1. Residents are assigned to rooms, wards, floors, sections, buildings, and other areas without regard to race, color, creed, national origin, religion, ancestry, payment source, or marital or veteran status.
      2. A room assignment is made on the basis of the first available bed that satisfies the resident’s medical/treatment requirements. The following factors shall be considered when making a room assignment:
         • The sex of the resident;
         • The medical classification of the resident;
         • The physician’s medical and treatment orders; and
         • The resident’s family’s wishes.
      3. Residents will be admitted to vacant bed space on a first-come first-served basis
      4. Residents may not be asked whether they are willing to share accommodations with persons of a different race, color, creed, national origin, or religion.
      5. Requests for transfers to other rooms in the same class of accommodations are not honored if based on racial or ethnic considerations.
      6. Exceptions to the above rules may be made only if the resident’s Attending Physician or the Medical Director certifies, in writing, that in his/her judgment, there are valid medical reasons or special compelling circumstances in the individual case. Such reasons must be clearly stated in the resident’s medical record.
      7. If a resident is admitted to a facility where his or her spouse is already a resident, and both spouses consent to live in the same room, they will be placed together as soon as it is feasible.
      8. A resident may request his or her roommate of choice and the request will be accommodated to the extent feasible, as long as both parties consent to the arrangement.

      References

      OBRA Regulatory Reference Numbers	§483.10(e)(4) The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement.
      Survey Tag Numbers	F559
      Other References
      Related Documents
      Version	1.1 (H5MAPL0045)

      
      
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    • Bed Hold Policy;

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      Bed-Holds and Returns

      
      

      Policy Statement

      Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy.

      Policy Interpretation and Implementation

      1. Residents may return to and resume residence in the facility after hospitalization or therapeutic leave as outlined in this policy.
      2. The current bed-hold and return policy established by the state (if applicable) will apply to Medicaid residents in the facility.
      3. Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail:
         • The rights and limitations of the resident regarding bed-holds;
         • The reserve bed payment policy as indicated by the state plan (Medicaid residents);
         • The facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid residents); and
         • The details of the transfer (per the Notice of Transfer).
      4. Medicaid residents who exceed the state’s bed hold limit and/or non-Medicaid residents who request a bed-hold are responsible for the facility’s basic per diem rate while his or her bed is held.
      5. If a Medicaid resident exceeds the state bed-hold period, he or she will be permitted to return to the facility, to his or her previous room (if available) or immediately upon the first availability of a bed in a semi-private room provided that the resident:
         • Requires the services of the facility; and
         • Is eligible for Medicare skilled nursing services or Medicaid nursing services.
      6. If the resident is transferred with the expectation that he or she will return, but it is determined that the resident cannot return, that resident will be formally discharged.
      7. The resident will be permitted to return to an available bed in the location of the facility that he or she previously resided. If there is not an available bed in that part, the resident will be given the option to take an available bed in another distinct part of the facility and return to the previous distinct part when a bed becomes available.

      
      

      References

      OBRA Regulatory Reference Numbers	483.15(d)(1)(2); 483.15(e)(1)
      Survey Tag Numbers	F625; F626
      Other References
      Related Documents	Transfer or Discharge Notice
      Version	1.2 (H5MAPL0379)

      
      
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    • Readmission Policy;

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      Readmission to the Facility

      
      

      Policy Statement

      Residents who have been discharged to the hospital or for therapeutic leave will be given priority in readmission to the facility.

      Policy Interpretation and Implementation

      1. A Medicaid resident whose hospitalization or therapeutic leave exceeds the bed hold period allowed by the state will be readmitted to the facility upon the first availability of a bed in a semi-private room if the resident:
         • Requires the services provided by the facility;
         • Meets the admission criteria as outlined in facility policy;
         • Was not discharged for any reason outlined in the Transfer or Discharge Notice policy; and
         • Is eligible for Medicaid nursing facility services.
      2. Residents who are not receiving Medicaid benefits will be readmitted to the facility upon the first availability of a bed if the resident:
         • Needs care and medical treatment that can be provided by the facility;
         • Was not discharged for non-payment of services; and
         • Was not discharged because of behavior problems.
      3. If it is determined that a resident who was transferred with an expectation that he or she will return cannot return to the facility, he or she will be discharged according to the discharge policy.
      4. Readmission procedures apply equally to all residents regardless of race, color, creed, national origin, or payment source.
      5. Inquiries concerning our readmission policies should be referred to the Administrator and/or the Director of Nursing Services.

      
      

      References

      OBRA Regulatory Reference Numbers	§483.15(e)(1) Permitting residents to return to facility.
      Survey Tag Numbers	F626
      Related Documents	Transfer or Discharge Notice
      Version	2.0 (H5MAPL0707)

      
      
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    • Ambulance Policy;

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      Do Not Resuscitate Order

      
      

      Policy Statement

      Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect.

      Policy Interpretation and Implementation

      1. Do not resuscitate orders must be signed by the resident’s Attending Physician on the physician’s order sheet maintained in the resident’s medical record.
      2. A Do Not Resuscitate (DNR) order form must be completed and signed by the Attending Physician and resident (or resident’s legal surrogate, as permitted by State law) and placed in the front of the resident’s medical record.
         • Use only State-approved DNR forms.
         • If no State form is required, use facility-approved form.
      3. In addition to the advance directive and DNR order form, state-specific forms may be used to specify whether to administer CPR in case of a medical emergency. State-specific forms include:
         • Physician Orders for Life-Sustaining Treatment (POLST);
         • Physician Orders for Scope of Treatment (POST);
         • Medical Orders for Life-Sustaining Treatment (MOLST);
         • Medical Orders for Scope of Treatment (MOST);
         • Clinicians Orders for Life Sustaining Treatment (COLST); and
         • Transportable Physician Orders for Patient Preference (TPOPP).
      4. Should the resident be transferred to the hospital, a photocopy of the DNR order form must be provided to the personnel transporting the resident to the hospital.
      5. Do not resuscitate (DNR) orders will remain in effect until the resident (or legal surrogate) provides the facility with a signed and dated request to end the DNR order.
         • Verbal orders to cease the DNR will be permitted when two (2) staff members witness such request.
         • Both witnesses must have heard the request and both individuals must document such information on the physician’s order sheet.
         • The Attending Physician must be informed of the resident’s request to cease the DNR order.
      6. The Interdisciplinary Care Planning Team will review advance directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives.
      7. The resident’s Attending Physician will clarify and present any relevant medical issues and decisions to the resident or legal representative as the resident’s condition changes in an effort to clarify and adhere to the resident’s wishes.
      8. Inquiries concerning do not resuscitate orders/requests should be referred to the Administrator, Director of Nursing Services, or to the Social Services Director.

      
      

      References

      OBRA Regulatory Reference Numbers	§483.10(b) Exercise of Rights; §483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.; §483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.; §483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.; §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.; §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).; §483.24(a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives.
      Survey Tag Numbers	F550; F552; F578; F678
      Related Documents	Advance Directives
      Version	1.3 (H5MAPL0218)

      
      
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    • Medicaid and Medicare Eligibility;

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      This is a State specific policy and a brochure should be given on site
      
      Close section

    • Spousal Impoverishment Laws of This State;

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      This is a State specific policy and a brochure should be given on site
      
      Close section

    • In Missouri only: "Missouri Guide to Home and Community Services" booklet provided;

      ---

      This is a State specific policy and a brochure should be given on site
      
      Close section

    • Dental Services.

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      Dental Services

      
      

      Policy Statement

      Routine and emergency dental services are available to meet the resident’s oral health services in accordance with the resident’s assessment and plan of care.

      Policy Interpretation and Implementation

      1. Routine and 24-hour emergency dental services are provided to our residents through:
         • A contract agreement with a licensed dentist that comes to the facility monthly;
         • Referral to the resident’s personal dentist;
         • Referral to community dentists; or
         • Referral to other health care organizations that provide dental services.
      2. A list of community dentists available to provide dental services to our residents is posted at each nurses’ station and the list is also available from Social Services.
      3. Residents have the right to select dentists of their choice when dental care or services are needed.
      4. Selected dentists must be available to provide follow-up care. Failure of a dentist to provide follow-up services will result in the facility’s right to use its Consultant Dentist to provide the resident’s dental needs.
      5. Medicare and Medicaid residents will be billed for routine and emergency dental services.
      6. Social services representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible.
      7. Direct care staff will assist residents with denture care, including removing, cleaning and storing dentures.
      8. Dentures will be protected from loss or damage, to the extent practicable, while being stored.
      9. Lost or damaged dentures will be replaced at the resident’s expense unless an employee or contractor of the facility is responsible for accidentally or intentionally damaging the dentures.
      10. If dentures are damaged or lost, residents will be referred for dental services within 3 days. If the referral is not made within 3 days, documentation will be provided regarding what is being done to ensure that the resident is able to eat and drink adequately while awaiting the dental services; and the reason for the delay.
      11. All dental services provided are recorded in the resident’s medical record. A copy of the resident’s dental record is provided to any facility to which the resident is transferred.

      
      

      References

      OBRA Regulatory Reference Numbers	§483.55 Dental services.
      Survey Tag Numbers	F790; F791
      Related Documents	Medication and Treatment Orders, Dental Services
      Version	1.3 (H5MAPL0185)

      
      
      Close section

1. Room, Board, and Nursing Care:
   

   Private Pay Resident - A resident is considered private pay when no State or Federal program is paying for the resident's room and board. A private pay resident may have private insurance or another third party which pays all or some of his/her charges. The resident will be provided with a list of current private pay daily room rates, supplies and services included in the facility's daily private rate and those supplies and services which are not covered by the daily private rate for which the resident will be separately charged. The resident shall receive notice prior to a daily room rate change according to the laws of this State, however, in no event less than 30 days.

   Medicare Resident - A resident's room, board, and nursing care is paid for by Medicare when the resident is entitled to Medicare benefits and meets the Federal requirements for Medicare Part A services. On admission, the resident will be provided with a list of supplies and services paid for by the Medicare program, and those supplies and services not paid for by the Medicare program and for which the resident will be charged, including the daily co-insurance rate. Residents who no longer qualify for Medicare A benefits and who remain in the facility will become Private Pay Residents, unless they become certified for Medicaid.

   Medicaid Resident - A resident's room, board and nursing care are partially paid for by Medicaid when certified by the State Medicaid Agency. Medicaid residents will be required to pay a portion of the daily rate as designated by the State Medicaid Agency. A resident may remain in the facility for as long as he/she is certified eligible for the Medicaid program, or for as long as any share of cost owed by the resident is paid as due. A resident who remains in the facility after Medicaid coverage has expired, or has been retroactively terminated, or denied certification, must pay the facility charges as a Private Pay Resident. On admission, the resident will be provided with a list of supplies and services paid for by the Medicaid program, for which the resident may not be charged, and those supplies and services not paid for by the Medicaid program for which the resident will be charged. The resident's co-payment is established by the State Medicaid Agency and may change according to their guidelines. Failure to pay the facility the resident's share of cost may result in discharge and notification of State and Federal authorities.

2. If not approved for Medicaid or Medicare, or if approval is denied for any reason, the resident will be retroactively billed to the date of denial, or date of admission, which ever is applicable, at the private rate schedule listed on the facility's "Private Pay Services and Charge Sheet".
3. Nursing supplies will be billed according to the published list in the business office. This list may not be comprehensive and changes may be made from time to time.
4. The facility will bill for these services according to the facility's prescribed billing procedure. All payments shall be due and payable at the facility by the first of each and every month. Sums not paid by the fifth (5th) of the month shall bear a FINANCE CHARGE at the maximum ANNUAL PERCENTAGE RATE allowed by law. Additionally, the facility will be entitled to its reasonable costs, including attorney's fees, expended in collection of delinquent accounts.
5. The facility shall inform the resident in writing before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicaid or Medicare or by the facility per diem rate. All bills for services and information related to changes in charges are to be mailed to:
   
   
   Name

   Street Address
   
   
   City/State/Zip

   Telephone

1. A resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.
2. A resident has the right to be free of interference, coercion, discrimination or reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights.

3. In the case of a resident who has not been judged incompetent by the state court, the resident has the right to delegate a representative, in accordance with State law and any legal surrogate so designated may exercise the resident's rights to the extent provided by state law. The same-sex spouse of a resident must be afforded treatment equal to that afforded to an opposite-sex spouse if the marriage was valid in the jurisdiction in which it is celebrated.

   In the event the resident is adjudged incompetent under laws of a State by a Court of competent jurisdiction, the rights of the resident devolve to and are exercised by the resident representative appointed under State law to act on the resident's behalf. The court-appointed resident representative exercises the resident's rights to the extent judged necessary by a court of competent jurisdiction, in accordance with State law.

4. The facility shall inform the resident both orally and in writing in a language the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility.
5. A resident has the right to inspect all records pertaining to himself or herself following an oral or written request. Photocopies of such records will be provided. The facility will charge a fee in accordance with a community standard for copying, or in accordance with established state guidelines, if they exist. The charges will be collected prior to the release of the copies.
6. A resident has the right to be fully informed in a language which he or she can understand of his or her total health status, including but not limited to his or her medical condition.
7. A resident has the right to request, refuse, and or discontinue treatment in accordance with State laws and to refuse to participate in experimental research and to make advance directives regarding care and treatment.
8. A resident has the right to be informed before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility's per diem rate.
9. Except in a medical emergency or when a resident is incompetent, this facility shall consult with the resident immediately and notify the resident's physician, and if known, the resident's legal representative or interested family member when there is:
   • An accident involving the resident which results in injury and has the potential for acquiring physician intervention with the exception of a minor injury that requires only general first aid care;
   • A significant change in the resident's physical, mental or psychosocial status;
   • A need to alter treatment significantly;
   • A decision to transfer or discharge the resident from the facility as specified in the TRANSFER or DISCHARGE section.
10. The facility shall promptly notify the resident and, if known, the resident's legal representative or interested family member when there is:
    • A change in room or roommate assignment; or
    • A change in resident rights under federal or state law or regulations.
11. A resident has the right to choose a personal attending physician, be fully informed in advance of care and treatment and of any changes in that care or treatment which may affect the resident's well-being; and, unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, participate in planning care and treatment or changes in care and treatment.
12. A resident has the right to personal privacy and confidentiality of his or her personal and clinical records:
    • Personal privacy shall include accommodations, medical treatment, written and telephone communications, personal care, visits and meetings with family and resident groups, however, this shall not require the facility to provide a private room;
    • The resident may approve or refuse the release of personal and clinical records to any individual outside the facility;
    • A resident's right to refuse release of personal and clinical records does not apply when the resident is transferred to another health care institution or the record release is required by law or third party contract.

13. A resident has the right to voice grievances with respect to treatment or care that is, or fails to be furnished, without discrimination or reprisal for voicing grievances and prompt efforts by the facility to resolve grievances the resident may have, including those with respect to the behavior of other residents.

    The Grievance Officer for the facility is:
14. A resident has the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility.
15. A resident has the right to receive information from agencies acting as client advocates and be afforded the opportunity to contact these agencies.
16. A resident has the right to refuse to perform services for the facility.
17. A resident may perform services for the facility if he or she chooses, when:
    • The facility has documented the need or desire for work in the plan of care;
    • The plan specifies the nature of the services performed and whether the services are voluntary or paid;
    • Compensation for said services is at or above prevailing rates; and
    • The resident agrees to the work arrangement described in the plan of care.
18. A resident has the right to privacy in written communications including the right to send and receive mail promptly that is unopened and to have access to stationery, postage and writing implements at the resident's own expense.
19. A resident has the right and the facility shall provide immediate access to any resident by the following:
    • Any representative of the Secretary of the Health and Human Resources Division;
    • Any representative of the State;
    • Any representative of the State;
    • The State long term care Ombudsman;
    • The agency responsible for the protection and advocacy system for developmentally disabled individuals;
    • The agency responsible for the protection and advocacy system for mentally ill individuals;
    • Subject to the resident's right to deny or withdraw consent at anytime, immediate family or other relatives of the resident; and
    • Subject to reasonable restrictions and the resident's right to deny or withdraw consent at any time, others who are visiting with the consent of the resident.

20. A resident has the right to have reasonable access to the private use of a phone including TTY and TDD services. This includes the right to retain and use a cellular phone at the resident's own expense.

    The resident has the right to have reasonable access to and privacy in their use of electronic communications such as email and video communications and for internet research, if the access is available to the facility and at the resident's expense, if additional expense is incurred by the facility to provide such access to the resident.

21. A resident has the right to retain and use personal possessions, including some furnishings and appropriate clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.
22. A resident has the right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement.
23. A resident has the right to self-administer drugs if the interdisciplinary team comprised of the attending physician, registered nurse and other appropriate staff has determined the practice is safe.
24. A resident has the right to be free from any physical restraints imposed or psychoactive drug administered for purposes of discipline or convenience and not required to treat the resident's medical symptoms.
25. A resident has the right to be free from verbal, sexual, physical or mental abuse, corporal punishment and involuntary seclusion, as well as having his/her property misappropriated.
26. The facility shall not employ individuals who have been convicted of abusing, neglecting or mistreating individuals.
27. The facility shall ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source, are reported immediately to the administrator of the facility or to other officials in accordance with state law through established procedures.
28. The facility must have evidence that all alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in progress.
29. The results of all investigations must be reported to the administrator or his designated representative or to other officials in accordance with state law and if the alleged violation is verified, appropriate corrective action is taken.
30. The facility shall care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life.
31. A resident has the right to organize and participate in resident groups in the facility.
32. A resident's family has the right to meet in the facility with the families of other residents in the facility.
33. The facility shall provide a resident or family group, if one exists, with private space.
34. Staff or visitors may attend meetings at the group's invitation.
35. The facility shall provide a designated staff person responsible for providing assistance and responding to written requests that results from group meetings.
36. When a resident or family group exists, the facility must listen to the views and act upon the grievances and recommendations of residents and families concerning proposed policy and operational decisions affecting resident care and life in the facility.
37. The resident has the right to be informed of and participate in his or her treatment.
38. The resident has the right to be informed in advance, by the attending physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.
39. The resident has the right to be informed in advance of the care to be furnished and the type of caregiver or professional that will furnish care.
40. The resident has the right to be informed in advance of changes to the plan of care.

1. A resident has the right to manage his or her financial affairs and the facility shall not require residents to deposit their personal funds with the facility.
2. The facility shall hold, safeguard, manage and account for the personal funds of the resident deposited with the facility in the following manner:
   • FUNDS IN EXCESS OF $50.00: The facility must deposit any resident's personal funds in excess of $50.00 in an interest bearing account that is separate from any of the facility's operating accounts and that credits all interest earned on the resident's account to his or her account;
   • FUNDS LESS THAN $50.00: The facility may maintain a resident's personal funds that do not exceed $50.00 in an interest bearing account or petty cash fund.
   • The facility must establish and maintain a system which assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf.
   • Said system shall preclude any commingling of resident funds with facility funds or with funds of any other person.
   • An individual financial record must be available on request to the resident or his or her legal representative.
   • The facility shall notify each resident that receives Medicaid benefits when the amount of the resident's account reaches $200.00 less than the SSI resource limit for one person and if the amount in the account is addition to the value of the resident's other nonexempt resources, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI.
3. Upon the death of a resident with a personal fund deposited with the facility, the facility shall promptly convey the resident's funds and a final account of those funds, to the individuals administering the resident's estate, and in accordance with specific state requirements.
4. A resident has the right to file a complaint with the State Survey and Certification Agency concerning resident abuse, neglect and misappropriation of resident's property in the facility.

Notices shall be mailed to the address(es) indicated below. The Resident, Designated Party and/or Legal Representative is responsible for notifying the Facility in writing of any change of address.

The Resident designates the following person(s) to be notified when any legally required notices are provided to the Resident, Designated Party, and/or Legal Representative:

1. I have received a copy of the State's pamphlet describing health care treatment decisions.
2. I have received a copy of the facility's policy and procedures on Advance Directives.
3. I have been given written materials about my right to accept or refuse medical treatments.
4. I have been informed of my rights to formulate Advance Directives.
5. I understand that I am not required to have an Advance Directive in order to receive medical treatment at this long term care facility.
6. I understand that the terms of any Advance Directive that I have executed will be followed by the long term care facility and my caregivers to the extent permitted by law.

1. You must satisfy the current deductible as required.
2. Medicare will pay 80% of the bill after the deductible has been satisfied.
3. The 20% unpaid balance will be billed to you or the person responsible for paying your bills. If you have Medicaid, a supplemental policy or other insurance that will pay the 20% balance, we will submit the bill to them.
4. This form must be signed by you or your family/responsible party giving us permission to:
   1. Bill 80% to Medicare, and
   2. Bill 20% (coinsurance) plus any deductible not already satisfied, to you or to your insurance company.
5. If you have a complaint regarding the services you receive, please contact our facility directly.

Insurance Information: Please attach image of front & back of Rx Insurance Card

1. Your representative the right to exercise your rights to the extent those rights are delegated to the representative.
2. You retain the right to exercise those rights not delegated to a representative, including the right to revoke a delegation of rights, (except as limited by State law).

1. An individual chosen by the resident to act on behalf of the resident in order to support the resident in decision-making; access medical, social or other personal information of the resident; manage financial matters; or receive notifications