Desert Cottages I
ADMISSION AGREEMENT FOR A RESIDENTIAL CARE FACILITY FOR THE ELDERLY
This admission agreement complieswith the referenced sectionsof the Health and Safety Codeand of the California Code of Regulations, Title 22, as of thedate shown at the end of thisagreement.
Facility Address: 83617 Himalaya Dr, Indio, CA 92203
Licensee: Desert Cottages, LLCAuthorized Rep: Elizabeth HengstlerLicensee Mailing Address:P.O. Box 5847, La Quinta, CA 92248Licensee Phone No. 949-510-3658 Facility Phone No. 760-342-7767License Number:336413271
This facilityis a residential care facilitylicensed bythe State Department of Social Services. The facilityis a non-medical care facilitywhich is not allowed to provide 24-hour skillednursing care.
Resident Name: Date of Birth:
Date of Admission:
NOTE: “Responsible person” meansthat individual or individuals, including a relative, health caresurrogate decision maker, or placement agency, who assist the resident in placement or assumevarying degrees of responsibilityfor the resident’s well-being.
Responsible Person:
Relationship:
Responsible Person Address:
Telephone No.
VISITING POLICY
Family and friends are encouraged to visit anytime from 10am-5pm. (No visiting during lunch) Every effort will be made to accommodatespecial requests for visitations at any time as long as the visitation does not violateanother resident’s personal rights.
PROVISION FOR CONTACT WITH FAMILY VISITORS
Desert Cottages I will ensure that all communications to thefacility from family and responsiblepersons answered promptlyand appropriately. We will encourageregular family involvement withthe resident and shall provideample opportunities for family participation at the facility. Visitors,including ombudspersons and advocacy representatives, are permitted to visit privately duringreasonable hours and without prior notice, provided that the rights of other residents are notinfringed upon. You shall have reasonable access to telephones,to both make and receiveconfidential calls. The facility does require reimbursement for long distance calls. You will also beable to mail and receive unopened correspondence in a prompt manner.
TELEPHONE SERVICE
A central telephone is availablefor all residents. Local callsmay be made at no charge. Longdistance calls will be billed to the resident monthly at the actual cost of the call as outlined on thetelephone bill.
RESIDENT PARTICIPATIONIN DECISION MAKING
As a resident, you, or your representative, or both, are entitled and encouraged to participate indecision-making regarding your care and services. Prior to, orwithin two weeks of admission of theresident, the licensee will arrangea meeting with the resident, the resident’s representative, if any,appropriate facility staff including the administrator, and a representative of the resident’s homehealth agency, if any, to prepare a written record of the care the resident will receive in the facility,and the resident’s preferences regarding services provided at the facility.
SIGN IN AND OUT PROCEDURES
All residents and visitorswill be requested to sign in uponentering and signout upon leavingthe facility.
1)Alog will be kept at the front door and the Caregiver on duty will oversee signing in and out.
2)For visitors, time in and out, date, and resident visited will be noted. For residents, time in andout, *destination, expectedreturn time and who accompanies them will be noted.
*Youarenotrequiredtodiscloseyourdestination.However,forsafetypurposesyourdestination may be recorded if it is voluntarily disclosed.
3)Residents leaving for extended periods should notify staff.
4)If residents are out duringmeal time, it is requested that staff be notified.
BASIC SERVICES
To ensure a safe and healthfulliving environment for all residents the following basic servicesmust be available. The services actually provided will be those the resident wants and those theresident needs, based on the individual’s pre-admission appraisal, and the needs and servicesplan. Subsequent resident appraisals may result in the need foradditional basic services.
Basic services at a minimum include:
Continuous care and supervision;
Observation for changes in physical, mental, emotional, and social functioning; andNotification to resident’s family, physician, and other appropriate person/agency of resident’sneeds.
Lodging:
single room
double room
Food Services:1. Three nutritious meals and snacks daily.
2. Special diets if prescribed by a doctor. Helping gain access to supportive services as follows:
The licensee shall provide assistance to residents requesting supportive services such asfinancial assistance programs, nutrition programs, outreach programs, adult day carecenters, visiting pet programs, elderly transportation services, legal representation, tax assistance programs, entertainment resources, etc. as well as medical, dental or other health related service.The licensee shall research telephonenumbers, contact names,schedules, etc. and pass this information onto the resident upon request.
Plan and/or arrange for transportation to medical and dental appointments as follows:
For all non-emergency transportation, the facility will assist in arranging for a transportationprovider such as a taxi, a Dial-A-Ride service, family or friend and the resident isresponsible for the *fare if any. Residents may direct requests for help in arrangingtransportation needs at any time tothe administrator or Caregiver on duty. In all cases, thefacility will ensure that theresident’s needs are met.
*In the event a SSI/SSP resident is admitted, transportation to all medical and dentalappointments or any transportationrequired to meet the resident’s medical and dental needsis a basic service and is included in the basic rate and the resident will not be charged. Thistransportation is arranged by the facility but provided by an outside transportation provider at the expense of the facility.
In an urgent situation, medical transport will be called immediately. Residents or theirinsurance are responsible for the emergency medical transport charge and will be billeddirectly by the medical transport company at the current rate which will vary depending onthe medical services provided during transport.
All vehicles used for facility business will be maintained ina safe operating condition anddriven by a licensed driver. Allvehicles will carry appropriate vehicle insurance, and will beregistered through the DMV. All drivers will be employed by the facility and meet all therequirements as listed in Staff Qualifications in Section B-4 of our facility program. They willhave a DMV clearance completedand will carry a current driver’s license, appropriate to thetype of vehicle to be operated. During transportation, seat belts are worn. Only the numberof persons for which seat belts are available will be transported in any one vehicle.
A planned activity program including arrangement for utilization of availablecommunity resources as follows:
We shall offer individualized program of recreational activities based on cooperativeplanning by the facility, family, Caregivers, physician, and rapport and communication with
the resident, and responsive, creative, and fluid planning of recreational activities. Residentsand families are interviewed to gather information on their personal preferences, beliefs,culture, values, attention spanand life experiences to determine activities that residents willenjoy and benefit from. The administrator shall arrange for utilization of community
resources and promote resident participation in community-centered activities. This caninclude worship, community events, senior center events, organized group activities, etc.
Assistance with personal activities of daily living as follows:dressing,
eating,toileting,bathing,grooming,
mobility tasks, and
other personal care needs:
Additional basic services that the resident needs or wants, and that will be provided by the facility,include those checked below:
Hygiene items of general use, such as soap and toilet paper.
Laundering personal clothing.
Clean bed and bath linens weekly, or as often as needed.
Cleaning of resident’s room
Comfortable and suitable bed andbedroom furniture unless the resident supplies it.
Assistance in meeting necessary medical and dental needs as follows:
Medical and dental appointments will be scheduled if requested.We shall remindresidents of upcoming appointments. We shall ensure that transportation is arrangedif assistance is needed or desired by the resident needed.
Assistance with taking prescribed and over-the-counter medications in accordance withphysician’s instructions unless prohibited by law or regulations.
Bedside care and tray service for minor temporary illnesses orrecovery from surgery.
Maintenance or supervision of resident cash resources as follows: We do not handleresident monies or valuables. Wedo not have a safe or other means of safely securingresident valuables. You are encouraged to use your own privatebanking institution toprovide this service. We shallprovide a lock for the resident’s bedside drawer or cabinetupon request of and at the expenseof the resident, the resident’s family, or authorizedrepresentative. The facility administrator shall have access tothe locked area upon request.
PREADMISSION FEES
This facility charges a one-time preadmission fee in the amount of $______to cover resident appraisal, room preparation, arrange and/or review physician’s assessment (cost of actual assessment is incurred by resident), medication set-up, inventory of belongings, cost of admission forms and materials, community maintenance, staff time, dietary provisions, and other admission-related expenses. This fee may be collectedpaid in full at admission, 50% of fee paid the first month and 50% paid the second month or fee to be deferred until termination of contract. Fee can be waived if any refund due upon death is declined. Refund upon death waived in lieu of admission fee. The fee is in addition to the regular monthly fee. ______initial
Conditions for Preadmission Fee Refund
The facility will refund the preadmission fee under the following circumstances:
1. If the applicant decides not to enter the facility prior to the facility’s completion of a preadmission appraisal or if the facility fails to provide full written disclosure of the preadmission fee charges and refund conditions, the applicant or the applicant’s representative shall be entitled to a refund of 100 percent of the preadmission fee.
2. Unless number 1 above applies, preadmission fees in excess of five hundred dollars ($500) shall be refunded according to the following:
a. If the applicant does not enter the facility after a preadmission appraisal is conducted, the applicant or the applicant’s representative shall be entitled to a refund of at least 80 percent of the preadmission fee amount in excess of five hundred dollars ($500).
b. If the resident leaves the facility for any reason during the first month of residency, the resident shall be entitled to a refund of at least 80 percent of the preadmission fee amount in excess of five hundred dollars ($500).
c. If the resident leaves the facility for any reason during the second month of residency, the resident shall be entitled to a refund of at least 60 percent of the preadmission fee amount in excess of five hundred dollars ($500).
d. If the resident leaves the facility for any reason during the third month of residency, the resident shall be entitled to a refund of at least 40 percent of the preadmission fee amount in excess of five hundred dollars ($500).
DAMAGES
The facility is not allowed to collect a deposit against possible damages caused by the resident. There is no prohibition against charging the resident or responsible person for damages that may be caused by the resident. This includes breakage of facility property, blocking of toilets or plumbing by placing inappropriate items into plumbing fixtures (i.e. clothing, adult briefs, etc.), and the soiling of facility carpeting. The facility will not attempt to collect a fee for normal wear and tear caused by the resident, and any suspected damage or breakage will be discussed with resident or responsible person. Any amount billed for damages will be the actual cost of replacement or repair.
RATE AND PAYMENT PROVIONS FOR BASIC SERVICES
The monthly rate for basic services as specified above $______. This rate, as defined by state law, represents Level 1, Base Care and Supervision, and does not include the optional services. Residents at this level are able to maintain a higher degree of independence and need only minimum care and supervision and minimal personal care assistance. An annual cost of living increase may be assessed. The fee for the basic, optional and additional levels of care services are due on the first of the month and due the first of every month thereafter. If the basic monthly fee is not received within five days of the due date, a late fee of 5% may be assessed. Payment should be made payable to:
Desert Cottages. Checks or cash is accepted. Should the facility receive a returned check from the bank, there will be a charge of $50.00 to cover bank fees.
NOTICE TO SSI/SSP BENEFICIARIES AND THEIR RESPONSIBLE PERSONS:
It is a violation of state law for the licensee to purposely obtain an SSI/SSP beneficiary’s personaland incidental (P&I) needs allowance to pay for basic services.To enable verification that this lawis being properly observed, theState Department of Social Services recommends that residentsvoluntarily disclose in this admission agreement whether the rate paid to the facility IncludesSSI/SSPbenefits The monthly rate: Includes SSI/SSP funds Does not include SSI/SSPfunds.
LEVELS OF CARE
Any change in the resident’s condition is documented by facility and/or a physician’s assessment. Levels 3 and 4 are outlined in California state law. When facility increases a resident’s level of care, it will provide a detailed explanation of the additional care provisions included in each level.
____ Level 2 – Residents rely on the facility for extensive assistance with personal activities of daily living. This level may include residents who also require the occasional services of an appropriate skilled professional due to chronic health problems and returning residents recovering form illness, injury, or treatment which required placement in facilities providing higher levels of care. Wanderers and or exit seekers Additional fee of $250.00 is in addition to Basic Services Fee
____ Level 3 – Restricted health conditions. Title 22 section 87701.1 classifies certain health conditions as “restricted,” such as indwelling urinary catheter, oxygen, contractures, incontinence, and pressure sores (dermal ulcers or other wounds). Additional fee of $ 250.00 is in addition to Basic Services Fee and Levels 2 and 3 fees.
____ Level 4 – Hospice care. Additional fee of $ 25.00 per day is in addition to Basic Services Fee.
RESPITE STAY DAILY RATE
Respite stays apply to residents entering into the community with the intent of leaving within 90 days or entering the facility with Level 3 or 4 care needs. Any residents determined to be on a sliding scale or unstable in their health condition. Respite charges are based on a daily rate of $285.00, not to exceed the monthly rate agreed upon. (Fee does not include optional services or supplies, night staff, etc.)
Total Monthly Fees
The Basic Services fee $______
Private Room fee$______
Level(s) of Care fees$______
Optional Services fee$______
Total of $______
OPTIONAL SERVICES (see Optional Services Menu Attachment)
If any optional services are requested and delivered to you, you shall receive a monthly statementitemizing any separate charges. If additional services are available for purchase through the facility
that were not available at the time the agreement was signed, alist of these services and chargesmust be provided to you or your representative, who must sign and date a statement acknowledging the acceptance orrefusal to purchase them.
THIRD PARTY SERVICES
Emergency medical transport charges will be billed to the resident or insurance company by themedical transport company at thecurrent rate which will vary depending on the medical servicesprovided during transport. No otherthird party services are available.
BASIC RATE INCREASE DISCLOSURE
On or before January 31 of each year, the licensee shall prepare a document disclosing thefacility's average monthly rate increases (if any) for each of the previous three years, indicating theaverage amount of rate increaseand the average percentage increase. The licensee shall providea written copy of the rate increase history disclosure to every resident who signs an admissionagreement, and the facility shallobtain and maintain a confirmation of receipt of the disclosure,signed by the resident. The licenseeshall provide a copy of the disclosure, upon request, to anyprospective resident, or his or her representative.
NOTICE OF RATE CHANGES
If the facility rate for basic services changes because the resident’s needed/desired serviceschange, the rate change will occurwhen the change in service occurs, as long as at least thirtydays have passed since the signing of the admission agreement. We shall provide the resident orthe representative a written notice of a rate increase that is due to a change in the level of carewithin 2 business days after the change in the level of care. If the facility rate changes to reflect a government fund increase, written notice from the licensee is required as soon as the facility isnotified of the increase and the rate change shall not take effect until the operative date of the government fund increase. For allother rate increases, 60 days written notice from the licensee tothe resident or resident’s responsible party is required and the licensee shall provide in writing theamount of the increase, the reason for the increase, and a general description of the additionalcosts, except for an increase in the rate due to a change in the level of care of the resident. Thisshall not apply to optional services that are provided by individuals, professionals, or organizationsunder a separate fee-for-service arrangement with residents.
Written notice will be provided to the resident and the resident’s representative, if any, withintwo business days of providing service at a new level of care that results in a rate increase. Thenotice will include a detailed explanation of the additional services provided at the new level of care.
LEGAL DOCUMENTATION
The facility must have copies of all legal documents, which allow someone other than the resident to make decisions regarding health and finances. These documents include, but are not limited to, Durable Powers of Attorney for Health Care, and Conservatorship.
CONSENT TO PHOTOGRAPH
By initialing below, I hereby authorize this facility to use my image (photo) for identification purposes only to ensure resident safety and well-being. Initials _____.
In addition, I hereby authorize this facility to use my image (photo) for possible use in public forms of advertising including brochures or local advertising. Initials ____.