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Resident Contract
2018
(A CONTRACT IS REQUIRED BY FEDERAL AND STATE REGULATIONS)
______(“Resident”) and
______(“Facility”) agree as follows:
In this contract: “Facility Standards” means the Rules and Regulations of the Illinois Department of Public Health for Long Term Care Facilities, applicable federal rules and regulations and, if the resident’s care is funded by Medicaid, regulations of the Illinois Department of Human Services and the Illinois Department of Healthcare and Family Services.
A.Facility Agreement
1.The facility shall offer personal care, room, board, dietary services and laundry services. The facility will also offer nursing care, activities, restorative and rehabilitative services and psychosocial care as identified in the residents’ Plan of Care established by the facility with the input of the resident (“Plan of Care”) to the extent required by the facility Standards and in accordance with the policies of the facility. The facility staff is permitted to access the resident’s room at reasonable times and for reasonable purposes.
2.Medicines, treatments or special diets will be offered to the resident if ordered by physician, the facility Medical Director, or any other physician approved by either of them or the resident (“Physician” means any of the foregoing).
3.The facility will offer equipment required under Facility Standards. If any Physician orders special equipment not required under Facility Standards it will be offered at the resident’s expense. Residents must have consent of the facility to bring special equipment; use of such equipment is at the resident’s risk.
4.The facility will exercise reasonable care toward the resident. However, the facility is not an insurer of the resident’s welfare or safety and assumes no such liability.
5.The facility may change the resident’s roommate. The facility retains the right to transfer the resident to a different room within the facility if required by law or for the efficient management of the facility. The facility will notify the resident before such change is made, and will try to accommodate the resident’s preferences.
B.Resident’s Rights and Obligations
- The resident acknowledges receipt of the written items identified in Supplement D: Admissions Checklist, and acknowledges that each item has been explained in language that the resident understands. All items identified and checked in Supplement D: Admissions Checklist are incorporated into this contract, including the Residents’ Right Handbook. The resident will abide by all rules and regulations of the facility and will cooperate in the carrying out of the residents’ Plan of Care. The resident will be given the opportunity to participate in the care planning process to the extent practicable.
2.The resident has the right to privacy in making and receiving telephone calls, sending and receiving mail (except as agreed to in the Authorization to Inspect and Open Official Correspondence),and in his/her use of electronic communications such as email and video comfort communications and for internet research. The resident will be responsible any additional expense incurred by the facility in providing internet access to the resident.
- The resident may file a grievance regarding any aspect of their care and treatment at the facility without fear of discrimination or reprisal. For information on filing a grievance, contact ______at ______. The resident may file a complaint with the Illinois Department of Public Health, without fear of discrimination or reprisal, concerning any suspected violation of state or federal nursing facility regulations, including, but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, and non-compliance with the advance directive requirements. Federal and state laws require the facility to have a policy that addresses abuse, neglect and financial exploitation.
- It is the goal of this facility to assist residents to return to the community when they are able to do so. For additional information on returning to the community, the resident may contact the Department on Aging Senior Hotline at 1-800-252-8966, (1-888-206-1327 (TTY)), .
- No food, liquids or medicines will be brought into the facility without permission of the Administrator or nurse in charge. Food must be sealed in containers. No medication will be kept in the resident’s room or possession unless in accordance with a Plan of Care.
- The facility may use, at the resident’s cost, the pharmacist, laboratory, and other outside service providers recommended by the facility. If the resident prefers to use any other provider, it will be at the resident’s cost. To compensate the facility for costs of monitoring such services, the resident will pay to the facility an amount to be set by the facility not to exceed $75.00 per month.
- The resident will be responsible for damage to any property or injury to any person caused by the resident.
8.The resident will be responsible to comply with the facility’s smoking policies. See attached, Resident and Visitor Smoking Policy Notification.
9.The resident has the right to manage his or her financial affairs and need not deposit personal funds with the facility.
10.The resident will provide his or her own spending money.
11.Upon the resident’s written authorization, the facility will hold the residents' personal funds in a Trust Account as further described in the “Resident Trust Fund Policy Notification and Agreement.”
12.The facility is not responsible for money, valuables, or personal effects of the resident unless delivered to the Administrator for safekeeping.
13.The resident has a right to have friends and family members visit at the facility, subject to the facility’s rules and regulations.
13.Responsible Party and Resident Representative. The resident may have a Responsible Party or Representative execute this Contract on behalf of the resident. The Resident Representative is an individual that has legal authority to make decisions on the resident’s behalf regarding healthcare and by executing the contract represents that he/she has authority to make healthcare decisions. The Representative agrees to provide the facility will a copy of all documentation relating to his or her legal authority to make healthcare decisions (Power of Attorney or Oath of Office for guardianship). The Responsible Party is an individual who has access and/or control over the resident’s funds and/or assets. The Responsible Party that executes this Contract agrees to cause payment of the fees and charges incurred by the resident to be paid from resident’s funds, estate or assets. The failure to cause payment of fees and charges and the failure to provide the necessary information to attain and maintain public aid benefits for the resident will constitute the failure to exercise due care and may subject the Responsible Party to individual and personal liability.
C.Financial Agreement
1.Charges for Services:
(a)Basic Rate. The Basic Rate includes personal care, laundry, room, board, and nursing care as required by Facility Standards. If a resident is paying privately, the resident will pay monthly in advance as set out in Supplement A: The Basic Rates. If the resident is transferred, discharged or otherwise ceases to reside at the facility, the resident will be charged a pro-rated portion of the Basic Rate until such time that the unit is vacated. The unit is considered vacated when the resident and his or her belongings are removed from the facility.
(b)Costs for Specified Supplemental Services and Products. The resident may also be charged for services of the type stated in Supplement B: Additional Charges. In addition to the Basic Rate, the resident agrees to pay for the Services and Products set out on the attached Facility Price List.
(c)Additional Costs. The resident is liable for any special treatment, services or supplies ordered by any Physician or requested by the resident and which is not covered in paragraphs C(1)(a) or C(1)(b). These costs cannot be determined in advance.
(d)Changes in Charges. The above charges may be changed at any time subject to notice under paragraph 4 of Section G.
(e)Late Payment. The facility may charge a fee equal to 1 ½ % each month, or to the fullest extent permitted by law, for all fees and charges that are outstanding by as of the 15th day of the month. These fees shall be paid by the parities liable for payment.
(f)Deposit. Pursuant to the Illinois Administrative Code, Chapter 77, Section 300.630(p), Resident, Resident’s Representative and/or Resident Representative, agree to pay a non-refundable deposit in the amount of $______. Such deposit shall be due and owing prior to or upon the admission of resident to the facility. Residents on Medicaid at the time of their initial admission are not required to pay a deposit.
2.Residents Paying Privately:
(a)Definition. A “Resident Paying Privately” is a resident for whom the facility does not receive payment from the Medicaid or from the Veteran’s Administration. A Resident Paying Privately may be covered by Medicare.
(b)Agreement and Undertaking. The resident paying privately represents to the facility that charges incurred by or on behalf of the resident will be paid from all available income, assets, benefits, and other resources. Persons with access to resident resources must sign Supplement C: Income and Personal Resource Statement.
(c)Pending Public Aid Approval. If the resident applies for Medicaid funding, the resident will be responsible to pay all charges through the date Medicaid authorizes the billing for the resident’s care. The resident is considered a Private Pay resident until the resident’s Medicaid application is approved and any spenddown is met. The parties further agree that the facility may require a deposit or assurance of payment from the resident prior to approval of Medicaid eligibility for nursing home care. To the extent that the deposit covers time after the date Medicaid payments are authorized, the deposit shall be returned to the depositor within 30 days of the date of such authorization except as such deposits may be drawn upon in accordance with Medicaid requirements. The resident and/or Responsible Party agrees to give the facility 60 days written notice of any anticipated change in financial status, including the need to establish eligibility for public aid benefits.
(d)Billing. The resident shall be billed monthly. Payment is due by the 5th of each month. Delivery of a bill shall be deemed demand for payment. Resident, Representative and/or Responsible Party shall be responsible for all reasonable costs of collection, including reasonable attorney’s fees.
3.Residents Receiving Public Assistance:
(a)The facility accepts Medicaid Recipients. Making application for Medicaid or veteran’s coverage and appeals of any decision are solely the responsibility of the resident and/or the Responsible Party or Representative. If the resident is a Medicaid Recipient, payment shall be in accordance with Medicaid regulations. The resident shall pay charges for services to the extent Medicaid determines that the resident pay from the resident’s sources. If eligibility for Medicaid payments is terminated, the resident shall pay all charges thereafter as a Resident Paying Privately. Resident is responsible for any fees or charges that are determined to not be covered by Medicaid.
(b)If the source of payment for the resident’s care changes from private to public or public to private funds, or if the consent for the resident’s Veteran’s Administration funded care is terminated, the resident shall execute a new written contract with the facility substantially the same as this Contract. If the change is to private funds, the resident will pay all charges as a Resident Paying Privately after the change and all other terms of this Contract shall remain in effect until the new contract is signed.
(c)Pursuant to state and federal law, the resident is permitted to retain $30 of their monthly income for personal expenses. Resident’s monthly income, inclusive of social security and pension, shall be turned over to the facility minus the $30 allowance. Failure of the resident to turn over his or her monthly income in its entirety will subject the resident to an involuntary discharge. The failure of the Responsible Party to turn over the resident’s monthly income may constitute abuse and/or financial exploitation and constitutes a failure to exercise due care.
D.Transfer or Discharge
- The facility may transfer or discharge the resident for one or more of the following reasons at any time by giving 30 days written notice to the resident, Representative and/or Responsible Party as required by Illinois law and regulations:
(a)medical reasons;
(b)resident’s physical safety;
(c)for the physical safety of other residents, facility staff or facility visitors;
(d)late payment or nonpayment;
(e)failure to comply with the facility’s contract or the policies and procedures, as defined in the resident handbook; or
(f)as otherwise permitted by law.
- The facility may transfer or discharge the resident on an emergency basis, without 30 days written notice, when the transfer or discharge:
(a)it is ordered by the resident’s attending physician because of the resident's health care needs; or
(b)it is mandated by the physical safety of other residents, the facility staff, or facility visitors, as documented in the clinical record.
E.Term and Termination
This Contract shall initiate on the day it is signed by the resident, Representative and/or Responsible Party and shall end under the following conditions:
- Resident may terminate this Contract at any time, with or without cause, by giving 30 days’ written notice to the facility. During the 30 day notice period, full monthly payment is required. Resident will continue to be liable for the monthly payment until the resident has vacated and his or her personal belongings are removed from the facility. Resident is entitled to a pro-rata refund of the monthly fee that the resident paid for the last month, less the cost of any repairs and replacement.
- If the resident is compelled by a change in physical or mental health to leave the facility, this Contract shall terminate on 7 days’ written notice or immediately upon the resident’s death.
- The resident’s absence from the facility for 30 consecutive days (except for therapeutic home leave, or hospitalization) shall be deemed a voluntary termination of this Contract by the resident. See Bed Reserve Policy regarding short-term absences from facility. Written notice shall be served on the resident by mailing to the resident’s last known address.
- The resident’s refusal upon 7 days’ notice to execute a new contract when required shall be deemed voluntary termination of this Contract by the resident.
The facility may change any charge on 30 days’ written notice to the resident or to the person executing this Contract for the resident. The resident or the person executing this Contract for the resident may elect to terminate this Contract and to transfer from the facility by giving the facility notice within such 30 days. The written notice to the resident shall become an addendum to this Contract and the Contract as so modified shall be in force if the resident does not terminate the Contract.
5. All other terms of this Contract shall remain in effect from termination until the resident is transferred from the facility.
F.Miscellaneous
1.(Optional: There is no Resident’s Representative unless designated in writing.)
The Resident’s Representative is ______. The resident may cancel or change the “Resident’s Representative” in writing at any time.
2.Severability. If any part of this Contract is ruled invalid by a court or is in violation of any applicable law, such part shall be deleted and the balance of this Contract shall remain in full force and effect.
3.Change of Law. If any law hereafter requires changes or additions to this Contract, such changes or additions shall be part hereof from the effective date.
4.Assignment. This Contract may be assigned by the facility to any successor in ownership or operation of the facility.
5.Notice. All notices required under this Contract will be in writing and mailed by registered or certified mail, or delivered in person, to the last known address. Notice to the facility shall be sent to:
______
______
6.Complete Agreement. This contract represents the entire agreement of the parties, except for the change to the Basic Rate and other charges for additional services, as outlined in Supplement B. This Contract may not be amended except in writing and executed by the parties below.
7.Attorney’s Fees. The parties agree that the facility is entitled to all costs of collection of unpaid charges for the enforcement of this Agreement including court costs and reasonable attorneys’ fees.
8.Waiver. Waiver of any provision of this Contract shall not be deemed a complete waiver of the requirements and shall not excuse the resident from his or her responsibilities under this Contract.
9.Indemnification. The resident will indemnify and hold harmless the facility from all claims, expenses, and damages arising out of property damage and/or physical injury caused by resident or any third party hired by resident, including repair or replacement of property of facility, its staff, or other residents, and injuries to the facility staff or other residents.