Long-Term Care Liability Insurance Application

HEALTH CARE FACILITIES PROGRAM

LONG-TERM CARE LIABILITY INSURANCE APPLICATION

NAMED INSURED: ______

ADDRESS: ______

______

PART I - GENERAL INFORMATION

Applicant is: (Check all appropriate boxes) / Yes / No
Medicare Certified
Medicaid Certified
Licensed/Approved by State Board of Health
Accredited by JCAHO
Conditional Accreditation by JCAHO
Eden Alternative Registered
Health Care Safety Specialists Certified
Number of years this facility has been:
Operating
Owned by Present Owners
Managed by Present Management

Do you have a website? If so, please provide website address:______

List all licenses held by your facility, including type and expiration dates.

______

Please attach a copy of the facility(ies) license to operate.

Has your license been suspended, revoked or placed under probation within the last five years?

Yes _____ No _____

Within the last five years have you or your organization been the subject of a criminal investigation or been convicted of any crime? Yes_____ No_____ If yes, please explain.

Are you or your organization currently in or have you declared bankruptcy or reorganization in the past

five years? Yes_____ No_____

If yes, what is your current status?

Please provide a current income statement.

Does an outside management company manage this facility? Yes_____ No_____

Name of Management Company: ______

Is the prospective Named Insured the parent company and sole owner of this facility? Yes _____ No _____

If no, explain: ______

PART II - DESCRIPTION OF SERVICES

A. / Type of Facility: / Total Number of Beds
Skilled Care Services
Intermediate Care Services
Residential Care Services
Independent Living

If the combined total number of beds equals 300 or more, please provide a current income statement.

B. / Recreational Facilities: / Yes / No
None
Swimming Pool
Sauna/Hot Tub
Tennis or Racquetball Court
Exercise/Weight Room
Other

Are recreational facilities used by anyone other than your residents? Yes ____ No ____

If yes, describe.

______

C. Indicate the type of outpatient care services provided by your facility and the number of visits per year.

Services / No. of Visits

C1 . Adult Day Care Services: Average Daily # of persons: ______

D. Patient/Resident Profile:

Age Group / Average Daily # of patients / % Non-ambulatory
Less than 21
21-49
50-65
Over 65

E. Percentage of Residents receiving Services Related to:

Illness / Percentage
Psychiatric Care
Dementia / Alzheimer’s

PART III - ADMINISTRATION AND STAFF

A. Provide the administrator’s name and a brief summary of administrative experience.

______

______

B. Do you employ a Medical Director? Yes ____ No ____ Full/Part-time ______

If yes, briefly describe the director’s medical qualifications.

______

______

Does the medical director also act as the attending physician for any residents? Yes ____ No ____

If yes, how many _____ Indicate the medical/professional liability limits required.

If a medical director isn’t employed or contracted, who is responsible for overseeing the delivery and quality of the medical services provided? ______

C. Staff selection and training

Please check each of the procedures you use when hiring medical professionals and para-professionals to provide patient care services at your facility

_____ Check of criminal background.

_____ Check of educational background, or residency program, when applicable.

_____ Check of previous employers _____ In writing ____ By telephone

_____ Check of personal references _____ In writing ____ By telephone

_____ Check on hospital privileges for physicians, oral surgeons, and dentists

How often do you update your list of specific privileges?

_____ Verify any pending license suspensions or revocation, or any pending disciplinary actions

by other facilities?

What training do you provide for new paraprofessionals (e.g. aides)?

______

______

Do you have a written policy addressing sexual abuse/molestation? Yes______No______

If yes, does your policy outline the following?

a. Complaint reporting procedure identifying to whom complaints or concerns should be reported? Yes______No______

b. Procedures for documenting, handling, and investigating a complaint? Yes_____ No______

c. Do you have a designated, specially trained, onsite investigator(s) in charge of handling all internal sexual Misconduct investigations? Yes______No______

Is your policy formally communicated to the following?

All Employees/Aides/Volunteers Yes______No______

Do you provide Sexual Abuse training at least annually, and to all new staff including volunteers ?

Yes______No______

Are records kept of this training? Yes______No______

Do you have a procedure of engaging law enforcement when sexual abuse allegations surface?

Yes______No______

Do you notify all applicants and current staff members that you report sexual abuse allegations to law enforcement and will you assist in prosecuting sexual abuse cases? Yes______No______

Do you perform federal criminal background checks on all employees and volunteers that are expected to have regular, unsupervised contact with residents ? Yes______No______

Are records maintained? Yes______No______

Do you perform prior employment verification or credential checks? Yes______No______

Are there written procedures that monitors staff in day-to-day relationships with

clients, both on and off premises? Yes______No______

Is there more than one person responsible for the welfare of any single patient? Yes______No______

Do you have a written crisis plan in place for dealing with employees, victims, parents, authorities, and

the media if you have an incident of abuse? Yes______No______

Have you or any employee currently seeking coverage, been involved in an allegation or claim related to sexual abuse, molestation, or misconduct? Yes______No______

If yes, please provide details on separate sheet of paper (date, disposition, circumstances)

Is there any record or knowledge of any previous incidents that might have resulted in such claims if

They had been pursued? Yes______No______

If yes, please provide details on a separate piece of paper (date, disposition, circumstances)

Has any insurer ever canceled or non-renewed this type of coverage? Yes______No______

PART IV - RULES AND PROCEDURES

A. Evacuation Procedures Yes No

Do you have a written emergency plan
Does your plan include advance arrangements for transportation/shelter
Are evacuation directions posted on all parts of your facility
Does your staff orientation plan include a review and “walk thru” disaster plan
How often are evacuation/fire drills conducted each year for each shift

Questions B through H apply only to facilities that provide skilled/intermediate nursing care.

B. Do all patients have their own attending physician? Yes _____ No _____

If no, who performs the role of attending physician? ______

C.

Are written orders from an attending physician required for: / Yes / No
All drugs or medicines
Specialty dietary requirements
Any other specific therapy/treatment?
If yes, describe

D. How often are attending physicians required to update their patients charts (# of days)? ______

E. Do you retain a physician on-site or on call on a 24-hour basis? Yes ____ No ____

F. Who determines if a patient must be transferred to another facility for further medical diagnosis or treatment?

______

G. Is smoking permitted in patient rooms? Yes ____ No ____

Describe rules applicable to smoking:

______

H. Are there alarms on exit doors to alert staff that patients may be leaving the premises without proper authorization? Yes ____ No ____

If no, how is this controlled?

______

PART V - CONTRACTUAL AGREEMENTS

Identify all contracted medical professional services performed for you and the minimum medical professional liability limits.

Medical
Dental
Nursing
Psychiatric
Pharmaceutical
Therapy (PT, OT, Speech)
Dietary
X-Ray
Medical Records
Laboratory
Social Services
Recreation Services
Barber/ Beautician
Transportation

PART VI - BUILDING AND EQUIPMENT FEATURES

The following information is needed for each building used for patient or resident occupancy. If you have more than one such building, you should complete a copy of this section for each additional building.

A. Was the building originally designed and constructed for nursing home occupancy? Yes ___ No ___

If no, what was the original building occupancy?

B. Does this location meet applicable NFPA life safety codes? Yes ____ No ____

If no, explain in the comments section.

C. Smoke detectors and automatic sprinkler system.

Check areas where smoke detectors are located / Check areas protected by approved automatic sprinkler
None / None
Entire Facility / Entire Facility
Common Areas / Common Areas
Hallways / Hallways
Patient or resident rooms / Patient or resident rooms
Other: / Soiled linen chutes and room
Trash collection area
Other

D. When was the building last inspected by the:

Local fire authorities ______State Department of Health ______

(*If the inspection was completed in the last three years please submit a copy.)

E. Are at least two exits, located remotely from each other, on each floor and fire section?

Yes ____ No ____

F. Do you have an auxiliary electrical supply system? Yes ____ No ____

If no, describe the type and location of any other emergency lighting system in this building.

______

G. Are handrails provided in hallways and bathrooms? Yes ____ No ____

H. Are bathtubs/showers equipped with non-slip surface? Yes ____ No ____

I. Are all skilled and intermediate care patient beds equipped with side-rails? Yes ____ No ____

J. Are you planning any new construction during the next twelve months? Yes ____ No ____

If yes, use the Comment Section to describe the purpose, estimated cost and estimated completion date for such construction.

K. Is there a formal Risk Management Program in Place? (Yes/No)

Is there a designated person responsible for risk management? (Yes/No)

Please give contact name.

PART VII - CLAIMS HISTORY

1. Has any insurance policy been canceled or non-renewed at any time in the past five years?

Yes ___ No ___

. Have there been any claims in the last five years? Yes ____ No ____

Please, submit hard copy loss runs and describe individual losses from ground up including defense costs.

3. State policy period, amounts paid, amounts in reserve and complete details of the claims.

______

______

______

______

______

______

______

PART VIII - SURVEY DATA

Name of the individual that our Loss Control Representative may contact for an on-site inspection of your facility:

THE COMPLETION OF THIS APPLICATION DOES NOT BIND COVERAGE.

THIS APPLICATION IS SUBJECT TO THE UNDERWRITING RULES OF THE COMPANY

NO FLAT CANCELLATION AND A 25% MINIMUM EARNED PREMIUM WILL APPLY

I declare that the information submitted herein is true to the best of my knowledge and becomes part of my application. I

understand that an incorrect or incomplete statement could void my coverage.

Signature of Applicant: ______Date and Title ______

Producer Name: ______Address ______

______Telephone Number ______

COMMENTS:

1

MEK:lb 7/30/2009

RESIDENTIAL CARE SUPPLEMENTAL APPLICATION

(Assisted Living or Independent Living)

1) / # of Units designated as Assisted Living
# of Units designated as Independent Living
# of Units Occupied
2) / # of Residents who are ambulatory and are not restricted physically from
entering/leaving the premises - no sign out required.
# of Residents today that require more than 3 ADL’s (Activities of Daily Living)
3) / Building:
A) / Was the building originally constructed for Assisted-Living or Independent Living apartments? / Yes / No
If no, answer the following:
1. / Date of conversion:
2. / Does building meet current NFPA codes? / Yes / No
3. / Original use of building:
B) / Are there smoke and heat detectors in the units? / Yes / No
C) / Are residents permitted to smoke in their rooms? / Yes / No
D) / Are private baths within Unit or on Common hallway? / Yes / No
E) / Are private baths on common hallway? / Yes / No
F) / Do residents have kitchenettes in the unit? / Yes / No
If yes, are they equipped with working stoves? / Yes / No
G) / Do the Units have lockable entries? / Yes / No
H) / Do the Units have individual Climate Controls? / Yes / No
I) / Is there an Emergency Response System within the resident’s units and
connected to a central location within the facility? / Yes / No
Describe the system installed:
J) / Does the facility provide any furniture or fixtures to the residents? / Yes / No
4) / Are you affiliated with any long term care facility? / Yes / No
Please list your affiliations
5) / What “services” are provided for the residents? Please include brochures.
6) / Are all “services” provided by the employees of the facility or are some contracted to a home health care
provider?
A) / If contracted, does the contract run between the facility and the provider, or between the individual
resident and the provider?
B) / To what extent does the facility participate in the contractual agreement?
C) / Are contractual agreements entered into by the facility with any of the following**:
Area Hospital:
Nurses’ Association:
Nursing Home:
** / Comment on each if applicable.
Liability Data
1) / Is the facility approved for Medicaid’s Group Adult Foster Care? / Yes / No
2) / How long has the facility been in operation and under present management?
3) / Is there a 24-hour “Awake Staff” on premises? / Yes / No
4) / How are the medications controlled and administered?
Please describe:
Staffing
1st
Shift / 2nd
Shift / 3rd
Shift
1) / How many medical service professionals do you employ?
2) / How many Personal Care Attendants do you employ?
3) / Do you contract with medical service professionals? / Yes / No
If yes, please complete the following:
A) / With respect to contracted professional, please list the firms whopresently have service contracts with
residents:
How do these firms verify the qualifications of these individuals?
B) / Are certificates of insurance provided by all subcontractors for
professional/general liability for limits of at least $1,000,000/$1,000,000?
Yes / No
C) / Is the facility included as an additional insured for each of these
subcontractors? / Yes / No
D) / Are certificates of insurance provided to the facility prior to the
subcontractor entering the premises? / Yes / No
E) / Is the facility provided with a minimum 30 days notice of cancellation
by the subcontractor’s professional/general liability carrier in the event
of cancellation? / Yes / No
Admission Policy
1) / Describe Admission policy including duties of assessment team, doctor recommendation, physical examination
etc.
2) / What is policy if a residents health changes and the facility is no longer appropriate for the resident?
3) / How often are residents evaluated?
4) / Please attach copies of promotional brochure(s).
Lease Agreements
*Please attach sample of Residency Agreement utilized by facility*
1) / Is there a uniform lease agreement that is applicable to each resident? / Yes / No
2) / Does the form require the resident to carry contents/liability coverage for his/her
coverage for his/her own unit for independent living residents? / Yes / No
3) / Are certificates of insurance for both contents/liability provided to the facility? / Yes / No
Resident Ages:

Under 35

/ 36-50 / 51-65 / 66-80 / 80-95 / Over 95
Youngest Resident / Oldest Resident / Average Age
Special Needs
1) / Are residents admitted who have Dementia/Alzheimers disease? / Yes / No
2) / If yes, are these residents housed in a separate wing of floor? / Yes / No
3) / What additional controls are in place to prevent or control “wandering” or other potential challenges for these
residents?
4) / Are other special needs residents admitted? / Yes / No
If yes, how is care structured to meet their needs?

THIS SUPPLEMENTAL APPLICATION IS PART OF THE HEALTH CARE FACILITIES PROGRAM LONG TERM CARE LIABILITY APPLICATION AND THE DECLARATION AND SIGNATURE ON THAT APPLICATION APPLY TO ALL INFORMATION PROVIDED HEREIN.