Resident Orientation

Document Sample
Resident Orientation Powered By Docstoc
					                          D.E.S.I.R.E. to Live
                          Application for Services
                               General Information

                           Date of Application________________________________

Name of Applicant:________________________________________________________
                  Last Name             First Name          Middle Initial

Present Address:   Street Address____________________________________________

Phone Number: (Home)_____________________(Other Emergency)_____________
Date of Birth :______________________________ Sex __Male __Female
Social Security number____________________________________________________
Marital Status:   _ Single __Married _ Divorced __ Widowed
Primary Language _ English _ Spanish __ other, specify:____________________
Communication Mode _ Verbal _ Gestures __Vocalizations _ Sign Language
Communication Device(s):_______________________________________________
Name of contact, _______________________________________________________
Relationship to applicant_________________________________________________
Phone: (Home)____________________________(Other Emergency)_____________

Place of Birth: City______________________County:___________________
US Citizenship __Yes __No Ethnicity:__________Religion:_______________
Legal Status _ Competent __ Incapacitated (has a court appoint guardian)

  If have a Guardian: Name of Guardian______________________________
                       Relationship of Applicant________________________
                       City___________State_______ Zip_________________
Date Appointed by Court_________________________State_______________

Medicaid                                       Medicare
__Yes, Number(#)__________                     __Yes, Number(#)__________
__No, have applied and be denied               __No, have applied and be denied
__No, have never applied                       __No, have never applied

HMO/PPO      _ Yes, Policy Number (#):_________________________________
               Company Name:_______________________________________
             _ No

Life Insurance _ Yes, Policy Number (#):_________________________________
                  Company Name:_______________________________________
                _ No
Burial Insurance    _ Yes, Policy Number (#):_________________________________
                      Company Name:_______________________________________
                    _ No

Estimated Annual Income of Applicant________________________________________
Primary source of Income _SSI __Wages __Other, specify: _______

Other Means of Financial Support::__________________________________________

                                   Medical / Health Care
 Primary Physician:_____________________________________________
                   City___________State_______ Zip_________________

Known Allergies;________________________________________________
Existing Medical Conditions/Diagnoses:_____________________________
Seizures __No __Yes, Explain_____________________________________
Hearing Impaired________________________________________________
Vision Impaired_________________________________________________
Takes Medications Independently _ Yes _ No

Medication                  Date Prescribed               Reason for use

                                       Medical History
Date                             List or Describe Hospitalization or surgery or illness

Has the Applicant ever been Convicted (or adjudicated) of a public offense __No __Yes
 If yes, will the conviction interfere with the admission at D.E.S.I.R.E. to Live _No _Yes

Please submit documents requested on the Application for Services Documentation Checklist.
Your application will not be considered complete until all documents have been giving to the
D.E.S.I.R.E. to Live Admissions Coordinator.

Please contact the D.E.S.I.R.E. to Live Admissions Coordinator (832) 512-3863.

I agree that the information provided is to the best of my ability, accurate and complete.

__________________________________               _________________________________
Applicant Signature         Date                  Guardian Signature        Date

Witness Signature           Date


                            DESIRE To Live
                           Resident Orientation

   A. ___ Tour of Facility
   B.   ____ Introduction to Staff
   C.   ____ Review of Fire Escape Plan
   D.   ____ Meal Service Schedules
   E.   ____ Personal Care Services
   F.    ____ Activity Schedule
   G.    ____ Medication Supervision or Routing
   H.   _____Bath Days
   I.   _____Grievance Plan
   J.   _____Residents Rights
   K.   _____Resident Rules and Responsibilities

___________________________                        ______________________________
    Resident                                                Date

_____Wanda Butler___________                       _______________________________
      Facility Representative                               Date
                              Individual Resident Service Plan

Resident:___________________________________ Date: _____________________

Eating:      __Independent     __Cue __Assist Describe: ________________________

Dressing:      __Independent     __Cue __Assist Describe: ________________________

Grooming:      __Independent     __Cue __Assist Describe: ________________________

Toileting:    __Independent     __Cue __Assist Describe: ________________________

Bathing:      __Independent     __Cue __Assist Describe: ________________________

Ambulation: __Independent        __Cue __Assist Describe: ________________________

Medication Self- administration:     __Yes          ___No

Diet:                                __Regular      ___Special _____________________

Can ask for assistance:              __Yes          ___No

Allergies: ______________________________________________________________

Wears:          __Glasses      ____Dentures __Hearing aid        __ Other ____________

DO NOT RESUSCITATE ORDER ON FILE                   ____Yes       ___No

Special instructions: ___________________________________________________

_____________________________________                _____________________________
Resident or Responsible Party Signature              Date

_____________________________________                 ____________________________
Facility Representative Signature                     Date
                     DESIRE To Live Admission Agreement

DESIRE To Live______________,is a Non- License
  (Facility Name)
Transitional Living Facility situated at __3083 Silver Cedar Trail___________
                                            (Facility Address)

and ____________________________________ agree to the following terms for the
       (Resident or Responsible Party)

care of ________________________________________________________________
                               (Name of Resident)

A. OBLIGATIONS OF ___ DESIRE To Live __________________
                    (Name of Transitional Living Facility)

      1. To furnish personal care, lodging, meals, linens and bedding, and other such
         items as may be required by the Resident’s known physical conditions or by law
         for his/her health, safety, and well being. The Facility does not furnish:

          a. Medical, nursing, hospital, rehabilitation, treatment or examination of eyes
             or teeth or other professional services. (These services may be contracted
             through a Home Health Care Agency and may be a Medicare benefit.)

           b. Medical equipment, supplies, medication, eyeglasses, contact lenses, hearing
              aids, orthopedic appliances, prosthetic devices, laboratory tests, x-ray
              services, some of these items.)

      2. To provide weekly linen laundry service for all residents and to furnish
         assistance to the resident who wishes to do his/her own laundry.
          Personal laundry is to be done by each resident. For those residents who cannot
              or will not do their own personal laundry we will do it for them as an extra
              service and will bill the resident or his/her responsible party monthly.
              Arrangements for this service can be made through the business office.

      3. To exercise due diligence to obtain the services of the Resident’s physician when
         his/her conditions warrants, simultaneously notifying the Responsible Party. If
         the Resident’s physician is not available, the Responsible Party will be contacted
         for alternate instructions. If the Responsible Party cannot be contacted, the
         Facility will exercise its best judgment, to ensure the health and well being of
         the Resident.
4. To provide transportation once (1) a month to a local medical facility for
   scheduled appointment. These appointments must be pre-scheduled with the
   business office / facility manager to assure availability of transportation. In the
   event a transport is needed for an emergency medical situation, 911 will be
   called. In a medical non-emergency and a resident’s responsible party or other
   designee is not available or cannot give support, a professional medical transport
   service will be utilized. If Medicare or other private insurance does not pay the
   charges incurred, then the resident or responsible party will be billed for the

     As stated above, we provide transportation to scheduled appointments once a
     month but due to time constraints this service is for a two hour period only.
     This includes the trip to the appointment, the return trip to the facility and the
     time waiting with resident in the doctor’s office. Any other charges incurred by
     the resident will be billed to the responsible party. The cost of any trip or trips
     during the month after the initial trip will be billed as follows: $50.00 for the
     first two hours and $10.00 per hour for any additional time it takes to complete
     the trip. The resident or responsible party will be billed accordingly

5. It is the primary responsibility of a resident’s family, guardian or responsible
   party to supply transportation to and from Sunday church services or any other
   type of church function if the resident cannot get there on his/her own. We will
   arrange transportation only if prior arrangements have been made with our
   business office and the resident or his/her responsible party will be billed for this
   support as an extra service.

6. To provide assistance with personal shopping, recreation pursuits or other off-
   premises activities as the availability of staff, time, and/or transportation
   permits. Costs of such activities shall be the responsibility of the residents and
   their responsible parties. Transportation costs will be billed as an extra service.
   Arrangements for such activities need to be made through the business office.

7. To manage the resident’s personal-spending funds entrusted to the Facility by
   the resident or his/her responsible party and to provide an accounting of
   expenditures. The Facility will not be responsible for any money, jewelry,
   documents, or any other personal property retained in the resident’s

8. To ensure that all records pertaining to a resident are treated as confidential
    and made available only to authorized persons and agencies.

                             Initials of Resident or Responsible Party_________

    1. To fully disclose all known information regarding the resident’s ability to
       perform the activities of daily living in a shared living environment as well as
       any risks or problems which could have adverse consequences for the
       resident, other residents, of staff.

    2. To arrange for the services of an attending physician. (The resident must have a
        physical examination within the period commencing thirty (30) days prior and
        ending fourteen (14) after admission.)

    3. To accept the consequences of any refusal or care or choice of noncompliance
       with physician’s orders by the resident.

    4. To assume responsibility for all physicians fees, home health fees, medications,
       special equipment, oxygen, and other services or aids, which might be ordered by
       the attending physician. (These items may be a Medicare benefit.)

    5. To assume responsibility as the sole family member or surrogate decision maker
       having jurisdiction over decisions made on behalf of the Resident.

    6. To comply with the Facility’s standards for sharp items and weapons. The
       following items may not be retained in the possession of the resident. Sharps,
       such as, hunting knives, pocketknives, pointed scissors, strait razors, etc.
       Weaponry, such as, guns, mace, projectiles, etc. may not be brought into the

    7. To provide personal clothing, effects, and spending money as the Resident may
       require. All personal clothing must be marked for easy identification, and in
       sufficient quantities to keep Resident neatly dressed.

     8. To notify the Facility in advance of a Resident’s planned absence.

     9. To provide haircuts and/or related grooming services, unless alternative
        arrangements are made with the Facility’s business office.

    10. To permit the Resident to be moved to a different room within the Facility when
        it is deemed necessary by the Management.

    11. To abide by the policies established in connection with the operation and
        maintenance of the Facility.

                                       Initials of Resident/ Responsible Party___________

  The Resident:
     1. Is not considered dangerous to self or other residents. Symptoms of mental or
        emotional disturbance that does not pose harm to self or others is acceptable.

     2. Is able to ask for staff assistance.

     3. Understands his/her rights to self-administer medications, but with full
        understanding and consent agrees to take medications under Staff supervision.

     4. Is able to communicate needs, and to understand and follow instructions.

     5. Agrees to comply with the requirement that all medications be keep in a locked
        cabinet under the supervision of Facility staff. This includes all over the
        counter medicines.

     6. Is able to tolerate a regular diet or a therapeutic diet that can be prepared using the
        Facilities menu planner.

     7. Is able to demonstrate unaided evacuation from the Facility, within thirteen (13)

                                          Initials of Resident/ Responsible Party __________


  1. Base Charge

          a. Responsible Party agrees to pay $___________per month for the services
             provided pursuant to Section A of this agreement. Base charge will be paid in
             advance, and will become due on the 1st of each month. A NON- refundable
             deposit of _____ to hold your bed until release date.

          b. The base charge will accrue from the date of bed consignment through the day
             which all of the Resident’s personal effects are removed, prorated by the number
             of days in the month.

          c. Unless prior arrangements are made:

                 i)   Payment received after the 5th of the month will be assessed a $50.00
                     late charge.
                 ii) Payment received after the 10th if the month will be assessed a
                      $100.00 late charge.
                 iii) Payment more that thirty (30) days in arrears will warrant
                      cancellation of this agreement, and termination of the individual’s

                                     Initials of Resident/Responsible Party_______
2. Medications

      All prescription medicines must be prescribed by a licensed physician. Over the
      counter medications such as vitamins, laxatives, and pain relievers shall be approved
      by the attending physician. Cost of medications and delivery is assumed by the
      Resident/Responsible Party. Arrangements for the purchase of medications
      shall be made by the Resident/Responsible Party. The Facility is authorized to
      order all medications and durable medical supplies prescribed for the Resident.
      Discontinued medications must be disposed of in accordance with State laws.

                                        Initials of Resident/Responsible Party_________

3. Other Charges

      a. Responsible Party will make provisions to be billed directly for physician’s
         visits and /or other medical attention furnished the Resident by third
         party or parties.

       b. Failure of the Responsible Party to pay for services deemed necessary and
          proper by the Facility, or prescribed by a physician, will release the Facility
          from any and all liability which may result from lack of such services and
          will be sufficient grounds for the Facility to request the immediate
          termination of residency.

       c. Should the Resident damage or destroy property, normal wear and tear
          excepted, the Responsible Party will pay for the repair or replacement, at
          the case may be.

       d. Responsible Party agrees to pay all costs of collection, including attorney’s
          fees, in the event of non-payment of account when due.

                                      Initials of Resident/Responsible Party__________

  1. Release of Liability

         The Resident/Responsible Party here by grants to _DESIRE to Live
         (Facility’s Name) and their agents, employees, and directors a release of
         liability and immunity from any and all liability claims, demands or suits
         related to the Resident’s:

         a. Living in a shared home environment which allows a choice for the
            least restrictive setting for the Resident, even though risks exist. The
            Resident/Responsible Party understands the principle of the law of
            ―assumed risk‖ and assumes the responsibility for know, unknown,
             and potential risks, and hold_ DESIRE To Live (Facility’s Name)
             and their agents, employees, and directors harmless for all liability
             and adverse consequences which may ensue from said risks, and the
             consequences of aging, including, but not limited to falls, wandering
             (elopements), accidents, or the Resident’s refusal or non-compliance
             with physician’s orders including, but not limited to medication, diet,
             physical activity or any other ordered therapy or treatment.

          b. Being transported off site in private vehicles owned by family
             members or other responsible adults, or Special Transit Services.

                                    Initials of Resident/Responsible Party_________

  2. Complaint Resolution

          Resident / Responsible Party complaints will first be reported to the
          management, and every effort will be exerted to resolve the dispute or
          complaint at the facility level. If resolution is not possible on the facility
          level then the Facility and/or the Resident/Responsible Party may report
          the dispute or complaint to the Texas Department of Protective and
          Regulatory Services, DHS at (512) 835-6678.

          The number of the Texas Ombudsman Program is (713) 500-3787 or
          1-800-252-2412 (UT-Houston - Center on Aging).
3. Refunds

     Residents discharged from the Facility shall receive a refund of any
     unused portion of the monthly base fee to which they are entitled,
     and any unused portion of their personal spending account, providing
     all terms of this agreement have been met and thirty (30) days written
     notice is given. The requirement for a written notice shall be waived
     if the Resident is transferred due to a need for a higher level of care or
     in the event of the resident’s death.

4. Acknowledgments

      Resident / Responsible Party acknowledges receipt of all pertinent
      Policies and Procedures for __ DESIRE To Live ______________.
                                           (Name of Facility)
      Resident’s individual service plan has been reviewed and agrees upon
      by all parties.

5. Duration of Agreement

     Either party may terminate this agreement, without cause, by
     giving written notice to the other party thirty days in advance of the
     effective termination date. Such notice does not act as cancellation of
     the providers care responsibility or the Resident /Responsible Party’s
     financial responsibility until the actual termination date.

6. General

      If any part of this Agreement should be ruled invalid by a court of
      competent jurisdiction or is in violation of any Local, State, or Federal
      law, then such part shall be considered deleted from this Agreement
     and the balance of this Agreement shall continue in full force and effect.

      Representatives of the Texas Department of Human Services may
      inspect the records on file of Transitional Living Residents as part of their
      evaluation of the facility.
The undersigned have read and understand the forgoing and jointly and severally agree to
the terms and conditions of this Agreement.

Executed on this_____________ day of __________________________, ___________,

at ______Katy____________________, __Texas_____________________________.
              (City)                               (State)

Facility Manager’s Signature______________________________________________

Resident / Responsible Party’s Signature_____________________________________



                          Telephone ______________________________________
                             DESIRE to Live Center
                          Rules and Regulations
1. A current physical exam report must be on file for all residents. This must occur
    30 days prior to or 14 days after admission to our facility.
2. The staff concerning doctors, social service appointments, family outing, etc
    requires a three-day advance notice. This is to help us schedule our resident time,
    which will ensure they make their appointment.
3. All residents’ doctors appointment, medicine orders or refills, etc. are to be made
    by office staff and only calls of an emergency nature will be permitted on office
4. Residents are asked to show utmost respect and courtesy for their roommates and
    the other residents and staff at the center. No loud TVs, radios or stereos. No
    loud conversations, as sound carries through walls. TVs, radios and stereos
    should be turned off when leaving rooms and after bedtime curfew.
5. This is a NO SMOKING facility. No smoking is allowed inside the DESIRE to
    Live Center. Two smoking zones have been established for the smokers. See
    SMOKING POLICY for details and disciplinary measures for non-compliance.
6. All residents are expected to sign-out when leaving facility, indicating destination,
    and sign back in upon return.
7. Staff nor residents may not borrow money, cigarettes, etc from each other.
    DESIRE to Live Center will not tolerate stealing. If caught stealing, resident will
    be subject to disciplinary action.
8. Candles or incense may not be burned inside the facility. This is a fire safety
    harzan. Help us keep this a safe place.
9. Shoes and shirts must be worn at all times unless program activities indicate
    otherwise. Proper clothes appropriate of seasons will be worn.
10. Personal hygiene is important at all times. Residents are required to take showers
    or baths (and shave) at least four times a week, hopefully daily and brush their
    teeth and wear clean clothing daily.
11. The resident will be responsible to doing his or her own laundry. A coin operated
    washer and dryer are available for their use. Coins for machines can be purchased
    for the office. Detergent, softener, etc. will be supplied to resident. If resident
    cannot or will not do his/her laundry, we will do it and bill the responsible party
12. Residents are expected to comply with their medication regime. You are required
    to take all medications as prescribed by doctor. Only the physician can make
    changes to prescription. All medications, prescribed and non-prescribed must be
    kept locked in the office until time for administration. Staff will administer all
    medications. Compliance is a must for staying at DESIRE to Live Center.
13. Allowances will be distributed daily between the 9:00 to 10:00 am. It is the
    resident’s responsibility to pick up his or her money on time.
14. Visiting hours are from 9 am to 7:00 pm. Visitors are encouraged to call prior to
    visit. All visitors must sign in, indicate who they are visiting, and observe the
    visiting hours.
15. All residents must be bathe and in their own rooms by 6:30 pm. Center doors are
    closed at 9:00 no one is allowed to neither exit nor enter after this time. Do not
    walk the halls at night.
16. No resident made bring a car or motorcycle to the facility. If one is necessary,
    arrangements and permission must come from the office, and proper insurances
    must be in place and a copy placed in residents file.
17. DESIRE to Live reserves the right to reject personal property brought to our
    facility by any resident, as we may not be able to ensure its safety.
18. All residents are required to attend a day program of some kind. You may also
    work or volunteer during the day. This is to help with self- esteem, self-
    improvement and will keep you from regressing. If not in a program during time
    of admittance, DESIRE to Live will help to find a program that is suitable to the
    residents need.
19. All meals and drinks will be prepared and serve to you in the kitchen only. Do
    not eat anywhere else in the facility.
20. NO LOITERING in the front of the facility. You may relax in the designated
21.NO ALCOHOL or non-controlled drugs allowed on premise.
22.NO FIGHTING or arguing between residents or with staff.
23. NO FIREARMS or weapons of any kind are allowed on premises.
24. All residents must keep their rooms clean by:
    a). Making their own beds daily. Change linens once a week.
    b). Pick up dirty clothes and put them in clothes bin or basket.
    c). Put all clean clothes away in dresser and /or closet.
    d). Put all trash in wastepaper basket and emptying it when full.
    e). Return all plates, cutlery, etc. to facility kitchen after each meal.
    f). Vacuum carpet in room weekly.
    i). Clean and straighten up bathroom daily. Make sure there is no water on the
         floor. Put dirty towels in your dirty laundry basket. Towels must be washed
    j). Do not stick things down any of the drains.
    k). Do not wad up tissue and place it in the toilets. Do not put female products in

   If you have trouble doing any of these tasks-check with the staff.
                                     DESIRE to Live

                                   SMOKING POLICY

   1. There will be absolutely NO SMOKING in any building at the center.
   2. Smoking is permitted on the back patio only, however when it is raining (only)
      smoking is permitted in the screened patio.
   3. Butts are to be placed in the smoking trays only.
   4. Never throw butts in trash or yard—hot ashes can start fires.
   5. If any fire or safety hazard problems are noted, please notify the staff
   6. Anyone who does not comply with this policy is subject to disciplinary action.
      This may consist of one or more of the following:
          a) Withholding of all or part of allowance money for a specific length of
          b) Withholding of cigarettes for a specific length of time.
          c) Required to attend smoking cessation group therapy.
          d) Required to replace any item damaged by client smoking.
          e) For continual non-compliance—you may be asked to leave the center.
          f) Or any combination of the above when necessary.

   7. NOTE: If the center is fined by the state agency and or local fire marshal
      due to non-compliance with state rules concerning smoking, said fine will be
      passed on to the resident and or resident responsible party. The responsible
      party, their parents or guardian will have to pay said fine and will be subject
      to disciplinary action.

I have read the smoking policy for DESIRE to Live Center and agree to abide by the

_________________________                    _________________________________
Signature of Resident                        Date

_________________________                    _________________________________
Signature of Parent/Guardian                 Date

_________________________                    _________________________________
Signature of Staff / Manager                 Date
                                DESIRE To Live

I ________________________ have read the rules & regulations and smoking policy. I
will comply with them as long as I am a resident at DESIRE to Live.

Signature of Resident _____________________ Date_______________________

Signature of Guardian ____________________ Date_______________________

Witnessed by (staff member) ______________________ Date________________
                                  DESIRE To Live
                          COMPREHENSIVE ASSESSMENT

Name:_____________________________________ DOB:________________________
Admitted From______________________________ Admit Date___________________
Primary Language Spoken_____________________ 2Nd language__________________
Diagnosis__________________________________ _Chronic _ Acute
Mental Health History_____________________________________________________

Any signs of _ Depression     __Anxiety __Sadness

Sleep Cycle______________________________________________________________

Behavioral Symptoms
Frequency (use appropriate number in box)
1. never 2. sometimes 3. most of the time 4.flare-ups 5. always
 __Depression w/crying __ Depression __Crying _ Violence __Pacing __Rummaging
__Cheeking food __ Anorexia __Elopement

Psychosocial Issues
__Feels agitated __Abnormal mood swings __Feeling helpless __Forgetfulness
__Disoriented __Difficulty communicating __Feels that life isn’t worth living

Daily Living Patterns
Restroom Habits: __Independents _ Need assistance __Need assistived aids
Bathing Habits: __Independent __Supervision __Assistance     ____Total help

Daily Events Cycles
Daily Naps: __Unusual napping __Unusual bedtime routine __Goes to bed early
            __Stays up late    __Routine bedtime
Spends Time: _Alone      ___Watching TV __Listening to radio/ stereo, etc
             __With others _ Group activities

Involvement Patterns
Frequency (use appropriate number in box)
1. daily 2. weekly 3. monthly 4. yearly 5. once in a while
Does resident have contact with: _ Family _Friends _ Church _ Other__________
Is resident involved with:         _Activities _Hobbies _ Interests______________
Cognitive skills for daily decision-making are best described as: (Circle one)
Independent             Modified               Moderately             Severely impaired
                        Independent            impaired
Alert                   Forgetful              Mild dementia          Severe dementia
                               DESIRE To Live
                        COMPREHENSIVE ASSESSMENT

Ability to communicate with others: __Yes         __No
Does resident use any assistive or communication devices? __Yes __No
__Cane __Walker __Wheelchair __Hearing aid __Glasses __Dentures __Other_____

Physical Functioning
                 Independent    Supervision    Assist         Total Assistance
Transfer Status
Toilet Use

Any problems:____________________________________________________________

Activity Pursuit Patterns
Involved in activities: _Yes    __No
Preferred activities:_______________________________________________________
General activity preferences________________________________________________

Are these medications __Administered __Supervised __Self administered
                               DESIRE To Live
                        COMPREHENSIVE ASSESSMENT

Health Conditions:
Does resident have any health condition? __Yes __No _ If yes explain:_____________

Is there any possible medication side effect? __Yes __No
If yes explain:____________________________________________________________

Is there any special treatment that the resident might need? __Yes __No
If yes explain:___________________________________________________________

Is there any special procedure that the resident might require? __Yes __No
If yes explain:____________________________________________________________

Hospitalization History
Has there been any hospitalization in the last 6 months? __Yes __ No
If so, when and Why?______________________________________________________

Has there been any hospitalization since the last assessment? __Yes __ No
If so, when and Why?______________________________________________________

Preventive Health needs
Blood Pressure: __Diet __Other__________________________________________
Diabetic:        __Diet __Exercise _ Other________________________________
Hearings: ______________________________________________________________
                                DESIRE To Live
                        COMPREHENSIVE ASSESSMENT

Resident’s Personal Plan of Service

Special Instructions/Comments

________________________________________    _____________________________
Resident or Responsible Party Signature      Date
________________________________________    _____________________________
Facility Representative Signature            Date
The purpose of this Disclosure Statement is to empower consumers by describing a facility’s polices and services in a uniform manner. This format gives
prospective residents and their families’ consistent consistent categories of information from which they can compare facilities and services. By requiring
the Disclosure Statement. The department is not mandating that all services listed should be provided, but provides a format to describe the services that
are provided.
The Disclosure Statement is not intended to take the place of visiting the facility, talking with residents, or meeting one-on-one with facility staff. After,
it serves as additional information for making an informed decision about the care provided in each facility.

                                                         INSTRUCTIONS TO THE FACILITY
      1.     Complete this Disclosure Statement according to the care and services that your facility provides. You may not amend the statement but you
             may attach an addendum to expand on your answers.
      2.     Provide copies of and explain this Disclosure Statement to anyone who requests information about your facility.

Facility Name                                            License No.                       Average No. Residents            Telephone No.
DESIRE to Live                                                                                 6                            832 512 3863
Address (street, City, State, Zip)
3083 Silver Cedar Trail                           Katy                     Texas             77449
Manager                                                                                       Date Disclosure Statement
Wanda Butler (Executive Chair person / Owner)

           A copy of the most recent survey report may be obtained from facility management.
                  To register a complaint about a Transitional living facility, contact:
                       Texas Department of Human Services at 1-800-458-9858

      I.            Pre-Admission Process
                    A. Indicate services which are not offered by your facility:

                    _X_ Assistance in transferring to/from wheelchair X_ Medication Injections X_ Oxygen Administration
                    _X_ Behavior management for verbal aggression
                    _X _Bladder Incontinence Care _X _Feeding residents _X_ _Special diets
                     X_ Behavior management for physical aggression
                    _X_ Bowel Incontinence Care _X _Intravenous (IV) therapy


                    B. What is involved in the pre-admission process?

                    X_ Facility tour __X _Family interview             X_ _Medical records assessment _X_ Application _X_ Home assessment

                    X Other: Interview with the prospective client_________________________________________________________

                    C. What services and / or amenities are included in the base rate?

                    X Meals (3 per day)         X Temporary use of wheelchair/walker              _ Select menu

                    X Housekeeping (1 day per week) _ Barber/beauty shop              _ Licensed nurse (__hours per day)
                    X Activities program (__days per week) __ Special diet            __Injections
                    _ Incontinence care                     __ Personal Laundry
                    X Transportation (specify): One trip monthly to scheduled doctors appointment._____________________________
                    X Other: Financial management (i. e allowances; trust funds, etc.)________________________________________
                D. What additional services can be purchased?

                 X Beauty/ barber services __ Injections                    __Minor nursing services provided by facility staff
                 __ Incontinence care      X Companion                      X Home health services
                 __ Incontinence products X Transportation to doctor visits
                 X Other: Additional housekeeping and laundry services_____________________________________________

                E. Do you charge more for different levels of care?                                            X Yes      _No

     II.        Admission Process

                A. Does the facility have a written contract for services?                                     X Yes _ No

                B. Is there a deposit in addition to rent (In special circumstances only) X Yes _ No
                   If yes, is it refundable                                               __ Yes X No
                   If yes, when ?_________________________________________________________

                C. Do you have a refund policy if the resident does not remain for the entire prepaid period?
                       If yes explain: A).within 30 day notice and no outstanding charges. B). move to another facility for a higher
level of care that we cannot supply.

                 D. What is the admission process for new resident?
                 __ Doctors’ orders          X Residency agreement  X History and physical X Deposit/ payment
                 __ Other:_________________________________________________________________________________

                  E. Does the facility have provisions for special resident communication needs?
                  __ Staff who can sign for the deaf                    ___Services for persons who are blind
                  __ Other:_________________________________________________________________________________

                 F. Is there a trail period for new residents?                       X Yes _ No
                 If yes, how long? Thirty days (30)___________________________________________

     III.       Discharge/Transfer
                A. What could cause temporary transfer to specialized care?
                X Medical condition requiring 24 hour nursing X Unacceptable physical or verbal behavior
                X Drug stabilization                          X Resident requires services the facility does not provide
                __ Other: ______________________________________________________________________________

                B. The need for the following services could cause permanent discharge:
                X 24 hr nursing care             _X_ Sitters     X Medication injections
                X Assistance in transferring to and from wheelchair X Bowel incontinence care
                X Feeding by staff X Behavior management for verbal aggression X Intravenous
                X Special diets

                C. Who would make this discharge decision?
                X Facility Manager X Other: Doctor, family, guardian, etc.

                D. Do families have input into these discharge decisions? . . . . . . . . . . . . .. . . . X Yes _ No
                E. Is there an avenue to appeal these decisions? . . . . . . . . . . . . . . . . . . . . .. … X Yes _ No
                F. Do you assist families in making discharge plans . . . . . . . . . . . . . . . . . . . . . X Yes _ No
IV.   Planning and Implementation of Care
      A. Who is involved in the service plan process:
      X Resident      X Family members _ Activity director X Attendants X Manager
      __ Licensed nurses X Social worker __Dietary X Physician
      __ Other:__________________________________________________________

      B. Does the service plan address the following?
      X Medical needs X Nursing needs X Activities of daily living X Psychosocial needs X Nutritional status
      __ Dental status __ Other:___________________________________________________________________

      C. How often is the service plan assessed?
      __Monthly _ Quarterly __Annually X As needed __ Other:____________________

      D. How many hours of structured activities are scheduled per day?
      __ 1-2 Hrs _ 2-4 hrs __4-6 Hrs _X_6-8 Hrs __8+Hrs

      E. What types of programs are scheduled?
      __ Music program __Arts program __Crafts ___Exercise ___Cooking
      __ Other: Outside contracted adult day care & day programs at partial Hosp./ day program

      F. Who assists with or administers medications?
      __RN __LVN __Medication aide _X_ Attendant
      __ Other:________________________________________________________________

V.    Change in Condition Issues
      What special provision do you allow for aging in place?
       __Sitters X additional services agreements __ Hospice X Home health
      __ Others: ________________________________________________________________________________

VI.   Staff Training
      A. What training do new employees receive?
      X Orientation: 4 Hrs _X_ Review at resident service plan _X_ On the job training with another employer
      X Other: On the job training with manager._____________________________________________________

      B. Is staff trained in CPR? . . . . . . . . . . . . . . . . . . . . .. . . . . . . .. .. . . . . . . . .. X Yes _ No

      C. How much on-going training is provided and how often? 30 Minutes monthly

      D. Who gives the training and what are their qualifications?

         Facility Manager / Administrator / Outside Specialists_________________________

      E. What type of training do volunteers receive?

           _X_ Orientation __4__ Hrs __X_ On the job training
           __ Other: ______________________________________________________________
         F.   In what type of endeavors are volunteers engaged?

         X Activities _ Meals __Religious X Entertainment X Visitation
         X Other: Maintenance, crafts, and clean-up

         G. List volunteer groups involved with the facility?
            __________________________________ _____________________________________

              __________________________________ _____________________________________

VII.     Physical environment
         A. What safety features are provided in your building?
          __Emergency call system X Fire alarm system __Built according to NFPA
       life safety code. Chapter 12 health care __Sprinkler system
       __Wander guard or similar system _ Built according to NFPA
       life safety code. Chapter 21 board and care

         B. Does the facility’s environment include the following?
         X_Plants __Pets ___ Vegetable/ flower gardens for use by residents
        __ Other:_________________________________________________

         C. Are the residents allowed to have:
        _X_Plants __Pets ___ Vegetable/ flower gardens for use by residents
        __ Other:_________________________________________________

VIII. Staffing Patterns
      A. What are the qualifications of the manager?
        High school graduate: graduate – asst. living/ personal care administor’s
       Course twelve/twenty-four hours extra training per year:

         B. Please list the facility’s normal 24 hr staffing pattern on:
                      1.    Attach chart or
                      2.    A separate attachment, which explains your facility’s unique staffing policies
                            and patterns.

IX.      Residents’ Rights
         A. Do you have a resident’s council . . . . . . . . . . . . . . . . . . . . . . . _Yes X_ No
            How often does it meet?

         B. Do you have a family council . . . . . . . . . . . . . . . . . . . . . . . . . ... Yes X_ No
          How often does it meet?

         C. Does the facility have a formal procedure for responding to resident grievances and
            suggestions for improvement? . . . . . . . . . . . . ... X Yes _ No

              Is there a Grievance Committee? . . . . . . . . . . . . . . . . . . . . . . . _ Yes _X No
              Is there a suggestion Box? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. X Yes _ No

         D. How can the company that owns the facility be contacted?

              By telephone (land line and / or cell phone)__________________
                                  DESIRE To Live

____DESIRE to Live______________________________has explained and
  (Name of Facility)

provided me with copies of the following:

      Transitional living disclosure statement
      Resident’s bill of rights
      Operational policy
      Admission agreement
      Advance directive criteria

______________________________                    ____________________________
Signature of Resident or                          Date
Responsible Party

           Shift times and staffing patterns at DESIRE to Live Center

Our facility has a live- in staff on site 24 hours with a rotating schedule (posted)
                                  DESIRE To Live
                               General Operational Policies

We at DESIRE to Live, hereafter known as DESIRE to Live Center, provide twenty-four
(24) hour supervision and the daily overseeing of our residents needs.

DESIRE to Live Center maintains an open-door policy to our family members and
visitors. Inquires about our facility are welcome at anytime; however, we do ask that
some respect and consideration be given to our staff and residents as not to interfere with
normal sleeping hours and the times when we are providing care to our residents,
especially at meal times.

Most residents are independent and able to maintain active daily living skills with
minimum help and supervision.

DESIRE to Live Center encourage our residents to maintain a daily personal hygiene
routine, as this is so very important to their health and self-esteem.

We provide weekly laundry service of bed linen and towels. Each resident is responsible
for doing their own personal laundry; either at their family’s home or at our coin operated
laundry as an extra service and will bill their responsible party on a monthly basis.

We provide three meals a day and snacks for our residents. The meals are planned in
advance and food is purchased accordingly. The menu’s call for healthy, nutritious and
balanced meals to satisfy the daily needs of our residents; so if a resident is allergic to
certain foods or if special foods are required, arrangements must be made at the time of

We maintain a high regard for the privacy of all our residents and strive to treat everyone
with respect, so they can maintain their human dignity and enhance their ability to
maintain their living skills in a social environment.

Residents must be provided with wearable clothing, underwear, sleepwear, etc. and good
sturdy shoes and or tennis shoes. Items are to be provided by resident, resident’s family
or responsible party. We encourage our residents to look their best every day.

We provide some storage space for each resident, but since it is very limited, we ask that
only needed items be retained. We especially ask that expensive items, such as, jewelry,
etc. be kept by resident’s family or responsible party as we cannot be responsible for the
safety of these items.
A current physical exam is required for each resident. State policy states that it must
occur either thirty (30) days prior to or fourteen (14) days after admission to our facility.
If a current exam is not available, arrangements will be made with a physician for one at
the expense of the resident or responsible party. If resident or resident’s responsible
party refuses to have physical exam done, then we cannot accept that person as a resident.

We will from time to time, due to health reasons, contact a resident’s physician by
telephone to have his or her medicine(s) adjusted or to correct other minor problems.
This is to avoid any extra office visits and if possible at no cost to the resident; however,
should an emergency situation occur, trained emergency help will be summoned to our
facility at the expenses of the said resident.

Our facility is not staffed to provide daily medical care or around the clock medical care
to our residents. Should this type of care become necessary, our facility may initiate
Home Health Care for a resident with the approval of his or her doctor and responsible
party. This will remain in effect until the crisis is over or until the resident is moved to
another facility to receive the appropriate long-term medical care needed.

We will not, directly or through contractual arrangement, discriminate against anyone on
the bases of race, creed, color, national origin or disability in admission to our facility or
the provision of services.
RESIDENT’S NAME: _____________________________________________________

  1. Have you ever signed an advanced directive?

            Yes_____           No____________

  2. If your answer is Yes what kind of advanced directive was it?

          Direction to Physician ________
          Power of attorney_________
          Durable Power of attorney _____
          Other _______________________

  3. Where is it Located?________________________________________

  4. If answer is No, would you like more information concerning an advance
     Advance directive?

            Yes________________ No ________________________

  5. If answer is Yes was the information left with the resident?

        Yes_____________             No____________

  _____________________________________             _____________________
   Signature of Resident or Legal Guardian           Date
                                  DESIRE To Live
3083 Silver Cedar               ---             Katy , Texas 77449
Office Phone 832 512 3863                       Fax # 281 398 0806


Dear Resident, Family Member (s)
     Resident’s Agent or Responsible Party

Attached to this letter is a copy of the Texas Natural Death Act. As part of our licensing
process, the State of Texas requires that all Adult Day Care Centers and Transitional
Living Facilities educate or at least familiarize the resident or his/her family, etc. about
―Advanced Directives‖.

An Advance Directive is simply a document, which lets a person (competent adult, 18
years or older) state their choice or choices about medical treatment or name someone to
make decisions about their medical treatment, if they become unable to make these
decisions or choices themselves. The word Advance is used because these Directives are
signed before the person becomes incapacitated and cannot make their wishes known. It
lets the doctors and other health care providers know how to proceed and still respect the
wishes of the person involved. Through advance directives, they can make legally valid
decisions about their future medical care.

Texas Law recognizes three types of Advance Directives:
          A Directive to Physicians (Living Will).
          A Durable Power of Attorney for Health Care.
          A Mental Health Treatment Declaration.

Please review the guidelines of the Texas Natural Death Act and if you would like more
information about Advance Directives you can contact:

              Texas Association for Home Care, Inc.
               3737 Executive Center Drive, # 151
               Austin, Texas 78731        Telephone #(512) 338 9293

               Texas Department of Health
               Facility Compliance Division
               1100 West 49th Street
               Austin, Texas 78756         Telephone # 1-(800) 228-1570
               Professional Media Resources
               P.O. Box 460380
               St. Louis, MO. 63146-7380 Telephone # 1 (800) 753-4251

In the event of a medical emergency, our policy is to perform life sustaining procedures,
UNLESS there is an Advance Directive on file or otherwise directed.

Thanking you in advance for your cooperation in this matter.

Wanda Butler, Executive Director
DESIRE to Live

I acknowledge by my signature that on this date _________________ I received
information on ―Advanced Directives‖ and a copy of the Texas Natural Death Act from
DESIRE To Live and it is my choice or that of my Responsible Agent/Party to act on the
information received.

__________________________________ ____________________________________
Signature of Resident               Signature of Resident’s Agent
                                     Or Responsible Party
                       MANAGEMENT OF PERSONAL FUNDS

I,______________________________ delegate              DESIRE to Live______________
   (Resident or Responsible Party)                     (Name of Home)

the responsibility of retaining and keeping records for certain of my personal cash funds

which are deposited with the Facility for such handling. I understand that I may make

deposits to, or withdrawals from, these funds upon request. I grant specific approval for

the Facility to apply these funds to the payment for certain personal goods and services

which I have approved and received from or through the Facility. The following items

are also subject to withdrawal; long distance telephone charges and cable charges, if


This account is subject to audit and inspection. This delegation shall automatically renew

annually from this date unless otherwise terminated by either party.


This delegation of responsibility is rescinded effective _______, _________,__________
                                                        (Day)     (Month)     (Year)

Resident/Responsible Party’s Signature:_______________________________________

Manager’s Signature:_____________________________________________________
                             DESIRE to Live

                       Health Examination Record

Resident Name: _____________________________________

Admission Date: ____________________________________

Date of Last Physical Examination: _____________________

Physician Signature: ________________________________

Date: _____________________________________________

Note: Resident must have a health examination by a physician performed
within 30 days prior to admission or 14 days after admission, unless a
transferring hospital or facility has a physical examination in the medical
                           DESIRE to Live

If you complete a directive and later change your mind, you may revoke it at any time by:

              You or someone in your presence and at your direction canceling,
               defacing, obliterating, burning, tearing or otherwise destroying the
              Signing and dating a written revocation that expresses your intent to
               revoke the directive;
              Orally signing your intent to revoke the directive.

If you revoke a directive in writing, that revocation takes effect only when your attending
physician has been notified by you, or by a person acting on your behalf, and the
revocation is mailed to your attending physician. If you revoke a directive orally, the
revocation takes effect only when you or someone on your behalf notifies your physician.

Signature:_______________________________ Date: ________________________

Signature (RP):__________________________ Date: ________________________

Witness :_______________________________ Date: ________________________
                        DESIRE to Live
 Advance Directive Information Receipt Acknowledgement Form

I acknowledge by my signature that on this date _______ I received
information on ―Advanced Directive‖ and a copy of the Texas Natural Death
Act from DESIRE to Live Center and it is my choice or that of my
Responsible Agent / Party to act on the information received.

___________________________            ___________________________
Signature or Resident                  Signature of Resident’ s Agent
                                        Or Responsible Party

___________________________             __________________________
Signature of Facility Representative     Date Received
                                   DESIRE TO LIVE
                                  3083 Silver Cedar Tr.
                                    Katy, TX 77449

                        Consent for Emergency Treatment

I, __________________________, do hereby authorize the staff of DESIRE to Live to
give medical aid/ treatment as necessary in case of an accident or emergency illness.
Efforts will be made to contact my family.

In case of an emergency, please contact:

Name: ______________________________________________
Address: ____________________________________________

Phone: ______________________________________________

Relationship: _________________________________________

Medical Doctor Preferred: _______________________________

Phone: ______________________________________________

Psychiatric Doctor Preferred: _______________________________

Phone: ______________________________________________

Other Agencies to be contacted:

Resident’s Signature: ________________________       Date: ______________________

Case Manager / Social Worker: _________________      Phone: _____________________

Witness:______________________________ Date: __________________

Shared By: