Vermont Assisted Living Facility License

Document Sample
Vermont Assisted Living Facility License Powered By Docstoc
					    Assisted Living Residence Licensure Cover Letter




                                                                     Division of Licensing and Protection
                                                                        103 South Main Street, Ladd Hall
                                                                              Waterbury VT 05671-2306
                                                                              http://www.dlp. vermont.gov
                                                                              VoicelTTY (802)-241-2345
                                                                   To Report Adult Abuse: 800-564-1612
                                                                                      Fax (802)-241-2358




    DATE




    Dear

    Thank you for your interest in Assisted Living Residence licensure. Issuance of a license is based
    on compliance with Assisted Living Residence Regulations and Residential Care Home Regulations
    licensing procedures. Prior to purchasing, constructing, renovating or changing levels please
    review the enclosed Assisted Living Residence Regulations and Residential Care Home
    Regulations carefully. These can also be accessed on line at the Division of Licensing and Protection's
    (DLP) web site: http://www.dlp.vermont.gov. To locate the Regulations click on Care Facility
    Regulations in the left hand column, scroll down until you see the applicable facility type.

    Should you decide to pursue licensure; the following steps need to be completed:

        1.     Complete the enclosed application and 2 (two) tax forms and return the originals to this
               office with a copy of the applicable environmental/zoning permits, and a floor plan of your
               proposed facility illustrating the locations, sizes of rooms, exits and stairways.

       2.      You must provide (3) letters of reference from unrelated persons that address the applicant's
               character and ability to run the facility. You must also submit the manager's name and their
               qualifications that meet the qualifications for the manager of the home outlined in Residential
               Care Home Regulation 4.13.d.

        3.     Submit for review and approval a copy of each of the following:

               a. Admission agreement (see attached sample),

               b. Grievance procedure,




L
APPLICANT'S NAME
Page Two
DATE


     c. Discharge notice (see sample of mandated discharge notice),

     d. Medication administration, and delegation and procedures for handling controlled
        substances,

     e. A copy of your emergency plan, that includes evacuation and sheltering in place.

     f.   A copy of the policies and procedures the facility is responsible for developing,
          revising and maintaining, that govern all aspects of the facility's operation.

4.   In addition to Department of Disabilities, Aging and Independent Living requirements
     noted above, no license can be granted until all required permits are obtained. You need
     to contact:

     a. Waterbury Environmental Conservation, Permits/Compliance and Protection
        Division at (802) 241-3822 in order to coordinate with the appropriate regional
        office regarding their permitting process.

     b. Division of Fire Safety to obtain a Certificate of Occupancy. Please refer to enclosed
        map for the 'district in your area.

5.   The following background checks must be completed on all current and future staff of
     the facility:

     a. Criminal Record Checks -- Contact the Vermont Criminal Information Center at
        (802) 244-8727 for information regarding setting up the criminal record check
        process.

     b. Child Abuse Registry Checks -- Contact the Department of Children & Families at
        (802) 241-2131 for information regarding setting up the child abuse record check
        process.                                                                .

     c. Adult Abuse Registry Checks -- Contact our office at (802) 241-2345 for
        information regarding setting up the adult abuse record check process.

     d. Motor Vehicle Driving Record .- Contact the Department of Motor Vehicles at (802)
        828-2000 for information regarding Motor Vehicle Driver Records.

     e. Federally Excluded Individuals/Entities - Go to the Federal Department of Health
        and Human Services Office ofInspector General's web site at www.oig.hhs.gov
        regarding the on-line search for excluded individuals.
APPLICANT'S NAME
Page Three
DATE

   6.         To be in compliance with the Americans with Disabilities Act, each facility must be
              accessible to and functional for physically handicapped residents, personnel and
              members of the public.

We have included other materials in this packet to provide assistance as you proceed with licensure.
The materials include a sample admission agreement including language used for ACCS
participants and other information on the ACCS program.

As determined by the licensing agency, or per applicant's request, a meeting may be held with staff
ofDLP to provide clarity of the regulatory process.

Once all required information has been submitted, reviewed and approved, you will be contacted to
arrange an initial licensure visit.

Please feel free to contact me at (802) 241-2345 or email me at suzanne.leavitt@ahs.state.vt.us     with
any questions or additional information you might need.

Sincerely,




Suzanne Leavitt, RN, MS
Assistant Director

SL:jl

Enclosures:      License Application
                 2 Tax Forms
                 Public Safety Division Fire Safety Map
                 Background Check Policy
                 Draft Admission Agreement
                 Enrolling as a Medicaid ACCS Provider
                 Employee Variances for Criminal Backgrounds
                 ALR Licensing Regulations
                 RCH Licensing Regulations
                                                                        AGENCY OF HUMAN SERVICES
                                DEPARTMENT OF DISABILITIES, AGING AND INDEPENDENT LIVING
                                                              Division of Licensing and Protection
                                                                 103 South Main Street, Ladd Hall
                                                                        Waterbury VT 05671-2306
                                                                       http://www.dail.vermont.gov
                                                                        Voicemy     (802) 241-2345
                                                            To Report Adult Abuse: 800564-1612
                                                                                Fax (802) 241-2358


                                       LICENSE
                             APPLICATION/REAPPLICATION
I.    IDENTIFYING INFORMATION

      Type Of License Applied For:

      D Assisted    Living Residence: # of Units:              Maximum Occupancy:              _

      D Home      for the Terminally III: # of Beds:                                           _

      D Residential    Care Home: Level III or IV:                 # of Beds:             _

      D Therapeutic       Community Residence: # of Beds:                                  _

      Name of facility:                                                                    _

      Address:    ---------------------------


      Licensee:                                                                            _

      Telephone:                                       Date of application:                    _

      Fax #:                               Email address:
               ---------                                    -------------
      Administrator or manager:                                                           _

II.   PERSONNEL (For all facilities as applicable)
      Name of Director of Nursing or Registered Nurse/Agency providing medication delegation:

      Name of Registered Nurse:                                       License #:               _

      Name of Agency (if applicable):                                                         _

      Address:    ---------------------------
      Phone Number:       ---------------
                                                       1
III.   CRIMINAL AND ADULT ABUSE REGISTRY CHECK
       Answer the following questions by circling YES or NO.
       If yes, list names and addresses of individuals under each question.

       A. Has any individual or organization owning or having more than 5% or more controlling
          interest in the facility been convicted of a criminal offense or had a substantiation of
          abuse, neglect or exploitation?                                YES      NO

          Name:
          Address:                                                                            _

       B. Are there any directors, officers or employees of the home who have had a
          substantiated complaint of abuse, neglect or exploitation? YES     NO

          Name:                                                                               _

          Address:
                     --------------------------
       C. Have Criminal Record Checks and Adult Registry Checks been completed on all staff,
          including the Manager/Administrator?                   YES    NO

IV.    OWNERSHIP

       A. List names and addresses for individuals or organizations having direct ownership or
          controlling interest in the business. Attach a separate page if needed.

          Name:                           Address:




       B. Is the facility a non-profit?    Yes       No

       C. Type of business (check one):
          _   Partnership _    Corporation           _    Sole Owner   _   Other (describe)

          If corporation is checked, list names and addresses of the Directors.
          Attach a separate page if needed.

           Name:                          Address:




                                                          2
V.     FOR REAPPLICATION ONLY Answer the following questions by circling YES or NO.
       Fill in additional information if applicable.

       A. Has there been a change of ownership or control in the past year? YES         NO
          If yes, give date              _
       B. Do you anticipate any change of ownership or control within the next year? YES          NO
          If yes, give date                _
       C. Do you anticipate filing for bankruptcy within the next year?          YES    NO
          If yes, give date                   _
       D. Is the facility operated by a management company, or leased in whole or part by
          another organization?                                            YES     NO
          If yes, name of company/organization                                            _
       E. Has there been a change in administrator/manager within the past year? YES         NO
          If yes, date(s) of change:                      _
          Name of new Manager:                                                                _
       F. Have you increased your bed capacity within the past year?             YES         NO
          If yes, give date of change:                 _
          # of current beds:           # of prior beds:            Current census:            _
       G. Does the facility have a designated special care unit?                       YES   NO
           i. purpose                                        _
          ii. number of beds/units
                                   -----------
       H. Has the nature of services been expanded or any changes anticipated (such as adult
          day care, senior meals site, etc.)?                     YES NO
          If yes, please describe:




VI.    REFERENCES (For initial application only)

       Please provide three (3) letters of reference from unrelated persons. Acceptable references
       will address the applicant's ability to run the facility and the applicant's character.

VII.   PERMITS (For initial application or request for increased licensed capacity, submit the
       following):

       A. Written evidence of compliance with local zoning codes or a statement signed by
          official representatives of the city, town or village clerk that zoning codes have not been
          adopted in the community.

       B. Written eviden.ce of compliance from Environmental Conservation in regard to water
          and sewage systems.



                                                   3
VIII. BUILDING PLANS (For initial application, new construction and/or request for increased
     licensed capacity)

     Building plans/blueprints must be submitted to the Department of Public Safety, Division of
     Fire Safety in your district. Address and phone numbers are included with initial application
     packet.

IX. TWO (2) ORIGINAL TAX FORMS (For initial application and reapplication)
     The applicant and licensee shall be in good standing with the Vermont Department of
     Taxes, pursuant to V.S.A. Section 3113. Failure to do so shall result in denial or revocation
     of license. Submit enclosed tax certification forms with application or reapplication, signed
     and dated.

X.   ASSISTIVE COMMUNITY CARE SERVICES (ACCS)*
     Please answer the following questions by circling YES or NO.

     A. Are you currently enrolled for participation?       YES     NO
     B. If no, do you wish to enroll?                       YES     NO
     C. If yes,
        1. What is the proposed date to begin participation?                                   _
        2. Are there any residents eligible for the program residing in the residence?   YES NO

*Reapplication also indicates reapplication for ACCS Program if you already participate.

The undersigned agrees to comply with the applicable State of Vermont and
Federal Regulations. In making this application for licensure, the undersigned
agrees to submit a written notice to the Vermont Department of Disabilities, Aging
and Independent Living, Division of Licensing and Protection, at least 90 days in
advance of sale or change in ownership of the facility, in the event residents will
be required to move.

I hereby certify that the above statements are made for the purpose of obtaining a
license to operate a facility of the type I have indicated above. Failure to provide
complete, truthful and accurate information as required shall be grounds for
automatic denial or revocation of a License to operate.



SIGNATURE OF LICENSEE or ADMINISTRATOR                   DATE



          RENEWAL APPLICATIONS ARE DUE 45 DAYS PRIOR
              TO THE EXPIRATION DATE OF LICENSE.



                                                 4
                     TAX CERTIFICATION FORM
  VERMONT DEPARTMENT OF DISABILITIES, AGING AND INDEPENDENT LIVING

By law (32 V.S.A. Section 3113) no agency of the state may renew a license or other authority to
conduct a trade or business (including a license to practice a profession) unless the licensee first
certifies, under the pains and penalties of perjury, that he/she is in good standing with the
Department of Taxes. A person is in good standing if no taxes are due and payable and all
returns have been filed, if the liability for any tax that may be due is on appeal, if the taxpayer is
in compliance with a payment plan approved by the Commissioner of Taxes, or if the licensing
authority determines that immediate payment of taxes due and payable would pose an
unreasonable hardship.                                        .

The maximum penalty for perjury is fifteen (15) years in prison, a $10,000 fine or both.

            CERTIFICATION OF COMPLIANCE WITH 32 V.S.A. SECTION 3113

I hereby certify, under the pains and penalties of perjury, that I am in good standing with respect
to, or in full compliance with a plan approved by the Commissioner of Taxes to pay, any and all
taxes due to the State of Vermont as of the date of this application.


          DATE                                            SIGNATURE

NAME OF FACILITY:

IF YOU ARE NOT IN GOOD STANDING AT THIS TIME, YOU MAY DO ONE OF THE
FOLLOWING THREE THINGS:

   1. Discontinue this license or license renewal application;
   2. Arrange with the Vermont Department of Taxes to bring yourself into good standing
      through a payment plan approved by the Commissioner or otherwise;
   3. Seek a determination from the Licensing Agency that immediate payment of taxes due
      and payable would impose an unreasonable hardship.

If you desire to continue this application you should complete the statement below:

                                ALTERNATE CERTIFICATION
I am not in good standing with the Department of Taxes at this time and,
    a) I will arrange with the Department of Taxes to bring myself into good standing, or
    b) Seek a determination that immediate payment would impose an unreasonable hardship.


         DATE                                                  SIGNATURE

Arrangement to achieve good standing should be made by contacting the Department of Taxes at
(802) 828-2518.
                     TAX CERTIFICATION FORM
  VERMONT DEPARTMENT OF DISABILITIES, AGING AND INDEPENDENT LIVING

By law (32 V.S.A. Section 3113) no agency of the state may renew a license or other authority to
conduct a trade or business (including a license to practice a profession) unless the licensee first
certifies, under the pains and penalties of perjury, that he/she is in good standing with the
Department of Taxes. A person is in good standing if no taxes are due and payable and all
returns have been filed, if the liability for any tax that may be due is on appeal, if the taxpayer is
in compliance with a payment plan approved by the Commissioner of Taxes, or if the licensing
authority determines that immediate payment of taxes due and payable would pose an
unreasonable hardship.

The maximum pen~lty for perjury is fifteen (15) years in prison, a $10,000 fine or both.

            CERTIFICATION OF COMPLIANCE WITH 32 V.S.A. SECTION 3113

I hereby certify, under the pains and penalties of perjury, that I am in good standing with respect
to, or in full compliance with a plan approved by the Commissioner of Taxes to pay, any and all
taxes due to the State of Vermont as of the date of this application.


          DATE                                            SIGNATURE

NAME OF FACILITY:

IF YOU ARE NOT IN GOOD STANDING AT THIS TIME, YOU MAY DO ONE OF THE
FOLLOWING THREE THINGS:

    1. Discontinue this license or license renewal application;
    2. Arrange with the Vermont Department of Taxes to bring yourself into good standing
       through a payment plan approved by the Commissioner or otherwise;
    3. Seek a determination from the Licensing Agency that immediate payment of taxes due
       and payable would impose an unreasonable hardship.

If you desire to continue this application you should complete the statement below:

                                ALTERNATE CERTIFICATION
I am not in good standing with the Department of Taxes at this time and,
    a) I will arrange with the Department of Taxes to bring myself into good standing, or
    b) Seek a determination that immediate payment would impose an unreasonable hardship.


         DATE                                                  SIGNATURE

Arrangement to achieve good standing should be made by contacting the Department of Taxes at
(802) 828-2518.




   )
     ~                 VERMONT                                      AGENCY OF HUMAN SERVICES
                          DEPARTMENT      OF DISABILITIES,     AGING AND INDEPENDENT         LIVING

                              BACKGROUND CHECK POLICY
                                  Effective: July 1,2009
I.       Introduction
Performing background checks on individuals who work with vulnerable people is a component
of preventing abuse, neglect and exploitation. This policy describes when a background check is
required, the components of a background check, and what is done if a background check reveals
a potential problem.
Background checks supplement but do not replace reference checks. Background checks should
never be relied upon as a substitute for personal contact with former employers or others who are
in a position to have personal knowledge about the employee's qualifications to work with
vulnerable people.
This policy does not pertain to licensed long-term care facilities (nursing homes, residential care
homes, assisted living residences, therapeutic community residences and homes for the terminally ill).
II.      Definitions
         A. "Background     check" includes all of the following:
             1. A request for information about all substantiated findings of abuse, neglect, and
                exploitation directed to the Department for Children and Families (DCF) child
                abuse registry;
             2. A request for information about all substantiated findings of abuse, neglect, and
                exploitation directed to the Department of Disabilities, Aging and Independent
                Living (DAIL), Division of Licensing and Protection adult abuse registry;
             3. A request for information about all criminal convictions directed to the Vermont
                Crime Information Center (VCIC);
             4. An on-line search of the Exclusions Database of the federal Department of Health
                and Human Services' Office ofInspector General as www.oig.hhs.gov;
             5. For volunteers or employees who will be paid to transport a person by motor
                vehicle, a complete Motor Vehicle Driver Record from the Vermont Department
                of Motor Vehicles.
         B. "Person who receives services" means an individual who receives support and/or
            services through a program administered by the Department of Disabilities, Aging and
            Independent Living (DAIL), including, but not limited to:
             •   Adult Day Services
             •   Attendant Services
             •   Children's Personal Care Services
             •   Choices for Care Medicaid Waiver home-based services
             •   Developmental Disability Services
             •   High Tech Services
             •   Homemaker Services
             •   Traumatic Brain Injury Waiver Services
       C. "Agency or provider" means an organization that operates programs/services
          administered by DAIL for any "person who receives services".
       D. "Employee" means an individual who is employed or contracted by or volunteers for an
          agency/provider (including contracted home providers, shared living providers,
          developmental home providers, adult foster care providers), surrogate, family member or
          person who receives services.
       E. "Volunteer" means an individual who is not paid (at all or more than just a stipend or
          expense reimbursement) but who has the potential for unsupervised interaction with a
          vulnerable adult or child.
III.   Requirements for Background Checks
       A. Background Checks by Long-term Care Facilities
           1. Long-term care facilities are required to conduct background checks as set forth in
              the regulations that govern each facility.
          2. Requests for waivers from those regulations shall be directed to and handled by the
             Division of Licensing and Protection.
       B. Background Checks by Agencies and/or Providers
           1. Background checks are required for all employees who are paid with funds
              administered by DAIL who:
              a. Provide care to a person who receives services; or
              b. Manage funds or services on behalf of a person who receives services.
          2. Background checks are required for any volunteers recruited and placed by an
             agency or provider who have the potential for unsupervised interaction with a
             vulnerable child or adult.
          3. Background checks are recommended for respite employees hired by families
             through Flexible Family Funding, the Dementia Respite Program, the National
             Family Caregiver Support Program (NFCSP) or Flex Funds.
          4. Background checks are recommended for all adults who reside in a,home (such as a
             developmental home or shared living home) when that home receives DAIL funding
             to provide residential supports to an individual.
          5. Any agency or provider employing an individual or supervising a volunteer is
             responsible for ensuring that the required background checks are completed.
          6. If a background check reveals a conviction or a motor vehicle violation, the
             agency/provider must use its discretion about whether to hire or contract with the
             individual.
       C. Background Checks by Intermediary Services Organizations
          1. An Intermediary Services Organization (ISO) is responsible for ensuring that the
             required background checks are conducted for any individuals who will be paid
             through the ISO.
          2. Funds administered by DAIL may not be used to employ, place or contract with a
             person who has:
              a. A substantiated record of abuse, neglect, or exploitation of a child or a vulnerable
                 adult;
             b. Been excluded from participation in Medicaid or Medicare services, programs, or
                facilities by the federal Department of Health and Human Services' Office of the
                Inspector General; and/or,
             c. A criminal conviction for an offense involving bodily injury, abuse of a
                vulnerable person, a felony drug offense, or a property/money crime involving
                violation of a position of trust, including, but not limited to:
                Aggravated assault                     Hate motivated crime
                Aggravated stalking                    Kidnapping
                Aggravated sexual assault              Lewd and lascivious conduct
                Assault and robbery                    Simple assault
                Manslaughter                           Sexual assault
                Assault upon law enforcement           Murder
                Cruelty to children                    Domestic assault
                Arson                                  Stalking
                Extortion                              Embezzlement
                Abuse, neglect, or exploitation        Recklessly endangering another person while
                of a vulnerable adult or child         driving
                Cruelty to Animals
IV.   Payment for Background Checks
Applicants for employment shall not be charged for the costs of background checks covered by
this policy. The costs of background checks are considered part of the administrative costs for an
agency or provider, and are part of the contract for services of an ISO.
V.    Employment Pending Completion of Background Checks
      A. An offer of employment or contract may be made contingent upon a satisfactory
         background check.
      B. An employee, contractor or volunteer may, at the discretion of the employer or
         contracting entity, provide services to a person pending receipt of the results of the
         background check, but under no circumstances mayan employee or contractor be paid
         for longer than sixty (60) days without receipt of a completed background check.
VI.   Periodic Updating of Background      Checks
Subsequent to the initial background check, an agency, provider or ISO shall have a policy for
conducting periodic random checks of employees and volunteers in its employ.
VII. Restriction upon Paying Persons with a History of Substantiated Abuse, Neglect, or
     Exploitation, or History of Certain Crimes
      Funds administered by DAIL may not be used to employ, place or contract with a person
      who has:
      A. A substantiated record of abuse, neglect, or exploitation of a child or a vulnerable adult;
         and/or
      B. Been excluded from participation in Medicaid or Medicare services, programs, or
         facilities by the federal Department of Health and Human Services' Office of the
         Inspector General.
VIII. Waivers
     Waivers from this policy may be granted only under exceptional circumstances.
     A. Agency or Provider
         1. The agency or provider employing or contracting with an employee or supervising a
            volunteer is responsible for the decision to grant a waiver under this policy.
        2. The following factors must be considered in the decision to grant or deny any
           WaIver:
            a. Age of the individual at the time of the crime or substantiation;
            b. Nature and seriousness of the crime (e.g., were there circumstantial reasons; was
               it related to a specific relationship, etc.);
            c. The person's involvement with the criminal justice system and/or child or adult
               abuse, neglect or exploitation systems since the occurrence;
            d. The amount of time that has passed since the substantiation or conviction;
            e. Disclosure to the person receiving services, the surrogate, and the legal guardian
               (if there is one).
         3. Written documentation of the decision to grant a waiver must be made stating the
            rationale for granting the waiver, with reference to each of the factors above, and
            listing any conditions. A copy of the written documentation shall be kept by the
            agency/provider and made available to quality reviewers.
     B. Individual Employers
         1. A home provider (e.g., developmental home, shared living, adult foster care)
            surrogate, family member or person who receives services who seeks a waiver to
            employ or contract with an individual with a record must provide a copy of the
            information in question. The request must be made in writing to:
            Division of Disability and Aging Services
            Department of Disabilities, Aging and Independent Living
            103 South Main Street, Weeks Building
            Waterbury, VT 05671-1601
         2. The following factors may be considered in the decision to grant or deny any waiver:
            a. Age of the individual at the time of the crime or substantiation;
            b. Nature and seriousness of the crime (e.g., were there circumstantial reasons;
               was it r~lated to a specific relationship, etc.);
            c. The person's involvement with the criminal justice system and/or child or adult
               abuse, neglect or exploitation systems since the occurrence;
            d. The amount of time that has passed since the substantiation or conviction;
            e. Disclosure to the person receiving services, the surrogate, and the legal guardian
               (if there is one).
         3. A copy of the decision regarding the waiver request and any supporting documentation
            (including the factors considered) shall be kept in the Department's files.
                           Division of Licensing and Protection
                                         May 2009

                        Variances for Criminal Backgrounds
                     Nursing Homes and Residential Care Homes


   Refer to State of Vermont Licensing and Operating Rules for Nursing Homes Section 3.17
                            Freedom from Restraints and Abuse or
         State of Vermont Residential Care Home Licensing Regulations Section 5.11.c

The decision regarding whether or not to seek a variance is voluntary on the part of the facility.
You may decide not to employ the person. It is up to you, but if you do, you need to seek and
obtain a variance.

Required documentation to submit to DLP

1. A letter from the facility administrator requesting the variance that describes the offence(s)
   and the reasons why the facility is seeking to employ the individual. Include the duties and
   hours of the prospective employee.

2. A copy of the criminal background check that contains the description of the offense and
   when it occurred.

3. A brief statement from the prospective employee that describes the offense and the reasons
   why the person wishes to be employed.

Please note that the variance is granted to the facility and not the individual. Please do not
encourage the prospective employee to contact DLP on his/her own. The variance may be
reviewed or revised by DLP at any time.
Date:
Resident Name:
Address:


Resident Representative:
Address:


                        [Discharge/Transfer]     Notice

Dear

This letter is to notify you that we intend to [discharge/transfer] you from this
home/your room on [date]. The specific reasons for your
[discharge/transfer] are:



You have the right to appeal the decision of discharge/transfer. You
have the right to remain in the home/your room until there is a final
decision on your appeal.
To appeal, you must complete the following steps:
• You or your legal representative must inform the home manager or
  the Director of the Licensing Agency, Frances Keeler that you wish
  to appeal this discharge/transfer notice. You can make this request
  verbally or in writing. You can contact the director of the licensing
  agency at the Division of Licensing and Protection, 103 South Main
  Street, Ladd Hall, Waterbury, VT 05671-2306; phone number 802-
  241-2345.
• You must request the appeal within 10 business days from the date
  you receive this notice.
• At the time you request the appeal, you or your legal representative
  must provide material or information to the Director explaining why
  you disagree with proposed discharge/transfer. You may present
  this material or information verbally if you are unable to do it in
  writing. At your request, the licensing agency will send you any
  material or information it receives from the home explaining why
  they want to discharge/transfer you.
      ASSISTED LIVING RESIDENCE                    AND SERVICE AGREEMENT
This Agreement is made between (Insert Name of Assisted Living Residence here) and (Insert
Narne of Resident here). (If more than one person is signing this Agreement, these terms refer
to each of you individually and both of you together.)

(Insert name of Owner and Operator of ALR here) owns and operates the (Insert Name of
Assisted Living Residence here), located at (Insert Address of Assisted Living Residence here),
to provide residence, care and services to residents. The (Insert Name of Assisted Living
Residence here) is operated on a nondiscriminatory basis and affords equal treatment and access to
services to eligible persons regardless of race, color, religion, sex, national origin, or ancestry.

You have applied for accommodations at (Insert Name of Assisted Living Residence here) and
your application has been accepted. The purpose of this Residence and Service Agreement is to
provide a statement of the services that will be furnished to you and other legal obligations that
will be assumed. This Agreement also sets forth your legal obligations to (Insert Name of
Assisted Living Residence here), both financial and non-financial.

           ARTICLE Ie SERVICES, AMENITIES AND FACILITIES
SECTION Ae BASIC SERVICES
(Insert Name of Assisted Living Residence here) (hereinafter referred to as "The Residence")
will provide you with the following basic services, subject to the terms of this Agreement:
(These services are included in your Monthly Fee, unless otherwise indicated).

1. Living Accommodations
   a. Residence. You have selected to live in apartment # (Insert Apt #), a (Insert sq. ft. & #
       of rooms) apartment at The Residence. You may live in your apartment, subject to the
       terms of this agreement and to the general policies contained in the Resident Handbook.
   b. Utilities. Your Apartment has water, electricity, heat, (include all provided utilities such
       as air conditioning and telephone and cable television hook-ups), the cost of which is
       included in your monthly fee. You will be responsible for (include utilities resident must
       pay for such as telephone and cable service), which will be billed directly to you by the
       responsible agency.
   c. Furnishings. The assisted apartment will contain a living/sleeping area, carpeting, window
       shades, full bath, sink, microwave and refrigerator. If desired and at no additional cost The
       Residence will provide a standard size full or twin bed with bedding. The independent
       apartment will contain a carpeted living area, and sleeping area, window treatments, full
       bath, and a kitchen area with a sink, electric stove/oven appliance, microwave and
       refrigerator. No additional furnishings will be provided. You may furnish your apartment
       with your own furniture. You are also free to use your minor appliances and special
       equipment, provided that safety standards are met. You or your estate will be responsible for
       removing all your furnishings when your apartment is vacated.
   d. Maintenance. Necessary maintenance and repairs of your Apartment are included in the
       monthly fee. However, you will be responsible to pay for any damage and/or repairs not
       caused by normal wear and tear.
   e. Alterations. Any physical change to your apartment requires the prior written approval of the
       Executive Director and shall be made at your expense. If alterations are made, you or your
        estate will be responsible for restoring the apartment to its original physical state when you
        vacate the apartment unless you receive a written exemption from such requirement.
   f.   Common Facilities. All residents share the use of the common areas, including the main
        dining room, a living room, lounge areas, (insert other common space available).

2. Laundry
   Assisted Living Resident: Staff will launder all bed and bath linens and personal laundry on
   a weekly basis.

   Independent Living Resident: Staff will launder all bed and bath linens on a bi-weekly
   basis. You may also receive additional laundry services or laundry services for personal
   clothes for an additional charge. (See Optional Services Fee Schedule.)

3. Housekeeping
   Assisted Living Resident: Staff will provide weekly housekeeping services for your
   apartment, as described in the Resident Handbook.

   Independent Living Resident: Staff will provide bi-weekly housekeeping services for your
   apartment, as described in the Resident Handbook.

4. Meals
   a. Dining Room. Three nutritionally-balanced meals each day, served in the dining room,
      are available. The cost for such meals is included in your monthly fee. Independent living
      residents receive one meal per day; the cost of which is included in the monthly fee. (See
      Optional Services Fee Schedule.)
   b. Tray Service. Tray service to your apartment is available during a temporary illness at no
      extra charge. At your request, optional routine tray service will be provided at an
      additional charge. (See Optional Services Fee Schedule.)
   c. Guests. You may invite guests to any meal. Guest meal charges will be billed on your
      monthly statement. (See Optional Services Fee Schedule.)
   d. Therapeutic Diet. Special diets, if prescribed by your physician, will be provided. A
      qualified dietitian periodically reviews therapeutic diet plans. You will be charged an
      additional fee for special food services and products you request that are not prescribed
      by your physician.

5. Overview
   Nursing overview assures that your health and psychosocial needs are met. The overview
   process includes: observation, assessment, goal setting, education of staff, and the
   development, implementation, and the evaluation of written individualized treatment plan.

6. Planned Activities
   A comprehensive program of social and recreational activities is available both on site and
   off site. You are welcome to participate in such activities as desired.

7. Transportation
   Scheduled transportation for shopping, medical and dental appointments, religious services,
   other errands and planned social events is available. There may be an additional charge for
   transportation services beyond four trips per month. (See Optional Services Fee Schedule.)




                                                  2
8. Fire Protection
   Your apartment is equipped with smoke detectors and a sprinkler system.
9. Emergency Response System/Security
   Your apartment is equipped with a twenty-four (24) hour call system and an emergency call
   button to alert staff to emergencies and illness. There are awake staff for your safety and
   security round the clock.

SECTION B. PERSONAL ASSISTANCE AND CARE
(Insert Name of Assisted Living Resident here) designs a specific and individualized service
plan for each resident based on assessed needs. Each resident participates in a service interview
and a comprehensive assessment to identify individual service needs and preferences. The
Residence is required to conduct the interview and assessment within fourteen days of your
moving in. Up to an hour a day of personal assistance is included as part of the monthly fee for
all Assisted Living residents. Independent Living residents can purchase these services on an as
needed basis. (See Optional Services Fee Schedule.) The following is a list of some of the
services available:
1.   Assistance with showering/bathing, daily dressing, grooming and other personal hygiene activities;
2.   Daily bed-making;
3.   Assistance with ambulating;
4.   Assistance with medications;
The following services are available to all residents at no extra charge:
5. Staff response to emergencies and sudden illnesses, including contacting your physician and
    assisting in transfer to the hospital, if needed;
6. Assistance with arranging transportation to medical appointments;
7. Consultations with staff regarding social, financial, or health-related problems;
8. Assistance to participate with available community resources;
9. On-duty staff member 24 hours per day;
10. Assistance with making of appointments for physical therapy or home health services; and
11. Nutritional supervision.
Services plans are reviewed at least every six (6) months, or more frequently, should your health
status or circumstances change.

SECTION C. OPTIONAL SERVICES
The Residence will make available several optional services at an additional charge, which will
be billed on a monthly basis. Optional services include but are not limited to: (See Optional
Services Fee Schedule.)
1.   Guest meals;
2.   Catering for private events;
3.   Beautylbarber shop services;
4.   Additional laundry and housekeeping services beyond your service plan;
5.   Repairs and maintenance of personal items;
6.   Routine meal tray service, if not prescribed by a physician;
7.   Transportation services beyond 4 trips per month; and
8.   (Add other services as applicable.)

                                                 3
SECTION D. EXCLUDED HEALTH-RELATED                                SERVICES
The Residence shall not be responsible for furnishing or paying for any health-care items or
services not expressly included in this agreement, including but not limited to, physician's
services, psychiatric services, nursing services, podiatry services, surgery, hospital care,
treatment or examination of eyes or teeth, medications, vitamins, eyeglasses, contact lenses,
hearing aids, orthopedic appliances, prosthetic devices, laboratory tests, x-ray services, toiletries
and personal supplies not required to be provided.

Residents may directly engage or contract with any licensed health care provider(s) to obtain
necessary health care services in their apartments.

                           ARTICLE II. RESIDENT RIGHTS
Pursuant to the regulations of the Vermont Department of Aging and Disabilities, as a resident of
an Assisted Living Residence you are assured of having certain rights. A list of those rights is
attached to this agreement.

                     ARTICLE III. TERMS AND OBLIGATIONS
SECTION A. TERM OF AGREEMENT
The term of this agreement shall be for a period of [Insert Time Frame], unless and until it is
terminated as set forth in Article III, Section D.

SECTION B. FEES
1. Entrance or Community Fee
   A one time, non-refundable Community Fee (see attached Fee Schedule) which covers
   admission/administrative costs, a preliminary services coordination plan, move-in assistance,
   and contribution toward the replacement reserve for building improvements, is payable in
   full upon the signing of this agreement. The fee is non-refundable.

2. Last Month's Rent
   The Residence acknowledges receipt of $ (Insert Amount in Dollars here). The "Last
   Month's Rent" shall be deposited in an interest-bearing escrow account according to
   landlord/tenant law. Last month's rent is not a security deposit and is not intended to secure
   performance of any obligation of the resident under this agreement other than last month's
   rent. Upon your vacating the apartment, the balance of Last Month's Rent plus interest
   earned will be returned to you according to Article III, Section D, 4b. of this agreement.

3. Monthly Fee
   Your monthly fee under this agreement is $ (Insert Amount) for basic services. Your first
   monthly fee is payable in full upon signing this agreement. The first monthly fee may be
   prorated based on the date you sign the Residence and Service Agreement. All monthly fees
   following are payable in advance, by the first (l5t) day of each successive calendar month.
   You understand that your right to occupy and use your Apartment and to receive services at
   (Insert Name of Assisted Living Residence here) is contingent upon the timely payment of
   your monthly fee and all other applicable charges and fees due under this agreement.


                                                   4
4. Optional Services
   The charges for all optional services shall be set forth in a separate schedule. (The current
   schedule may be attached to this agreement as "Optional Services Fee Schedule.")

5. Adjustments to Fees or Services
   a. Fees. (Insert Name of Assisted Living Residence here) shall        give you ninety (90) days
      written notice of any change in your monthly fee or in charges     for optional services, as
      described above in Article I, Section C and Article III, Section   B, 4. When a change is
      made in your fees, you will be required to sign a new Resident     and Service Agreement or
      an addendum to this agreement.

   b. Services. The Residence may modify the services provided to you based on results of the
      comprehensive assessment or a negotiated risk process under this agreement upon thirty
      (30) day's written notice, provided that the services or modifications do not restrict
      potential for aging in place. When a change is made in your services, you will be required
      to sign a new Residence and Service Agreement or an addendum to this agreement.

6. Failure to Make Payments
   You will be required to make all payments in a timely manner and otherwise to take care of
   your financial obligations. If you fail to pay your monthly fee or other charges by the tenth
   (loth) day of each calendar month, the Residence may in its discretion, terminate this
   agreement, upon thirty (30) days written notice, under Article III, Section D below.

7. Responsible Party Agreement
   If so required by The Residence, you shall designate an individual the "Responsible Party"
   who has agreed to pay your financial obligations in the event you do not make payments
   when due or make decisions related to your service plan under this agreement. If required,
   you, the Responsible Party and The Residence shall enter into a Responsible Party
   Agreement, which evidences this obligation.

SECTION C. RELOCATION FROM APARTMENT
1. Relocation for More Appropriate Care
   The Residence is intended to be an environment in which residents maintain the highest
   possible level of personal independence for as long as possible. You are encouraged to
   participate in development of a service plan and to remain in your apartment as long as your
   needs for personal independence, your safety and well-being and the safety and well-being of
   the other residents can be met. If the Executive Director determines in consultation with you,
   your family and your physician that you are unable to maintain yourself or your Apartment
   under your current service plan or if you are unable to maintain yourself under a more
   intensive service plan, that includes services from licensed health-care providers, you may be
   asked to move to a more suitable apartment. Residents may directly engage or contract with
   any licensed health care provider to obtain necessary health services in their apartments.

    If you relocate to a new apartment, you shall pay the monthly fee applicable to that
    apartment. If you change to a different service plan, you shall pay the fee applicable to the
    added services involved. When a change is made in your apartment, you will be required to
    sign a new Residence and Service Agreement or an addendum to this agreement.



                                                  5
2. Substitution of Apartment                                                                 .
   The Residence may need to substitute your apartment with another apartment, temporarily, to
   comply with any law or lawful order of any authorized public official, or for any other
   reasonable purpose. Causes for such a substitution could include, but are not limited to,
   extensive repairs, scheduled renovations, infectious diseases, or quarantines. The Residence
   shall make every reasonable effort to substitute your apartment with a comparable apartment.
   When a change is made in your apartment, you will be required to sign a new Residence and
   Service Agreement or an addendum to this agreement.

SECTION D. TERMINATION

1. Termination By Resident
   You may terminate this agreement at any time, with or without cause, by giving the
   Executive Director thirty (30) days prior written notice oftermination.

2. Termination By (Insert Name of ALR here)
   A 30-Day notice is required when:
   1.    The resident's care needs exceed those which the home is licensed or approved through a
         variance to provide; or
   11.   The home is unable to meet the resident's assessed needs; or
   iii. The resident presents a threat to the resident's self or the welfare of other residents or
        staff; or
   IV.   The discharge or transfer is ordered by a court; or
   v: The resident has failed to pay monthly charges for room, board and care in accordance
      with the admission agreement.

   A 90-day notice is required when the Residence's services, rates, retention policies or
   physical plant will change so as to significantly enhance or significantly restrict the potential
   for aging in place.

3. Death of Resident
   This Agreement shall terminate automatically, except for your financial obligations to The
   Residence, upon your death.

4. Refund
   a. Vacating Apartment. Upon any termination of this Agreement described in Article III,
      Section D, you or your estate shall vacate and remove all your property from your
      apartment. You or your estate shall remain liable for the monthly fee until your apartment
      is vacated, all your property is removed from it, and it is restored to its original condition
      (except for normal wear and tear.).

         If your personal property is not claimed or removed within thirty (30) days of your move
         or death, The Residence shall store or dispose of your property, and your estate shall be
         obligated to pay any and all costs of storage or disposition. Any such costs may be
         deducted from any amounts otherwise due as a refund under this Agreement. .


                                                   6
   b. Amount of Refund. Within fourteen (14) days after your apartment has been vacated,
      your property has been removed from it, and it has been restored to its original condition,
      you or your estate shall receive a refund equal to any unused portion of your Last
      Month's Rent plus interest, minus (1) the amount of any unpaid monthly fees or other
      charges that you under this agreement; (2) the costs of any repairs to your apartment not
      caused by normal wear and tear; (3) the cost of any repairs to property that was damaged
      by you; and (4) any expense incurred to remove and/or store your property that was not
      removed when you vacated your apartment. If the amount you owe exceeds the balance
      of your Last Month's Rent, you will be billed for the difference.

5. Couples
   If you are a couple, and one of you dies or permanently vacates your apartment, this
   agreement shall continue in full force and effect and the monthly fee applicable to single
   occupancy of your apartment shall apply. You may be required to sign a new Residence and
   Service Agreement.

SECTION E. YOUR PROPERTY RIGHTS & OBLIGATIONS

1. No Management Or Property Interest
   This Agreement shall give you no property rights or any assets, and no management interest
   in (Insert Name of Corporation and/or Assisted Living Residence)'s personal property
   located at (Insert Address of Assisted Living Residence here), including furnishings
   provided and fixtures in your apartment and in the common areas.

2. Liability For Damage
   You agree to maintain your apartment in a clean, sanitary and orderly condition. You further
   agree to reimburse for any loss of or damage to property owned by the residence inside or
   outside your apartment, caused by you and/or your guest, excluding normal wear and tear.

3. Responsibility For Your Property
   The Residence shall not be responsible for the loss of any personal property belonging to you
   due to theft, fire, or any other cause, unless the loss or damage was caused by the negligence
   of its employees or agents.

4. Liability and Release
   You are responsible for maintaining at all times your own insurance coverage, including
   health, personal property, liability, and automobile.

SECTION F. MISCELLANEOUS

1. Right of Entry
   For your safety and comfort, staff must be permitted to enter your apartment to perform basic
   housekeeping services, respond to emergencies, and make repairs and improvements, as
   necessary or advisable. Therefore, additional locks are not permitted on the entrance door of
   your apartment. Whenever feasible, staff will give you reasonable notice before entering your
   apartment.

                                                7
              ----------------------------------------



2. Overnight Guest Visits
   The resident will notify the Executive Director of any overnight guests and their anticipated
   length of stay. The intent of such a policy is to accommodate stays of short duration up to
   (Insert time frame) by residents' guests, where such stays will not adversely affect the
   operation of the residence.

3. Accuracy Of Application Documents
   As part of your application to The Residence, you have filed an application form and a
   physician's report. You warrant that all information contained in these documents is true and
   correct, and you understand that The Residence has relied on this information in accepting you.

4. Resident Handbook
   You agree to abide by the general policies of The Residence contained in the Resident
   Handbook. You understand that your failure to abide by such rules and regulations may
   result in termination of this agreement. You hereby acknowledge receipt of a copyof the
   current Resident Handbook.

5. Grievance Policy
   All residents and/or their families are encouraged to bring grievances to the attention of the
   Executive Director. Grievances will be responded to in writing within three business days of
   the Executive Director receiving the complaint. All efforts will be made to resolve the
   grievance in the best interest of the Resident as well as the entire community. At any time
   during this process, the Resident has the right to contact the Department of Aging and
   Disabilities, Division of Licensing and Protection at (802) 241-2345 or the State Long Term
   Care Ombudsman Program (802) 863-5620, or the VT Legal Aid (800) 769-7459.

6. Examination Of Records
   You acknowledge with written consent that the Department of Aging and Disabilities, Division
   of Licensing and Protection (DLP), may inspect your records as part of an evaluation of
   (Insert Name of Assisted Living Residence here). The Residence must make records
   available to DLP for purposes of determining that required care and services are available,
   provided and satisfactory. In addition the residence is required to release your health records to
   other health care providers to which you are transferred or from whom you receive treatment,
   and to The Residence's liability carrier or legal counsel.

7. Non-transferability by Resident
   Except with respect to any refund payable to a Resident's estate in accordance with this agreement,
   the rights and privileges of the Resident under this agreement are personal to Resident and cannot be
   transferred or assigned by Resident by a proceeding at law, or otherwise.

8. Pet Policy
   The Residence supports pet ownership. You may maintain a dog, cat or other pet upon the
   approval of and on terms prescribed by the Executive Director. You will be responsible for
   ensuring that your pet is properly cared for and that your pet does not create any disturbance
   or otherwise constitute a nuisance, and agree to comply with written pet policies.




                                                 8
9. Entire Agreement
   This agreement is the entire agreement between you and (Insert Name of Assisted Living
   Residence here) and may be amended only be a written instrument signed by you or your
   legal representative and by an authorized representative of (Insert Name of Assisted Living
   Residence here). If any part of this Agreement is held to be invalid or unenforceable, the
   reset of the Agreement shall remain .valid and enforceable. This agreement is not assignable
   by you without prior written consent of (Insert Name of Assisted Living Residence here).

   (Insert Name of Assisted Living Residence here) will comply with applicable federal and
   state laws and regulations concerning consumer protection and protection from abuse,
   neglect and financial exploitation of the elderly and disabled.

10. Governing Law
This Agreement shall be governed by the laws of the State of Vermont. This Agreement shall be
    effective as of                      , 20__




   Resident                                                Date




   Resident                                                Date


   (Insert Name of Assisted Living Residence here)


   By:                                             _
                                                           Date

   Title:




                                               9

				
DOCUMENT INFO
Categories:
Tags:
Stats:
views:8
posted:8/8/2012
language:English
pages:24
PermitDocsPrivate PermitDocsPrivate http://
About