admission and discharge summary...admission and discharge summary resident name sex station/roombed...

ADMISSION AND DISCHARGE SUMMARY RESIDENT NAME SEX STATION/ROOMBED MED REC NO. ORIGINAL ADMIT DATE CURRENT ADMIT DATE DISCHARGE

NICKNAME DATE OF BIRTH AGE MARITAL STATUS

SSN PAY TYPE LEVEL OF CARE

PLACE OF BIRTH CITIZEN RACE/ NATIONALITY

RELIIGION

MEDICAID/MEDI-CAL NO COUNTY MEDICARE NO. BC/BS VA INS. INS.

SPOUSE ADDRESS CITY STATE ZIP PHONE

W H

RESPONSIBLE PARTY (RELATION) ADDRESS CITY STATE ZIP PHONE

W H

EMERGENCY CONTACT (RELATION) ADDRESS CITY STATE ZIP PHONE

W H

EMERGENCY CONTACT (RELATION) ADDRESS CITY STATE ZIP PHONE

W H

PHYSICIAN ADDRESS CITY STATE ZIP PHONE

ALTERNATE PHYSICIAN ADDRESS CITY STATE ZIP PHONE

DENTIST ADDRESS CITY STATE ZIP PHONE

PHARMACY PHONE ALLERGIES REHAB POTENTIAL PROGNOSIS

FUNERAL HOME / MORTUARY PHONE ADMITTED FROM PHONE HOW TRANSFERRED DATES OF STAY

ADMITTING DIAGNOSES (PRIMARY AND SECONDARY) PRIMARY:

CODE STATUS RESIDENT IS AWARE OF PRIMARY DIAGNOSIS: REASONS: HOSPITAL PREFERENCE PHONE AMBULANCE PREFERENCE PHONE

NAME OF CHURCH PHONE CLERGY PHONE

POWER OF ATTORNEY PHONE EDUCATION LEVEL PRIMARY LANGUAGE

PREVIOUS OCCUPATION INDUSTRY NURSING ALERT

PREVIOUS ADDRESS CITY/STATE/ZIP COMMENTS

DISCHARGE DIAGNOSIS

DISCHARGED: WITH APPROVAL AGAINST APPROVAL TRANSFERRED DIED: __________________ NO. OF DAYS STAYED: ___________________________________ (DATE AND TIME)

DISCHARGE TO: OWN HOME FRIEND / RELATIVE’S HOME HOSPITAL OTHER FACILITY: ___________________________________________________________________

REVIEWED BY: ___________________________________________________________________ DATE: _________________ (SIGNATURE) (TITLE)

RESIDENT NAME SEX STATION/ROOM/BED ADMISSION NO ORIGINAL ADMIT DATE CURRENT ADMIT DATE DISCHARGE

CDPH 327 (05/11)

CALIFORNIA ADMISSION AGREEMENT CHECKLIST

Resident Name: ________________________ Admit Date: ___________

1. California Standardized Admission Agreement for SNF’s

2. Attachment A – Facility Owner and Licensee Identification

3. Attachment B-1 – Supplies and Services Included in Basic Daily Rate for Private Pay & Privately Insured Residents

4. Attachment B-2 – Optional Supplies and Services Not Included in Basic Daily Rate for Private Pay & Privately Insured Residents

5. Attachment C-1 – Supplies and Services Included in Basic Daily Rate for Medi-Cal Residents

6. Attachment C-2 – Supplies and Services NOT Included in the Medi-Cal Basic Daily Rate That Medi-Cal Will Pay the Dispensing Provider For Separately

7. Attachment C-3 – Optional Supplies and Services NOT Covered by Medi-Cal That May Be Purchased By Medi-Cal Residents

8. Attachment D-1 – Supplies and Services Covered by the Medicare Program for Medicare Residents

9. Attachment D-2 - Optional Supplies and Services NOT Covered by Medicare that may be purchased by Medicare Residents

10. Attachment E – Authorization for Disclosure of Medical Information

11. Attachment F – Resident Bill of Rights

Admission Completed By: _______________________ Date: ___________

Notes:

CDPH 327 (05/11)

CALIFORNIA STANDARD ADMISSION AGREEMENT FOR SKILLED NURSING FACILITIES

AND INTERMEDIATE CARE FACILITIES

State of California Health and Human Services Agency

Department of Public Health

State of California – Health and Human Services Agency California Department of Public Health

CDPH 327 (05/11) i

CALIFORNIA STANDARD ADMISSION AGREEMENT FOR SKILLED NURSING FACILITIES

AND INTERMEDIATE CARE FACILITIES

TABLE OF CONTENTS

I. Preamble

II. Identification of Parties to this Agreement

III. Consent to Treatment

IV. Your Rights as a Resident

V. Financial Arrangements A. Charges for Private Pay Residents B. Security Deposits C. Charges for Medi-Cal, Medicare, or Insured Residents D. Billing and Payment E. Payment of Other Refunds Due To You

VI. Transfers and Discharge

VII. Bed Holds and Readmission

VIII. Personal Property and Funds

IX. Photographs

X. Confidentiality of Your Medical Information

XI. Facility Rules and Grievance Procedure

XII. Entire Agreement and Signature Page


CDPH 327 (05/11) ii

CALIFORNIA STANDARD ADMISSION AGREEMENT

FOR SKILLED NURSING FACILITIES AND INTERMEDIATE CARE FACILITIES

TABLE OF CONTENTS

(continued) ATTACHMENT A – Facility Owner and Licensee Identification

ATTACHMENT B-1 – Supplies and Services Included in the Basic Daily

Rate for Private Pay and Privately Insured Residents

ATTACHMENT B-2 – Optional Supplies and Services Not Included in the

Basic Daily Rate for Private Pay and Privately Insured Residents

ATTACHMENT C-1 – Supplies and Services Included in the Basic Daily

Rate for Medi-Cal Residents

ATTACHMENT C-2 – Supplies and Services NOT Included in the Medi-Cal

Basic Daily Rate That Medi-Cal Will Pay the Dispensing Provider

For Separately

ATTACHMENT C-3 – Optional Supplies and Services Not Covered By

Medi-Cal That May Be Purchased By Medi-Cal Residents

ATTACHMENT D-1 – Supplies and Services Covered By the Medicare

Program For Medicare Residents

ATTACHMENT D-2 – Optional Supplies and Services Not Covered By

Medicare That May Be Purchased By the Medicare Residents

ATTACHMENT E – Authorization for Disclosure of Medical Information

ATTACHMENT F – Resident Bill of Rights


CDPH 327 (05/11) -1-

Resident Name: ________________________________________________________

Admission Date: __________________ Resident Number: ____________________

Facility Name: _________________________________________________________

CALIFORNIA STANDARD ADMISSION AGREEMENT FOR SKILLED NURSING FACILITIES AND INTERMEDIATE CARE FACILITIES

I. Preamble

The California Standard Admission Agreement is an admission contract that this Facility is required by state law and regulation to use. It is a legally binding agreement that defines the rights and obligations of each person (or party) signing the contract. Please read this Agreement carefully before you sign it. If you have any questions, please discuss them with Facility staff before you sign the agreement. You are encouraged to have this contract reviewed by your legal representative, or by any other advisor of your choice, before you sign it.

You may also call the Office of the State Long Term Care Ombudsman at 1-800-231-4024, for more information about this Facility. The report of the most recent state licensing visit to our facility is posted ________________________________________, and a copy of it or of reports of prior inspections may be obtained from the local office of the California Department of Public Health (CDPH), Licensing and Certification Division _______________________________________. (Location of District Office)

If our facility participates in the Medi-Cal or Medicare programs, we will keep survey certification and complaint investigation reports for the past three years and will make these reports available for anyone to review upon request.

If you are able to do so, you are required to sign this Agreement in order to be admitted to this Facility. If you are not able to sign this Agreement, your representative may sign it for you. You shall not be required to sign any other document at the time of, or as a condition of, admission to this Facility.

II. Identification of Parties to this Agreement

DEFINITIONS

In order to make the Agreement more easily understood, references to “we,” “our,” “us,” “the Facility,” or “our Facility” are references to:

(Insert the Name of the Facility as it appears on its License)


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Attachment A provides you with the name of the owner and licensee of this facility, and the name and contact information of a single entity responsible for all aspects of patient care and operation at this facility.

References to “you,” “your,” “Patient,” or “Resident” are references to ___________________________________________, the person who will be receiving care in this Facility. For purposes of this Agreement, “Resident” has the same meaning as “Patient.”

The parties to this agreement are the Resident, the Facility, and the Resident’s Representative. References to the “Resident’s Representative” are references to: ____________________________________________, the person who will sign on your behalf to admit you to this Facility, and/or who is authorized to make decisions for you in the event that you are unable to. To the extent permitted by law, you may designate a person as your Representative at any time.

Note: the person indicated as your “Resident’s Representative” may be a family member, or by law, any of the following: a conservator, a person designated under the Resident’s Advance Health Care Directive or Power of Attorney for Health Care, the Resident’s next of kin, any other person designated by the Resident consistent with State law, a person authorized by a court, or, if the Resident is a minor, a person authorized by law to represent the minor.

Signing this Agreement as a Resident’s Representative does not, in and of itself, make the Resident’s Representative liable for the Resident’s debts. However, a Resident’s Representative acting as the Resident’s financial conservator or otherwise responsible for distribution of the Resident’s monies, shall provide reimbursements from the Resident’s assets to the Facility in compliance with Section V. of the agreement.

IF OUR FACILITY PARTICIPATES IN THE MEDI-CAL OR MEDICARE PROGRAM, OUR FACILITY DOES NOT REQUIRE THAT YOU HAVE ANYONE GUARENTEE PAYMENT FOR YOUR CARE BY SIGNING OR COSIGNING THIS ADMISSION AGREEMENT AS A CONDITION OF ADMISSION.

The Parties to this Agreement are:

Resident: ______________________________________________________ (Type or Print Resident’s Name Here)

Resident’s Representative: ________________________________________ (Type or Print Representative’s Name Here)

Relationship: _________________________________

Facility: _______________________________________________________ (Type or Print Facility’s Name as it appears on the License)


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III. Consent to Treatment The Resident hereby consents to routine nursing care provided by the Facility, as well as emergency care that may be required. However, you have the right, to the extent permitted by law, to refuse any treatment and the right to be informed of potential medical consequences should you refuse treatment. We will keep you informed about the routine nursing and emergency care we provide to you, and we will answer your questions about the care and services we provide you. If you are, or become, incapable of making your own medical decisions, we will follow the direction of a person with legal authority to make medical treatment decisions on your behalf, such as a guardian, conservator, next of kin, or a person designated in an Advance Health Care Directive or Power of Attorney for Health Care. Following admission, we encourage you to provide us with an Advance Health Care Directive specifying your wishes as to the care and services you want to receive in certain circumstances. However, you are not required to prepare one, or to provide us a copy of one, as a condition of admission to our Facility. If you already have an Advance Health Care Directive, it is important that you provide us with a copy so that we may inform our staff. If you do not know how to prepare an Advance Health Care Directive and wish to prepare one, we will help you find someone to assist you in doing so. IV. Your Rights as a Resident Residents of this Facility keep all their basic rights and liberties as a citizen or resident of the United States when, and after, they are admitted. Because these rights are so important, both federal and state laws and regulations describe them in detail, and state law requires that a comprehensive Resident Bill of Rights be attached to this Agreement. Attachment F, entitled “Resident Bill of Rights,” lists your rights, as set forth in State and Federal law. For your information, the attachment also provides the location of your rights in statute. Violations of state laws and regulations identified above may subject our Facility and our staff to civil or criminal proceedings. You have the right to voice grievances to us without fear of any reprisal, and you may submit complaints or any questions or concerns you may have about our services or your rights to the local office of the California Department of Public Health, Licensing and Certification District Office _________________________, or the State Long-Term Care Ombudsman (see page 1 for contact information) You should review the attached “Resident Bill of Rights” very carefully. To acknowledge that you have been informed of the “Resident Bill of Rights,” please sign here:_____________________________________________________


CDPH 327 (05/11) -4-

V. Financial Arrangements

Beginning on ________________ (date), we will provide routine nursing and emergency care and other services to you in exchange for payment.

Our Facility has been approved to receive payment from the following government insurance programs: X Medi-Cal X Medicare

At the time of admission, payment for the care we provide to you will be made by:

______ Resident (Private Pay) ______ Medi-Cal ______ Medicare Part A Medicare Part B: ______________ ______ Private Insurance: _________________________________

(Enter Insurance Company Name and Policy Number)

______ Managed Care Organization: ________________________ ______ Other: ___________________________________________

Resident’s Share of Cost. Medi-Cal, Medicare, or private payor may require that the Resident pay a co-payment, co-insurance, or a deductible, all of which the Facility considers to be the Resident’s share of cost. Failure by the Resident to pay his or her share of cost is grounds for involuntary discharge of the Resident.

If you do not know whether your care in our Facility can be covered by Medi-Cal or Medicare, we will help you get the information you need. You should note that, if our Facility does not participate in Medi-Cal or Medicare and you later want these programs to cover the cost of your care, you may be required to leave our Facility.

[APPLICABLE ONLY IF DATE IS ENTERED:] On _____________ (date) our Facility notified the California Department of Health Care Services of our intent to withdraw from the Medi-Cal Program. If you are admitted after that date, we cannot accept Medi-Cal reimbursement on your behalf, and we will not be required to retain you as a Resident if you convert to Medi-Cal reimbursement during your stay here. If, on the other hand, you were a Resident here on that date, we are required to accept Medi-Cal reimbursement on your behalf, even if you become eligible for Medi-Cal reimbursement after that date.

YOU SHOULD BE AWARE THAT NO FACILITY THAT PARTICIPATES IN THE MEDI-CAL PROGRAM MAY REQUIRE ANY RESIDENT TO REMAIN IN PRIVATE PAY STATUS FOR ANY PERIOD OF TIME BEFORE CONVERTING TO MEDI-CAL COVERAGE. NOR, AS A CONDITION OF ADMISSION OR CONTINUED STAY IN SUCH A FACILITY, MAY THE FACILITY REQUIRE ORAL OR WRITTEN ASSURANCE FROM A RESIDENT THAT HE OR SHE IS NOT ELIGIBLE FOR, OR WILL NOT APPLY FOR, MEDICARE OR MEDI-CAL BENEFITS.


CDPH 327 (05/11) -5-

A. Charges for Private Pay Residents

Our Facility charges the following basic daily rates:

$________________ for a private, single bed room

$________________ for a room with two beds

$________________ for a room with three beds

$________________ for __________________________________ (Specify any other accommodation here)

The basic daily rate for private pay and privately insured Residents includes payment for the services and supplies described in Attachment B-1.

The basic daily rate will be charged for the day of admission, but not for any day beyond the day of discharge or death. However, if you are voluntarily discharged from the Facility less than 3 days after the date of admission, we may charge you for a maximum of 3 days at the basic daily rate.

We will provide you with a 30-day written notice before increasing the basic daily rate, unless the increase is required because the State increases the Medi-Cal rate to a level higher than our regular rate. In this case, state law waives the 30-day notification.

Attachment B-2 lists for private pay and privately insured Residents optional supplies and services not included in our basic daily rate, and our charges for those supplies and services. We will only charge you for optional supplies and services that you specifically request, unless the supply or service was required in an emergency. We will provide you a 30-day written notice before any increase in charges for optional supplies and services.

If you become eligible for Medi-Cal at any time after your admission, the services and supplies included in the daily rate may change, and also the list of optional supplies and services. At the time Medi-Cal confirms it will pay for your stay in this Facility, we will review and explain any changes in coverage.

B. Security Deposit

If you are a private pay or privately insured Resident, we require a security deposit of _________.

We will return the security deposit to you, with no deductions for administration or handling charges, within 14 days after you close your private account or we receive payment from Medi-Cal, whichever is later.


CDPH 327 (05/11) -6-

If your care in our Facility is covered by Medi-Cal or Medicare, no security deposit is required.

C. Charges for Medi-Cal, Medicare, or Insured Residents

IF YOU ARE APPROVED FOR MEDI-CAL COVERAGE AFTER YOU ARE ADMITTED TO OUR FACILITY, YOU MAY BE ENTITLED TO A REFUND. WE WILL REFUND TO YOU ANY PAYMENTS YOU MADE FOR SERVICES AND SUPPLIES THAT ARE LATER PAID FOR BY MEDI-CAL, LESS ANY DEDUCTIBLE OR SHARE OF COST. WHEN OUR FACILITY RECEIVES PAYMENT FROM THE MEDI-CAL PROGRAM, WE WILL ISSUE A REFUND TO YOU.

If you are entitled to benefits under Medi-Cal, Medicare, or private insurance, and if we are a participating Provider, we agree to accept payment from them for our basic daily rate. NEITHER YOU NOR YOUR REPRESENTATIVE SHALL BE REQUIRED TO PAY PRIVATELY FOR ANY MEDI-CAL COVERED SERVICES PROVIDED TO YOU DURING THE TIME YOUR STAY HAS BEEN APPROVED FOR PAYMENT BY MEDI-CAL. UPON PRESENTATION OF THE MEDI-CAL CARD OR OTHER PROOF OF ELIGIBILITY, THE FACILITY SHALL SUBMIT A MEDI-CAL CLAIM FOR REIMBURSEMENT. However, you are still responsible for paying all deductibles, copayments, coinsurance, and charges fro services and supplies that are not covered by Medi-Cal, Medicare, or your insurance. Please note that our Facility does not determine the amount of any deductible, copayment, or coinsurance you may be required to pay: rather, Medi-Cal, Medicare or your insurance carrier determines these amounts.

Attachments C-1, C-2, and C-3 describe the services covered by the Medi-Cal daily rate, services that are covered by Medi-Cal but are not included in the daily rate, and services that are not covered by Medi-Cal but are available if you wish to pay for them.

Attachment D-1 and D-2 describe the services covered by Medicare, and services that are not covered by Medicare but are available if you wish to pay for them.

You should note that Medi-Cal will only pay for covered supplies and services if they are medically necessary. If Medi-Cal determines that a supply or service is not medically necessary, we will ask whether you still want that supply or service and if you are willing to pay for it yourself.

We will only charge you for optional supplies and services that you specifically request, unless the supply or services was required in an emergency. We will provide you a 30-day written notice before any increase in charges for optional supplies and services.


CDPH 327 (05/11) -7-

D. Billing and Payment

We will provide to you an itemized statement of charges that you must pay every month. You agree to pay the account monthly on ___________________ (enter day of month).

Payment is overdue _________ days after the due date. A late charge at an interest rate of _____% is charged on past due accounts and is calculated as follows: __________________________________________________________ __________________________________________________________

E. Payment of Other Refunds Due to You

As indicated in Section V.C. above, refunds may be due to you as a result of Medi-Cal paying for services and supplies you had purchased before your eligibility for Medi-Cal was approved or for any security deposit you may have made. At the time of your discharge, you may also be due other refunds, such as unused advance payments you may have made for optional services not covered by the daily rate. We will refund any money due to you within 14 days of your leaving our Facility. We will not deduct any administration or handling charges from any refund due to you.

VI. Transfers and Discharges

We will help arrange for your voluntary discharge or transfer to another facility.

Except in an emergency, we will not transfer you to another room within our Facility, or to another facility, and we will not discharge you from our Facility against your wishes, unless we give prior reasonable written notice to you, determined on a case by case basis, in accord with applicable state and federal requirements. For example, you have a right to refuse the transfer if the purpose of the transfer is to move you to or from a Medicare-certified bed.

Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance. However, we may provide less than 30 days notice if the reason for the transfer or discharge is to protect your health and safety or the health and safety of other individuals, if your improved health allows for a shorter notice, or if you have been in our Facility for less than 30 days. Our written notice will include the effective date, the location to which you will be transferred or discharged, and the reason the action is necessary.

The only reasons that we can transfer you to another facility or discharge you against your wishes are:

1). It is required to protect your well-being, because your needs cannot be met in our Facility;

2). It is appropriate because your health has improved enough that you no longer need the services of our Facility;


CDPH 327 (05/11) -8-

3). Your presence in our Facility endangers the health and safety of other individuals;

4). You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance;

5). Our Facility ceases to operate;

6). Material or fraudulent misrepresentation of your finances to us.

If we participate in Medi-Cal or Medicare, we will not transfer you from the Facility or discharge you solely because you change from private pay or Medicare to Medi-Cal payment.

In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman.

If you are transferred or discharged against your wishes, we will provide transfer and discharge planning as required by law.

VII. Bed Holds and Readmission

If you must be transferred to an acute hospital for seven days or less, we will notify you or your representative that we are willing to hold your bed. You or your representative have 24 hours after receiving this notice to let us know whether you want us to hold your bed for you.

If Medi-Cal is paying for your care, then Medi-Cal will pay for up to seven days for us to hold the bed for you. If you are not eligible for Medi-Cal and the daily rate is not covered by your insurance, then you are responsible for paying $________ for each day we hold the bed for you. You should be aware that Medicare does not cover costs related to holding a bed for you in these situations.

If we do not follow the notification procedure described above, we are required by law (Title 22 California Code of Regulations Sections 72520(c) and 73504(c)) to offer you the next available appropriate bed in our Facility.

You should also note that, if our Facility participates in Medi-Cal and you are eligible for Medi-Cal, if you are away from our Facility for more than seven days due to hospitalization or other medical treatment, we will readmit you to the first available bed in a semi-private room if you need the care provided by our Facility and wish to be readmitted.


CDPH 327 (05/11) -9-

VIII. Personal Property and Funds

Our Facility has a theft and loss prevention program as required by state law. At the time you are admitted, we will give you a copy of our policies and procedures regarding protection of your personal property, as well as copies of the state laws that require us to have these policies and procedures.

If our Facility participates in Medi-Cal or Medicare and you give us your written authorization, we will agree to hold personal funds for you in a manner consistent with all federal and state laws and regulations. If we are not certified for Medi-Cal or Medicare, we may offer these services but are not required to. You are not required to allow us to hold your personal funds for you as a condition of admission to our Facility. At your request, we will provide you with our policies, procedures, and authorization forms related to our holding your personal funds for you. Please see VIII Addendum.

IX. Photographs & Video Surveilance

You agree that we may take photographs of you for identification and health care purposes. We will not take a photograph of you for any other purpose, unless you give us your prior written permission to do so.

X. Confidentiality of Your Medical Information

You have a right to confidential treatment of your medical information. You may authorize us to disclose medical information about you to a family member or other person by completing the “Authorization for Disclosure of Medical Information” form in Attachment E.

XI. Facility Rules and Grievance Procedure

You agree to comply with reasonable rules, policies and procedures that we establish. When you are admitted, we will give you a copy of those rules, policies, and procedures, including a procedure for you to suggest changes to them.

A copy of the Facility grievance procedure, for resolution of resident complaints about Facility practices, is available; we will also give you a copy of our grievance procedure for resolution of any complaints you may have about our Facility. You may also contact the following agencies about any grievance or complaint you may have:

California Department of Public Health Licensing and Certification District Office Phone number: _________________________

(OR)

State Long-Term Care Ombudsman Program Phone number: 408-944-0567


CDPH 327 (05/11) -10-

XII. Entire Agreement

This Agreement and the Attachments to it constitute the entire Agreement between you and us for the purposes of your admission to our Facility. There are no other agreements, understandings, restrictions, warranties, or representations between you and us as a condition of your admission to our Facility. This Agreement supersedes any prior agreements or understandings regarding your admission to our Facility.

All captions and headings are for convenience purposes only, and have no independent meaning.

If any provision of this Agreement becomes invalid, the remaining provisions shall remain in full force and effect.

The Facility’s acceptance of a partial payment on any occasion does not constitute a continuing waiver of the payment requirements of the Agreement, or otherwise limit the Facility’s rights under the Agreement.

This Agreement shall be construed according to the laws of the State of California.

Other than as noted for a duly authorized Resident’s Representative, the Resident may not assign or otherwise transfer his or her interests in this Agreement.

Upon your request, we shall provide you or your legal representative with a copy of the signed agreement, all attachments and any other documents you sign at admission and shall provide you with a receipt for any payments you make at admission.

By signing below, the Resident and the Facility agree to the terms of this Admission Agreement:

________________________________________ ____________ Representative of the Facility Date

________________________________________ ____________ Resident Date

________________________________________ ____________ Resident’s Representative – if applicable Date


CDPH 327 (05/11) -1-

ATTACHMENT A

Facility Owner and Licensee Identification

The owner and licensee of _______________________________________is: (Name of Facility)

___________________________________________________________________. (Name of Owner/Licensee)

If you have any questions concerning any aspect of patient care in this facility, or about the operation of this facility, you may contact:

(Name of Individual/Entity Responsible for Patient Care and Facility Operation)

Address: ___________________________________________________________

___________________________________________________________

___________________________________________________________

Telephone: ___________________________________________________________


CDPH 327 (05/11) -1-

ATTACHMENT B-1

Supplies and Services Included in the Basic Daily Rate for Private Pay and Privately Insured Residents

24-Hour Comprehensive Nursing Care

Personal Laundry Services (Dry Cleaning Excluded)

Building Security System

Three Meals Per Day Plus Snacks

Telephone/Cable or Satellite Ready Rooms

Assistance with Daily Activities/Personal Care

Incontinent Supplies Including Briefs

Restorative Aide Nursing / Ambulation Program

Maintenance Services

Restorative Aide Services

Medical Records Services

Bath Basins

Emesis Basins

Medication Administration

Daily Activities / Bi-Monthly Resident Shopping

Special Diet Needs

Social and Advocacy Services

Discharge Planning

Personal Toiletry Items

Resident Care Plans / Conferences

Linen and Bedding

Housekeeping Services

Restorative Feeding Program

Non-Sterile Tongue Depressors

Bed Pans / Urinals

Water Pitcher


CDPH 327 (05/11) -1-

ATTACHMENT B-2

Optional Supplies and Services Not Included in the Basic Daily Rate for Private Pay and Privately Insured Residents

Description of Supply or Service Price

Ancillary Services • Physical Therapy• Occupational Therapy• Speech Therapy

Prices available from the Business Office

Wound Care Supplies Prices available from the Business Office

Beauty Shop Services Prices available from the Business Office

Central Supplies • Accuchecks• Insulin Syringes• NG Tube• Wanderguards

Prices available from the Business Office

Medical Supplies Prices available from the Business Office

Pharmacy charges vary with medications ordered by physician Prices available from the Business Office

Enteral feeding supplies and delivery system - varies Prices available from the Business Office

Other Services: • Podiatry Care• Dental Care• Optometry• Audiology

Billed by Outside Provider, can vary * Inquire with Social Services


CDPH 327 (05/11) -1-

ATTACHMENT C-1

Supplies and Services Included in the Basic Daily Rate for Medi-Cal Residents

Nursing services Variable height beds Respiratory therapy Emergency oxygen and other equipment Personal hygiene items and services, such as: • Denture cleaners• Denture adhesives• Dental floss• Oral cleansing swabs• Hair combs and brushes• Lotions• Shaving soaps/creams• Toothbrushes and toothpaste• Laundry• Tissue wipes• Shaves• Shampoos• Periodic hair trim• Periodic nail trimCommonly used items of equipment, supplies and services used for medical and nursing care, such as: • Standard wheelchair (not exclusively for individual patient use)• Incontinence suppliesMaintenance therapies • Range of motion• Getting patients out of bed• Providing activities• Changing position in bed• Assisting with self-care and activities of daily living• Maintenance of proper body alignment and joint movementNon-legend drugs, such as: • Aspirin• Acetaminophen• Cough Syrup

Room and board


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ATTACHMENT C-2

Supplies and Services NOT Included in the Medi-Cal Basic Daily Rate That Medi-Cal Will Pay the Dispensing Provider For Separately

Physician services Optometry services Dental services Audiology services Durable medical equipment, other than as listed in Attachment C-1 • Specialty anti-decubitus beds / cushions• Oxygen concentrators and accessories• Intermittent Positive Pressure Breathing (IPPB) equipment• Oxygen, except emergency, including administration sets and tanks• Custom equipment for individual patient use (cane, crutches, wheelchair), including

parts and repairs• MacLaren or Pogon Buggy• Osteogenesis stimulator device• Precontoured structures (VASCO-PASS, cut out foam)• Variable height beds

Therapy services provided by a licensed therapist, identified in the Minimum Data Set (MDS) and included in the patient’s plan of care

• Physical therapy• Occupational therapy• Speech therapy

Chiropractic services Laboratory services Outpatient heroin detoxification services Organized outpatient clinic services Home health agency services Radioisotope services Prayer or spiritual healing Rehabilitation center outpatient services Prosthetic and orthotic appliances

(continued on next page)


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ATTACHMENT C-2 (continued)

Supplies and Services NOT Included in the Medi-Cal Basic Daily Rate That Medi-Cal Will Pay the Dispensing Provider For Separately

Hospital outpatient department services Chronic hemodialysis Podiatry services Psychology Radiology (x-rays) Early and periodic screening services Hearing aids Blood and blood derivatives Nurse anesthetist services Inpatient hospital services Eyeglasses, prosthetic eyes, and other eye appliances Pharmaceutical services and prescribed drugs • Insulin• Legend drugsMedical supplies, other than those listed in Attachment C-1 • IV trays• IV tubing• Blood infusion sets• Nasal cannula• Reagent testing sets (urine testing)Other equipment and supplies for which prior authorization has been granted to

another provider Short-Doyle Medi-Cal provider services (mental health) Traction equipment and accessories Transportation

***

*

* May be billed by outside services.


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ATTACHMENT C-3

Optional Supplies and Services NOT Covered By Medi-Cal That May Be Purchased By Medi-Cal Residents

Description of Supply or Service

Price

Allied Health Services ordered by the attending physician, excluding respiratory therapy

Billed by Outside Provider

Alternating pressure mattresses/pads with motor Billed by Outside Provider

Atmospheric oxygen concentrators and enrichers with accessories


Blood, plasma, and substitutes Billed by Outside Provider

Dental Services Billed by Outside Provider

Durable Medical Equipment as specified in CCR 51321 Billed by Outside Provider

Insulin Billed by Outside Provider

Intermittent positive pressure breathing equipment Billed by Outside Provider

Intravenous trays, tubing, and blood infusion sets Billed by Outside Provider

Laboratory Services Billed by Outside Provider

Legend Drugs Billed by Outside Provider

Liquid Oxygen Systems Billed by Outside Provider

MacLaren or Pogon Buggy Billed by Outside Provider

Medical Supplies as specified in CCR 59998 Billed by Outside Provider

Nasal Cannula Billed by Outside Provider

Osteogenesis Stimulator Billed by Outside Provider

Parts and labor for repairs of durable equipment owned by the beneficiary


Physicians Services Billed by Outside Provider

Portable gas oxygen system and accessories Billed by Outside Provider


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Pre-contoured structures Billed by Outside Provider

Prescribed prosthetic and orthotic devices for exclusive use of Resident


Reagent testing sets Billed by Outside Provider

Therapeutic air/fluid support systems/beds Billed by Outside Provider

Traction equipment and accessories Billed by Outside Provider

X-Rays Billed by Outside Provider

Not included in the payment rate nor in the Medi-Cal schedule of benefits are personal items such as cosmetics, tobacco products and accessories, beauty shop services (other than shaves or shampoos performed by Facility staff as part of the Resident care and periodic hair trims).



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ATTACHMENT D-1

Supplies and Services Covered By the Medicare Program For Medicare Residents

The Medicare Program is administered by the federal government, and the federal government defines what supplies and services are covered under the basic daily rate and what additional supplies and services may be available to the Resident that Medicare will pay the dispensing provider for.

The following two pages were excerpted from the brochure entitled “Your Medicare Benefits”, which is published by the federal Centers for Medicare and Medicaid Services and describe Medicare Skilled Nursing Facility coverage. You can call toll free 1-800-MEDICARE to order a copy of this publication or to get additional information. You can also find this publication and other useful information at the Medicare Internet site at www.medicare.gov.



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ATTACHMENT D-1 (continued)


Medicare covers skilled care in a skilled nursing facility (SNF) under certain conditions for a limited time. Skilled care is health care given when you need skilled nursing or rehabilitation staff to manage, observe, and evaluate your care. Examples of skilled care include changing sterile dressings and physical therapy. It is given in a Medicare-certified SNF. Care that can be given by non-professional staff is not considered skilled care. Medicare covers certain skilled care services that are needed daily on a short-term basis (up to 100 days).

Medicare will cover skilled care only if all these conditions are met:

1. You have Medicare Part A (Hospital Insurance) and have days left in your benefitperiod to use.

2. You have a qualifying hospital stay. This means an inpatient hospital stay of threeconsecutive days or more, not including the day you leave the hospital. You mustenter the SNF within a short time (generally 30 days) of leaving the hospital. Afteryou leave the SNF, if you re-enter the same or another SNF within 30 days, youdon’t need another 3-day qualifying hospital stay to get additional SNF benefits.This is also true if you stop getting skilled care while in the SNF and then startgetting skilled care again within 30 days.

3. Your doctor has decided that you need daily skilled care. It must be given by, orunder the direct supervision of, skilled nursing or rehabilitation staff. If you are in theSNF for skilled rehabilitation services only, your care is considered daily care even ifthese therapy services are offered just 5 or 6 days a week.

4. You get these skilled services in a SNF that has been certified by Medicare.



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ATTACHMENT D-1 (continued)


5. You need these skilled services for a medical condition that: a) was treated during aqualifying 3-day hospital stay, or b) started while you were getting Medicare-coveredSNF care. (For example, if you are in the SNF because you had a stroke and youfall and sprain your wrist.)

Medicare Part A covered services include meals, skilled nursing and rehabilitative services, and other hospital services and supplies, such as anesthesia, limited ambulance service, blood, chemotherapy, clinical trials, kidney dialysis, durable medical equipment, mental health care, hospice care, some types of transplants, and physician-prescribed pharmaceutical and medical equipment. Physical therapy, occupational therapy, speech therapy, and other allied health services as physician-prescribed may be included.

This does not include private duty nursing. It also does not include a private room, unless medically necessary.

In addition, you may be eligible for Medicare Part B program. Contact the Business Office in your facility for further information.


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ATTACHMENT D-2

Optional Supplies and Services NOT Covered By Medicare That May Be Purchased By Medicare Residents

Description of Supply or Service Price

Ambulance Services Billed by Outside Provider

Dialysis Services Billed by Outside Provider


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ATTACHMENT E

AUTHORIZATION FOR DISCLOSURE OF MEDICAL INFORMATION

I, ________________________________________, hereby (Resident’s Name)

authorize the Facility, ___________________________________________, (Name of Facility)

to provide information regarding my medical history, mental or physical condition, care, or treatment as specified below:

This authorization is limited to disclosure to the following persons: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

This authorization is limited to the following types of medical information: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

The persons to whom records and information are disclosed pursuant to this authorization may use those records and information only for the following purposes:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

This authorization shall become effective immediately and shall remain in effect until ______________________. (Date)



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I understand that a person to whom records and information are disclosed pursuant to this authorization may not further use or disclose the medical information unless another authorization is obtained from me or unless such disclosure is specifically required or permitted by law. However, if I authorize the disclosure of my medical information to person(s) and/or organization(s) who are not health care providers or other people who not are subject to laws governing the disclosure of medical information, they may be permitted to redisclose the information without my prior permission. Re-disclosure in such cases may not be limited by state or federal law.

I further understand that the Facility will give me a copy of this signed authorization.

I understand that I have the right to revoke this authorization, in writing, at any time before it ends. I also understand that my written revocation will not affect any disclosures of my information that the person(s) and/or organization(s) listed on the first page of this authorization have already made, in reliance on this authorization, before the time I revoke it.

I further understand that I am under no obligation to sign this authorization, and may refuse to do so. Except as permitted under applicable law, the Facility may not refuse to provide treatment or other health care services because of my refusal to sign.

Resident Signature:______________________ Date:___________

Resident’s Representative* Signature:______________________________ Date:___________

* The Resident’s Representative is authorized to sign for the residentbecause _______________________________________________

______________________________________________________.


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ATTACHMENT F

RESIDENT BILL OF RIGHTS

The State of California Department of Public Health (CDPH) has prepared this comprehensive Resident Bill of Rights for people who are receiving care in skilled nursing or intermediate care facilities.

If you have any questions about what the statements in this Resident Bill of Rights mean, you may look them up in the laws or regulations. The rights are found in state laws and regulations under California Health and Safety Code Section 1599; Title 22 of the California Code of Regulations, Section 72527 for Skilled Nursing Facilities, and Section 73523 for Intermediate Care Facilities; and Chapter 42 of the Code of Federal Regulations, Chapter IV, Part 483.10 et seq. The California Health and Safety Code is abbreviated as “HSC,” Title 22 of the California Code of Regulations is abbreviated as “22CCR,” and Title 42 of the Code of Federal Regulations is abbreviated as “42CFR.”

You may also contact the Office of the State Long-Term Care Ombudsman at 1-800-231- 4024, or the local District Office of the CDPH DHS Licensing and Certification Division ___________________ if you have any questions about the meaning of these rights.


CDPH 327 (05/11) 2

RESIDENT BILL OF RIGHTS

California Code of Regulations Title 22

Section 72527. Skilled Nursing Facilities

(a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right:

(1)To be fully informed, as evidenced by the patient's written acknowledgement prior to or at the time of admission and during stay, of these rights and of all rules and regulations governing patient conduct.

(2)To be fully informed, prior to or at the time of admission and during stay, of services available in the facility and of related charges, including any charges for services not covered by the facility's basic per diem rate or not covered under Titles XVIII or XIX of the Social Security Act.

(3)To be fully informed by a physician of his or her total health status and to be afforded the opportunity to participate on an immediate and ongoing basis in the total plan of care including the identification of medical, nursing and psychosocial needs and the planning of related services.

(4)To consent to or to refuse any treatment or procedure or participation in experimental research.

(5)To receive all information that is material to an individual patient's decision concerning whether to accept or refuse any proposed treatment or procedure. The disclosure of material information for administration of psychotherapeutic drugs or physical restraints or the prolonged use of a device that may lead to the inability to regain use of a normal bodily function shall include the disclosure of information listed in Section 72528(b).

(6)To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patients or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record.

(7)To be encouraged and assisted throughout the period of stay to exercise rights as a patient and as a citizen, and to this end to voice grievances and recommend changes in policies and services to facility staff and/or outside representatives of the patient's choice, free from restraint, interference, coercion, discrimination or reprisal.


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(8)To be free from discrimination based on sex, race, color, religion, ancestry, national origin, sexual orientation, disability, medical condition, marital status, or registered domestic partner status.

(9)To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529 [for SNFs] Section 73557 [for ICFs].

(10) To be free from mental and physical abuse.

(11) To be assured confidential treatment of financial and health records and to approve or refuse their release, except as authorized by law.

(12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs.

(13) Not to be required to perform services for the facility that are not included for therapeutic purposes in the patient's plan of care.

(14) To associate and communicate privately with persons of the patient's choice, and to send and receive personal mail unopened.

(15) To meet with others and participate in activities of social, religious and community groups.

(16) To retain and use personal clothing and possessions as space permits, unless to do so would infringe upon the health, safety or rights of the patient or other patients.

(17) If married or registered as a domestic partner, to be assured privacy for visits by the patient's spouse or registered domestic partner and if both are patients in the facility, to be permitted to share a room.

(18) To have daily visiting hours established.

(19) To have visits from members of the clergy at any time at the request of the patient or the patient's representative.

(20) To have visits from persons of the patient's choosing at any time if the patient is critically ill, unless medically contraindicated.

(21) To be allowed privacy for visits with family, friends, clergy, social workers or for professional or business purposes.

(22) To have reasonable access to telephones and to make and receive confidential calls.


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(23) To be free from any requirement to purchase drugs or rent or purchase medical supplies or equipment from any particular source in accordance with the provisions of Section 1320 of the Health and Safety Code. (24) To be free from psychotherapeutic drugs and physical restraints used for the purpose of patient discipline or staff convenience and to be free from psychotherapeutic drugs used as a chemical restraint as defined in Section 72018, except in an emergency which threatens to bring immediate injury to the patient or others. If a chemical restraint is administered during an emergency, such medication shall be only that which is required to treat the emergency condition and shall be provided in ways that are least restrictive of the personal liberty of the patient and used only for a specified and limited period of time. (25) Other rights as specified in Health and Safety Code, Section 1599.1. (26) Other rights as specified in Welfare and Institutions Code, Sections 5325 and 5325.1, for persons admitted for psychiatric evaluations or treatment. (27) Other rights as specified in Welfare and Institutions Code Sections 4502, 4503 and 4505 for patients who are developmentally disabled as defined in Section 4512 of the Welfare and Institutions Code. (b) A patient's rights, as set forth above, may only be denied or limited if such denial or limitation is otherwise authorized by law. Reasons for denial or limitation of such rights shall be documented in the patient's health record. (c) If a patient lacks the ability to understand these rights and the nature and consequences of proposed treatment, the patient's representative shall have the rights specified in this section to the extent the right may devolve to another, unless the representative's authority is otherwise limited. The patient's incapacity shall be determined by a court in accordance with state law or by the patient's physician unless the physician's determination is disputed by the patient or patient's representative. (d) Persons who may act as the patient's representative include a conservator, as authorized by Parts 3 and 4 of Division 4 of the Probate Code (commencing with Section 1800), a person designated as attorney in fact in the patient's valid Durable Power of Attorney for Health Care, patient's next of kin, other appropriate surrogate decisionmaker designated consistent with statutory and case law, a person appointed by a court authorizing treatment pursuant to Part 7 (commencing with Section 3200) of Division 4 of the Probate Code, or, if the patient is a minor, a person lawfully authorized to represent the minor. (e) Patients' rights policies and procedures established under this section concerning consent, informed consent and refusal of treatments or procedures shall include, but not be limited to the following:


CDPH 327 (05/11) 5

(1)How the facility will verify that informed consent was obtained or a treatment or procedure was refused pertaining to the administration of psychotherapeutic drugs or physical restraints or the prolonged use of a device that may lead to the inability of the patient to regain the use of a normal bodily function.

(2)How the facility, in consultation with the patient's physician, will identify consistent with current statutory case law, who may serve as a patient's representative when an incapacitated patient has no conservator or attorney in fact under a valid Durable Power of Attorney for Health Care.

Section 73523. Intermediate Care Facilities

(a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right:

(1) To be fully informed, as evidenced by the patient's written acknowledgment prior to or at the time of admission and during stay, of these rights and of all rules and regulations governing patient conduct.

(2) To be fully informed, prior to or at the time of admission and during stay, of services available in the facility and of related charges, including any charges for services not covered by the facilities' basic per diem rate or not covered under Title XVIII or XIX of the Social Security Act.

(3) To be fully informed by a physician of his or her total health status and to be afforded the opportunity to participate on an immediate and ongoing basis in the total plan of care including the identification of medical, nursing, and psychosocial needs and the planning of related services.

(4) To consent to or to refuse any treatment or procedure or participation in experimental research.

(5) To receive all information that is material to an individual patient's decision concerning whether to accept or refuse any proposed treatment or procedure. The disclosure of material information for administration of psychotherapeutic drugs or physical restraints, or the prolonged use of a device that may lead to the inability to regain use of a normal bodily function shall include the disclosure of information listed in Section 73524(c).

(6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patients or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record.


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(7) To be encouraged and assisted throughout the period of stay to exercise rights as a patient and as a citizen, and to this end to voice grievances and recommend changes in policies and services to facility staff and/or outside representatives of the patient's choice, free from restraint, interference, coercion, discrimination or reprisal.

(8) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept his or her written delegation of this responsibility subject to the provisions of Section 73557.

(9) To be free from mental and physical abuse. (10) To be assured confidential treatment of financial and health records and to approve or refuse their release, except as authorized by law.

(11) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care for personal needs.

(12) To be free from discrimination based on sex, race, color, religion, ancestry, national origin, sexual orientation, disability, medical condition, marital status, or registered domestic partner status.

(13) Not to be required to perform services for the facility that are not included for therapeutic purposes in the patient's plan of care.

(14) To associate and communicate privately with persons of the patient's choice, and to send and receive his or her personal mail unopened.

(15) To meet with and participate in activities of social, religious and community groups at the patient's discretion.

(16) To retain and use his or her personal clothing and possessions as space permits, unless to do so would infringe upon the health, safety or rights of the patient or other patients.

(17) If married or registered as a domestic partner, to be assured privacy for visits by the patient's spouse or registered domestic partner and if both are patients in the facility, to be permitted to share a room.

(18) To have daily visiting hours established.

(19) To have visits from members of the clergy at the request of the patient or the patient's representative.

(20) To have visits from persons of the patient's choosing at any time if the patient is critically ill, unless medically contraindicated.


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(21) To be allowed privacy for visits with family, friends, clergy, social workers or for professional or business purposes. (22) To have reasonable access to telephones both to make and receive confidential calls. (23) To be free from any requirement to purchase drugs or rent or purchase medical supplies or equipment from any particular source in accordance with the provisions of Section 1320 of the Health and Safety Code. (24) To be free from psychotherapeutic and/or physical restraints used for the purpose of patient discipline or staff convenience and to be free from psychotherapeutic drugs used as a chemical restraint as defined in Section 73012, except in an emergency which threatens to bring immediate injury to the patient or others. If a chemical restraint is administered during an emergency, such medication shall be only that which is required to treat the emergency condition and shall be provided in ways that are least restrictive of the personal liberty of the patient and used only for a specified and limited period of time. (25) Other rights as specified in Health and Safety Code Section 1599.1. (26) Other rights as specified in Welfare and Institutions Code Sections 5325 and 5325.1 for persons admitted for psychiatric evaluations or treatment. (27) Other rights as specified in Welfare and Institutions Code, Sections 4502, 4503 and 4505 for patients who are developmentally disabled as defined in Section 4512 of the Welfare and Institutions Code. (b) A patient's rights as set forth above may only be denied or limited if such denial or limitation is otherwise authorized by law. Reasons for denial or limitation of such rights shall be documented in the patient's health record. (c) If a patient lacks the ability to understand these rights and the nature and consequences of proposed treatment, the patient's representative shall have the rights specified in this section to the extent the right may devolve to another, unless the representative's authority is otherwise limited. The patient's incapacity shall be determined by a court in accordance with state law or by the patient's licensed healthcare practitioner acting within the scope of his or her professional licensure unless the determination of the licensed healthcare practitioner acting within the scope of his or her professional licensure is disputed by the patient or patient's representative. (d) Persons who may act as the patient's representative include a conservator, as authorized by Parts 3 and 4 of Division 4 of the Probate Code (commencing with Section 1800), a person designated as attorney in fact in the patient's valid Durable Power of Attorney for Health Care, patient's next of kin, other appropriate surrogate decisionmaker, designated consistent with statutory and case law, a person appointed by a court authorizing treatment pursuant to Part 7 (commencing with Section 3200) of


CDPH 327 (05/11) 8

Division 4 of the Probate Code, or, if the patient is a minor, informed consent must be obtained from a person lawfully authorized to represent the minor. (e) Patients' rights policies and procedures established under this section concerning consent, informed consent and refusal of treatments or procedures shall include, but not be limited to the following: (1) How the facility will verify that informed consent was obtained pertaining to the administration of psychotherapeutic drugs or physical restraints or the prolonged use of a device that may lead to the inability of the patient to regain the use of a normal bodily function. (2) How the facility, in consultation with the patient's licensed healthcare practitioner acting within the scope of his or her professional licensure, will identify, consistent with current statutory and case law, who may serve as a patient's representative when an incapacitated patient has no conservator or attorney in fact under a valid Durable Power of Attorney for Health Care. California Health & Safety Code Section 1599 1599.1. Written policies; rights of patients and facility obligations Written policies regarding the rights of patients shall be established and shall be made available to the patient, to any guardian, next of kin, sponsoring agency or representative payee, and to the public. Those policies and procedures shall ensure that each patient admitted to the facility has the following rights and is notified of the following facility obligations, in addition to those specified by regulation: (a) The facility shall employ an adequate number of qualified personnel to carry out all of the functions of the facility. (b) Each patient shall show evidence of good personal hygiene, be given care to prevent bedsores, and measures shall be used to prevent and reduce incontinence for each patient. (c) The facility shall provide food of the quality and quantity to meet the patients' needs in accordance with physicians' orders. (d) The facility shall provide an activity program staffed and equipped to meet the needs and interests of each patient and to encourage self-care and resumption of normal activities. Patients shall be encouraged to participate in activities suited to their individual needs. (e) The facility shall be clean, sanitary, and in good repair at all times.


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(f) A nurses' call system shall be maintained in operating order in all nursing units and provide visible and audible signal communication between nursing personnel and patients. Extension cords to each patient's bed shall be readily accessible to patients at all times. (g)(1) If a facility has a significant beneficial interest in an ancillary health service provider or if a facility knows that an ancillary health service provider has a significant beneficial interest in the facility, as provided by subdivision (a) of Section 1323 (see below), or if the facility has a significant beneficial interest in another facility, as provided by subdivision (c) of Section 1323 (see below), the facility shall disclose that interest in writing to the patient, or his or her representative, and advise the patient, or his or her representative, that the patient may choose to have another ancillary health service provider, or facility, as the case may be, provide any supplies or services ordered by a member of the medical staff of the facility. (2) A facility is not required to make any disclosures required by this subdivision to any patient, or his or her representative, if the patient is enrolled in an organization or entity which provides or arranges for the provision of health care services in exchange for a prepaid capitation payment or premium. (h)(1) If a resident of a long-term health care facility has been hospitalized in an acute care hospital and asserts his or her rights to readmission pursuant to bed hold provisions or readmission rights of either state or federal law and the facility refuses to readmit him or her, the resident may appeal the facility's refusal. (2) The refusal of the facility as described in this subdivision shall be treated as if it were an involuntary transfer under federal law and the rights and procedures that apply to appeals of transfers and discharges of nursing facility residents shall apply to the resident's appeal under this subdivision. (3) If the resident appeals pursuant to this subdivision, and the resident is eligible under the Medi-Cal program, the resident shall remain in the hospital and the hospital may be reimbursed at the administrative day rate, pending the final determination of the hearing officer, unless the resident agrees to placement in another facility. (4) If the resident appeals pursuant to this subdivision, and the resident is not eligible under the Medi-Cal program, the resident shall remain in the hospital if other payment is available, pending the final determination of the hearing officer, unless the resident agrees to placement in another facility. (5) If the resident is not eligible for participation in the Medi-Cal program and has no other source of payment, the hearing and final determination shall be made within 48 hours.


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(i) Effective July 1, 2007, Sections 483.10, 483.12, 483.13, and 483.15 of Title 42 of the Code of Federal Regulations in effect on July 1, 2006, shall apply to each skilled nursing facility and intermediate care facility, regardless of a resident's payment source or the Medi-Cal or Medicare certification status of the skilled nursing facility or intermediate care facility in which the resident resides, except that a noncertified facility is not obligated to provide notice of Medicaid or Medicare benefits, covered services, or eligibility procedures. 1599.2. Preamble or preliminary statement; form Written information informing patients of their rights shall include a preamble or preliminary statement in substantial form as follows: (a) Further facility requirements are set forth in the Health and Safety Code, and in Title 22 of the California Administrative Code [California Code of Regulations]. (b) Willful or repeated violations of either code may subject a facility and its personnel to civil or criminal proceedings. (c) Patients have the right to voice grievances to facility personnel free from reprisal and can submit complaints to the State [Department of Public Health] or its representative. 1599.3. Representative of patient; devolution of rights Any rights under this chapter of a patient judicially determined to be incompetent, or who is found by his physician to be medically incapable of understanding such information, or who exhibits a communication barrier, shall devolve to such patient's guardian, conservator, next of kin, sponsoring agency, or representative payer, except when the facility itself is the representative payer. 1599.4. Construction and application of chapter In no event shall this chapter be construed or applied in a manner which imposes new or additional obligations or standards on skilled nursing or intermediate care facilities or their personnel, other than in regard to the notification and explanation of patient's rights or unreasonable costs. California Welfare and Institutions Code Sections 4502-4505, 4512 4502. Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds.


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It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (a) A right to treatment and habilitation services and supports in the least restrictive environment. Treatment and habilitation services and supports should foster the developmental potential of the person and be directed toward the achievement of the most independent, productive, and normal lives possible. Such services shall protect the personal liberty of the individual and shall be provided with the least restrictive conditions necessary to achieve the purposes of the treatment, services, or supports. (b) A right to dignity, privacy, and humane care. To the maximum extent possible, treatment, services, and supports shall be provided in natural community settings. (c) A right to participate in an appropriate program of publicly supported education, regardless of degree of disability. (d) A right to prompt medical care and treatment. (e) A right to religious freedom and practice. (f) A right to social interaction and participation in community activities. (g) A right to physical exercise and recreational opportunities. (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. (i) A right to be free from hazardous procedures. (j) A right to make choices in their own lives, including, but not limited to, where and with whom they live, their relationships with people in their community, the way they spend their time, including education, employment, and leisure, the pursuit of their personal future, and program planning and implementation. 4502.1. The right of individuals with developmental disabilities to make choices in their own lives requires that all public or private agencies receiving state funds for the purpose of serving persons with developmental disabilities, including, but not limited to, regional centers, shall respect the choices made by consumers or, where appropriate, their parents, legal guardian, or conservator. Those public or private agencies shall provide consumers with opportunities to exercise decision-making skills in any aspect of day-to-day living and shall provide consumers with relevant information in an understandable form to aid the consumer in making his or her choice. 4503. Each person with developmental disabilities who has been admitted or committed to a state hospital, community care facility as defined in Section 1502 of the Health and Safety Code, or a health facility as defined in Section 1250 of the Health and Safety Code shall have the following rights, a list of which shall be prominently posted in English, Spanish, and other appropriate languages, in all facilities providing those services and otherwise brought to his or her attention by any additional means as the Director of Developmental Services may designate by regulation: (a) To wear his or her own clothes, to keep and use his or her own personal possessions including his or her toilet articles, and to keep and be allowed to spend a reasonable sum of his or her own money for canteen expenses and small purchases. (b) To have access to individual storage space for his or her private use.


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(c) To see visitors each day. (d) To have reasonable access to telephones, both to make and receive confidential calls. (e) To have ready access to letter writing materials, including stamps, and to mail and receive unopened correspondence. (f) To refuse electroconvulsive therapy. (g) To refuse behavior modification techniques which cause pain or trauma. (h) To refuse psychosurgery notwithstanding the provisions of Sections 5325, 5326, and 5326.3. Psychosurgery means those operations currently referred to as lobotomy, psychiatric surgery, and behavioral surgery and all other forms of brain surgery if the surgery is performed for any of the following purposes: (1) Modification or control of thoughts, feelings, actions, or behavior rather than the treatment of a known and diagnosed physical disease of the brain. (2) Modification of normal brain function or normal brain tissue in order to control thoughts, feelings, action, or behavior. (3) Treatment of abnormal brain function or abnormal brain tissue in order to modify thoughts, feelings, actions, or behavior when the abnormality is not an established cause for those thoughts, feelings, actions, or behavior. (i) To make choices in areas including, but not limited to, his or her daily living routines, choice of companions, leisure and social activities, and program planning and implementation. (j) Other rights, as specified by regulation. 4505. For the purposes of subdivisions (f) and (g) of Section 4503, if the patient is a minor age 15 years or over, the right to refuse may be exercised either by the minor or his parent, guardian, conservator, or other person entitled to his custody. If the patient or his parent, guardian, conservator, or other person responsible for his custody do not refuse the forms of treatment or behavior modification described in subdivisions (f) and (g) of Section 4503, such treatment and behavior modification may be provided only after review and approval by a peer review committee. The Director of Developmental Services shall, by March 1, 1977, adopt regulations establishing peer review procedures for this purpose. California Welfare and Institutions Code Sections 5325-5326 5325. Each person involuntarily detained for evaluation or treatment under provisions of this part, each person admitted as a voluntary patient for psychiatric evaluation or treatment to any health facility, as defined in Section 1250 of the Health and Safety Code, in which psychiatric evaluation or treatment is offered, and each mentally retarded person committed to a state hospital pursuant to Article 5 (commencing with Section 6500) of Chapter 2 of Part 2 of Division 6 shall have the following rights, a list of which shall be prominently posted in the predominant languages of the community and explained in a language or modality accessible to the patient in all facilities providing


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such services and otherwise brought to his or her attention by such additional means as the Director of Mental Health may designate by regulation: (a) To wear his or her own clothes; to keep and use his or her own personal possessions including his or her toilet articles; and to keep and be allowed to spend a reasonable sum of his or her own money for canteen expenses and small purchases. (b) To have access to individual storage space for his or her private use. (c) To see visitors each day. (d) To have reasonable access to telephones, both to make and receive confidential calls or to have such calls made for them. (e) To have ready access to letter writing materials, including stamps, and to mail and receive unopened correspondence. (f) To refuse convulsive treatment including, but not limited to, any electroconvulsive treatment, any treatment of the mental condition which depends on the induction of a convulsion by any means, and insulin coma treatment. (g) To refuse psychosurgery. Psychosurgery is defined as those operations currently referred to as lobotomy, psychiatric surgery, and behavioral surgery and all other forms of brain surgery if the surgery is performed for the purpose of any of the following: (1) Modification or control of thoughts, feelings, actions, or behavior rather than the treatment of a known and diagnosed physical disease of the brain. (2) Modification of normal brain function or normal brain tissue in order to control thoughts, feelings, actions, or behavior. (3) Treatment of abnormal brain function or abnormal brain tissue in order to modify thoughts, feelings, actions or behavior when the abnormality is not an established cause for those thoughts, feelings, actions, or behavior. Psychosurgery does not include prefrontal sonic treatment wherein there is no destruction of brain tissue. The Director of Mental Health shall promulgate appropriate regulations to assure adequate protection of patients' rights in such treatment. (h) To see and receive the services of a patient advocate who has no direct or indirect clinical or administrative responsibility for the person receiving mental health services. (i) Other rights, as specified by regulation. Each patient shall also be given notification in a language or modality accessible to the patient of other constitutional and statutory rights which are found by the State Department of Mental Health to be frequently misunderstood, ignored, or denied. Upon admission to a facility each patient shall immediately be given a copy of a State Department of Mental Health prepared patients' rights handbook. The State Department of Mental Health shall prepare and provide the forms specified in this section and in Section 5157. The rights specified in this section may not be waived by the person's parent, guardian, or conservator. 5325.1. Persons with mental illness have the same legal rights and responsibilities guaranteed all other persons by the Federal Constitution and laws and the Constitution and laws of the State of California, unless specifically limited by federal or state law or regulations. No otherwise qualified person by reason of having been involuntarily detained for evaluation or treatment under provisions of this part or having been admitted as a voluntary patient to any health facility, as defined in Section 1250 of the


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Health and Safety Code, in which psychiatric evaluation or treatment is offered shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the legislature that persons with mental illness shall have rights including, but not limited to, the following: (a) A right to treatment services which promote the potential of the person to function independently. Treatment should be provided in ways that are least restrictive of the personal liberty of the individual. (b) A right to dignity, privacy, and humane care. (c) A right to be free from harm, including unnecessary or excessive physical restraint, isolation, medication, abuse, or neglect. Medication shall not be used as punishment, for the convenience of staff, as a substitute for program, or in quantities that interfere with the treatment program. (d) A right to prompt medical care and treatment. (e) A right to religious freedom and practice. (f) A right to participate in appropriate programs of publicly supported education. (g) A right to social interaction and participation in community activities. (h) A right to physical exercise and recreational opportunities. (i) A right to be free from hazardous procedures. 5325.2. Any person who is subject to detention pursuant to Section 5150, 5250, 5260, or 5270.15 shall have the right to refuse treatment with antipsychotic medication subject to provisions set forth in this chapter. 5326. The professional person in charge of the facility or his or her designee may, for good cause, deny a person any of the rights under Section 5325, except under subdivisions (g) and (h) and the rights under subdivision (f) may be denied only under the conditions specified in Section 5326.7. To ensure that these rights are denied only for good cause, the Director of Mental Health shall adopt regulations specifying the conditions under which they may be denied. Denial of a person's rights shall in all cases be entered into the person's treatment record.


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Code of Federal Regulations—Title 42—Public Health Chapter IV--Centers For Medicare & Medicaid Services, Department Of Health And Human Services Part 483--Requirements For States And Long Term Care Facilities Subpart B--Requirements for Long Term Care Facilities Sec. 483.10 Resident rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident, including each of the following rights: (a) Exercise of rights. (1) The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. (2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights. (3) In the case of a resident adjudged incompetent under the laws of a State by a court of competent jurisdiction, the rights of the resident are exercised by the person appointed under State law to act on the resident's behalf. (4) In the case of a resident who has not been adjudged incompetent by the State court, any legal -surrogate designated in accordance with State law may exercise the resident's rights to the extent provided by State law. (b) Notice of rights and services. (1) The facility must inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility must also provide the resident with the notice (if any) of the State developed under section 1919(e)(6) of the Act. Such notification must be made prior to or upon admission and during the resident's stay. Receipt of such information, and any amendments to it, must be acknowledged in writing; (2) The resident or his or her legal representative has the right-- (i) Upon an oral or written request, to access all records pertaining to himself or herself including current clinical records within 24 hours (excluding weekends and holidays); and


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(ii) After receipt of his or her records for inspection, to purchase at a cost not to exceed the community standard photocopies of the records or any portions of them upon request and 2 working days advance notice to the facility. (3) The resident has the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition; (4) The resident has the right to refuse treatment, to refuse to participate in experimental research, and to formulate an advance directive as specified in paragraph (8) of this section; and (5) The facility must-- (i) Inform each resident who is entitled to Medicaid benefits, in writing, at the time of admission to the nursing facility or, when the resident becomes eligible for Medicaid of-- (A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each resident when changes are made to the items and services specified in paragraphs (5)(i)(A) and (B) of this section. (6) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility's per diem rate. (7) The facility must furnish a written description of legal rights which includes-- (i) A description of the manner of protecting personal funds, under paragraph (c) of this section; (ii) A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment under section 1924(c) which determines the extent of a couple's non-exempt resources at the time of institutionalization and attributes to the community spouse an equitable share of resources which cannot be considered available for payment toward the cost of the institutionalized spouse's medical care in his or her process of spending down to Medicaid eligibility levels; (iii) A posting of names, addresses, and telephone numbers of all pertinent State client advocacy groups such as the State survey and certification agency, the State licensure


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office, the State ombudsman program, the protection and advocacy network, and the Medicaid fraud control unit; and (iv) A statement that the resident may file a complaint with the State survey and certification agency concerning resident abuse, neglect, misappropriation of resident property in the facility, and non-compliance with the advance directives requirements. (8) The facility must comply with the requirements specified in subpart I of part 489 of this chapter relating to maintaining written policies and procedures regarding advance directives. These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the individual's option, formulate an advance directive. This includes a written description of the facility's policies to implement advance directives and applicable State law. Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. If an adult individual is incapacitated at the time of admission and is unable to receive information (due to the incapacitating condition or a mental disorder) or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's family or surrogate in the same manner that it issues other materials about policies and procedures to the family of the incapacitated individual or to a surrogate or other concerned persons in accordance with State law. The facility is not relieved of its obligation to provide this information to the individual once he or she is no longer incapacitated or unable to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. (9) The facility must inform each resident of the name, specialty, and way of contacting the physician responsible for his or her care. (10) The facility must prominently display in the facility written information, and provide to residents and applicants for admission oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. (11) Notification of changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is-- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or


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(D) A decision to transfer or discharge the resident from the facility as specified in Sec. 483.12(a). (ii) The facility must also promptly notify the resident and, if known, the resident's legal representative or interested family member when there is— (A) A change in room or roommate assignment as specified in Sec. 483.15(e)(2); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (b)(1) of this section. (iii) The facility must record and periodically update the address and phone number of the resident's legal representative or interested family member. (12) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in Sec. 483.5(c) of this subpart) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under Sec. 483.12(a)(8). (c) Protection of resident funds. (1) The resident has the right to manage his or her financial affairs, and the facility may not require residents to deposit their personal funds with the facility. (2) Management of personal funds. Upon written authorization of a resident, the facility must hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility, as specified in paragraphs (c)(3)-(8) of this section. (3) Deposit of funds. (i) Funds in excess of $50. The facility must deposit any residents' personal funds in excess of $50 in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account. (In pooled accounts, there must be a separate accounting for each resident's share.) (ii) Funds less than $50. The facility must maintain a resident's personal funds that do not exceed $50 in a non-interest bearing account, interest-bearing account, or petty cash fund. (4) Accounting and records. The facility must establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf.


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(i) The system must preclude any commingling of resident funds with facility funds or with the funds of any person other than another resident. (ii) The individual financial record must be available through quarterly statements and on request to the resident or his or her legal representative. (5) Notice of certain balances. The facility must notify each resident that receives Medicaid benefits— (i) When the amount in the resident's account reaches $200 less than the SSI resource limit for one person, specified in section 1611(a)(3)(B) of the Act; and (ii) That, if the amount in the account, in addition to the value of the resident's other nonexempt resources, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI. (6) Conveyance upon death. Upon the death of a resident with a personal fund deposited with the facility, the facility must convey within 30 days the resident's funds, and a final accounting of those funds, to the individual or probate jurisdiction administering the resident's estate. (7) Assurance of financial security. The facility must purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility. (8) Limitation on charges to personal funds. The facility may not impose a charge against the personal funds of a resident for any item or service for which payment is made under Medicaid or Medicare (except for applicable deductible and coinsurance amounts). The facility may charge the resident for requested services that are more expensive than or in excess of covered services in accordance with Sec. 489.32 of this chapter. (This does not affect the prohibition on facility charges for items and services for which Medicaid has paid. See Sec. 447.15, which limits participation in the Medicaid program to providers who accept, as payment in full, Medicaid payment plus any deductible, coinsurance, or copayment required by the plan to be paid by the individual.) (i) Services included in Medicare or Medicaid payment. During the course of a covered Medicare or Medicaid stay, facilities may not charge a resident for the following categories of items and services: (A) Nursing services as required at Sec. 483.30 of this subpart. (B) Dietary services as required at Sec. 483.35 of this subpart. (C) An activities program as required at Sec. 483.15(f) of this subpart. (D) Room/bed maintenance services.


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(E) Routine personal hygiene items and services as required to meet the needs of residents, including, but not limited to, hair hygiene supplies, comb, brush, bath soap, disinfecting soaps or specialized cleansing agents when indicated to treat special skin problems or to fight infection, razor, shaving cream, toothbrush, toothpaste, denture adhesive, denture cleaner, dental floss, moisturizing lotion, tissues, cotton balls, cotton swabs, deodorant, incontinence care and supplies, sanitary napkins and related supplies, towels, washcloths, hospital gowns, over the counter drugs, hair and nail hygiene services, bathing, and basic personal laundry. (F) Medically-related social services as required at Sec. 483.15(g) of this subpart. (ii) Items and services that may be charged to residents' funds. Listed below are general categories and examples of items and services that the facility may charge to residents' funds if they are requested by a resident, if the facility informs the resident that there will be a charge, and if payment is not made by Medicare or Medicaid: (A) Telephone. (B) Television/radio for personal use. (C) Personal comfort items, including smoking materials, notions and novelties, and confections. (D) Cosmetic and grooming items and services in excess of those for which payment is made under Medicaid or Medicare. (E) Personal clothing. (F) Personal reading matter. (G) Gifts purchased on behalf of a resident. (H) Flowers and plants. (I) Social events and entertainment offered outside the scope of the activities program, provided under Sec. 483.15(f) of this subpart. (J) Noncovered special care services such as privately hired nurses or aides. (K) Private room, except when therapeutically required (for example, isolation for infection control). (L) Specially prepared or alternative food requested instead of the food generally prepared by the facility, as required by Sec. 483.35 of this subpart.


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(iii) Requests for items and services. (A) The facility must not charge a resident (or his or her representative) for any item or service not requested by the resident. (B) The facility must not require a resident (or his or her representative) to request any item or service as a condition of admission or continued stay. (C) The facility must inform the resident (or his or her representative) requesting an item or service for which a charge will be made that there will be a charge for the item or service and what the charge will be. (d) Free choice. The resident has the right to— (1)Choose a personal attending physician; (2)Be fully informed in advance about care and treatment and of any changes in that care or treatment that may affect the resident's well-being; and (3)Unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, participate in planning care and treatment or changes in care and treatment. (e) Privacy and confidentiality. The resident has the right to personal privacy and confidentiality of his or her personal and clinical records. (1)Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident; (2)Except as provided in paragraph (e)(3) of this section, the resident may approve or refuse the release of personal and clinical records to any individual outside the facility; (3)The resident's right to refuse release of personal and clinical records does not apply when-- (i) The resident is transferred to another health care institution; or (ii)Record release is required by law. (f) Grievances. A resident has the right to-- (1) Voice grievances without discrimination or reprisal. Such grievances include those with respect to treatment which has been furnished as well as that which has not been furnished; and (2) Prompt efforts by the facility to resolve grievances the resident may have, including those with respect to the behavior of other residents.


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(g) Examination of survey results. A resident has the right to— (1)Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. The facility must make the results available for examination in a place readily accessible to residents, and must post a notice of their availability; and (2)Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies. (h) Work. The resident has the right to-- (1)Refuse to perform services for the facility; (2)Perform services for the facility, if he or she chooses, when-- (i) The facility has documented the need or desire for work in the plan of care; (ii) The plan specifies the nature of the services performed and whether the services are voluntary or paid; (iii) Compensation for paid services is at or above prevailing rates; and (iv) The resident agrees to the work arrangement described in the plan of care. (i) Mail. The resident has the right to privacy in written communications, including the right to-- (1)Send and promptly receive mail that is unopened; and (2)Have access to stationery, postage, and writing implements at the resident's own expense. (j) Access and visitation rights. (1) The resident has the right and the facility must provide immediate access to any resident by the following: (i) Any representative of the Secretary; (ii) Any representative of the State: (iii) The resident's individual physician; (iv) The State long term care ombudsman (established under section 307(a)(12) of the Older Americans Act of 1965);


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(v)The agency responsible for the protection and advocacy system for developmentally disabled individuals (established under part C of the Developmental Disabilities Assistance and Bill of Rights Act); (vi) The agency responsible for the protection and advocacy system for mentally ill individuals (established under the Protection and Advocacy for Mentally Ill Individuals Act); (vii) Subject to the resident's right to deny or withdraw consent at any time, immediate family or other relatives of the resident; and (viii) Subject to reasonable restrictions and the resident's right to deny or withdraw consent at any time, others who are visiting with the consent of the resident. (2)The facility must provide reasonable access to any resident by any entity or individual that provides health, social, legal, or other services to the resident, subject to the resident's right to deny or withdraw consent at anytime. (3)The facility must allow representatives of the State Ombudsman, described in paragraph (j)(1 )(iv) of this section, to examine a resident's clinical records with the permission of the resident or the resident's legal representative, and consistent with State law. (k) Telephone. The resident has the right to have reasonable access to the use of a telephone where calls can be made without being overheard. (l) Personal property. The resident has the right to retain and use personal possessions, including some furnishings, and appropriate clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. (m) Married couples. The resident has the right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement. (n) Self-Administration of Drugs. An individual resident may self-administer drugs if the interdisciplinary team, as defined by Sec. 483.20(d)(2)(ii), has determined that this practice is safe. (o) Refusal of certain transfers. (1) An individual has the right to refuse a transfer to another room within the institution, if the purpose of the transfer is to relocate -- (i) A resident of a SNF from the distinct part of the institution that is a SNF to a part of the institution that is not a SNF, or


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(ii) A resident of a NF from the distinct part of the institution that is a NF to a distinct part of the institution that is a SNF. (2) A resident's exercise of the right to refuse transfer under paragraph (o)(1) of this section does not affect the individual's eligibility or entitlement to Medicare or Medicaid benefits. PART 483 REQUIREMENTS FOR STATES AND LONG TERM CARE FACILITIES Subpart B -- Requirements for Long Term Care Facilities Sec. 483.12 Admission, transfer and discharge rights. (a) Transfer and discharge— (1) Definition: Transfer and discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility. (2) Transfer and discharge requirements. The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless— (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v)The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate. (3) Documentation. When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (a)(2)(i) through (v) of this section, the resident's clinical record must be documented. The documentation must be made by-- (i) The resident's physician when transfer or discharge is necessary under paragraph (a)(2)(i) or paragraph (a)(2)(ii) of this section; and


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(ii) A physician when transfer or discharge is necessary under paragraph (a)(2)(iv) of this section. (4) Notice before transfer. Before a facility transfers or discharges a resident, the facility must-- (i) Notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. (ii)Record the reasons in the resident's clinical record; and (iii) Include in the notice the items described in paragraph (a)(6) of this section. (5) Timing of the notice. (i) Except when specified in paragraph (a)(5)(ii) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice may be made as soon as practicable before transfer or discharge when-- (A) the safety of individuals in the facility would be endangered under paragraph (a)(2)(iii) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (a)(2)(iv) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (a)(2)(ii) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (a)(2)(i) of this section; or (E) A resident has not resided in the facility for 30 days. (6) Contents of the notice. The written notice specified in paragraph (a)(4) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement that the resident has the right to appeal the action to the State;


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(v)The name, address and telephone number of the State long term care ombudsman; (vi) For nursing facility residents with developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act; and (vii) For nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. (7)Orientation for transfer or discharge. A facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. (8)Room changes in a composite distinct part. Room changes in a facility that is a composite distinct part (as defined in Sec.483.5(c)) must be limited to moves within the particular building in which the resident resides, unless the resident voluntarily agrees to move to another of the composite distinct part's locations. (b) Notice of bed-hold policy and readmission--(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the nursing facility must provide written information to the resident and a family member or legal representative that specifies— (i) The duration of the bed-hold policy under the State plan, if any, during which the resident is permitted to return and resume residence in the nursing facility; and (ii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (b)(3) of this section, permitting a resident to return. (2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and a family member or legal representative written notice which specifies the duration of the bed-hold policy described in paragraph (b)(1) of this section. (3) Permitting resident to return to facility. A nursing facility must establish and follow a written policy under which a resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, is readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the resident- (i) Requires the services provided by the facility; and (ii) Is eligible for Medicaid nursing facility services. (4) Readmission to a composite distinct part. When the nursing facility to which a resident is readmitted is a composite distinct part as defined in Sec. 483.5(c) of this


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subpart), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of readmission, the resident must be given the option to return to that location upon the first availability of a bed there. (c) Equal access to quality care. (1)A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all individuals regardless of source of payment; (2)The facility may charge any amount for services furnished to non- Medicaid residents consistent with the notice requirement in Sec. 483.10(b)(5)(i) and (b)(6) describing the charges; and (3)The State is not required to offer additional services on behalf of a resident other than services provided in the State plan. (d) Admissions policy. (1) The facility must-- (i) Not require residents or potential residents to waive their rights to Medicare or Medicaid; and (ii)Not require oral or written assurance that residents or potential residents are not eligible for, or will not apply for, Medicare or Medicaid benefits. (2) The facility must not require a third party guarantee of payment to the facility as a condition of admission or expedited admission, or continued stay in the facility. However, the facility may require an individual who has legal access to a resident's income or resources available to pay for facility care to sign a contract, without incurring personal financial liability, to provide facility payment from the resident's income or resources. (3) In the case of a person eligible for Medicaid, a nursing facility must not charge, solicit, accept, or receive, in addition to any amount otherwise required to be paid under the State plan, any gift, money, donation, or other consideration as a precondition of admission, expedited admission or continued stay in the facility. However,-- (i) A nursing facility may charge a resident who is eligible for Medicaid for items and services the resident has requested and received, and that are not specified in the State plan as included in the term “nursing facility services” so long as the facility gives proper notice of the availability and cost of these services to residents and does not condition the resident's admission or continued stay on the request for and receipt of such additional services; and


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(ii) A nursing facility may solicit, accept, or receive a charitable, religious, or philanthropic contribution from an organization or from a person unrelated to a Medicaid eligible resident or potential resident, but only to the extent that the contribution is not a condition of admission, expedited admission, or continued stay in the facility for a Medicaid eligible resident. (4) States or political subdivisions may apply stricter admissions standards under State or local laws than are specified in this section, to prohibit discrimination against individuals entitled to Medicaid. PART 483 REQUIREMENTS FOR STATES AND LONG TERM CARE FACILITIES Subpart B -- Requirements for Long Term Care Facilities Sec. 483.13 -- Resident behavior and facility practices. (a)Restraints. The resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. (b)Abuse. The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. PART 483 REQUIREMENTS FOR STATES AND LONG TERM CARE FACILITIES Subpart B -- Requirements for Long Term Care Facilities Sec. 483.15 Quality of life. A facility must care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life. (a)Dignity. The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. (b)Self-determination and participation. The resident has the right to-- (1)Choose activities, schedules, and health care consistent with his or her interests, assessments, and plans of care; (2)Interact with members of the community both inside and outside the facility; and (3)Make choices about aspects of his or her life in the facility that are significant to the resident.


CDPH 327 (05/11) 29

(c) Participation in resident and family groups. (1) A resident has the right to organize and participate in resident groups in the facility; (2)A resident's family has the right to meet in the facility with the families of other residents in the facility; (3)The facility must provide a resident or family group, if one exists, with private space; (4)Staff or visitors may attend meetings at the group's invitation; (5)The facility must provide a designated staff person responsible for providing assistance and responding to written requests that result from group meetings; (6)When a resident or family group exists, the facility must listen to the views and act upon the grievances and recommendations of residents and families concerning proposed policy and operational decisions affecting resident care and life in the facility. (d) Participation in other activities. A resident has the right to participate in social, religious, and community activities that do not interfere with the rights of other residents in the facility. (e) Accommodation of needs. A resident has the right to-- (1)Reside and receive services in the facility with reasonable accommodation of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered; and (2)Receive notice before the resident's room or roommate in the facility is changed.

ANCILLARY FORMS CHECKLIST

Resident Name: ________________________ Admit Date: ___________

1. Resident’s Appointment of Representative or Agent Controlling Admission to Facility2. Financial Responsibility Identification3. Facility Policy Regarding Implementation of Patient Self-Determination Act4. PSDA Brochure5. Arbitration Agreement6. Privacy Notice and Acknowledgment7. Facility Rules8. Theft & Loss Prevention Program Requirements9. Theft & Loss P&P (Insert Facility Specific P&P)10. Grievance P&P (insert Facility Specific P&P)11. Resident Trust Fund Requirements & Authorization12. Consent for Photograph13. Resident Mail Handling Authorization14. Laundry Authorization15. Audio and Video Policy16. Financial Payor Verification17. HMO Insurance Admission Screening Form18. Prior Stay Information Form19. Assignment of Insurance Benefits 20. Medicare Denial Notice (if applicable)21. Medicare Secondary Payer Screen 22. Notice Regarding Standards for Medi-Cal Eligibility 23. Notice Regarding Medi-Cal Application and Share of Cost Requirements 24. MC171 25. Pharmacy Services – Resident Selection 26. Pharmacy Services – Omnicare Admission Record and Agreement27. Facesheet 28. Verify temporary Consent to Treat completed by nursing at time of admission29. Verify PICC form completed by nursing at time of admission30. POLST31. Copy of DPOA for Health Care obtained32. Copy of DPOA for Finances obtained33. Copy of Advance Directive obtained34. Copies of all insurance cards front and back (i.e. Medi-Cal, Medicare, etc…)35. Common Working File36. Medicaid/Medi-Cal Eligibility37. Initial HMO Authorization (if applicable)38. Referral with Orders

Notes:

Admission Completed By: _______________________ Date: ___________

RESIDENT’S APPOINTMENT OF REPRESENTATIVE OR AGENT CONCERNING ADMISSION TO FACILITY

I, ______________________________________________________, declare as follows:

1. I am a competent adult over the age of 18.

2. I make the following representations to ___________________________________________, hereafter referred to as Facility.

3. It is my desire to be admitted to Facility to receive skilled nursing or custodial care according to my needs. It is my intention and understanding that Facility will rely upon these representation.

4. Although I may be competent to do so myself, I designate ______________________________ as my Agent/Representative to make all decisions and execute all documents and agreements related to my admission to the Facility.

5. I make this designation willingly and knowing that I am relinquishing the right to make these decisions. I understand and accept that I will be bound by the decisions and agreements that are entered into by the above named Agent/Representative.

I declare under penalty or perjury under the laws of the State of California that the foregoing is true and correct. Executed this ________ day of _____________, 20____. _____________________________________ Signature of Resident _____________________________________ Signature of Agent/Representative

FINANCIAL RESPONSIBILITY IDENTIFICATION

I, __________________________________________________________ , declare as follows:

1. I make the following representations to _______________________________________, hereafter referred to as Facility.

2. I declare that I am responsible for distribution of the Resident’s monies and per the California admission agreement understand that I am responsible for providing reimbursement from the Resident’s assets to the Facility in compliance with Section V. of the agreement.

3. I have read and understand the billing requirements as outlined in the admission agreement.

4. Please send all bills to my attention at the following address:

Street: __________________________________________ City: ____________________________ State: _______ Zip: ____________

*If available please include copy of DPOA for Financial

Copy of DPOA for Financial Attached Dated: __________ ____________________________________

Signature of Resident (if applicable) Dated: __________ _____________________________________

Signature of Agent/Representative

FACILITY POLICY REGARDING IMPLEMENTATION OF PATIENT SELF-DETERMINATION ACT

The following information is being provided to the Resident as a result of a Federal Law, the Patient Self-Determination Act” which requires certain health care institutions, including skilled nursing facilities, to notify Residents of their rights under Federal and State law to make decisions regarding their medical treatment. Pursuant to this law, on Admission, the Facility will provide each Resident with the most current copy of the PSDA brochure, Your Right to Make Decisions About Medical Treatment, as approved by the California Department of Health Services and the Facility will ask each Resident whether he or she has stated, formulated and/or signed an advance directive, and document the Resident’s answer. This Facility recognizes the dignity and value of each Resident’s life and the right of each Resident to make decisions regarding his or her medical treatment. When a Resident lacks medical decision-making capacity, this Facility recognizes the Resident’s right to have these decisions made on his or her behalf by a surrogate decision-maker in accordance with State law and this Facility’s policies and procedures. This Facility recognizes the rights of each Resident to state, formulate, sign or execute an advance directive. This Facility complies with California laws and court decisions on advance directives. An advance directive is an oral statement or a written document that states choices for health care and/or names someone to make those choices in the event that a Resident is unable to do so. These choices may include the refusal of certain types of care. A Power of Attorney for Health Care and a Natural Death Act Declaration are examples of written advance directives. This Facility does not condition the provision of care or otherwise discriminate against anyone based on whether or not they have stated, formulated or signed an advance directive. This Facility has policies to ensure that Residents’ wishes about treatment will be followed. Questions about the Facility’s policies regarding decision-making about medical treatment and/or advance directives may be addressed to the Facility Administrator or other designated staff member. If this Facility cannot follow an advance directive based on conscience, any limitations are clearly and precisely stated in these policies. Questions regarding whether to state, formulate or sign an advance directive or about its content should be discussed with the Resident’s physician, nurse, or Resident’s representative. It is the Resident’s responsibility to provide notice of any oral advance directive(s) or a copy of any written advance directive(s) to this Facility so that it can be kept with the Resident’s records. By signing here, the Resident/Representative acknowledges that he or she has been provided information regarding advance directives. Resident: ________________________________ Signature: _________________________________ Date: ________ Resident Representatiave: ___________________________ Signature: _________________________________ Date: ________

NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL AND FINANCIAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. PURPOSE OF THIS NOTICE We must provide this notice to each patient. We must make a good faith effort to obtain written acknowledgement of receipt of this notice from each patient. We must have this notice available at the facility for patients to request to take with them. We must post the notice in our office in a clear and prominent location to be reviewed by the patient. This notice is also available on our website at http://www.mvhealthcare.com/.. MVHC is committed to maintaining your health andfinancial information in a private and confidential manner. This Notice will give you information regarding our privacy practices. This notice applies to all of your health and financial information maintained in our facility and includes any information that we receive from other health care providers or facilities. The Notice describes the ways in which we may use or disclose your health and financial information and also describes your rights and our obligations concerning such uses or disclosures. OUR LEGAL DUTY We are required by applicable federal and state law to maintain the privacy of your health and financial information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health and financial information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect immediately and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health and financial information that we maintain, including health and financial information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request. You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us. USES AND DISCLOSURES OF HEALTH AND FINANCIAL INFORMATION FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS 1. Treatment, Payment and Health Care Operations. The following section describes different ways that we may use and disclose your health and financial information for purposes of treatment, payment, and health care operations. We have not listed every type of use or disclosure, but the ways in which we use or disclose your information will fall under one of these purposes.

a. Treatment. We may use your health and financial information to provide you with health care treatment and services. We may disclose your health and financial information to doctors, dentists, nurses, dental hygienists, dental assistants, technicians, or other personnel who are involved in your health care. b. Payment. We may use or disclose your health and financial information so that we may bill and receive payment from you, an insurance company, or another third party for the healthcare services you receive from us. We also may disclose health and financial information about you to your health plan in order to obtain prior approval for the services we provide to you, or to determine that your health plan will pay for the treatment. c. Health Care Operations. We may use and disclose your health and financial information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. d. Facility Operations: We may display and/or post within the facility or on the facility/company website, names, photographs, films, videotapes, and/or audio recordings taken or made by the company. The above may only be used by the corporation and/or facility in publications or postings as issued by the corporation, facility or subsidiaries.

USES AND DISCLOSURES OF HEALTH AND FINANCIAL INFORMATION IN SPECIAL SITUATIONS 1. Appointment Reminders. We may use or disclose your health information for purposes of contacting you to remind you of a health care appointment (i.e., voicemail messages, postcards, email, or letters). 2. Family Members and Friends. We may disclose your health and financial information to individuals, such as family and friends, who are involved in your care or who help pay for your care. We may make such disclosure when: (a) we

have your verbal agreement to do so; (b) we make such disclosures and you do not object; or (c) we can infer from the circumstances that you would not object to such disclosures. For example, if your spouse comes into the exam room with you, we will assume that you agree to our disclosure of your information while your spouse is present in the room. We also may disclose your health and financial information to family members or friends in instances when you are unable to agree or object to such disclosures, provided that we feel it is in your best interest to make such disclosures and the disclosures relate to that family member or friend’s involvement in your care. OTHER PERMITTED OR REQUIRED USES AND DISCLOSURES OF HEALTH AND FINANCIAL INFORMATION There are certain instances in which we may be required or permitted by law to use or disclose your health and financial information without your permission. These instances are as follows: 1. As required by law. We may disclose your health and financial information when required by federal, state, or local law to do so. For example, we are required by the Department of Health and Human Services (DHHS) to disclose your health and financial information in order to allow DHHS to evaluate whether we are in compliance with the federal privacy regulations. 2. Public Health Activities. We may disclose your health and financial information to public health authorities that are authorized by law to receive and collect heath information for the purpose of preventing or controlling disease, injury, or disability; to report births, deaths suspected abuse or neglect, reactions to medications; or to facilitate product recalls. 3. Health Oversight Activities. We may disclose your health and financial information to a health oversight agency that is authorized by law to conduct health oversight activities, including audits, investigations, inspections, or licensure and certification surveys. These activities are necessary for the government to monitor the persons or organizations that provide health care to individuals and to ensure compliance with applicable state and federal laws and regulations. 4. Judicial or Administrative Proceedings. We may disclose your health and financial information to courts or administrative agencies charged with the authority to hear and resolve lawsuits or disputes. We may disclose your health and financial information pursuant to a court order, a subpoena, a discovery request, or other lawful process issued by a judge or other person involved in the dispute, but only if efforts have been made to (i) notify you of the request for disclosure or (ii) obtain an order protecting your health and financial information. 5. Worker’s Compensation. We may disclose your health and financial information to worker’s compensation programs when your health condition arises out of a work-related illness or injury. 6. Law Enforcement Official. We may disclose your health and financial information in response to a request received from a law enforcement official to report criminal activity or to respond to a subpoena, court order, warrant, summons, or similar process. 7. Coroners, Medical Examiners, or Funeral Directors. We may disclose your health information to a coroner or medical examiner for the purpose of identifying a deceased individual or to determine the cause of death. We also may disclose your health information to a funeral director for the purpose of carrying out his/her necessary activities. 8. Organ Procurement Organizations or Tissue Banks. If you are an organ donor, we may disclose your health and financial information to organizations that handle organ procurement, transplantation, or tissue banking for the purpose of facilitating organ or tissue donation or transplantation. 9. Research. We may use or disclose your health information for research purposes under certain limited circumstances. Because all research projects are subject to a special approval process, we will not use or disclose your health information for research purposes until the particular research project for which your health information may be used or disclosed has been approved through this special approval process. However, we may use or disclose your health information to individuals preparing to conduct the research project in order to assist them in identifying patients with specific health care needs who may qualify to participate in the research project. Any use or disclosure of your health information that is done for the purpose of identifying qualified participants will be conducted onsite at our facility. In most instances, we will ask for your specific permission to use or disclose your health information if the researcher will have access to your name, address, or other identifying information. 10. To Avert a Serious Threat to Health or Safety. We may use or disclose your health information when necessary to prevent a serious threat to the health or safety of you or other individuals. 11. Military and Veterans. If you are a member of the armed forces, we may use or disclose your health and financial information as required by military command authorities. 12. National Security and Intelligence Activities. We may use or disclose your health and financial information to authorized federal officials for the purposes of intelligence, counterintelligence, and other national security activities, as authorized by law.

USES AND DISCLOSURES PURSUANT TO YOUR WRITTEN AUTHORIZATION Except for the purposes identified above, we will not use or disclose your health and financial information for any other purposes unless we have specific written authorization. You have the right to revoke a written authorization at any time as long as you do so in writing. If you revoke your authorization, we will no longer use or disclose your health and financial information for the purposes identified in the authorization, except to the extent that we have already taken some action in reliance upon your authorization. YOUR RIGHTS REGARDING YOUR HEALTH AND FINANCIAL INFORMATION You have the following rights regarding your health and financial information. You may exercise each of these rights, in writing, by providing us with a completed form that you can obtain from our office. In some instances, we may charge you for the cost(s) associated with providing you with the requested information. Additional information regarding how to exercise your rights, and the associated costs, can be obtained from our office. 1. Right to Inspect and Copy. You have the right to inspect and copy health and financial information that may be used to make decisions about your care. We may deny your request to inspect and copy your health and financial information in certain limited circumstances. If you are denied access, you may request the denial be reviewed. 2. Right to Amend. You have the right to request an amendment of your health and financial information that is maintained by or for our office and is used to make health care decisions about you. We may deny your request if it is not properly submitted or does not include a reason to support your request. We may also deny your request if the information sought to be amended; (a) was not created by us, unless the person or entity that created the information is no longer available to make the amendment; (b) is not part of the information that is kept by or for our office; (c) is not part of the information which you are permitted to inspect and copy; or (d) is accurate and complete. 3. Right to an Accounting of Disclosures. You have the right to request an accounting of the disclosures of your health and financial information made by us. This accounting will not include disclosures of health and financial information that we made for purposes of treatment, payment or health care operations pursuant to a written authorization that you have signed. 4. Right to Request Restrictions. You have the right to request a restriction or limitation on the health and financial information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the health and financial information we disclose about you to someone, such as a family member or friend, who is involved in your care or in the payment of care. For example, you could ask that we not use or disclose information regarding a particular treatment that you received. We are not required to agree to your request. If we do agree, that agreement must be in writing and signed by you and us. 5. Right to Request Confidential Communications. You have the right to request that we communicate with you about your health care in a certain way or at a certain location. For example, you can ask that we only contact you at work or by email. 6. Right to a Paper Copy of this Notice. You have the right to receive a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. QUESTIONS OR COMPLAINTS If you have any questions regarding this Notice or wish to receive additional information about our privacy practices, please contact our Privacy Officer at the address below. If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of DHHS. To file a complaint with our office, contact our Privacy Officer at the address below. All complaints must be submitted in writing. You will not be penalized for filing a complaint. The Administrator, Mountain View Healthcare Center 2530 Solace Place, Mountain View, CA 94040

. EFFECTIVE DATE OF THIS NOTICE This Notice is effective August 1, 2013 Resident: ________________________________ Signature: _________________________________ Date: ________ Resident Representative: ___________________________ Signature: _________________________________ Date: ________

THEFT AND LOSS PREVENTION PROGRAM REQUIREMENTS HEALTH AND SAFETY CODE SECTIONS 1289.3-5

§1289.3 Failure to safeguard patient property; reimbursement; citation

(a) A long-term health care facility, as defined in Section 1418, which fails to make reasonable efforts to safeguard patient property shall reimburse a patient for or replace stolen or lost patient property at its then current value. The facility shall be presumed to have made reasonable efforts to safeguard patient property if the facility has shown clear and convincing evidence of its efforts to meet each of the requirements specified in Section 1289.4. The presumption shall be a rebuttable presumption, and the resident or the resident’s representative may pursue this matter in any court of competent jurisdiction.

(b) A citation shall be issued if the long-term health care facility has no program in place or if the facility has not shown clear and convincing evidence of its efforts to meet all of the requirements set forth in Section 1289.4. The department shall issue a deficiency in the event that the manner in which the policies have been implemented is inadequate or the individual facility situation warrants additional theft and loss protections.

(c) The department shall not determine that a long-term health care facility’s program is inadequate based solely on the occasional occurrence of theft or loss in the facility.

§ 1289.4 Theft and Loss Programs

A theft and loss program shall be implemented by the long-term health care facilities within 90 days after January 1, 1988. The program shall include all of the following:

(a) Establishment and posting of the facility’s policy regarding theft and investigative procedures.

(b) Orientation to the policies and procedures for all employees within 90 days of employment.

(c) Documentation of lost and stolen patient property with a value of twenty-five dollars ($25) or more and, upon request, the documented theft and loss record for the past 12 months shall be made available to the State Department of Health Services, the county health department, or law enforcement agencies and to the office of the State Long-Term Care Ombudsman in response to a specific complaint. The documentation shall include, but not be limited to, the following:

(1) A description of the article. (2) Its estimated value. (3) The date and time the theft or loss was discovered. (4) If determinable, the date and time the loss or theft occurred. (5) The action taken.

(d) A written patient personal property inventory is established upon admission and retained during the resident’s stay in the long-term health care facility. A copy of the written inventory shall be provided to the resident or the person acting on the resident’s behalf. Subsequent items brought into or removed from the facility shall be added to or deleted from the personal property inventory by the facility at the written request of the resident, the resident’s family, an agent/representative, or a person acting on behalf of the resident. The facility shall not be liable for items which have not been requested to be included in the inventory or for items which have been deleted from the inventory. A copy of a current inventory shall be made available upon request to the resident, agent/representative, or other authorized representative. The resident, resident’s family, or an agent/representative may list those items which are not subject to addition or deletion from the inventory, such as personal clothing or laundry, which are subject to frequent removal from the facility.

(e) Inventory and surrender of the resident’s personal effects and valuables upon discharge to the resident and authorized representative in exchange for a signed receipt.

(f) Inventory and surrender of personal effects and valuables following the death of a resident to the authorized representative in exchange for a signed receipt. Immediate notice to the public administrator of the county upon the death of a resident without known next of kin as provided in Section 7600.5 of the Probate Code.

(g) Documentation, at least semiannually, of the facility’s efforts to control theft and loss, including the review of theft and loss documentation and investigative procedures and results of the investigation by the administrator and, when feasible, the resident council.

(h) Establishment of a method of marking, to the extent feasible, personal property items for identification purposes upon admission and as added to the property inventory list, including engraving of dentures and tagging of other prosthetic devices.

(i) Reports to the local law enforcement agency within 36 hours when the administrator of the facility has reason to believe patient property with a then current value of one hundred dollars ($100) or more has been stolen. Copies of those reports for the preceding 12 months shall be made available to the State Department of Health Services and law enforcement agencies.

(j) Maintenance of a secured area for patients’ property which is available for safekeeping of patient property upon the request of the patient or the patient’s agent/representative. Provide a lock for the resident’s bedside drawer or cabinet upon request of and at the expense of the resident, the resident’s family, or authorized representative. The facility administrator shall have access to the locked areas upon request.

(k) A copy of this section and Sections 1289.3 and 1289.5 is provided by a facility to all of the residents and their responsible parties, and, available upon request, to all of the facility’s prospective residents and their responsible parties.

(l) Notification to all current residents, and all new residents, upon admission, of the facility’s policies and procedures relating to the facility’s theft and loss prevention program.

§ 1289.5 Contracts of admission; lesser standards of responsibility prohibited

No provision of a contract of admission, which includes all documents which a resident or his or her representative is required to sign at the time of, or as a condition of, admission to a long-term health care facility, shall require or imply a lesser standard of responsibility for the personal property of residents than is required by law.

By signing here, the Resident/Representative acknowledges that he or she has been provided information regarding the Facility Theft & Loss Program Requirements.

Resident: ________________________________ Signature: _________________________________ Date: ________

Resident Representative: ___________________________ Signature: _________________________________ Date: ________

* Please see addendum of Theft and Loss on next page.

RESIDENT TRUST FUNDS

A Resident Trust Fund is an amount of money held by the Facility for the Resident’s personal use. (Examples of use: to allow the Resident to pay for room and board, beauty shop charges, cigarettes, postage stamps, or other similar expenses as desired by the Resident.) The Facility handles Resident Trust Funds in the following manner:

The Facility shall deposit funds in excess of fifty dollars ($50) in an interest-bearing account insured by the Federal Deposit Insurance Corporation (FDIC) that is separate from any Facility operating accounts, or in a federally insured bank or savings and loan association under a plan approved by the Department of Health Services, or shall purchase a surety bond to assure the security of all such personal funds. All interest earned on the Resident’s funds shall be credited to his or her account. The Facility shall have the option of depositing funds of less than fifty dollars ($50) in one of the following: a non-interest bearing account, an interest bearing account, or petty cash fund. The Facility shall inform the Resident as to how his or her funds are being held. The Facility’s policy is to maintain all Resident funds in a separate account, except for a nominal amount maintained in a petty cash fund for the Residents’ convenience.

The Facility shall have a system that ensures a complete and separate accounting, based on generally accepted accounting principles, of the personal funds deposited with the Facility by each Resident or on his or her behalf. This system shall also ensure that the Resident’s funds are not commingled with the Facility’s funds or with any other funds besides those of other Residents. In addition to the required quarterly accounting, the Facility shall provide individual financial records at the written request of the Resident.

The personal balances of Residents who receive Medi-Cal benefits must remain within a certain dollar range to satisfy State and Federal laws. The Facility shall notify a Medi-Cal Resident if his or her account balance is within two hundred dollars ($200) of the Federal Supplemental Security Income (SSI) limit. The Facility shall also notify the Resident if the account balance, in addition to the Resident’s known non-exempt assets, reaches the SSI resource limit. A balance in excess of this limit may cause the Resident to lose eligibility for Medi-Cal or SSI.

If a Resident who has personal funds deposited with the Facility expires, the Facility shall refund the Resident’s account balance within thirty (30) days and provide a full accounting of these funds to the individual, probate jurisdiction administering the Resident’s estate, or other entity as required by State law or regulation.

If the Resident wants the Facility’s assistance with managing personal funds, the Resident is required to complete and sign the Resident Trust Fund Authorization on the following page.

RESIDENT TRUST FUND AUTHORIZATION

By signing below, the Resident authorizes the Facility to set up a trust fund in his/her name. The individual financial records for the Resident’s Trust Fund shall be available through quarterly statements and on request, to the Resident/Representative. The Resident understand that all withdrawals shall be authorized by the Resident/Representative in writing.

The following person(s) are authorized by the Resident/Representative to withdraw funds from the Resident’s Trust Fund:

1. _______________________________________________________________

2. _______________________________________________________________

3. _______________________________________________________________

4. _______________________________________________________________

5. _______________________________________________________________



2530 Solace Place Mountain View California 94040 650.961.6161 FAX 650.967.7878

INFORM CONSENT TO PHOTOGRAPH ANDUSE OF VIDEO SURVEILANCE

I, __________________________________, am a resident at ___________________________

(facility/location). I agree that agents for Mountain View HC, or designated

vendor, can record, videotape and photograph my image and/or voice for such purposes as

Mountain View HC Therapies deems appropriate, including but not limited to advertising,

employee handbooks, training materials and brochures. I waive any and all fees in connection

with such use.

I further understand that no special compensation will be provided to me for use of my image

and that I may not be informed in advance of the specific use of my image.

________________________________________ Signature Date

________________________________________ Witness Date

RESIDENT MAIL HANDLING AUTHORIZATION

Resident Name: ___________________________ Admit Date: __________

The facility is authorized to hand the Resident’s mail as follows:

□ All mail given directly to the Resident*

□ Forward all of the Resident’s mail to:

Name:______________________________ Relationship to Resident:__________

Street:___________________________City:__________State:_____Zip:________

□ Give personal mail to the Resident*; forward business mail to:

Name:______________________________ Relationship to Resident:__________

Street:___________________________City:__________State:_____Zip:________

□ All personal mail will be directed to the Resident; the facility may process all business mail.*

*If any mail given to resident, please select one:

□ All mail to be read to the resident

□ Upon request, mail may be read to the resident



LAUNDRY AUTHORIZATION

Resident Name: _________________________________ Admit Date: _____________

□ The family will pick up and clean the Resident’s laundry as needed. The family will also provide plasticbags in covered plastic containers to the Resident’s dirty laundry.

□ The facility will clean the Resident’s laundry and will charge a rate of $ _______ per day to theResident. Facility staff will make the Resident’s clothing is pre-marked with his or her name and isremarked periodically as needed. In addition, I understand that the facility does not assume responsibilityfor lost or damaged laundry except as required by State Law and any normal wear and tear. Please keepin mind that the community uses industrial detergents in commercial machines on very high heat.(Medicare, Medi-Cal, and VA covered service.)

□ An outside laundry service will clean the Resident’s laundry. The Resident is responsible for directlypaying the outside laundry service.



Audio Video Policy March 2011

AUDIO AND VIDEO POLICY (RESIDENT/PUBLIC/FACILITY)

Policy

BASIC RESPONSIBILITY Facility Administrator, or designee and All Facility Employees

POLICY GUIDELINES The resident has the right to privacy, confidential care, and protection of health information.

Healthcare professionals have a duty to protect each resident’s healthcare information and privacy. Violations of the resident’s rights undermine the public’s confidence in healthcare organizations. Similarly, all persons, including residents, healthcare professionals and visitors to the facility, have

an interest in how their recorded likeness, image and voice are subsequently used. In order to safeguard these identified interests, the facility does not permit photographing of any kind or use of audio or video recording devices, unless prior written consent is obtained from the resident and any other persons depicted within the facility

DEFINITIONS

A photographic device is any device that captures an image and outputs the resulting image on a display surface. This includes all video and still captures devices.

An audio device is any device that records sound.

PROCEDURAL COMPONENTS a) All photographic and audio devices must be turned off or have their recording ability disabled upon

entering the facility. Photographic and audio devices may include, but are not limited to: i) Cell phone, iPhone, smart-phone cameras ii) Video cameras that create digital or film recordings iii) Still cameras, both digital and film iv) Instant or Polaroid™-type cameras v) Tape recorders vi) iPods, MP3 players vii) Laptops, iPads

b) If written consent has been obtained for the use of photographic and audio devices, consents will become part of the resident’s medical record. Only after written consent has been obtained may the recording function of photographic and audio devices be turned on or enabled.

c) The recording function of photographic and audio devices must be utilized in such a manner to only

include the likeness, images and/or voices of the persons that have provided written consent. As a result, the location of the use of the photographic and audio devices as well as the persons present in those areas must be carefully considered.

d) The facility educates all residents/patients and family members about this policy upon admission and

thereafter as needed. This information is included in the admission consent that is signed by the resident/patient or responsible party. Example language includes: In order to protect resident/patient privacy and in order to comply with privacy regulations, I agree that the use of photographic, video or audio devices will not be used by staff, residents/patients, or the public within the facility without the prior written authorization of the residents/patient) and approval by facility management.

e) Visitors who do no comply with this policy are required to leave the facility. Any unauthorized

recording or images must be deleted.

f) The facility may have surveillance cameras in use for security purposes. In this event, this fact will be posted in accordance with applicable state/local laws.

g) Anyone who observes a violation of this policy should immediately inform facility administration.

Resident: ________________________________ Signature: _________________________________ Date: ________ Resident Representative: ___________________________ Signature: _________________________________ Date: ________

FINANCIAL PAYOR VERFICATION Resident Name: _____________________ Admit Date: ___________ Date of Birth: ___________ Medicare – Run CWF to verify:

Medicare # (HIC): _______________________________ Medicare Eligible: Yes No

Part A Effective Date: ______________ Part B Effective Date: ______________

Last billing date: _____________ # of days remaining: ______________ (as stated on CWF)

Based on CWF and Prior Stay form, the ACTUAL available days are: Full Coverage Days: ____________________________ Co-insurance Days: ____________________________

Co-insurance Begins: ___________________________ Benefit Period Ends: ___________________________

HMO(C): Yes No Code: __________ Name of Insurance: _______________________________________ *If HMO is Yes, please complete HMO/Insurance Screening Form

Hospice: Yes No

MSP (List any open MSPs):_________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Comments: _____________________________________________________________________________________

_______________________________________________________________________________________________

Medi-Cal/Medicaid – Call or use electronic look-up: Medi-Cal/Medicaid # (BIC): _______________________________ Medi-Cal/Medicaid Eligible: Yes No

Share of Cost / Patient Liability Amount: ______________________ Collected: Yes No

Managed Care: ________________________________________ Custodial Skilled LOA

Billing Address: __________________________________________________________________________________

Phone #: _____________________ Contact Person: ___________________________________________________

Authorization #: __________________________________________________________________________________ _

Comments: _____________________________________________________________________________________

_______________________________________________________________________________________________

Private Pay – Please complete if primary or secondary: Please indicate if Private pay is Primary or Secondary at time of Admission: Primary Payor Secondary Payor

Private Responsibility discussed with Resident/RP/Agent: Yes No

Amount due upon admit (if applicable): ________________ Collected: Yes No

Comments: _____________________________________________________________________________________

_______________________________________________________________________________________________ Verified By: _________________________________________________________ Date: _____________

Resident/RP/Agent: __________________________________________________ Date: _____________

HMO / INSURANCE SCREENING ON ADMISSION Resident Information:

Resident Name: ______________________________ Date of Birth: _____________ Admit Date: _____________

Member ID#: _________________________________ Group#: _______________________

Subscriber Name (if different than resident): ___________________________________________________________ Plan Information:

Plan Name: _________________________________________________ Phone #: __________________________

Billing Address: _________________________________________________________________________________

Payor Electronic ID#:________________________________ Pre-Enrollment Required? Yes No

Verification of Eligibility and Benefits:

Rep. spoke with: _______________________________________________ Plan Effective Date: _________________

Member currently eligible for payment for skilled nursing care services? Yes No

Medicare Primary Coverage? Yes No Pre-authorization? Yes No

Part B Coverage? Yes No Pre-authorization? Yes No

Do you require Medicare’s 100 days to be exhausted before benefits will be paid? Yes No

Do you pay for Room & Board? Yes No How much per day? ____________________

What is included? ________________________________________________________________________________

Therapy Coverage: PT Yes No OT Yes No ST Yes No

Will they pay for?

Part A co-insurance while in SNF? Yes No How many days? _______________________

Part B co-insurance while in SNF? Yes No

Co-pay: Beginning: ______________ day for $_____________ Pre-authorization? Yes No

Deductible: Total Amount $______________ − Amount Met $______________ = Amount Due $______________

Max. Out-of-Pocket $__________________ Max. Covered Days: _______________________________________

Authorization:

Rep. spoke with: _______________________________________________ Phone #: _________________________

Authorization #: ___________________________________________ Written Copy Received: Yes No

Days Covered: ______________________ Level/Rate: _________________________________________________

Procedure to follow for initial and continued authorization: _________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________ Special Billing Instructions:

Special Billing Requirements: _______________________________________________________________________

Do you require we bill with RUGS (Medicare PPS)? Yes No

Will claim be paid at RUGS? Yes No MDS notified for RUGS needed if indicated? Yes No

Verified By: _________________________________________________________ Date: _____________


5.1.(a)

__________________________ _______________________________ _______________________________

Assignment of Insurance Benefits

Resident Name: ________________________________

Medicare Number: ________________________________

Insurance Company: ________________________________

Group Insurance Number: ________________________________

The undersigned authorizes, whether he/she signs as agents or as residents, direct payment to the facility of any insurance benefits otherwise payable to or on behalf of the resident, for this hospitalization or for all the services rendered at the facility. It is agreed that payment to the facility pursuant to this authorization, by an insurance company, shall discharge said insurance company of any and all obligations under a policy to the extent of such payment. It is understood by the undersigned that he/she is financially responsible for charges not covered by this assignment.

Resident’s Signature Resident’s Agent Signature

Witness

Date

PRIOR STAY INFORMATION Resident Name: ______________________________________ Admit Date: ___________ HIC#: _______________________

Most Recent Acute Hospital Stay:

Hospital Name: _____________________________________ Inpatient Stay: Yes No

Hospital Admit: _______________ Hospital Discharge: _______________

Prior Stays: (Please Include: Acute, B&C, Assisted Living, and SNF stays including any prior stay at this facility)

Facility Name Type of Facility

From To Medicare

Days Used Last Covered

Day Date Custodial Level of Care

*Please indicate Actual Days Available as determined by Prior Stay on the Financial Verification Form

Notes from calls to other facilities / Comments:

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Verified By: _________________________________________________________ Date: _____________


SNF DETERMINATION ON ADMISSION _____________________________ ____________________________ ____________________________

TO: ______________________ ______________________ ______________________ RE: ______________________ ______________________ ______________________ On _____________, we reviewed your medical information available at the time of, or prior to your admission, and we believe that services (your or beneficiary’s name) needed did not meet the requirements for coverage under Medicare. The reason is: This decision has not been made by Medicare. It represents our judgment that the services you needed did not meet Medicare payment requirements. Normally, under this situation, a bill is not submitted to Medicare. A bill will only be submitted to Medicare if you request that a bill be submitted. Furthermore, if you want to appeal this decision, you must request that a bill be submitted. If you request that a bill be submitted, the Medicare intermediary will notify you of its determination. If you disagree with that determination, you may file an appeal. Under a provision of the Medicare law, you do not have to pay for noncovered services determined to be custodial care or not reasonable or necessary unless you had reason to know the services were noncovered. You are considered to know that these services were noncovered effective with the date of this notice. If you have questions concerning your liability for payment for services you received prior to the date of this notice, you must request that a bill be submitted to Medicare. We regret that this may be your first notice of the noncoverage of services under Medicare. Our efforts to contact you earlier in person or by telephone were unsuccessful. Please check one of the boxes below to indicate whether or not you want your bill submitted to Medicare and sign the notice to verify receipt. Sincerely yours, _______________________________________________________________________________ Signature of Administrative Officer

REQUEST FOR MEDICARE INTERMEDIARY REVIEW

// A. I want my bill submitted to the intermediary for a Medicare decision. You will be informed when the bill is submitted.

If you do not receive a formal Notice of Medicare Determination within 90 days of this request you should contact: (Name and address of intermediary).

// B. I do not want my bill submitted to the intermediary for a Medicare decision. I understand that I do not have Medicare appeal rights if no bill is submitted. NOTE: You are not required to pay for services until a Medicare decision has been made. VERIFICATION OF RECEIPT OF NOTICE C. This acknowledges that I received this notice of noncoverage of services under Medicare on (date of receipt). _____________________________________________________________ (Signature of Beneficiary or Person acting on Beneficiary’s behalf) D. This is to confirm that you were advised of the noncoverage of the services under Medicare by telephone on (date of telephone contact). _____________________________________________________________ (Name of Beneficiary or Representative contacted) _____________________________________________________________ (Signature of Administrative Officer)

KEEP A COPY OF THIS FOR YOUR RECORDS

MEDICARE SECONDARY PAYER QUESTIONNAIRE Provider Name: ____________________________________________________________ Admission Date: _______________

Resident Name:_____________________________________________________________ Medicare #: ___________________

PART I 1. Are you receiving Black Lung (BL) Benefits?

Yes; Date benefits began: _______________ BL is primary only for claim related to BL.

No

2. Are the services to be paid by a government program such as a research grant?

Yes; Government Program will pay primary benefits for these services.

No

3. Has the Department of Veterans Affairs (DVA) authorized and agreed to pay for care at this facility?

Yes; DVA is primary for these services.

No

4. Was the illness / injury due to work related accident / condition? Yes; Date of illness / injury: _______________

Complete payor information below. WC is primary payor only for claims related to work related injuries or illness. GO TO PART III.

No; GO TO PART II.

PART II

1. Was illness / injury due to a nonwork related accident?

Yes; Date of accident: _______________

No; GO TO PART III.

2. What type of accident caused the illness / injury?

Automobile Non-automobile

Complete payor information below. Liability insurer is primary only for those claims related to the accident. GO TO PART III. 3. Was another party responsible for this accident?

Yes; Complete payor information below. Liability is primary only for those claims related to the accident. GO TO PART III.

No; GO TO PART III.

PART III 1. Are you entitled to Medicare based on?

Age; GO TO PART IV.

Disability; GO TO PART V.

ESRD; GO TO PART VI.

PART IV - Age 1. Are you currently employed?

Yes; Complete payor information below.

No; Retirement Date: __________

2. Is your spouse currently employed?


No; Retirement Date:__________

If the resident answered NO to both questions 1 and 2, Medicare is primary unless the resident answered YES to question in Part I or II. Do Not preceed any further.

3. Do you have group health plan (GHP) coverage based on your own, or a spouse’s current employment?

Yes

No; Medicare is primary payer unless the resident answered YES to the questions in Part I or II.

4. Does the employer that sponsors your GHP employ 20 or more employees?

Yes; Complete payor information below. Group health plan is primary.


PART V - Disability 1. Are you currently employed?


No; Retirement Date: _____________

2. Is a family member currently employed?


No If the resident answered NO to both questions 1 and 2, Medicare is primary unless the resident answered YES to question in Part I or II. Do Not preceed any further.

3. Do you have group health plan (GHP) coverage based on your own, or a family member’s current employment?

Yes

No; Medicare is primary unless the resident answered YES to question in Part I or II.

4. Does the employer that sponsors your GHP employ 100 or more employees?

Yes; Complete payor information below. Group health plan is primary.


PART VI - ESRD 1. Do you have group health plan (GHP) coverage?


No; Medicare is primary

2. Have you received a kidney transplant?

Yes; Date of transplant: _______________

No

3. Have you received maintenance dialysis treatements?

Yes; Date of dialysis started: _____________

If you participated in a self dialysis training program, provide date training started: ____________

No

4. Are you within the 30 month coordiation period?

Yes

No; Medicare is primary 5. Are you entitled to Medicare on the basis of either ESRD and age or

ESRD and disability?

Yes

No; GHP is primary during the 30 month coordination period.

6. Was your initial entitlement to Medicare (including simultaneous entitlement) based on ESRD?

Yes; GHP continues to pay primary during the 30 month coordination.

No; Initial entitlement based on age or disability.

7. Does the working aged or disability MSP provision apply (i.e. is the GHP primary based on age or disability entitlement)?

Yes; GHP continues to pay primary during the 30 month coordination.

No; Medicare continues to pay primary.

COMMENTS: ________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________

PRIMARY PAYER INFORMATION

EMPLOYER (Patient): _____________________

Address: ________________________________

City /St /Zip: _____________________________

Phone: _________________________________

PATIENT ID: ____________________________

EMPLOYER (Spouse): _____________________

Address: ________________________________

City /St /Zip: _____________________________

Phone: _________________________________

PATIENT ID: ____________________________

INSURER: ______________________________

Address: ________________________________

City /St /Zip: _____________________________

Phone: _________________________________

PATIENT ID: ____________________________

Facility Staff Signature: ______________________________________________________ Date: ___________________

NOTICE REGARDING STANDARDS FOR MEDI-CAL ELIGIBILITY If you or your spouse is in or is entering a nursing facility, read this important message! You or your spouse do not have to use all your resources, such as savings, before Medi-Cal might help pay for all or some of the costs of a nursing facility. You should be aware of the following to take advantage of these provisions of the law: Unmarried Resident An unmarried resident is financially eligible for Medi-Cal benefits if he or she has less than $2,000 in available resources. A home is an exempt resource and is not considered against the resource limit, as long as the resident states on the Medi-Cal application that he or she intends to return home. Clothes, household furnishings, irrevocable burial plans, burial plots, and an automobile are examples of other exempt resources. If an unmarried resident is financially eligible for Medi-Cal reimbursement, he or she is allowed to keep from his or her monthly income a personal allowance of $35 plus the amount of health insurance premiums paid monthly. The remainder of the monthly income is paid to the nursing facility as a monthly deductible called the “Medi-Cal share-of-cost.” Married Resident If one spouse lives in a nursing facility, and the other spouse does not live in a nursing facility, the Medi-Cal program will pay some or all of the nursing facility costs as long as the couple together does not have more than $113,640 in available assets. The couple’s home will not be counted against this $113,640 as long as one spouse or a dependent relative, or both, lives in the home, or the spouse in the nursing facility states on the Medi-Cal application that he or she intends to return to the couple’s home to live. If a spouse is eligible for Medi-Cal payment of nursing facility costs, the spouse living at home is allowed to keep a monthly income of at least his or her individual monthly income or $2,841, whichever is greater. Of the couple’s remaining monthly income, the spouse in the nursing facility is allowed to keep a personal allowance of $35 plus the amount of health insurance premiums paid monthly. The remaining money, if any, generally must be paid to the nursing facility as the Medi-Cal share-of-cost. The Medi-Cal program will pay remaining nursing facility costs. Under certain circumstances, an at-home spouse can obtain an order from an administrative law judge that will allow the at-home spouse to retain additional resources or income. Such an order can allow the couple to retain more than $113,640 in available resources if the income that could be generated by the retained resources would not cause the total monthly income available to the at-home spouse to exceed $2,841.Such an order also can allow the at-home spouse to retain more than $2,841 in monthly income, if the extra income is necessary “due to exceptional circumstances resulting in significant financial duress.” An at-home spouse also may obtain a court order to increase the amount of income and resources that he or she is allowed to retain, or to transfer property from the spouse in the nursing facility to the at-home spouse. You should contact a knowledgeable attorney for further information regarding court orders. The paragraphs above do not apply if both spouses live in a nursing facility and neither previously has been granted Medi-Cal eligibility. In this situation, the spouses may be able to hasten Medi-Cal eligibility by entering

into an agreement that divides their community property. The advice of a knowledgeable attorney should be obtained prior to the signing of this type of agreement. Note: For married couples, the resource limit ($113,640 in 2012) and income limit ($2,841 in 2012) generally increase a slight amount on January 1 of every year. Transfer of Home for Both a Married and an Unmarried Resident A transfer of a property interest in a resident’s home will not cause ineligibility for Medi-Cal reimbursement if either of the following conditions is met: (a) At the time of transfer, the recipient of the property interest states in writing that the resident would have been allowed

to return to the home at the time of the transfer, if the resident’s medical condition allowed him or her to leave the nursing facility. This provision shall only apply if the home has been considered an exempt resource because of the resident’s intent to return home.

(b) The home is transferred to one of the following individuals:

(1) The resident’s spouse.

(2) The resident’s minor or disabled child.

(3) A sibling of the resident who has an equity interest in the home, and who resided in the resident’s home for at least one year immediately before the resident began living in institutions.

(4) A son or daughter of the resident who resided in the resident’s home at least two years before the resident began

living in institutions, and who provided care to the resident that permitted the resident to remain at home longer. This is only a brief description of the Medi-Cal eligibility rules; for more detailed information, you should call your county welfare department. You will probably want to consult with the local branch of the state long-term care ombudsman, an attorney, or a legal services program for seniors in your area. I have read the above notice and have received a copy.

Signature of person being admitted Date

Signature of spouse Date

Signature of legal representative Date

NOTICE REGARDING MEDI-CAL APPLICATION AND SHARE OF COST REQUIREMENTS

For Medi-Cal Beneficiaries and the Individuals Who Handle Their Money. Regarding the Amount of Income Determined by the California Medi-Cal Program to be the Resident’s “Share of Cost” that Must Be Paid to This Facility and the Resident’s Right to Appeal Medi-Cal’s Share of Cost Determination. The payment of the Resident’s Share of Cost as determined by the California Medi-Cal Program is required by law. The amount of the Share of Cost that must be paid to this Facility is determined by the California Medi-Cal program through the Department of Social Services. This amount is not something that the Facility decides or controls. If you believe that the Share of Cost assigned to the Resident by Medi-Cal is not correct, you may apply for a state hearing (through the Medi Cal office that is handling the Resident’s case) for a determination as to the accuracy of the amount of the Resident’s Share of Cost. The assigned Share of Cost must be paid to this Facility unless there is a final determination by Medi-Cal following an appeal that the Resident’s Share of Cost amount is incorrect. The telephone number and address of the Medi-Cal field office closest to this Facility is: Address: ______________________________________________ Phone: _________________________ If you have any questions regarding this notice or the legal responsibility to pay the Resident’s Share of Cost, please contact _________________________________________ as soon as possible. If the Resident has converted from a non Medi-Cal payment category to the Medi-Cal payment category, and you are unsure of the amount of the Resident’s Share of Cost that must be paid to the Facility, you may obtain an estimate of the amount by contacting the local Medi-Cal office for this information regarding the amount of the Resident’s Share of Cost. If, for any reason, the Resident becomes ineligible for Medi-Cal benefits, the Resident will be responsible for paying the private rates for care at this Facility unless the Resident qualifies for payment by another third-party payer category. Resident: ________________________________ Signature: _________________________________ Date: ________ Resident Representative: ___________________________ Signature: _________________________________ Date: ________

State of California–Health and Human Services Agency Department of Health Services

MEDI-CAL LONG-TERM CARE FACILITY ADMISSION AND DISCHARGE NOTIFICATION (Instructions and distribution on reverse.)

I. COMPLETE THIS PORTION FOR ALL ACTIONS

Patient’s name (last) (first) (MI) Name of facility

Social security number Address (number and street)

Note: Level of care is SNF/ICF unless checked here as board and care.

City State ZIP code

II. COMPLETE THIS PORTION ONLY FOR ADMISSIONS

Medi-Cal ID number (taken from the Medi-Cal card) Admission date (month/day/year)

A. Do you have Medicare Part A, Hospital Coverage?

Yes No

B. Expected length of stay:

At least one full month after the month of admission

Less than one full month after the month of admission

C. Medi-Cal is expected to pay over 50% of facility cost of care.

Yes, beginning with month of _______, 20___

No, other insurance, private pay, etc.

D. Current income (check all applicable boxes):

Supplemental Security Gold Checks

Social Security Green Checks

Other Income (i.e., railroad, military, retirement, etc.)

None

E. Admission from:

Home Board and Care

Household of another

Acute Hospital–Home, B&C, other household immediately prior to acute

Acute Hospital–SNF/ICF immediately prior to acute

Acute Hospital extended stay–over 30 days

Another SNF/ICF

F. If known, enter your address prior to facility admission. If

admitted from an acute hospital, enter your address prior to the acute hospital admission. (Do not give the acute hospital’s address.)

Address (number and street)

City State ZIP code

G. Signature of recipient or representative payee or family member/other:

Signature of recipient Signature of Representative Payee Phone number

If recipient’s signature cannot be obtained, please indicate reason in this space.

Signature of family member/other (indicate your relationship to the recipient.) Phone number

III. COMPLETE THIS PORTION ONLY FOR DISCHARGES

A. Reason for discharge:

Discharged to Acute Hospital

Discharged to another SNF/ICF

Discharged to residence/home of another

Discharged to Board and Care

Discharged to other

Discharged due to death

B. Date of discharge (month/day/year) C. Medi-Cal ID number (taken from the Medi-Cal card)

D. Complete the forwarding address for discharge other than death:

Name of facility (if not discharged home)

Address (number and street)

City State ZIP code

Facility representative signature

Date

MC171 (6/02)

PHARMACY SERVICES You have the option to choose your own pharmacy.

□ I choose to use the pharmacy selected by the Facility 1. Will pay for all medications and medical supplies

Consent is given to the Facility to order from a pharmacy of its choice, all medications and medical supplies, prescribed by the Resident’s attending physician, including those not covered by the Medi-Cal program, an HMO and/or other third-party payer. If the Resident is a Medi-Cal beneficiary, this consent includes all medications and medical supplies not covered by Medi-Cal and the Facility is authorized to deduct the cost of eligible medications from the Resident’s Share of Cost. The Resident/Representative shall pay the pharmacy directly for all medications and medical supplies furnished to the Resident.

□ Accepted □ Denied

2. Will pay for no medications or medical supplies The Facility shall not order any medications or medical supplies prescribed by the Resident’s attending physician that are not covered by the Medi-Cal program, an HMO and/or other third-party payer. The Resident/Representative releases the Facility from any and all liability for outcomes that may result if the Resident is not provided such medications or medical supplies as ordered by the Resident’s physician.


3. Will pay for emergency only medications or medical supplies The Facility shall order from a pharmacy of its choice only those medications and medical supplies that are prescribed by the Resident’s attending physician in an emergency, including those not covered by the Medi-Cal program, an HMO and/or other third-party payer. The Resident/Representative shall pay the pharmacy directly for all medications and medical supplies furnished by the Resident. The Resident/Representative releases the Facility from any and all liability for outcomes that may result if the Resident is not provided such medications or medical supplies as ordered by the Resident’s physician.


□ I do not choose to use the pharmacy selected by the Facility I will promptly arrange for delivery of all medications and supplies ordered by the physician providing services to the Resident to the Facility in accordance with the provisions of paragraph VI A.

By signing here, the Resident/Representative acknowledges that medications and medical supplies shall be ordered for the Resident in accordance with the instructions above. Resident: ________________________________ Signature: _________________________________ Date: ________ Resident Representative: ___________________________ Signature: _________________________________ Date: ________

Patient Admission Record and Agreement Facility Name: Admission Date: Pharmacy Name:

Room#:

PATIENT INFORMATION

Resident Name:

Medicare (HICN) #: Date of Birth:

Sex: M F

Physician’s Name: Phone Number :

Patient is solely responsible for the financial and legal authorizations: YES NO If NO, please list the Legal Representative below:

Address: City: State: Zip:

A Legal Representative is a person who has been granted the authority in writing by either the Patient or a court of law to make medical and/or financial decisions on behalf of the Patient.

PRIMARY CONTACT and FINANCIALLY RESPONSIBLE PARTY INFORMATION

Name: Relationship to Patient:

Address:

Phone Number :

City:

State:

Zip:

Primary Contact is also Financially Responsible Party YES NO If NO, please list Financially Responsible Party below:

Address:

Phone Number :

City:

State:

Zip:

A Financially Responsible Party is a person, other than the Patient, who agrees to be responsible for payment.

PAYMENT SOURCE FOR PHARMACY PRODUCTS AND SERVICES

To assist in billing for medications and services provided to the patient while at this facility, please check all pay sources that apply:

MEDICARE-A MEDICARE-B (medications only) MEDICARE-D SELF MEDICAID

INSURANCE MEDICARE ADVANTAGE HOSPICE VETERAN or OTHER

(Please describe “other” and provide pharmacy with copies (FRONT and BACK) of ALL Drug Coverage cards.)

Authorization for Invoice Payments by the following methods:

Credit Card: Visa/MC/Discover/Amex# ____________________________________________________________________

Exp. Date (mm/yyyy) __________________ Security Code __________

Bank Account Transfer: Name of Bank __________________________________ Acct# _____________________________

Routing Number __________________________________ City ______________________ State _____ Zip ____________

By signing below, the Patient or their Legal Representative and the Financially Responsible Party acknowledge and agree to each of the terms described on the next page. Patient/Legal Representative Name (Please Print)

Signature Date

Financially Responsible Party Name (Please Print)

Signature Date

NOTE: If patient has personally signed, it is not necessary to complete the information below. If the patient is unable to sign, an authorized Representative may sign on his/her behalf, but must complete all information, including the patient’s medical reason for an inability to sign. Medical Reason for Patient’s Inability to Sign ________________________________________ __________________________________________ _______________________________ _______________________ Authorized Representative’s Relationship to Patient Street Address City, State and Zip Code

Patient Name: _____________________________________ Facility Name: _________________________________

Terms of Patient Admission Record and Agreement

1. Authorizations: Omnicare, Inc. and its subsidiaries (“Omnicare”) are authorized to provide the Patient all products and services prescribed or ordered by the Patient’s Physician or by the facility. The Patient requests the products provided by Omnicare be dispensed in containers that are not child resistant. The Patient requests that the facility and/or Omnicare dispose of or otherwise process, all unused and/or discontinued medications dispensed to the patient, according to facility and pharmacy policy as allowed by professional standards and regulations.

2. Legal Representative: Legal Representatives will provide Omnicare with documentation establishing their legal authority.

3. Assignment of Benefits: The Patient or Legal Representative hereby requests and authorizes any third-party payer to make payment directly to Omnicare for products and services provided to the Patient.

4. Payment: The Patient and Financially Responsible Party are responsible for paying all charges for products and services provided to the Patient by Omnicare. As a courtesy, Omnicare will submit claims to any insurance companies or other third-party payers listed above or of which Omnicare is subsequently notified in writing; however, the Patient and Financially Responsible Party are ultimately responsible for paying any charges not covered by insurance or another third party payer. Payment in full is due within 30 days of the invoice date, and a finance charge equal to the lesser of 1.5 % per month or the maximum rate permitted by law will accrue on all delinquent accounts beginning on the day after the payment is due. The Patient or their Legal Representative and/or Financially Responsible Party hereby authorize Omnicare to charge any credit card or bank account number identified above for any amounts owed.

5. Fees and Expenses: The Patient and Financially Responsible Party are responsible for paying all costs and expenses incurred by Omnicare in the collection of amounts owed and the enforcement of its rights under this agreement, including without limitation, attorneys fees, court costs and expenses.

6. Assurance of Payment Termination at Services: The Patient or Legal Representative and Financially Responsible Party acknowledge that if the Patient and Financially Responsible Party are delinquent on payment of any amount owed to Omnicare, Omnicare may, in its sole discretion, do either or both of the following: (a) condition its continued provision of products and services to the Patient upon Omnicare’s receipt of assurance of payment acceptable to Omnicare, which may include, without limitation, a requirement that Omnicare receive authorization to charge all amounts owed, past and future, to a valid credit card number; and/or (b) suspend or terminate its provision of products and services to the Patient. Such suspension or termination will in no way affect the Patient’s or Financially Responsible Party’s obligations to pay all amounts owed under this agreement, including costs of collection.

7. Reliance and Consideration: Omnicare is relying upon the Financially Responsible Party’s agreements herein in determining to provide products and services to the Patient, and Omnicare’s provision of products and services to the Patient constitutes good and adequate consideration for Financially Responsible Party’s agreements contained in this agreement.

8. Disclosure or Use of Patient Information for Treatment, Payment, and Healthcare Operations: The Patient or Legal Representative hereby authorizes Omnicare, its employees, agents, and sub-contractors to disclose to Medicare, Medicaid or any other third party payer any medical or other information needed for payment for all products and services provided by Omnicare to the Patient until payment has been made in full. The Patient or Legal Representative further authorizes Omnicare, its employees, agents and sub-contractors to use and disclose the Patient’s medical and other information for the provision of products and services, for the business operations of Omnicare and for the review of Omnicare’s services, including review by accrediting bodies or government agencies.

9. Modification: No modification or amendment of this agreement shall be effective unless agreed to in writing by Omnicare.

ARBITRATION AGREEMENTS

The following Arbitration Agreements are optional for both the Resident and the facility.

Arbitration Agreement is not a precondition for either medical treatment or admission. Please

check below the box for the Arbitration Agreement(s) agreed to by the Resident and the

Facility.

Arbitration of Medical Malpractice Disputes

Arbitration of Disputes Other than Medical Malpractice

No arbitration is agreed to by the parties.

ATTACHMENT A

ARBITRATION OF MEDICAL MALPRACTICE DISPUTES

(OPTIONAL FOR RESIDENTS & FACILITY)

The parties understand that any dispute as to medical malpractice (that is, whether any medical

services rendered under this admission agreement were necessary or unauthorized or were improperly, negligently or incompetently rendered), will be determinate by submission to neutral arbitration as provided by California law, and not by lawsuit or court process, except as

California law provides for judicial review of arbitration proceeding. By entering into this arbitration agreement, both parties give up their constitutional right to have any such dispute

decided in a court of law before a jury, and instead accept the use of arbitration.

By signing this arbitration agreement below, the Resident agrees to be bound by the foregoing arbitration provisions. The Resident acknowledges that he or she has the option of not signing this arbitration agreement and not being bound by the arbitration provisions contained herein. The execution of this arbitration agreement is not a precondition to receiving medical treatment or for admission to the Facility. This arbitration agreement may be rescinded by written notice from either party, including the Resident’s Legal Representative and/or Agent, if

any, and as appropriate, to the other party within thirty (30) days of signature.

The Parties hereby acknowledge that arbitration is preferable to judicial forum and that California law favors the enforcement of valid arbitration provisions. The arbitration shall be conducted by one or more neutral arbitrators selected from JAMS in San Jose, California and in accordance with discovery procedures set forth in the California Arbitration Act, California Code of Civil Procedure Section 1280 et seq. The arbitrator shall be selected from a panel of JAMS

arbitrators. If the Parties are unable to agree on one arbitrator, each party shall select one arbitrator, with the third arbitrator selected by the other two arbitrators. In reaching a decision

the arbitrator(s) shall prepare findings of fact and conclusions of law. Each party shall bear its own costs and fees for the arbitration.

Pursuant to California Health and Safety Code Section 1430, the Resident does not waive

his/her right to bring a lawsuit in court against the Facility for violations of the Patient’s Bill of Rights contained in Title 22 of the California Code of Regulations Section 72527. Further,

appeals made by the Resident concerning his/her transfer or discharge, as provided under state and federal law, will not be subject to this arbitration agreement. Finally, claims relating to

disputes over payments owed to the Facility or the payment of the Resident’s “share of cost”

required by the Medi-Cal program, if applicable, will also not be subject to this arbitration

agreement.

This arbitration agreement binds the parties hereto, including the heirs, representative, executors, administrators, successors, and assigned of such parties.

NOTICE: BY SIGNING THIS AGREEMENT, THE RESIDENT AGREES TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, AND GIVES UP THE RIGHT TO A

JURY OR COURT TRIAL. SEE THE FIRST PARAGRAPH OF THIS AGREEMENT. HOWEVER, UNDER SECTION 1430 OF THE CALIFORNIA HEALTH AND SAFETY CODE, THIS RESIDENT DOES NOT WAIVE HIS/HER RIGHT TO BRING A LAWSUIT IN COURT AGAINST THE FACILITY FOR VIOLATIONS OF THE PATIENT’S BILL OF RIGHTS CONTAINED IN TITLE 22 OF THE CALIFORNIA CODE OF REGULATIONS SECTION 72527. FURTHER, APPEALS MADE BY THE RESIDENT CONCERNING HIS/HER TRANSFER OF DISCHARGE, AS PROVIDED UNDER STATE AND FEDERAL LAW, WILL NOT BE SUBJECT TO ARBITRATION. FINALLY, CLAIMS RELATING TO DISPUTES OVER PAYMENTS OWED TO THE FACILITY OR THE PAYMENT OF THE RESIDENT’S “SHARE OF COST” REQUIRED BY THE MEDI-CAL PROGRAM, IF APPLICABLE, WILL ALSO NOT BE SUBJECT TO ARBITRATION.

By virtue of Resident’s consent, instruction and/or durable power of attorney, I hereby certify that I am authorized to act as Resident’s agent in executing and delivering of this arbitration agreement.

Resident: _________________________________________

Signature: _________________________________________ Date: _____/_____/_____

Resident Representative: _____________________________

Signature: _________________________________________ Date: _____/_____/_____

Facility Representative: _____________________________

Signature: _________________________________________ Date: _____/_____/_____

ATTACHMENT B

ARBITRATION OF DISPUTE OTHER THAN MEDICAL MALPRACTICE

(OPTIONAL FOR RESIDENTS AND FACILITY)

The parties understand that, except as provided below, any claim other than a claim for medical

malpractice, arising out of the provision of services by the Facility, the admission agreement, the validity, interpretation, construction, performance and enforcement thereof, or which

allege violations of Elder Abuse and Dependent Adult Civil Protection Act, or the Unfair Competition Act, or which seek an award of punitive damages or attorneys’ fees, will be

determined by submission to natural arbitration as provided by California law, and not by a lawsuit or court process, except as California law provides for judicial review of arbitration

proceedings. By entering into this arbitration agreement, both parties give up their constitutional right to have any such dispute decided in a court of law before a jury, and instead accept the use of arbitration.

By signing this arbitration agreement below, the Resident agrees to be bound by the foregoing arbitration provisions. The Resident acknowledges that he or she has the option of not signing

this arbitration agreement and not being bound by the arbitration provisions contained herein. The execution of this arbitration agreement is not a precondition to receiving medical treatment or for admission to the Facility. This arbitration agreement may be rescinded by written notice from either party, including the Resident’s Legal Representative and/or Agent, if any, and as appropriate, to the other party within thirty (30) days of signature.

The Parties hereby acknowledge that arbitration is preferable to judicial forum and that California law favors the enforcement of valid arbitration provisions. The arbitration shall be conducted by one or more neutral arbitrators selected from JAMS in San Jose, California and in accordance with discovery procedures set forth in the California Arbitration Act, California Code of Civil Procedure Section 1280 et seq. The arbitrator shall be selected from a panel of JAMS arbitrators. If the Parties are unable to agree on one arbitrator, each party sha ll select one arbitrator, with the third arbitrator selected by the other two arbitrators. In reaching a decision the arbitrator(s) shall prepare findings of fact and conclusions of law. Each party shall bear its

own costs and fees for the arbitration. Pursuant to California Health and Safety Code Section 1430, the Resident does not waive his/her right to bring a lawsuit in court against the Facility

for violations of the Patient’s Bill of Rights contained in Title 22 of the California Code of Regulations Section 72527. Further, appeals made by the Resident concerning his/her transfer

or discharge, as provided under state and federal law, will not be subject to this arbitration agreement. Finally, claims relating to disputes over payments owed to the Facility or the

payment of the Resident’s “share of cost” required by the Medi-Cal program, if applicable, will

also not be subject to this arbitration agreement.

This arbitration agreement binds the parties hereto, including the heirs, representative, executors, administrators, successors, and assigned of such parties.

NOTICE: BY SIGNING THIS AGREEMENT, THE RESIDENT AGREES TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, AND GIVES UP THE RIGHT TO A

JURY OR COURT TRIAL. SEE THE FIRST PARAGRAPH OF THIS AGREEMENT. HOWEVER, UNDER SECTION 1430 OF THE CALIFORNIA HEALTH AND SAFETY CODE, THIS RESIDENT DOES NOT WAIVE HIS/HER RIGHT TO BRING A LAWSUIT IN COURT AGAINST THE FACILITY FOR VIOLATIONS OF THE PATIENT’S BILL OF RIGHTS CONTAINED IN TITLE 22 OF THE CALIFORNIA CODE OF REGULATIONS SECTION 72527. FURTHER, APPEALS MADE BY THE RESIDENT CONCERNING HIS/HER TRANSFER OF DISCHARGE, AS PROVIDED UNDER STATE AND FEDERAL LAW, WILL NOT BE SUBJECT TO ARBITRATION. FINALLY, CLAIMS RELATING TO DISPUTES OVER PAYMENTS OWED TO THE FACILITY OR THE PAYMENT OF THE RESIDENT’S “SHARE OF COST” REQUIRED BY THE MEDI-CAL PROGRAM, IF APPLICABLE, WILL ALSO NOT BE SUBJECT TO ARBITRATION.

By virtue of Resident’s consent, instruction and/or durable power of attorney, I hereby certify that I am authorized to act as Resident’s agent in executing and delivering of this arbitration agreement.

Resident: _________________________________________

Signature: _________________________________________ Date: _____/_____/_____

Resident Representative: _____________________________

Signature: _________________________________________ Date: _____/_____/_____

Facility Representative: _____________________________

Signature: _________________________________________ Date: _____/_____/_____

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