Admission Agreement - PACE Subsidized


ADMISSION AGREEMENT

Resident’s First and Last Name:

Resident Social Security #

Resident date of birth  

Resident’s Agent Full Legal Name:

The parties to this Admission Agreement (“Agreement) are ASPEN CARE, whose address is 3225 GEORGIA St., NE, Albuquerque, New Mexico 87110 (“Facility”), hereinafter referred to as “Operator”, and (“Resident”). The Facility is licensed as an Aging and Long Term Care Facility by the New Mexico Department of Health to provide residency, care, and services, as needed, to qualified persons.

This agreement sets out the terms and conditions of residency; the duties and responsibilities of the Operator, the Resident, and the Authorized Representative (Placing Agent), and the means by which this agreement may be terminated. This agreement shall not be altered, changed or amended except by a written instrument executed by the Operator and the Resident/Resident’s Agent.

This Agreement is effective from date of signature until its revision or termination. The Agreement supersedes all previous Agreements.

  1. TERMS OF RESIDENCY
    • For payment of fees and promises made herein by the Resident, the Operator will provide personal services, other services, and residential accommodations otherwise stated more precisely herein at the facility located at 3225 Georgia St., NE, Albuquerque, New Mexico, 87110, for residency from Month to Month commencing on the date of admission at a rate of  Patient Responsibility according to PACE  plus an any additional fee not covered by PACE  plus tax per month payable in advance by the 1st day of each and every month for the following month. Any portion of the month shall be billed at the rate of $123.33 per day. If payment is not received by the 5th of the month at 5 p.m. of each month, a $100.00 late fee will be assessed.
    • Payment can be made in the following methods:
      • Check payable to Aspen Care INC.
        • Mailed to ASPEN Care PO BOX 50727 Albuquerque. NM 87181
      • ACH electronic transfer right from the invoice. There will be a $10.00 fee if you utilize this method.

             Total Monthly Patient Responsibility PLUS any fee not covered by PACE

           

For InnovAge/PACE participants:

  • You further agree that this is subject to increase in the event funds become  available.
  • You must notify Aspen Care to any changes in funds within five business days.

 

 

  • There is a one-time, nursing assessment fee of $50.00 payable at the time of admission to the Facility.
  • If the resident moves in during the middle of the month, the total monthly rate will be due at move in. The following month will be prorated, calculated on a daily rate as agreed upon in Aspen Care contract.
  • The monthly rate is subject to immediate change if the amount or frequency of assisted living services or optional services provided increases, for example if it becomes necessary for additional staff to assist with the Resident. This rate change will be prorated on a daily basis if the services are increased during the month. Thereafter, the new rate will be due on the 5th of the month. These services are reviewed by Facility staff on a monthly basis, or more frequently if there is a change in condition. The change of condition may warrant an increase or decrease in service or may lead to a determination that the Facility can no longer meet the Resident’s needs.
  • If monthly rates are increased by the Facility for reasons other than a change in the level of assisted living services, the Resident or Authorized Representative will be given at least 30 days written notice.

2 DUTIES AND RESPONSIBILITIES OF OPERATORS

    • The Operator will provide full time programmatic supervision and assistance as needed with daily living activities such as showering, grooming/hygiene, dressing, toileting, meals, laundry cleaning, housekeeping, and mobility. Depending on the resident’s abilities and Resident/Resident’s Agent desires, additional services can be provided, such as arts and crafts, movies, senior companion volunteers, monthly outings in the community, senior center functions, and church services. The facility can also refer a physician, nurse, pharmacist, occupational therapist, physical therapist, speech therapist, and/or a phlebotomist as requested by the Resident/Resident’s Agent. Any cost incurred by these services will be the sole responsibility of the Resident/Resident’s Agent.
    • The Operator shall post in a common conspicuous place in the facility the Rules and Regulations of Conduct promulgated by the Operator for the Residents of the facility.
    • The Operator will recognize and be bound by the Resident-Client’s Bill of Rights promulgated by the State Licensing Agency for Adult Residential Care Facilities.
    • The Operator shall maintain the facility to meet all of the standards and regulations adopted by the State Licensing Agency for Residential Care Facilities.
    • All services including personal services provided by the Operator under this Agreement shall meet all standards and regulations adopted by the State Licensing Agency for Residential Shelter Care Facilities.
    • The Operator shall establish reasonable visiting hours to be posted in a common conspicuous area in the facility.
    • The Operator shall assure that the Resident shall have the right to have private and unrestricted communications and/or visits with any person of his or her choice.
    • The Operator will make the Resident/Resident’s Agent aware of all the Regulations by the State Licensing Agency concerning medications. The Operator will make certain that all medications are handled in a proper manner.

3 DUTIES AND RESPONSIBILITIES OF RESIDENT

    • The Resident shall abide by the rules and regulations of contact promulgated by the Operator.
    • The Resident/Resident’s Agent shall make payment of fees on time and as called for in this Agreement.
    • The Resident shall respect the rights of other residents in the facility.
    • The Resident shall cooperate with the Operator in the day to day routine of the facility.
    • The Resident shall abide by the rules and regulations concerning medications promulgated by the State Licensing Agency and enforced by the Operator.
    • Any violations of the above-listed duties and responsibilities are grounds for immediate termination by the Operator of this Agreement.

   

4 DUTIES AND RESPONSIBILITIES OF RESIDENT’S AGENT

  • The Resident’s Agent agrees to provide to the Operator a Medical/Psychological/Social Summary of the Resident. Resident’s Agent shall accurately and fully disclose all pertinent information relative to the Resident’s medical or psychological condition, and any other information which might be useful to the Operators in caring for the Resident.
  • The Resident’s Agent will make certain that the Operators will be provided within 2 WEEKS of Resident’s admission all completed forms as submitted to Resident’s Agent at the time of signing this agreement.
  • The Resident’s Agent shall have a duty to provide ongoing assistance in meeting any existing or latent special problems concerning the Resident while the Resident is in this facility.
  • If the Resident’s Agent is responsible for financial arrangements for the Resident, the Resident’s Agent shall make a diligent effort to ensure that all payments due to the facility are made in a timely manner.
  • Any violations of the above-listed duties and responsibilities are grounds for immediate termination by the Operator of this agreement.

           

5 ADDITIONAL CHARGES

      5.1The Operator is willing to assist in taking the Resident to medical appointments when       prior arrangements are made with the Operator to do so. An additional charge of $50.00 per appointment will be added to the Resident’s bill to cover the cost of transporting the Resident to any such appointments. An additional $10.00 per hour will be added for appointments that exceed two hours.

5.2 A one time intake and assessment fee of $300.00 is due upon admission.

5.3 A late fee of $100.00 shall be assessed if monthly fees are not received by the due date.

5.4 The Resident/Resident’s Agent agrees to be responsible for any damage caused by any acts of the Resident that are not covered by the Operator’s insurance. A letter of coverage denial  shall be sufficient to establish non-coverage.

5.5 The Resident/Resident’s Agent is responsible for individual telephone and/or newspaper services while under this Agreement.

5.6 The Facility is not responsible for furnishing or paying for healthcare or hygiene items or services not expressly included in the Agreement, including, but not limited to, incontinence products, toothpaste, Kleenex for room, over-the-counter medications, physician’s services, nursing services, medical treatment or equipment. If a case arises where out of necessity the Operator does purchase supplies for the Resident, the cost of supplies shall be added to the Resident’s bill with an additional five percent (5%) fee.

           

  1. TERMINATION OF AGREEMENT

6.1 If Resident/Resident’s Agent fails to pay for all fees due under the agreement, the Operator will give Resident/Resident’s Agent a Seven Day Notice in writing to pay fees plus late charges, if any due, or to vacate the facility. If such charges are not paid within 7 days of the Resident/Resident’s Agent receiving such notice, this agreement will terminate automatically and the Resident will be subject to removal from the facility. Under such condition, Resident’s Agent shall assume full responsibility for locating a new facility for the Resident, and for transporting the Resident to such new facility.

6.2 The Facility, may upon at least 15 days written notice to the Resident and/or Resident’s Agent, discharge the Resident for one or more of the following reasons:

  1. Failure of Resident/Resident’s Agent to comply with State or Local Law after receiving notice of such violation.
  2. Failure of Resident/Resident’s Agent to comply with general policies of the Facility as outlined in this agreement.
  3. Inability of the Facility to meet the Resident’s needs, based upon reassessment of these needs by the Facility Management and/or qualified evaluator engaged by the Facility Management. A change of mental or physical conditions that require hospitalization will prompt reassessment prior to the Resident’s return to the Facility. At that it will be determined if the Facility can continue to meet the Resident’s needs. If not, the Resident will not be readmitted to the Facility.

6.3 The Operator shall have the right to remove or to request the removal of any resident, if the resident’s conduct or physical condition is life-endangering to the Resident, to other residents, or to the staff, or if the resident is causing a severe disturbance to the normal routine of the facility or other residents. Under such circumstances, the Operator shall give 1 day notice to the

 

 

Resident/Resident’s Agent that the Resident must be removed. The Operator will fully assist the Resident/Resident’s family in locating an appropriate placement and help make the transition as smooth as possible. In this instance, prepaid fees will be refunded at a prorated per day rate as soon as the resident’s room is completely vacated.

6.4 In the event that a Resident’s condition presents an immediate and serious risk to the health, safety or welfare of the Resident, staff, or others and emergency termination of this Admission Agreement is necessary, a 15-day notification of the planned discharge does not apply. Additionally, emergency termination of this Admission Agreement may occur under the following situations:

  1. The transfer to a treatment facility or discharge from the Facility is necessary for the Resident’s welfare and the Resident’s needs cannot be met in the Facility.
  2. The safety or health of individuals in the Facility is endangered.
  3. The Resident/Resident’s Agent has failed to pay for services within time-frame set out in this document.
  4. The Facility ceases to operate or is no longer able to provide services to the Resident.
  5. Due to sanctions or remedies imposed by the New Mexico Department of Health.

6.5 There will be a prorated refund of prepaid rates in the event of death of the Resident. As soon as the Resident’s room is completely vacated the refund will be returned within 5 days.

            ASSISTED LIVING FACILITIES CONTRACT – LIMIT ON CHARGES AFTER RESIDENT DEATH.

  1. This contract includes a refund policy that is to be implemented at the time of a residents death. This policy provides the resident’s estate or responsible party a prorated refund based on the calculated daily rate for any unused portion of payment beyond the termination date after all charges have been paid to the licensee. For the purpose of this section, the termination date shall be the date the unit is vacated by the resident due to the resident’s death and cleared of all personal belongings.
  2. If a resident’s belongings are not removed within one week of the resident’s death and the amount of belongings does not preclude renting the unit, storing the items at a rate equal to the actual cost to the facility, not to exceed ten percent of the regular rate for the unit; provided that the responsible party for the resident is given notice at least one week before the resident’s belongings are removed. If the resident’s belongings are not claimed within forty-five days after notification, the facility may dispose of then.

6.6 The Resident/Resident’s Agent agrees to give the Facility at least thirty 30 days written notice of an intent to move from the Facility. Facility Management may grant exceptions if the Resident’s condition prevents advanced notice from being given (see 6.4.a).

           

7 MISCELLANEOUS PROVISIONS

  • It is the policy of the Operator to invite its residents to furnish their room with their own personal possession of furniture, lamps, pictures, etc…, to give their rooms a more personal and familiar atmosphere. Such personal property is not covered by the Facility’s Multipurpose Insurance Coverage and, if the Resident wishes to protect such items from loss, then the Resident must insure them.
  • Cooperation with General Rules. The Resident/Resident’s Agent agrees to cooperate with the general policies of the Facility that make it possible for the residents to live together in a pleasant environment. The Facility reserves the right to make reasonable modifications and additions to the Facility rules as they judge necessary to enhance the quality of care, safety and lifestyle of all residents. Notice of any additions or changes to the Facility’s rules shall be discussed with Resident/Resident’s Agent and given to the Resident/Resident’s Agent in writing prior to the rules being implemented or amended, with the exception of any rule deemed by the Facility Administrator as necessary for safety, which will be implemented immediately.
  • The Facility management/staff will provide general maintenance and repairs to Resident’s rooms. The Facility management/staff reserves the right to inspect and disapprove of furnishings that may cause a safety risk to the residents of the Facility.
  • If carpet or furniture needs cleaning on an ongoing basis as a result of the Residents having an “accident”, Resident/Resident’s Agent may be billed for cleaning.
  • Meals: The Facility will provide three nutritious meals in our dining room. Snacks are offered between meals. We will prepare or alter diet according to physician’s orders.
  • Housekeeping and Laundry: The Facility will provide weekly cleaning of rooms, or more often if needed. Laundry will be done daily.
  • Bed Hold Policy: If the Resident is transferred to a medical facility, the facility will hold the Resident’s room so long as the monthly fee continues to be paid.
  • Theft and Loss Policy: Personal effects (including, but not limited to, clothing, jewelry and furniture) are not covered by the Facility’s insurance. We recommend that they be insured by the Resident. Suggested coverage includes rental insurance that encompasses losses incurred from fire, theft and earthquake. We kindly ask that you do not bring expensive jewelry to the facility as it is impossible to ensure the safety of such items.
  • Pet Policy: The Facility does not currently allow resident to have pets. We do allow family to bring pets for short visits. If any accidents that occur from the pet being at the Facility will be the responsibility of the individual who brings the pet into the facility.. Visiting pets will please bring a copy of their current shot record to be kept at Aspen Care.
  • Attorney Fees: The Resident may be held responsible for attorney fees and expenses incurred to collect unpaid fees as allowed by law and/or directed by a court of law.
  • Outside Service Policy: The Facility provides standard services and assisted living services. However, if it is determined through assessments that additional outside services are necessary to maintain the Resident’s safety and quality of life while at the Facility, Resident/Resident’s Agent will be notified.
  • Resident/Facility Files: The New Mexico Department of Health has the authority to review the Facility and the Resident records without prior notification. In addition, they have the authority to privately interview staff and residents.
  • Any modifications to this agreement must be in writing.
  • The Laws of the State of New Mexico shall govern this Agreement.

In case of emergency, Operator shall notify the following:

 

This agreement shall be binding upon the parties, their successors, assigns and personal representatives. Time is of the essence on all undertakings. My signature below as “Resident” or “Resident’s Agent” indicates that I have read the provisions of this agreement. I sign this Agreement voluntarily.

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Signature Certificate
Document name: Admission Agreement - PACE Subsidized
lock iconUnique Document ID: 9415395eb27715657e90b17feafb77e459906aaf
Timestamp Audit
April 13, 2022 4:16 pm MDTAdmission Agreement - PACE Subsidized Uploaded by Aspen Care - info@aspencare.com IP 98.48.97.99