Aspen Care Consent Forms


PROGRAM NARRATIVE

At Aspen Care, we offer a warm homelike setting for elderly men and women that are: somewhat oriented to time, place and person; that may or may not have control of their bladder/bowels; that are either ambulatory with or without assistive devices or wheelchair bound as long as they can transfer to and from their wheelchair with the assistance, from a single staff.

Aspen Care is located in a quiet northeast neighborhood 2 blocks west of Louisiana and just north of Candelaria. The owner is a special education teacher who wanted to work with the elderly population and people with special needs. Her husband is a clinical psychologist in Albuquerque. The owner is on the premises daily and always available by cell phone. At least one caregiver is on duty 24 hours a day. There is double staffing provided for showers, cleaning or whenever needed. The staff is first aid and med aid certified and is offered in-service training annually in many areas of care for the residents. Fingerprinting and background check are required for each staff. The night staff will remain awake and make rounds to check on residents every 2-3 hours throughout the night. Each resident’s room has a call light that signals an alert tone at two different stations in the house. The 7 bedroom, 2 ½ bath home have all private with one semi-private (or large private) accommodations. Each room offers free cable TV, and is wired for private phone lines. Bathrooms have toilets that are slightly higher than normal, with grab bars around toilets and showers, and emergency call buttons by each toilet.  Advanced security and alarm system includes an alert tone activated by all exits and entrances to the facility. Aspen Care is fully handicapped accessible, including one complete handicapped bathroom, wheelchair entrance, widened door to bedrooms and bathrooms, all door handles are designed for easy grip, and carpeted areas of home is glued without padding to facilitate easy mobility of wheelchair and/or walker use.

Aspen Care provides highly nutritious meals and can provide special needs diets.

PLEASE NOTE THAT DUE TO COVID-19 OUR DAILY ACTIVITIES HAVE CHANGED. Please speak to Administrator concerning our activities.

Aspen Care utilizes any licensed home health agency the resident elects to use in case intermittent nursing care, physical therapy, occupational therapy or hospice is needed.

 

 

RESIDENT’S RIGHTS

STATE OF NEW MEXICO

CLIENT’S RIGHTS AND RESPONSIBILITIES

As a resident, you have the following rights:

  • To be fully informed in advance about the care and treatment to be provided by this facility.
  • To be fully informed in advance of any changes in the care and treatment to be provided by this facility that may affect your well being.
  • To participate in planning your care and treatment or changes in your care or treatment unless you are judged incompetent.
  • To voice grievances with respect to treatment or care that is or fails to be furnished without discrimination or reprisal for voicing such grievances.
  • To confidentiality of your clinical records.
  • To have your property treated with respect.
  • To be fully informed, orally and in writing, of all changes for services to be performed by the facility and of any changes in these charges.
  • To be informed of New Mexico’s home health agency hotline telephone number and hours of operation: 1-800-752-8649, 8:00 am-5:00 pm Monday thru Friday.
  • To be fully informed, in writing of your rights and obligations pursuant to these regulations.
  • As a resident you have the following responsibilities:
  • To actively participate in decisions regarding your healthcare.
  • To be as accurate as possible when providing information about your history and personal care needs.
  • To ask for additional information about any aspect of your care or treatment which you do not understand.
  • To follow your physicians advice and instructions.
  • To notify your nurse or physician if you notice a change in your condition.
  • To inform this facility of any changes in your health or personal care needs.
  • To cooperate with and respect the rights of facilities care givers providing services.

I have reviewed and received (via email or print out) a copy of Resident's Rights - Initial Here:  

  ASPEN CARE

STAFFING PATTERN

 

According to 7 NMAC 8.2, section 19, STAFFING;

  1. When residents are awake, all facilities shall have at least 1 direct care staff person on duty and awake for each 15 residents.
  2. During resident sleeping hours, facilities with 15 or fewer residents shall have at least 1 direct care staff person on duty and responsible for the care and supervision when residents are in the facility.

Aspen Care will meet or exceed these directives at all times.

Aspen Care will have one direct care staff person on duty and awake for each 8 residents. There will be two direct care staff on duty when extra help is needed to care for residents.

 

The undersigned is the duly authorized agent or relative of who is A resident at 3225 Georgia St. NE, Albuquerque, New Mexico, a community residential program for senior adults, operated by Aspen Care, a New Mexico Corporation.

 

In consideration of the acceptance of as a resident in the facility, I

hereby release Aspen Care, its directors, stockholders, and employees of and from any and every claim, demand, action or right of action of whatever kind of nature which might arise from or be reason of any bodily injury or personal injuries  known or unknown, death, or property damage resulting from any activities and the performance of duties and care while a resident in the facility, including first aid treatment or medical refusal.

This release does not include release of liability for acts of negligence by Aspen Care of its staff.

ADVANCE DIRECTIVES

 It is the policy of this facility to inform new clients about Advance Directive options, in accordance with state regulations, before providing services, and give each new client information concerning his/her rights to:

  1. Refuse or accept medical treatment
  2. Have a Living Will, Durable Power of Attorney (healthcare proxy; and or  
  3.  Appoint a surrogate decision-maker for healthcare

 

Some clients have an Advance Directive and some do not. This facility does not decline requests for services based on whether a person has or does not have an Advance Directive.

Please indicate if you have an Advance Directive and want the facility to abide by it.

You may decline to answer. A checkmark denotes indication that you have Advance Directive.

 

 

CLIENT ACKNOWLEDGEMENT

I have received and reviewed a copy of the facility questions and answers about Advance Directives, and have discussed it with a representative of the facility; I fully understand my rights concerning these issues.

I further understand that if I have an Advance Directive and want the facility to abide by it, it is my responsibility to provide a copy to the facility’s office.

 

RELEASE OF LIABILITY

 

The undersigned is the duly authorized agent or relative of who is

A resident at 3225 Georgia St. NE, Albuquerque, New Mexico, a community residential program for senior adults, operated by Aspen Care, a New Mexico Corporation.

 

In consideration of the acceptance of as a resident in the facility, I hereby release Aspen Care, its directors, stockholders, and employees of and from any and every claim, demand, action or right of action of whatever kind of nature which might arise from or be reason of any bodily injury or personal injuries  known or unknown, death, or property damage resulting from any activities and the performance of duties and care while a resident in the facility, including first aid treatment or medical refusal.

This release does not include release of liability for acts of negligence by Aspen Care of its staff.

EMERGENCY TREATMENT

 

 

TO WHOM IT MAY CONCERN

Regarding:

We, the undersigned, hereby give Aspen Care/Staff permission to take  to an emergency room or other emergency facility for treatment deemed necessary, and may sign for said treatment in lieu of family. Emergency services may also be used if a resident has a fall.

MEDICATION ASSISTANCE

 

 

TO WHOM IT MAY CONCERN

Regarding:

 

I, , hereby authorize Aspen Care/Staff to assist in the self-administration of medications.

MEDICAL INFORMATION RELEASE

 

 

I authorize this facility to obtain information regarding the physical and mental condition of and I direct that all healthcare givers, pharmacists, and other holding medical information including, but not limited to, medical records and diagnosis respond as if I were requesting the information for myself.

House Rules

  1. Smoking by residents and staff is permitted outdoors. In the event of inclement weather, smoking will be allowed in designated area.
  2. Residents are NOT ALLOWED to smoke in their room.
  3. Smoking is NOT PERMITTED in areas common use or food preparation areas.
  4. Smoking is NOT PERMITTED in areas where oxygen is in use.
  5. The use of alcohol is permitted only with written permission from a physician.
  6. Residents shall have access to a telephone, and shall be provided with privacy to conduct personal conversations. However, restrictions may be placed on the telephone calls if such calls are clinically contradicted. If such restrictions are imposed, justification must be documented in Resident’s records. Phone calls should be kept to a reasonable length. Long distance calls are limited to emergencies with pre-authorization from management and guardian.
  7. The operation of television radios and stereos must be kept at a volume as not to disturb other residents.
  8. All personal property must be stored in the resident’s room.
  9. Residents are discouraged from keeping valuables in their rooms. The facility will assume NO RESPONSIBILITY for loss. However, if the resident deems it necessary to keep valuable on the premises, it shall be locked in the office. This facility retains the right to refuse at its own discretion in these matters. Additionally, it is the responsibility of the resident or guardian to notify the staff if personal items of unusual value are brought into the facility.
  10. Meals will be served at the following times:
    • Breakfast         8:00-9:00 am
    • Lunch               12:00-1:00 pm
    • Dinner              5:00-6:00 pm
    • Snacks              10:00 am, 2:00 pm, and 8:00 pm
    • Meal times are flexible and Residents do have options on what meals they want or don't want.
  11. A multipurpose room for the use of residents is available. Reading lamps, tables, chairs, and couches are provided to meet varied interests and needs of residents.
  12. No resident pets are allowed.
  13. The use of electric blankets or small appliances is not permitted.
  14. All medications, prescriptions, and over-the-counter medications MUST BE LOCKED in the medication cabinet. Any medication brought by family must be kept locked within Residents room.
  15. Due to COVID-19 family visitation is only allowed under strict guidelines from the Department of Health. The visitation guidelines may change, please speak to Administrator for current guidelines.
  16. Residents shall be offered 2 showers per week. Residents are allowed to take more or less at their discretion. 
  17. Resident’s names must be on all clothing and personal effects.
  18. All residents must sign in/out on the Sign-In/Out Log before leaving the facility. Due to COVID-19 residents are encouraged not to leave the facility.
  19. This facility retains the right to amend the house rules, as it deems necessary.

DUE TO COVID-19 Precautions and as required by New Mexico Department of Health:

  • All visitors must complete the COVID-19 Questionnaire located on the iPad at the main entrance. 
  • Visitors must wear a mask that cover the mouth and nose at all times while within the home.

Bed Hold Policy

A. BEDHOLD: A resident who is on leave or temporarily discharged has expressed an intention to return to the facility under the terms of the
admission policy for bedhold, shall not be denied readmission, if level of 7.9.2 NMAC 18 care remains the same. B. LIMITATION: The facility
shall hold a resident's bed until the resident returns, until the resident waives his right to have the bed held or until the maximum time allowable as defined by facility policies expires. The facility is responsible for notifying resident and/or family of their bedhold policy

ADMISSION CONSENT FORM

 

I, ,hereby request/consent that  be admitted

To ASPEN CARE, 3225 Georgia St., NE, Albuquerque, NM 87110.

I acknowledge that the facility has provided me/us with the following information.

  1. The facility’s program narrative.
  2. The facility’s rules.
  3. The facility’s admission agreement, including costs and charges, refund provision, contract termination policies.
  4. The facility’s bed hold policy.
  5. Information about resident’s right under New Mexico Law to make decisions regarding healthcare, including the right to make Advance Directives.
  6. A written description of the legal rights of the residents translated into another language, if necessary.

 

 

 

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Signature Certificate
Document name: Aspen Care Consent Forms
lock iconUnique Document ID: fee81b1f88720f36c4038a9a58b43971618636ce
Timestamp Audit
February 7, 2022 8:24 pm MDTAspen Care Consent Forms Uploaded by Aspen Care - info@aspencare.com IP 98.48.73.14