d.transfer or discharge - health care council of...

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Resident Contract2018

(A CONTRACT IS REQUIRED BY FEDERAL AND STATE REGULATIONS)

________________________________________________________________ (“Resident”) and

_______________________________________________________ (“Facility”) agree as follows:

In this contract: “Facility Standards” means the Rules and Regulations of the Illinois Department of Public Health for Long Term Care Facilities, applicable federal rules and regulations and, if the resident’s care is funded by Medicaid, regulations of the Illinois Department of Human Services and the Illinois Department of Healthcare and Family Services.

A. Facility Agreement

1. The facility shall offer personal care, room, board, dietary services and laundry services. The facility will also offer nursing care, activities, restorative and rehabilitative services and psychosocial care as identified in the residents’ Plan of Care established by the facility with the input of the resident (“Plan of Care”) to the extent required by the facility Standards and in accordance with the policies of the facility. The facility staff is permitted to access the resident’s room at reasonable times and for reasonable purposes.

2. Medicines, treatments or special diets will be offered to the resident if ordered by physician, the facility Medical Director, or any other physician approved by either of them or the resident (“Physician” means any of the foregoing).

3. The facility will offer equipment required under Facility Standards. If any Physician orders special equipment not required under Facility Standards it will be offered at the resident’s expense. Residents must have consent of the facility to bring special equipment; use of such equipment is at the resident’s risk.

4. The facility will exercise reasonable care toward the resident. However, the facility is not an insurer of the resident’s welfare or safety and assumes no such liability.

5. The facility may change the resident’s roommate. The facility retains the right to transfer the resident to a different room within the facility if required by law or for the efficient management of the facility. The facility will notify the resident before such change is made, and will try to accommodate the resident’s preferences.

B. Resident’s Rights and Obligations1. The resident acknowledges receipt of the written items identified in Supplement D: Admissions Checklist,

and acknowledges that each item has been explained in language that the resident understands. All items identified and checked in Supplement D: Admissions Checklist are incorporated into this contract, including the Residents’ Right Handbook. The resident will abide by all rules and regulations of the facility and will cooperate in the carrying out of the residents’ Plan of Care. The resident will be given the opportunity to participate in the care planning process to the extent practicable.

2. The resident has the right to privacy in making and receiving telephone calls, sending and receiving mail (except as agreed to in the Authorization to Inspect and Open Official Correspondence), and in his/her use of electronic communications such as email and video comfort communications and for internet research. The

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resident will be responsible any additional expense incurred by the facility in providing internet access to the resident.

3. The resident may file a grievance regarding any aspect of their care and treatment at the facility without fear of discrimination or reprisal. For information on filing a grievance, contact __________________________ at _________________________. The resident may file a complaint with the Illinois Department of Public Health, without fear of discrimination or reprisal, concerning any suspected violation of state or federal nursing facility regulations, including, but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, and non-compliance with the advance directive requirements. Federal and state laws require the facility to have a policy that addresses abuse, neglect and financial exploitation.

4. It is the goal of this facility to assist residents to return to the community when they are able to do so. For additional information on returning to the community, the resident may contact the Department on Aging Senior Hotline at 1-800-252-8966 , (1-888-206-1327 (TTY)), or [email protected] .

5. No food, liquids or medicines will be brought into the facility without permission of the Administrator or nurse in charge. Food must be sealed in containers. No medication will be kept in the resident’s room or possession unless in accordance with a Plan of Care.

6. The facility may use, at the resident’s cost, the pharmacist, laboratory, and other outside service providers recommended by the facility. If the resident prefers to use any other provider, it will be at the resident’s cost. To compensate the facility for costs of monitoring such services, the resident will pay to the facility an amount to be set by the facility not to exceed $75.00 per month.

7. The resident will be responsible for damage to any property or injury to any person caused by the resident.

8. The resident will be responsible to comply with the facility’s smoking policies. See attached, Resident and Visitor Smoking Policy Notification.

9. The resident has the right to manage his or her financial affairs and need not deposit personal funds with the facility.

10. The resident will provide his or her own spending money.

11. Upon the resident’s written authorization, the facility will hold the residents' personal funds in a Trust Account as further described in the “Resident Trust Fund Policy Notification and Agreement.”

12. The facility is not responsible for money, valuables, or personal effects of the resident unless delivered to the Administrator for safekeeping.

13. The resident has a right to have friends and family members visit at the facility, subject to the facility’s rules and regulations.

13. Responsible Party and Resident Representative. The resident may have a Responsible Party or Representative execute this Contract on behalf of the resident. The Resident Representative is an individual that has legal authority to make decisions on the resident’s behalf regarding healthcare and by executing the contract represents that he/she has authority to make healthcare decisions. The Representative agrees to provide the facility will a copy of all documentation relating to his or her legal authority to make healthcare decisions (Power of Attorney or Oath of Office for guardianship). The Responsible Party is an individual who has access and/or control over the resident’s funds and/or assets. The Responsible Party that executes this Contract agrees to cause payment of the fees and charges incurred by the resident to be paid from resident’s funds, estate or assets. The failure to cause payment of fees and charges and the failure to provide the necessary information to attain and maintain public aid benefits for the resident will constitute the failure to exercise due care and may subject the Responsible Party to individual and personal liability.

mailto:[email protected]

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C. Financial Agreement1. Charges for Services:

(a) Basic Rate. The Basic Rate includes personal care, laundry, room, board, and nursing care as required by Facility Standards. If a resident is paying privately, the resident will pay monthly in advance as set out in Supplement A: The Basic Rates. If the resident is transferred, discharged or otherwise ceases to reside at the facility, the resident will be charged a pro-rated portion of the Basic Rate until such time that the unit is vacated. The unit is considered vacated when the resident and his or her belongings are removed from the facility.

(b) Costs for Specified Supplemental Services and Products. The resident may also be charged for services of the type stated in Supplement B: Additional Charges. In addition to the Basic Rate, the resident agrees to pay for the Services and Products set out on the attached Facility Price List.

(c) Additional Costs. The resident is liable for any special treatment, services or supplies ordered by any Physician or requested by the resident and which is not covered in paragraphs C(1)(a) or C(1)(b). These costs cannot be determined in advance.

(d) Changes in Charges. The above charges may be changed at any time subject to notice under paragraph 4 of Section G.

(e) Late Payment. The facility may charge a fee equal to 1 ½ % each month, or to the fullest extent permitted by law, for all fees and charges that are outstanding by as of the 15th day of the month. These fees shall be paid by the parities liable for payment.

(f) Deposit. Pursuant to the Illinois Administrative Code, Chapter 77, Section 300.630(p), Resident, Resident’s Representative and/or Resident Representative, agree to pay a non-refundable deposit in the amount of $__________. Such deposit shall be due and owing prior to or upon the admission of resident to the facility. Residents on Medicaid at the time of their initial admission are not required to pay a deposit.

2. Residents Paying Privately:

(a) Definition. A “Resident Paying Privately” is a resident for whom the facility does not receive payment from the Medicaid or from the Veteran’s Administration. A Resident Paying Privately may be covered by Medicare.

(b) Agreement and Undertaking. The resident paying privately represents to the facility that charges incurred by or on behalf of the resident will be paid from all available income, assets, benefits, and other resources. Persons with access to resident resources must sign Supplement C: Income and Personal Resource Statement.

(c) Pending Public Aid Approval. If the resident applies for Medicaid funding, the resident will be responsible to pay all charges through the date Medicaid authorizes the billing for the resident’s care. The resident is considered a Private Pay resident until the resident’s Medicaid application is approved and any spenddown is met. The parties further agree that the facility may require a deposit or assurance of payment from the resident prior to approval of Medicaid eligibility for nursing home care. To the extent that the deposit covers time after the date

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Medicaid payments are authorized, the deposit shall be returned to the depositor within 30 days of the date of such authorization except as such deposits may be drawn upon in accordance with Medicaid requirements. The resident and/or Responsible Party agrees to give the facility 60 days written notice of any anticipated change in financial status, including the need to establish eligibility for public aid benefits.

(d) Billing. The resident shall be billed monthly. Payment is due by the 5th of each month. Delivery of a bill shall be deemed demand for payment. Resident, Representative and/or Responsible Party shall be responsible for all reasonable costs of collection, including reasonable attorney’s fees.

3. Residents Receiving Public Assistance:

(a) The facility accepts Medicaid Recipients. Making application for Medicaid or veteran’s coverage and appeals of any decision are solely the responsibility of the resident and/or the Responsible Party or Representative. If the resident is a Medicaid Recipient, payment shall be in accordance with Medicaid regulations. The resident shall pay charges for services to the extent Medicaid determines that the resident pay from the resident’s sources. If eligibility for Medicaid payments is terminated, the resident shall pay all charges thereafter as a Resident Paying Privately. Resident is responsible for any fees or charges that are determined to not be covered by Medicaid.

(b) If the source of payment for the resident’s care changes from private to public or public to private funds, or if the consent for the resident’s Veteran’s Administration funded care is terminated, the resident shall execute a new written contract with the facility substantially the same as this Contract. If the change is to private funds, the resident will pay all charges as a Resident Paying Privately after the change and all other terms of this Contract shall remain in effect until the new contract is signed.

(c) Pursuant to state and federal law, the resident is permitted to retain $30 of their monthly income for personal expenses. Resident’s monthly income, inclusive of social security and pension, shall be turned over to the facility minus the $30 allowance. Failure of the resident to turn over his or her monthly income in its entirety will subject the resident to an involuntary discharge. The failure of the Responsible Party to turn over the resident’s monthly income may constitute abuse and/or financial exploitation and constitutes a failure to exercise due care.

D. Transfer or Discharge1. The facility may transfer or discharge the resident for one or more of the following reasons at any time

by giving 30 days written notice to the resident, Representative and/or Responsible Party as required by Illinois law and regulations:

(a) medical reasons;

(b) resident’s physical safety;

(c) for the physical safety of other residents, facility staff or facility visitors;

(d) late payment or nonpayment;

(e) failure to comply with the facility’s contract or the policies and procedures, as defined in the resident handbook; or

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(f) as otherwise permitted by law.

2. The facility may transfer or discharge the resident on an emergency basis, without 30 days written notice, when the transfer or discharge:

(a) it is ordered by the resident’s attending physician because of the resident's health care needs; or

(b) it is mandated by the physical safety of other residents, the facility staff, or facility visitors, as documented in the clinical record.

E. Term and TerminationThis Contract shall initiate on the day it is signed by the resident, Representative and/or Responsible Party and shall end under the following conditions:

1. Resident may terminate this Contract at any time, with or without cause, by giving 30 days’ written notice to the facility. During the 30 day notice period, full monthly payment is required. Resident will continue to be liable for the monthly payment until the resident has vacated and his or her personal belongings are removed from the facility. Resident is entitled to a pro-rata refund of the monthly fee that the resident paid for the last month, less the cost of any repairs and replacement.

2. If the resident is compelled by a change in physical or mental health to leave the facility, this Contract shall terminate on 7 days’ written notice or immediately upon the resident’s death.

3. The resident’s absence from the facility for 30 consecutive days (except for therapeutic home leave, or hospitalization) shall be deemed a voluntary termination of this Contract by the resident. See Bed Reserve Policy regarding short-term absences from facility. Written notice shall be served on the resident by mailing to the resident’s last known address.

4. The resident’s refusal upon 7 days’ notice to execute a new contract when required shall be deemed voluntary termination of this Contract by the resident.

The facility may change any charge on 30 days’ written notice to the resident or to the person executing this Contract for the resident. The resident or the person executing this Contract for the resident may elect to terminate this Contract and to transfer from the facility by giving the facility notice within such 30 days. The written notice to the resident shall become an addendum to this Contract and the Contract as so modified shall be in force if the resident does not terminate the Contract.

5. All other terms of this Contract shall remain in effect from termination until the resident is transferred from the facility.

F. Miscellaneous

1. (Optional: There is no Resident’s Representative unless designated in writing.)

The Resident’s Representative is _______________________________. The resident may cancel or change the “Resident’s Representative” in writing at any time.

2. Severability. If any part of this Contract is ruled invalid by a court or is in violation of any applicable law, such part shall be deleted and the balance of this Contract shall remain in full force and effect.

3. Change of Law. If any law hereafter requires changes or additions to this Contract, such changes or additions shall be part hereof from the effective date.

4. Assignment. This Contract may be assigned by the facility to any successor in ownership or operation of the facility.

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5. Notice. All notices required under this Contract will be in writing and mailed by registered or certified mail, or delivered in person, to the last known address. Notice to the facility shall be sent to:

____________________________________________________________

____________________________________________________________

6. Complete Agreement. This contract represents the entire agreement of the parties, except for the change to the Basic Rate and other charges for additional services, as outlined in Supplement B. This Contract may not be amended except in writing and executed by the parties below.

7. Attorney’s Fees. The parties agree that the facility is entitled to all costs of collection of unpaid charges for the enforcement of this Agreement including court costs and reasonable attorneys’ fees.

8. Waiver. Waiver of any provision of this Contract shall not be deemed a complete waiver of the requirements and shall not excuse the resident from his or her responsibilities under this Contract.

9. Indemnification. The resident will indemnify and hold harmless the facility from all claims, expenses, and damages arising out of property damage and/or physical injury caused by resident or any third party hired by resident, including repair or replacement of property of facility, its staff, or other residents, and injuries to the facility staff or other residents.

10. Governing Law. This Contract shall be governed by and construed under the laws of the State of Illinois, except as to any conflict of law issues.

11. Hold Harmless. The resident agrees to hold harmless the facility, its owners, management, all their officers, trustees, staff, and personnel from all claims arising from an injury or illness incurred through natural or normal causes during his life at the facility.

12. Arbitration. The resident agrees to submit all claims or controversies arising out of or in any way relating to the Agreement, but not involuntary transfer and discharge proceedings, eviction proceedings, or matters that are properly filed in a small claims court or with the State Agency, in accordance with the Arbitration Agreement attached as Supplement E. Resident voluntarily agrees that execution of the Agreement.

Pursuant to the Federal Arbitration Act, 9 U.S.C. Sections 1-16, and other applicable law, the parties agree to submit any dispute, claim, or controversy (“Dispute”), arising out of or relating to (i) this Agreement or any amendment to this Agreement or (ii) the breach, termination, enforcement, interpretation, or validity of this Agreement, including the determination of the scope or applicability of this agreement to arbitrate (“Arbitration Agreement”), to final and binding arbitration before one arbitrator. If such arbitrator finds any portion of this Arbitration Agreement unenforceable, that portion will not be effective and the remainder of this Arbitration Agreement will remain in effect. The Federal Arbitration Act will govern the proceedings and interpretation of this Arbitration Agreement. A party to the arbitration may enter a judgment on the arbitration award in any court of competent jurisdiction.

This Arbitration Agreement does not limit, impair, or waive any defenses of any party, including the statute of limitations, and nothing in this Agreement prevents you or any other person from contacting regulatory or administrative agencies in relation to services the Facility provides. This Arbitration Agreement binds all parties to this Agreement and their spouses, heirs, representatives, executors, administrators, successors, and assigns, as applicable. After this Agreement terminates, this Arbitration Agreement shall remain in effect for the resolution of all future Disputes between the parties.

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THE UNDERSIGNED RESIDENT HAS RECEIVED A COPY AND HAS READ AND AGREES TO THE TERMS AND CONDITIONS OF THIS CONTRACT.

For the Facility:

______________________________________________________________________________Signature of Licensee, or by Administrator of the Facility as an Agent of the Licensee

______________________________________________________________________________Date of Signature Title of Facility Representative

For the Resident:

______________________________________________________________________________Resident, Resident Representative, Resident’s Guardian, Resident’s agent under a Power of Attorney executed pursuant to the Illinois Power of Attorney Act or a member of Resident’s immediate family

______________________________________________________________________________Date of Signature Specify Capacity if Signer is not the Resident

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Supplement A: Basic Rates

Effective _______ / _______ / ____________.[month] [day] [year]

____________________________________ per day (Private Room)____________________________________ per day (Two-Bed Room)____________________________________ per day (Three-Bed Room)____________________________________ per day (Four Bed Room)

The above charges are subject to change with 30 days written notice

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Supplement B: Additional Charges

The following list provides examples of common charges that may be incurred during a stay at the facility, and are not included in the facility’s Basic Rate.

Residents of this facility will be charged for the following services/products:

Clothing Shoes Cigarettes Beautician or barber Special outings (field trips) Optical care, including glasses Podiatric care not covered under Medicare Part B Hospice services not covered by Medicare Part A Pharmacy for items not covered by Medicaid or Medicare

Residents MAY also be charged for the following, if not covered by resident payor source:

Pharmacy services and medications Laboratory services Physician services Routine dental care Radiological (x-ray) services Ambulance services Oxygen tank usage Medical supplies Isolation care Tracheostomy care Incontinence care Therapies Other similar items

Actual charges cannot be given because of market fluctuations, and/or until the nature of the service is known.

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Supplement C: Income and Personal Resource StatementAgreement and Undertaking

I hereby agree as follows:

I hereby represent to the facility that I have access to the resident’s income and resources available to pay for care provided by the facility as follows:

I shall pay such income and resources of the resident or funds I receive from the resident to the facility when and to the extent needed for payment for the resident’s care at the facility.

I shall not use such income and resources for any purposes other than the foregoing or for the resident’s benefit.

I shall assign such income and resources to the facility at the facility’s request to the extent necessary to pay for the resident’s care at the facility.

This agreement and Undertaking is limited to the resident’s income and resources to which I have access and does not bind me to make any payment for the resident from my personal assets.

______________________________________________________________________________Signature(s) of Person or Persons with Access to the Resident’s Funds Date

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Supplement D: Admissions Checklist - Care Issues

Page 13 of 21Residents’ Rights Handbook Provide One Copy to Resident/Authorized Representative

Choice of Physician and Physician Policy Notification

Complete Form and Obtain Signatures Provide One Copy to Resident/Authorized Representative Keep One Copy for Facility Records

Admission Information on Advance Directives and Potential Health Care Surrogate


Statement of Facility Policy To Our Residents: Advance Directives and Life Sustaining Treatment and the Statement of Illinois Law on Advance Directives

Provide One Copy of each to Resident/Authorized Representative

State and Federal Notification Requirements Complete Form Provide One Copy To Resident/Authorized Representative

Notification of Federal MDS Electronic Data Transfer / Identified Offender Notification Criminal Hx Background Checks

Provide One Copy to Resident/Authorized Representative

Notice of Facility Privacy PracticesPrivacy Act Statement – Health Care RecordsPrivacy Act Statements

Obtain Signatures Provide One Copy to Resident/Authorized Representative Keep Original for Facility Records

Consent for Release of Information (HIPAA) Complete Form Provide One Copy to Resident/Authorized Representative Keep Original for Facility Records

Authorization and Release for Pneumococcal Vaccine / Vaccine Information Sheet


Authorization and Release for Influenza Vaccine / Vaccine Information Sheet

Obtain Signatures Provide One Copy to Resident/Authorized Representative Keep Original for Facility Records

Resident and Visitor Smoking Policy Notification Complete Form Provide One Copy To Resident/Authorized Representative

Consideration of a Funeral Home Complete Form Provide One Copy to Resident/Authorized Representative Keep Original for Facility Records

Notice of Special Characteristics or Service Limitations


Supplement D: Admissions Checklist - Lifestyle Issues

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Bed Reserve Policy Notification Enter Facility Bed Reserve % Provide One Copy to Resident/Authorized Representative

Resident Trust Fund Policy Notification and Authorization

Complete Form and Obtain Signatures Provide One Copy to Resident/Authorized Representative Keep Original for Facility Records

Laundry Services Complete Form Provide One Copy to Resident/Authorized Representative Keep Original for Facility Records

Notification of Facility Policy Regarding Personal Property Provide One Copy to Resident/Authorized Representative

Authorization to Inspect and Open Official Correspondence

Complete Form and Obtain Signatures Provide One Copy to Resident/Authorized Representative Keep Original for Facility Records

Special Notifications: Resident Council Care Plan Conferences Participation in Resident Field Trips Special Notice to Families and Visitors


Audio, Video and Photographic Release Form Complete Form and Obtain Signatures Provide One Copy to Resident/Authorized Representative Keep Original for Facility Records

Financial Notifications and Information

Assignment of Medicare Benefits andAuthorization for Release of Information Obtain Information and Signatures

Your Benefits Under Medicare Provide One Copy to Resident/Authorized Representative

Your Benefit Rights and Eligibility Information Under Medicaid

Choose the Appropriate Form, For Single Individuals or Married Couples With One Person in the Community)


Medicaid Services and Supplies Covered by the Illinois Medical Assistance Program Provide One Copy to Resident/Authorized Representative

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Supplement D: Admissions ChecklistMedicare-Specific Issues (If Applicable)

Medicare as Second Payor - Screening Questionnaire

Complete Form Provide One Copy to Resident/Authorized Representative Keep One Copy for Facility Records

Waiver of Medicare Benefits (Optional)

Notice of Non-Coverage Under Medicare Determination on Admission Determination on Continued Stay Technical Denial Intermediary Decision Advanced Beneficiary Notice

Advance Directives (Optional)

Illinois Statutory Form Power of Attorney for Health Care

Complete Form and Obtain Signatures Provide One Copy to Resident/Authorized Representative Keep Original for Facility Records Forward One Copy to the Resident’s Chart

Illinois Living Will Declaration

Certification for Surrogate Decision-Making (With Qualifying Conditions)

Certification for Surrogate Decision-Making (Without Qualifying Conditions)

Practitioner Order for Life-Sustaining Treatment (POLST) and Uniform Do-Not-Resuscitate (DNR)IDPH Advance Directive Guidance for Individuals (POLST & DNR)

Complete Form and Obtain Signatures Provide One Copy of form plus IDPH Guidance to

Resident/Authorized Representative Keep Original for Facility Records Forward One Copy to the Resident’s Chart

I acknowledge that the areas of this checklist that have been marked have been explained to me in terms that I understand. I have been provided with an opportunity to ask questions, and those questions have been answered to the best of the facility’s ability. Additionally, I have received copies of all appropriate handouts and supplemental materials.

________________________________________________ __________________

Signature of Resident/Authorized Representative Date

Supplement E: Arbitration AgreementARBITRATION AND LIMITATION OF LIABILITY RIDER

TO RESIDENCY AGREEMENT BETWEEN

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RESIDENT AND FACILITY

This Arbitration and Limitation of Liability Rider (the “Rider”) to Facility’s Resident Contract (the “Agreement”) is entered

into this _____ day of _____________, 20___ by and between Facility, ____________________________________ (“Resident”), ______________________________________ (“Responsible Party”) and __________________________ (“Resident Representative”).

NOW, THEREFORE, in consideration of the mutual covenants hereinafter contained, the parties agree as follows:

A. ARBITRATION PROVISION

1. The parties agree the disputes identified in Article 2, below, between: a) the Resident or his/her spouse, heirs or assigns; and b) Facility or its affiliates, officers, directors, agents, license holders, managers, or employees, shall be submitted to binding arbitration, as provided below, and shall not be filed in a court of law.

2. The disputes subject to arbitration in accordance with this Rider, include:

(a) all claims or controversies arising out of or in any way relating to the Agreement, but not involuntary transfer and discharge proceedings, eviction proceedings, or matters that are properly filed in a small claims court or with the State Agency;

(b) the Resident’s stay at the Facility, but not administrative involuntary termination or involuntary transfer or discharge proceedings, eviction proceedings, or matters that are properly filed in a small claims court or with the State Agency;

(c) the services rendered for any condition, and any dispute arising out of the diagnosis, treatment, or care of the Resident;

(d) disputes involving amounts in controversy greater than $150,000.00; or

(e) disputes regarding interpretation of this Rider,

The enumerated disputes will be subject to this Rider whether arising out of State or federal law, whether existing or arising in the future, whether for statutory, compensatory or punitive damages and whether sounding in breach of contract, tort or breach of statutory duties, irrespective of the basis for the duty or the legal theories upon which the claim is asserted.

Supplement E: Arbitration Agreement

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3. The parties to this Rider further understand that Claims, including malpractice claims, cannot be brought in a lawsuit in court before a judge or jury and that a jury will not decide their case.

4. This Rider shall be governed by and interpreted under the Federal Arbitration Act (“FAA”), 9 U.S.C. 1-16. In the event that it is determined that the FAA is inapplicable, the parties desire that this agreement be interpreted under the applicable Illinois law so as to give effect to the parties’ intent. Further, nothing in this Rider is to be construed to contradict any applicable Illinois statutory grievance or mediation procedure. Any party who demands arbitration must do so for all claims or controversies that are known, or reasonably should have been known, by the date of the demand for arbitration, and if learned of during the course of the arbitration proceeding shall amend the claims or controversies to reflect the same. All current damages and reasonably foreseeable damages arising out of such claims or controversies shall also be incorporated into the initial demand or amendment thereto.

5. The Resident also understands that nothing in this Rider prevents him/her from contacting regulatory or administrative agencies in relation to services provided by Facility.

6. Demand for Arbitration by Resident, his or her guardian, a person or organization acting on behalf of a Resident with the consent of the Resident or his or her guardian, the Resident Representative as defined by the Agreement, or the personal representative of the estate of a deceased Resident (collectively “Responsible Party”) shall be made in writing and submitted to the Administrator of Facility, via certified mail, return receipt requested. Demand for Arbitration by Facility shall be made in writing and submitted to the Resident or his or her agent, their representative, successor or assign and/or Resident’s Attorney-in-Fact, Resident Representative, and/or Responsible Party via certified mail, return receipt requested.

7. The Resident and/or Responsible Party shall have the option to select the venue for the arbitration proceedings. If the Resident and/or Responsible Party declines the opportunity to select the venue, the arbitration will proceed in the county in which Facility is located.

8. Facility will be responsible for payment of the arbitrator’s fees and costs associated with the arbitration.

9. Facility will pay up to $5,000 of the Resident’s attorney’s fees and/or costs associated with the arbitration


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10. Facility will bear its own attorneys’ fees and costs associated with the arbitration.

11. The arbitration proceedings shall be held in accordance with the rules and procedures as outlined in the National Arbitration Forum’s Code of Procedure. In the event that the National Arbitration Forum is unable or unwilling to arbitrate the dispute, the parties agree that the dispute shall be arbitrated before a nationally recognized arbitration organization pursuant to its code of conduct.

12. The arbitrator’s decision shall be final and binding without the right to appeal.

13. The arbitration proceeding shall remain confidential in all respects, including the Demand for Arbitration, all arbitration filings, deposition transcripts, documents produced or obtained in discovery, or other material provided by and exchanged between the parties and the arbitrator’s findings of fact and conclusions of law. Following receipt of the arbitrator’s decision, each party agrees to return to the producing party within thirty (30) days the original and all copies of documents exchanged in discovery and at the arbitration hearing, except those documents required to be retained by counsel pursuant to law. For electronically stored or produced documents, each party shall delete or destroy to the other party’s satisfaction all electronic documents received through the arbitration discovery and proceedings. Further, the parties to the arbitration also agree not to discuss the amount of the arbitration award or any settlement, the names of the parties, or the name/location of the Residence except as required by law.

14. This Arbitration Provision and the Limitation of Liability Provision below shall survive the death of the Resident.

15. This Rider shall remain in effect after the expiration of the underlying Agreement and shall apply to all renewal Agreements.

16. If any action is brought by either party to this Rider for which arbitration is not allowed by law, excluding involuntary transfer and discharge proceedings, eviction proceedings, or matters that are properly filed in a small claims court or before a State Agency, the dispute shall be brought in the appropriate court before a judge. The parties expressly WAIVE THEIR RIGHT TO BRING THE MATTER BEFORE A JURY. In such case, Facility will be responsible for the Resident and/or Responsible Party’s court costs and up to $5,000 of the Resident and/or Responsible Party’s attorneys’ fees. Facility will bear its own costs and attorney’s fees.


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B. LIMITATION OF LIABILITY PROVISION:Read Carefully Before Signing

1. The parties to this Rider understand that the purpose of this “Limitation of Liability Provision” is to limit, in advance, each party’s liability in relation to this Rider.

2. Interest and/or late fees on unpaid facility charges shall not be awarded.

3. Should any sub-sections provided above, be deemed invalid, the validity of the remaining sub-sections will not be affected.

C. SEVERABILITY

In the event a court having jurisdiction finds any portion of this Rider unenforceable, that portion shall not be effective and the remainder of the Rider shall remain effective.

The Resident, Responsible Party, or his or her legal guardian, or authorized Power of Attorney understands that other nursing homes’ residency contracts may not contain an arbitration provision, or limitations of liability provision. The parties agree that the reasons stated above are proper consideration for the acceptance of the Arbitration and Limitation of Liability Provisions.

The undersigned acknowledges that he or she has been encouraged to discuss this Rider with an attorney.

By signing below you acknowledge that you have reviewed this Rider and understand it.

[SIGNATURES TO FOLLOW]

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IN WITNESS WHEREOF, the Parties have hereto affixed their signatures as of the date and year first above mentioned.

Resident Date

Responsible Party Date

Resident Representative Date(Both on behalf of the Resident and on his/her own personal behalf)

For FACILITY

By:

Title:

Date:

d.transfer or discharge - health care council of...

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