AMSTERDAM NURSING HOME (1992) ADMISSION PACKET …Sponsor agree to pay or arrange payment for the private pay room and board rate and the Amsterdam Admission Packet Rev. 4/14/2020

AMSTERDAM NURSING HOME (1992) ADMISSION PACKET ACKNOWLEDGEMENT

By execution of this agreement, the Resident, Resident Representative and/or Sponsor acknowledge receipt of the following documents and information in addition to the Admission Agreement (pages 2 – 19):

Page(s)

1. Attachment “A”: Schedule of Coverage and Fees for Ancillary Services 20 – 22

2. Attachment “B”: Special Rules Regarding Selected Payors 23 – 25

3. Attachment “C” Arbitration Agreement – What it Means to You 26 - 27

4. Monthly Personal Allowance Form 28

5. Consent for use of Photographs 29

6. Medicare Assignment of Benefits Form – Signature on File 30

7. Medicare Part A Resident Acknowledgement 31

8. MBS, LTD. Medicare / Insurance Authorization Form 32 - 36

9. Assignment of Benefits for L.I. Script, LLC. 37 - 40

10. Notice of Uniform Assignment and Release of Information Statements 41

11. Appointment of Authorized Representative and Consent to Release Information 42

12. Acknowledgement of Restraint Policies 43

13. Notice of Privacy Practices 44 - 49

14. Authorization for Handling of Mail 50

15. Emergency & Disaster Preparedness Form 51

16. Notice of Veterans Benefits and Services 52

17. Medicare Minimum Data Set (MDS) and the Privacy Act of 1974 Statement 53 - 54

18. Deciding About Health Care - NYS Department of Health Guide 55 - 62

19. Health Care Proxy – NYS Department of Health Information 63 - 70

20. Planning in advance for your medical treatment – NYS Information: 71 - 72

New York Living Will 73 - 74

Do-Not-Resuscitate (DNR) Orders 75 - 77

21. Your Rights as a Nursing Home Resident in New York State 78 - 92

__________________________________ Print Name

__________________________________ ______________ Resident or Resident Representative Signature Date

Amsterdam Admission Packet Rev. 4/14/2020 Page 1 of 94

AMSTERDAM NURSING HOME CORPORATION (1992) 1060 Amsterdam Avenue

New York, New York 10025 (212) 316-7700

ADMISSION AGREEMENT

Agreement dated _______________, 20___ between AMSTERDAM NURSING HOME CORPORATION (1992), located at 1060 Amsterdam Avenue, New York, New York 10025 (hereinafter “Amsterdam” or the “Facility”) and _________________________________ (hereinafter referred to as “Resident”) whose residence is located at _______________________________ and _________________________________________ (hereinafter “Resident Representative”) residing at_____________________________________________________ and _____________________________________________, Resident’s sponsor1 (hereinafter “Sponsor”, if not listed as Resident Representative), residing at ___________________________________.

The Facility accepts the Resident for admission subject to the following terms and conditions:

I. ADMISSION AND CONSENT

The undersigned hereby agrees, subject to both federal and state laws, rules and regulations, that the Resident will be admitted to the Facility only upon the order of a New York State licensed physician and upon a determination that the Resident satisfies the admission assessment criteria set by the New York State Department of Health and by the Facility. The Resident and/or Resident Representative and/or Sponsor hereby consent to such care and treatment as may be provided by the Facility and/or ancillary providers in accordance with the Resident’s plan of care, including but not limited to, transfer to an acute care hospital when necessary, dental, medical and/or surgical consultation, examination by staff, routine diagnostic tests and procedures, and the administration of pharmaceuticals. The Resident and/or Resident Representative and/or Sponsor shall have the right to participate in the development of the plan of care and shall be provided with information concerning his or her rights, to consent or refuse treatment at any time to the extent allowable under applicable law. The Resident and/or Resident Representative and/or Sponsor hereby understand and agree that Admission to the Facility is conditioned upon the review and execution of this Agreement, as more fully set forth herein.

II. MUTUAL CONSIDERATION OF PARTIES

The facility agrees to provide all basic (routine) services to the Resident, as well as either provide or arrange for available ancillary services, which the Resident requires. Attachment “A” lists the routine, ancillary and additional services provided and/or arranged for by the Facility. A list of private pay charges for certain ancillary and other available services is attached to this Agreement and included in your admission package.

1 A Sponsor, usually the Resident’s spouse, as defined pursuant to 10 NYCRR §415.2, is “the agency or the person or persons, other than the resident, responsible in whole or in part for the financial support of the Resident, including the costs of care in the Facility.”


The Resident, Resident Representative and/or Sponsor understand and agree that the Facility’s acceptance of the Resident is based on the Resident’s and/or Resident Representative’s and/or Sponsor’s representation that the Resident has resources, insurance coverage and/or is eligible for government benefit (including Medicare and/or Medicaid) to cover the cost of care at the Facility. Furthermore, the Resident, Resident Representative and/or Sponsor agree to take all necessary steps to ensure that the Facility and its associated providers receive payment from these and/or other available sources consistent with this Agreement. The Resident, Resident Representative and/or Sponsor may be required to file an application for admission, make full and complete disclosure to the Facility of all income (including Social Security, pension and other periodic receipts), assets, insurance coverage and any other resources available to the Resident that could be available to pay for the cost of care and provide a certification regarding the full and complete disclosure of all financial resources, all of which the Facility will rely upon in accepting the Resident for admission. We also require proof of U.S. citizenship.

The Resident, Resident Representative and Sponsor agree to comply with all applicable policies, procedures, regulations and rules of the facility.

III. TRUTH OF STATEMENTS

The Resident guarantees to the Facility that all statements and financial information provided to the Facility are true and accurate. The Resident acknowledges that the Facility relies on the information provided by the Resident or by a third party at the Resident’s request. The Resident agrees to pay promptly all of the Facility’s damages including, but not limited to, all charges, expenses, court costs, and attorney’s fees and expenses incurred by or on behalf of the Facility, directly or indirectly resulting from any inaccuracy or misrepresentation of information provided to the Facility, or from failure to abide by any promise or guarantee in this Agreement. No other language in this Agreement may be construed to impair the guarantee or promise to pay damages contained in this paragraph.

IV. RESIDENT REPRESENTATIVE DOCUMENTATION

The Resident’s Resident Representative agrees to obtain and provide the Facility with documentation confirming authorization to act on behalf of the Resident with respect to financial and/or personal matters. Upon receipt and verification of such documentation the Facility will give to the Resident Representative all notification of information which is required to be given to the Resident by applicable laws or regulations, subject to applicable limitations based on confidentiality.

V. ANTICIPATED SERVICES

It is anticipated that the Resident will initially require the following level of care (should the Resident’s condition and level of care needs change, such change will be noted in the Resident’s medical record):

Sub-Acute Care*: [Check one of the following: ___ Medically Complex ___Rehabilitation]

Long Term Care

Hospice Care

Other


*Amsterdam defines sub-acute care as goal oriented, comprehensive, inpatient care designedfor an individual who has an acute illness, injury, or exacerbation of a disease process and whointends to be discharged to the community. It is generally rendered at the Facility immediatelyafter, or instead of, acute hospitalization. Sub-acute care lasts for a limited time or until acondition is stabilized or a predetermined treatment course is completed.

Residents admitted for sub-acute care services are admitted with the expectation that, unless continued placement in the Facility is medically appropriate, they will be discharged once sub-acute services are no longer required. It is the mutual objective of the Resident and the Facility that the Resident returns to his/her home or a less restrictive setting, if appropriate. The Resident, his/her Resident Representative and/or Sponsor agree to Facility discharge as soon as medically appropriate and hereby represent and agree that they will work with the Facility staff to secure an appropriate and timely discharge.

In the event Resident is admitted for sub-acute services and subsequently, by virtue of his or her health condition, requires long-term care placement, a room change or transfer to a more appropriate setting may be necessary. Any such room change, transfer or discharge shall be carried out in accordance with applicable law and the Facility’s policies and procedures.

VI. FINANCIAL ARRANGEMENTS

By entering into this Agreement, the Resident, Resident Representative and/or Sponsor understand and agree to the payment obligations set forth herein:

(a) Obligation of Resident, Resident Representative and/or Sponsor

The Resident and/or Resident Representative and/or Sponsor shall ensure that the Resident has a continuous payment source and/or shall pay the Facility on a private pay basis, with private insurance, and/or by means of a third-party government payor, such as Medicare or Medicaid. A Resident’s obligation to guarantee payment is personal and limited to the extent of his/her finances, and, consistent with applicable laws, rules and regulations, to the extent of his/her spouse’s income and resources as well. The Resident Representative is responsible for providing payment from the Resident’s income and resources to the extent he/she has access to such income and resources with the Resident Representative incurring personal financial liability. By signing this Agreement, however, the Resident Representative personally guarantees a continuity of payment from the Resident’s funds to which he/she has access or control and agrees to arrange for third-party payment, if necessary, to meet the Resident’s cost of care. Unless the Resident Representative is also the Resident’s spouse or Sponsor, the Resident Representative is not obligated to pay for the cost of the Resident’s care from his/her own funds, except to the extent of his/her breach of this Agreement. The Resident, Resident Representative and/or Sponsor agree to provide or arrange for payment for any portion or all of the applicable private pay room and board rate, the ancillary charges incurred for services not covered by third party payors and/or any required deductibles, co-insurance or monthly income budgeted by the Medicaid program (the Resident’s Net Available Monthly Income [“NAMI”]) and may be responsible to the Facility for the damages arising from his/her breach of this Agreement. Payment to the Facility shall be made on a monthly basis as billed.

If the Resident has no third party coverage or if the Resident remains in the facility after any such coverage terminates because it is deemed no longer “medically necessary” or for any other reason consistent with the applicable law, the Resident, Resident Representative and/or Sponsor agree to pay or arrange payment for the private pay room and board rate and the


ancillary charges incurred until discharge or until another source of coverage becomes available to in accordance with applicable Federal and State laws and regulations. The Facility will notify the Resident, Resident Representative and/or Sponsor of a third-party payor’s discontinuation of coverage.

The execution of this Agreement by the Resident Representative and/or Sponsor cannot, and shall not, serve as a third-party guarantee of payment in violation of applicable law and regulation. Notwithstanding the foregoing, the Resident Representative and/or Sponsor will be held personally responsible and liable for a breach of his/her actions or omissions under the terms of this Agreement which actions or omissions have caused and/or contributed to non-payment of the Facility’s fees. Such actions or omissions constituting a breach of this Agreement include, but are not limited to, the following: (i) failing to utilize the Resident’s funds to pay for the Resident’s care at the Facility when the Resident Representative and/or Sponsor has control over the Resident’s funds through a Power-of-Attorney, access to joint accounts and/or other jointly held assets; (ii) misappropriation, diversion and/or transfer(s) of the Resident’s funds which result in the Resident having insufficient private resources to pay for the cost of the Resident’s care and/or in being ineligible to receive third-party benefits (i.e., Medicaid); (iii) failure to remit the Resident’s social security and/or pension income to the Facility; (iv) failure to provide requested information and/or documentation to the Facility or to third-party payer(s), such as an insurer or Medicaid; and/or (v) the provision of false, misleading or incomplete information and/or documentation, regarding matters including, but not limited to, the Resident’s financial resources, citizenship or immigration status, and/or third-party insurance coverage, to the extent that the Facility relies on such information and/or documentation to its detriment. Any failure of the Resident Representative and/or Sponsor to use the Resident’s funds in accordance with the terms of this Agreement will constitute a breach of contract on the part of the Resident Representative and/or Sponsor.

(b) Anticipated Payor

The Resident, Resident Representative and/or Sponsor represent to the Facility that it is anticipated that the cost of the Resident’s care will be paid in whole or in part by (check all that apply, including both primary and secondary payors):

_____Medicare _____Medicaid _____Veteran’s Administration Benefits

_____Private Payment _____No Fault Insurance _____Worker’s Compensation Benefits

_____Managed Care Organization: (Specify Name of Organization):

_____Other private insurance: (Specify Name of Insurance Company): ____________________

The Resident and/or the Resident Representative and/or Sponsor agree to provide the Facility with all relevant information and documentation regarding all potential third party payors. The Resident and/or the Resident Representative and/or Sponsor understand that if the anticipated payor does not pay for the full cost of care, then the Resident and/or the Resident Representative and/or Sponsor will be responsible for paying the cost of such care through the Resident’s funds to which he/she has legal access and/or by securing coverage through another third party payor. This provision will be applied consistent with any agreement the Facility may have with a third party payor.


The Resident and/or the Resident Representative and/or Sponsor understand that, although the Facility will be available to assist the Resident, Resident Representative and/or Sponsor to apply for third party coverage, it is ultimately the responsibility of the Resident, the Resident Representative and/or Sponsor to timely apply for and meet the requirements of third party payors (including, but not limited to, Medicaid). In the case of a Resident who does not meet the eligibility criteria for coverage by third party payors, the Resident, Resident Representative and/or Sponsor will be billed at the Facility’s private pay room and board rate.

(c) Private Payment

If the Resident is paying privately for the cost of his or her care, and part or all of such payment is not covered by a third party payor, the room and board rate for a semi-private room is $655.00 per day and the room and board rate for a private room is $697.00 per day. In addition, the Resident will be billed for ancillary services including, but not limited to, urinary care supplies, tracheostomy and other ostomy supplies, surgical supplies, parenteral and enteral feeding supplies, occupational, speech and physical therapy, physician services, prescription medications, laboratory tests, x-rays and other diagnostic services, ambulance/ambulate services, beauty and barber services, personal telephone and newspaper delivery and extraordinary rehabilitative devices according to the Facility’s and/or the service providers’ charge schedules. However, rates of payment to the Facility may differ for individuals with additional sources of payment such as Medicare, Medicaid and third-party insurance. A copy of the Facility charge schedule for ancillary services is attached to this Agreement and included in your admission package. Payment must be made to the Facility upon receipt of the bill by the Resident, Resident Representative and/or Sponsor. The private pay room and board rate and additional services charges are subject to increase upon thirty (30) days written notice to the Resident, Resident Representative and/or Sponsor.

(d) Security Deposits

In the event the Resident is not eligible for Medicaid or Medicare coverage on admission, the Resident agrees to pay a security deposit equivalent to sixty (60) days at the basic daily rate. If the Resident fails to pay the Facility for services rendered, the deposit and any accrued interest will be applied to the outstanding indebtedness, without further notice to the Resident.

(e) Private Pay Advance Billing Policy

Upon admission, the Resident agrees to pay in advance for the first month of care. Subsequent payments are due upon the first day of each succeeding month of the Resident’s stay. Bills for ancillary charges are generated in the month following the month the services were rendered. All bills are generated by the end of each month and cover the next month of room and board charges and the previous month’s ancillary charges. All payments are due upon receipt of the bill by the Resident, Resident Representative and/or Sponsor.

Advance payments are not required upon admission from individuals eligible for Medicare/Medicaid/Veterans Administration benefits. However, immediately upon the ineligibility of a Resident and/or the expiration or discontinuation of coverage for service at the Facility by Medicare, Medicaid or the Veterans Administration, the Resident will be required to remit advance payment at the Facility’s private pay room and board rate in accordance with the above-mentioned policies of the Facility.


(f) Late Charges

Resident will be charged a late payment fee of 1% interest per month for all payments that are not received when due.

(g) Collection Costs, Including Attorney and Court Fees

If the Resident, the Resident Representative and/or the Sponsor fail to make payments within thirty (30) days of the date payment is due, the Resident, Resident Representative and/or Sponsor shall pay (in accordance with the terms and provisions of this Agreement) all expenses incurred by the Facility, in connection with its attempts to collect the outstanding payment. Such collection costs will include, but may not be limited to, attorneys’ fees, court costs and related disbursements. In addition, the Resident, Resident Representative and/or Sponsor shall pay (in accordance with the terms and provisions of this Agreement) all late charges as noted above.

(h) Refunds to Residents

The facility will refund amounts to the Resident in accordance with the following terms:

If the Resident leaves and does not return to Amsterdam, the Facility shall refund to the Resident, within thirty (30) days of the Resident’s departure, the balance, if any, remaining of any security deposit, personal funds retained by the Facility, or any other charges already paid, plus accrued interest, less the Facility’s per diem rate, for the days the Resident actually resided, reserved, or retained a bed in the Facility or any other amount due from the Resident, shall be refunded to the Resident, along with a final accounting of these funds.

Upon the death of a Resident, the Facility will convey the balance, if any, remaining of any security deposit, personal funds retained by the Facility, or any other charges already paid, plus accrued interest, less the Facility’s per diem rate, for the days the Resident actually resided, reserved, or retained a bed in the Facility or any other amount due from the Resident, and a final accounting of those funds to the individual or probate jurisdiction administering the Resident’s estate within thirty (30) days of the date the Facility is furnished with evidence of the identity of the fiduciary or probate jurisdiction to whom the funds may be legally disbursed.

(i) Third Party Private Insurance and Managed Care

If the Resident is covered by a private insurance plan or under a private managed care benefit plan that has a contract with the Facility, payment of his or her care will be according to the rates for coverage of skilled nursing facility benefits set forth in the written financial agreement with the Facility and the third party insurer or managed care payor. Residents who are members of a managed care benefit plan that is under a contract with the Facility to provide specified services to plan members will have such services covered as long as the Resident meets the eligibility requirements of the managed care benefit plan; Resident will be financially responsible only for those services that are not included in the list of covered services under his or her plan and applicable co-pays and deductibles.

If Resident is covered by a private insurance plan or under a managed care benefit plan that does not have a contract with the Facility, and where the insurance proceeds under the private plan are insufficient to cover the cost of care, the Resident will be responsible for any difference. The Facility will bill the Resident for any such difference on a monthly basis as described in the “Private Payment” section above. The coverage requirements for nursing home care vary


depending on the terms of the insurance or managed care plan. Questions regarding private insurance and managed care coverage should be directed to the social work staff, the business office and/or the Resident’s insurance or managed care plan, carrier or agent.

If Resident is covered by a private insurance plan or under a managed care benefit plan for either all or a portion of the Facility’s charges pursuant to the terms of the Resident’s plan, the Resident by execution of this Agreement hereby authorizes the Facility to utilize participating physicians and providers of ancillary services or supplies, if required by the plan for full benefit coverage, unless the Resident specifically requests a non-participating provider with the understanding and agreement that the Resident will be responsible for the additional charges, if any, as a result of using such non-participating providers.

The Resident is responsible for timely notifying the Facility of what benefits, if any, may be available from his or her private insurance and/or managed care plan. Notwithstanding such notice, the Facility may assess charges above the covered benefit for skilled nursing facility care depending on the insurance coverage, managed care plan and/or written agreement with the Facility. Furthermore, the Resident’s coverage may be subject to co-insurance deductibles and/or copayments, which will be the Resident’s responsibility and billed according to the terms for private payment stated above.

In the event of denial of payment by a third-party payor, exhaustion of benefits and/or termination of coverage, the Resident, Resident Representative and/or Sponsor shall be responsible (in accordance with the terms and provisions of this Agreement) for payment to the Facility as described in the “Private Pay” section above and in accordance with applicable law.

(j) Medicaid

If and when the Resident’s assets/funds have fallen below the Medicaid eligibility levels and the Resident otherwise satisfies the Medicaid eligibility requirements, and the Resident is not entitled to any other third-party coverage, the Resident should be eligible for Medicaid (see Attachment “B”), often referred to as the “payor of last resort.” The Resident, Resident Representative and/or Sponsor agree to notify the Facility at least three (3) months prior to the exhaustion of the Resident’s funds and/or insurance coverage to confirm that the Resident, Resident Representative and/or Sponsor has submitted or will submit a timely Medicaid application and ensure that all eligibility requirements have been met. The Resident, Resident Representative and/or Sponsor agree to apply for Medicaid benefits prior to the exhaustion of the Resident’s resources. Services reimbursed under Medicaid are outlined in Attachment “A” to this Agreement.

Transfer(s) of the Resident’s assets that occurred on or after five (5) years prior to admit date of admission to the Facility may result in a period of Medicaid ineligibility. The Resident, Resident Representative and/or Sponsor represent that no such transfer(s) have been made that would leave the Resident without a payment source when he or she is otherwise eligible for Medicaid.

If the Resident’s care is covered by Medicaid, the Resident, Resident Representative and/or Sponsor agree to remit to the Facility the NAMI on a timely basis, pursuant to the Resident’s Medicaid budget (see Attachment “B”). The Resident’s NAMI, as determined by Medicaid, generally equals his or her income (for example Social Security income, pension income, etc.) which is available to offset the cost of care after all allowable deductions have been made. The Facility has no control over the determination of NAMI amounts. When the Resident is awaiting


the issuance of a Medicaid budget, the Resident, Resident Representative and/or Sponsor shall remit the anticipated NAMI to the Facility in a timely manner.

If Medicaid denies coverage, the Resident, Resident Representative and/or Sponsor hereby agree to remit to the Facility any outstanding amounts for unpaid services not covered by other third-party payors subject to applicable federal and state laws and regulations. Such amounts shall be calculated in accordance with the Facility’s applicable prevailing private rates and charges for all basic and additional services provided.

(k) Direct Deposit

All long-term Residents and all short-term Residents transferred to long-term may have their Net Available Monthly Income or NAMI (Social Security, pension benefits, etc.) deposited in the Facility’s account and/or their “personal income allowance” (“PNA”) deposited in their personal account via electronic direct deposit. If you would like the Facility to assist you/the Resident in obtaining direct deposit of these income sources, please initial all that apply below. By initialing below you are agreeing to allow the Facility to become representative payee for direct deposit purposes.

_____ I wish to have my/the Resident’s Social Security Income directly deposited into the Facility’s account as Representative Payee.

_____ I wish to have my/the Resident’s Pension Income directly deposited into the Resident’s PNA account at the Facility and, if my/the Resident’s pension check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident do the Facility’s address.

(Specify Name of Pension benefit organization) _____________________________

I wish to have my/the Resident’s income directly deposited into the Resident’s PNA account at the Facility, and, if my/the Resident’s income check cannot be directly deposited, then I wish to change the address so that such income check is physically sent to the Resident c/o the Facility’s address.

(Specify Name of the income source) _____________________________________

I understand that the Facility will apply any income received towards my/the Resident’s NAMI obligation in accordance with applicable Social Services Law and regulations and/or towards my/the Resident’s NAMI obligation in accordance with applicable Social Services Law and regulations and/or towards my/the Resident’s anticipated NAMI obligation and that the Facility will deposit my/the Resident’s personal income allowance in my/the Resident’s personal account at the Facility.

(l) Medicare

If the Resident meets the eligibility requirements for Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, the Facility will bill Medicare directly for Part A services provided to the Resident. Medicare will reimburse the Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUGS IV guidelines. If the Resident meets the eligibility criteria, Medicare may provide coverage of up to 100 days of care. The first 20 days of covered services may be fully paid for, and a portion of the next 80 days


(days 21 through 100) of the covered services may be paid for by Medicare subject to a daily co-insurance amount for which the Resident is responsible. Please note an individual who is a Medicare beneficiary under Part A and Part B and/or Part D programs, and who subsequently exhausts their coverage under Part A or is no longer in need of a covered level of skilled care under Part A, may still be eligible to receive coverage for certain Part B services (previously included in the Part A payment to the Facility) and Part D services after they are no longer eligible for coverage under Part A. Residents covered under Medicare Part C may have their nursing home stay or a portion thereof covered depending on the plan’s agreement with the Facility.

Medicare will terminate coverage for Medicare beneficiaries receiving physical, occupational and/or speech therapy (“therapy services”) if the Resident does not receive therapy for three (3) consecutive days, whether planned or unplanned, for any reason, including illness or refusals, doctor appointments or religious holidays. If such therapy was the basis for Medicare Part A coverage, the Resident, Resident Representative and/or Sponsor would be responsible for the cost of such stay, in accordance with applicable Federal and State laws and regulations, unless another payor source is available.

If Medicare denies coverage or the Residents’ plan is not accepted by the Facility, the Resident, the Resident Representative and/or the Sponsor hereby agree to remit to the Facility any outstanding amounts of unpaid services not covered by other third party payors subject to applicable federal and state laws and regulations. Such amounts shall be calculated in accordance with the Facility’s applicable prevailing private rates and charges for all basic and additional services provided to the Resident.

For further information on third party payor sources, please refer to Attachment “B”.

MEDICARE PART A BENEFICIARIES

Except for specifically excluded services, nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements. Under these requirements, the Facility is responsible for furnishing directly, or arranging for, the services for its residents covered by Medicare Part A. When not directly providing services, the Facility is required to enter into arrangements with outside providers and must exercise professional responsibility and control over the arranged-for services. All services that the Resident requires must be provided by the Facility or an outside provider approved by the Facility. Before obtaining any services outside of the Facility, the Resident must consult the Facility.

While the Resident has the right to choose a health care provider, the Resident understands that by selecting the Facility, the Resident has effectively exercised his/her right of free choice with respect to the entire package of services for which the Facility is responsible under the consolidated billing requirements. The Resident agrees that he/she will not arrange for the provision of ancillary services unless the Resident has obtained prior approval of the Facility.

VII. AUTHORIZATIONS AND ASSIGNMENTS TO THE FACILITY

(a) Authorization to Release Information

By execution of this Agreement, the Resident, Resident Representative and/or Sponsor authorizes the Facility to release to government agencies, insurance carriers or others who could be financially liable for any medical care provided to the Resident, all information needed


to secure and substantiate payment for such medical care and to permit representatives thereof to examine and make copies of all records relating to such care.

(b) Assignment of Benefits and authorization to Pursue Third-Party Payment

By execution of this Agreement, the Resident, Resident Representative and/or Sponsor hereby assign to the Facility any and all applicable insurance benefits and other third-party payment sources to the extent required by the Facility to secure reimbursement for the care provided to the Resident. The Resident, Resident Representative and/or Sponsor authorize the Facility to seek and obtain all information and documentation necessary for the processing of any third-party claim(s).

(c) Authorization to Obtain Records, Statements and Documents

By execution of this Agreement, the Resident, Resident Representative and/or Sponsor authorizes the Facility to obtain from financial institutions, including, but not limited to, banks, insurance companies, broker and credit units and government agencies, such as the Social Security Administration and Department of Social Services, records, statements, correspondence and other documents pertaining to the Resident for the purposes of, including but not limited to, securing payment to the Facility.

(d) Authorization to Represent Resident Regarding Medicaid

By execution of this Agreement, the Resident, Resident Representative and/or Sponsor authorizes the Facility to obtain from financial institutions, including, but not limited to, banks, insurance companies, broker and credit unions and government agencies, such as the Social Security Administration and Department of Social Services, records, statements, correspondence and other documents pertaining to the Residents for the purposes of, including but not limited to, securing payment to the Facility.

(e) Authorization to Take Resident’s Photograph

By execution of this Agreement, the Resident, Resident Representative and/or Sponsor authorize the Facility to take and keep a photograph of the Resident for the purposes of identification as part of this Facility’s responsibility to provide for the care and protection of Residents. All such photographs shall become part of the Resident’s file at the Facility.

(f) Public Relations Release Form

By execution of the attached “Consent for Use of Photographs” form, the Facility shall be authorized to take and use photographs of the Resident during the normal routine of activities and/or events at the Facility, which photographs may be used solely for the purpose of publicity to further enhance the Facility’s image. All such photographs, images and stories regarding such activities and/or events will be used and displayed with discretion by the Facility carefully respecting the Resident’s rights.

(g) Authorization to Search Resident’s Room

By execution of this Agreement, the Resident, Resident Representative and/or Sponsor hereby authorize the Facility to search the Resident’s room when, in the Facility’s sole discretion, there


is reason to believe that there may be materials in the room that may cause harm to the Resident or anyone else in the Facility and to confiscate such materials.

(h) Security Cameras

The Facility may determine to install security cameras throughout the Facility. In the event that security cameras are installed, they will not be used in areas where there is an expectation of privacy, such as restrooms or patient care areas, unless, in the Facility’s sole discretion, there is reason to believe that unlawful, dangerous, or harmful conduct or activities may be occurring in such areas.

(i) Camera Use Throughout the Facility

Taking pictures and videos of other residents and/or staff may violate their privacy rights and may subject you to legal action, including but not limited to, civil and monetary damages. Accordingly, taking pictures and/or video at the Facility, by or on behalf of the Resident, Resident Representative, or Sponsor, or by any family members or other visitors, is strictly prohibited and constitutes a breach of this Agreement.

VIII. TEMPORARY ABSENCE (also referred to as “bed hold” or “bed leave”)

If the Resident leaves the Facility due to hospitalization or a therapeutic leave, the Facility shall NOT be obligated to hold the Resident’s bed available until his or her return, unless prior arrangements have been made for a bed hold pursuant to the Facility’s “Bed Hold Reservation Policy and Procedure” and pursuant to applicable law. In the absence of a bed hold, the Resident may be placed in any appropriate bed available in the Facility at the time of his or her return from hospitalization or therapeutic leave.

Before a Resident is transferred to a hospital, the attending physician or a Facility designee will inform the Resident, Resident Representative, Sponsor or other responsible family member accordingly, except in an emergency, when the Facility staff has tried but has been unable to immediately reach the Resident Representative, Sponsor or family member. In that circumstance, the Resident Representative, Sponsor or family member will be forwarded a letter restating when and where the Resident was transferred and restating the Facility’s bed hold policy and procedure.

(a) Private Pay Residents who elect to retain a bed in the Facility during a period ofhospitalization or therapeutic leave may do so by:

1. Notifying the Admission Department by telephone;

2. Signing a bed guarantee letter with the Admission Department stating their intentto hold a bed at the Facility’s private pay rate; and/or

3. Continuing payment at the private pay rate

Private Pay Residents may also authorize a bed hold (if the Resident is hospitalized) in advance for a period of at least three (3) days by signing below:

_____ I wish to have the Facility retain my/the Resident’s bed for a period of three (3) days if hospitalized. By initialing this section, I have agreed to ensure prompt payment, from


my/the Resident’s funds, of the Facility’s private pay daily rate for the three-day bed hold period.

_____ I do not wish to authorize the Facility at this time to retain my/the Resident’s bed if hospitalized. However, should hospitalization be required, I will be consulted at that time as to whether or not I would choose to hold the bed.

(b) Medicare Residents are not entitled to coverage or reimbursement for bed hold ortherapeutic leave under the Medicare Program. Medicare Residents who are absent from theFacility past twelve (12) midnight on any given day are deemed to be discharged from theFacility. However, a Medicare Resident may elect to retain his/her bed in the Facility byfollowing the Private Pay Resident Bed Reservation policy above.

(c) Medicaid Recipients may be eligible for a bed hold due to hospitalization for amaximum of fourteen (14 days) for each calendar year. In order to be eligible, Residents mustmeet a thirty (30) day residency requirement in the Facility and the Facility must satisfyapplicable Medicaid occupancy requirements. Medicaid recipients (i) who do not meet the 30-day residency requirement, (ii) who are transferred when the occupancy requirement is notsatisfied, or (iii) whose bed-hold has expired or has been terminated, may elect to secure thesame bed in the Facility by:

1. Notifying the Admission Department by telephone; and

2. Signing a bed guarantee letter with the Admission Department stating their intentto hold a bed at the Facility’s private pay rate.

If the Resident, Resident Representative and/or Sponsor does not choose to hold the bed privately, a Medicaid Resident temporarily hospitalized or on therapeutic leave will be given priority for re-admission when an appropriate bed becomes available, unless there are special circumstances which would preclude a Resident’s return.

Please Note: Medicaid Residents who are not entitled to bed-hold or therapeutic leave and who choose to leave the Facility (i.e., family members chooses to take resident home for the weekend/holiday) may only secure their bed by following the Private Pay bed hold procedure stated above and paying the Facility at the Private Pay rate.

(d) Hold Harmless

During any leave of absence or “out on pass” absence from the Facility, the Resident shall be solely responsible and hereby releases and holds harmless Facility, its directors, officers, employees and/or agents from and against any and all responsibility or liability (including attorneys’ fees and expenses) relating to the welfare of the Resident, for injury, death or damage or loss of any personal property removed from the Facility by the Resident, Resident Representative, Sponsor, family member or friend of the Resident, or any other person or party authorized by the Resident, Resident Representative and/or Sponsor to remove such property.


IX. DISCHARGE, TRANSFER AND INTRA-FACILITY ROOM CHANGES

(a) Involuntary Discharge for Non-Payment

To the extent authorized by applicable law, the Facility reserves the right to discharge the Resident if the Resident, Resident Representative and/or Sponsor fail to pay for, or secure third-party coverage of the Resident’s care at the Facility.

(b) Involuntary Discharge for Non-Financial Matters

The Facility may transfer or discharge the Resident if the transfer or discharge is necessary for the Resident’s welfare and/or for any other reason permitted by applicable law.

(c) Voluntary Discharge

If the Resident no longer requires the services provided by the Facility, or voluntarily wishes to be discharged, the Resident, Resident Representative, Sponsor and Facility will cooperate in the development and implementation of a safe, appropriate, and timely discharge plan.

(d) Intra-Facility Room Change

The Facility makes all resident room assignments. The Facility reserves the right to move the Resident to a new room on an as-needed basis, consistent with applicable law and the Resident’s rights. Residents who are admitted as sub-acute residents and who subsequently become long term residents will be moved to rooms that are better suited for long term residents. By execution of this Agreement the Resident understands and agrees that if he/she or any third party payor, no longer pays the private rate covering the private room or upon Medicaid coverage, he/she will move to a semi-private room if requested by the Facility unless the provision of a private room is medically necessary. The Facility may also initiate a room change for medical or social reasons consistent with applicable law and the Resident’s rights. In the event that a Resident not requiring sub-acute care is placed on the sub-acute unit, it is understood that a room change will be implemented as soon as a room becomes available elsewhere in the Facility.

(e) Appeal Rights

The Resident will be informed of his or her due process rights in the event that the Facility initiates a transfer or discharge under (a) or (b) above and Resident may appeal the Facility’s determination in accordance with applicable regulations. The Facility may not transfer or discharge Resident while an appeal is pending, unless the failure of the Facility to discharge or transfer the Resident would endanger the health or safety of the Resident or other individuals in the Facility.

X. RESIDENT’S PERSONAL PROPERTY

Amsterdam will provide each Resident with a locked drawer within Resident’s room. It is the responsibility of the Resident, the Resident Representative and/or Sponsor to arrange for the disposition of the Resident’s property upon discharge. Property left in the Facility for more than thirty (30) days after discharge will be disposed of at the discretion of the Facility.


XI. RESIDENT’S PERSONAL BANK ACCOUNT

The Resident, Resident Representative and/or Sponsor have the option to request that the Facility retain the Resident’s personal funds. All funds over $100.00 (over $50.00 for Residents whose care is funded by Medicaid) shall be kept in an interest-bearing account by the Facility. The Resident, Resident Representative and/or Sponsor will receive account statements on a quarterly basis and all inquiries will be addressed in a timely fashion. The Resident, Resident Representative and/or Sponsor hereby agree to and acknowledge that upon the discharge of the Resident, and after any outstanding payments are made to the Facility, the account balance, if any, will be distributed to the Resident, Resident Representative, Sponsor, the Resident’s estate and/or the Department of Social Services, as permitted by law. Please initial one of the lines below:

____ I wish to have the Facility retain my/the Resident’s personal funds.

____ I do not wish to have the Facility retain my/the Resident’s personal funds.

(Please Note: The Resident Representative and/or the Sponsor must have legal authorization to handle the Resident’s funds should he/she choose to receive the funds directly. If not, the Resident Representative and/or Sponsor may purchase items on behalf of the Resident and be reimbursed upon presentation of adequate documentation to the Facility’s Finance Department.)

XII. SMOKING POLICY

The Facility is committed to maintaining a smoke-free environment and Smoking is strictly prohibited. The Resident agrees that under no circumstances will he/she and/or his/her visitors smoke anywhere in Amsterdam Nursing Home, including resident’s room and bathrooms. Smoking at Amsterdam Nursing Home is a danger to the welfare and safety of all Amsterdam Nursing Home residents and staff. The New York City Law (Smoke Free Air Act) also prohibits smoking on the outdoor grounds of medical facilities, including residential health care facilities.

XIII. BINDING ARBITRATION

(a) Arbitration of Disputes and Claims

The Facility believes that arbitration is a more cost-effective and efficient means for resolution of the parties’ disputes and claims. Resident, Resident Representative and/or Sponsor agree to binding arbitration of any claims or disputes that may arise, or relate to the care and services provided to Resident, during the Resident’s stay at the Facility. Resident Representative and/or Sponsor acknowledge possessing authority to agree to arbitrate such claims or disputes. The terms of this agreement to arbitrate are more fully set forth in Attachment “C”.


(b) Waiver of Judicial Remedies

Resident, Resident Representative and/or Sponsor also agree to waive any right to a trial by jury or to bring claims in a court of law that may arise, or relate to the care and services provided, during the Resident’s stay at the Facility, including claims asserted under New York Public Health Law section 2801-d or for punitive damages. Resident Representative and/or Sponsor acknowledge possessing authority to agree to waive any right to a trial by jury with respect to such claims or to bring such claims in a court of law.

(c) Opt-out of Agreement to Arbitrate

Admission to the Facility is not conditioned on your agreeing to arbitration at this time. Notwithstanding (a) and (b) above, Resident, Resident Representative and/or Sponsor may opt-out of the agreement to resolve any claims or disputes through arbitration.

By signing in the space provided directly below, Resident, Resident Representative and/or Sponsor at this time is choosing not to agree to arbitrate any claims or disputes with the Facility, and not to waive the right to a trial by jury or to sue in court:

_____________________________________ Resident, Resident Representative, or Sponsor

If you do not sign in the space above, Resident, Resident Representative and/or Sponsor will be bound to arbitration and waiver of judicial remedies as provided for in (a) and (b) above.

XIV. GENERAL PROVISIONS

(a) Governing Law

Except as noted below, this Agreement shall be governed by and construed in accordance with the laws of the State of New York without giving effect to conflict of law provisions. If Resident, Resident Representative and/or Sponsor have opted-out of the arbitration provisions contained in section XIII above, any and all actions arising out of or related to this Agreement, including all actions for personal injury or negligence, shall be brought in, and the parties agree to exclusive jurisdiction of, the New York State Supreme Court located in New York County, New York.

Resident, Resident Representative and/or Sponsor acknowledge that the Federal Arbitration Act preempts any state law prohibiting or in any manner limiting the arbitration of claims and disputes or the enforcement of arbitration agreements.

(b) Binding Effect

This Agreement shall be binding on the parties, their heirs, administrators, distributes, successors and assignees.


(c) Continuation of This Agreement

Temporary transfer of the Resident to another health care facility for medical or surgical treatment, or the Resident’s authorized temporary absence from the Facility for any other purpose shall not terminate this Agreement. Upon the Resident’s return and re-admission in accordance with the admission assessment criteria set by the New York State Department of Health and by the Facility, this Agreement shall continue in full force and effect. Should the Resident subsequently be re-admitted within one (1) year of the initial admission, if a new agreement is not executed, then this Agreement will be deemed to remain in full force and affect for such admission(s) barring any appreciable changes that occurred since the Resident’s discharge.

(d) Entire Agreement

This Agreement contains the entire understanding between the Resident, the Designated Representative and/or Sponsor and the Facility. This Agreement cannot be modified orally and any changes must be in writing, signed by the parties to this Agreement.

(e) Severability

Should any provision in this Agreement be determined to be inconsistent with any applicable law or to be unenforceable, such provision will be deemed amended so as to render it legal and enforceable and to give effect to the intent of the provision; however, if any provision cannot be so amended, it shall be deemed deleted from this Agreement without affecting or impairing any other part of this Agreement.

(f) Counterparts

For the convenience of the parties hereto, this Agreement may be executed in counterparts and all such counterparts shall together constitute the same Agreement.

(g) Relationship between Parties

Execution of this Agreement is not intended, nor shall it be deemed, to create a landlord-tenant relationship between the Facility and the Resident.

(h) Section Headings

The section headings used herein are for convenience of reference only and shall not limit or otherwise affect any of the terms or provisions hereof.


(i) Non-Discrimination

IN ACCORDANCE WITH STATE AND FEDERAL LAW, INCLUDING THE PROVISIONS OF TITLE VI OF THE CIVIL RIGHTS ACT OF 1964, SECTION 504, OF THE REHABILITATION ACT OF 1973, THE AGE DISCRIMINATION ACT OF 1975, AND THE RELATIONS OF THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES ISSUED PURSUANT TO THE ACTS, TITLE 45 CODE OF FEDERAL REGULATIONS PART 80, 85 AND 91, NO PERSON SHALL, ON GROUNDS OF RACE, COLOR, CREED, NATIONAL ORIGIN, SEX OR SEXUAL ORIENTATION, RELIGION OR DISABILITY, AGE, MARITAL STATUS, BLINDNESS, SOURCE OF PAYMENT OR SPONSORSHIP, BE EXCLUDED FROM PARTICIPATION IN, BE DENIED THE BENEFITS OF, OR BE OTHERWISE SUBJECTED TO DISCRIMINATION UNDER ANY PROGRAM OR ACTIVITY PROVIDED BY THE FACILITY, INCLUDING BUT NOT LIMITED TO, THE ADMISSION, CARE AND RETENTION OF RESIDENTS.


THE UNDERSIGNED HAVE READ, UNDERSTAND AND AGREE TO BE LEGALLY BOUND BY THE TERMS AND CONDITIONS AS SET FORTH HEREIN, AND IN ALL ADDENDA TO THIS AGREEMENT.

I HAVE SPECIFICALLY READ AND UNDERSTAND SECTION XIII (BINDING ARBITRATION) AND ATTACHMENT C (ARBITRATION AGREEMENT).

ACCEPTED AND AGREED:

_______ ___________________________ __________________________________ Date Signature of RESIDENT Print Name

_______ ___________________________ __________________________________ Date Signature of WITNESS Print Name

*If a Resident is unable to sign due to physical limitations, Resident should affix an “X” in thepresence of a witness.

_______ ___________________________ __________________________________ Date Signature of RESIDENT Print Name

REPRESENTATIVE

_______ ___________________________ __________________________________ Date Signature of SPONSOR Print Name

Amsterdam Nursing Home Corporation (1992)

_______ Date

_______________________________ WILLIAM J. PASCOCELLO SR. V.P. & ADMINISTRATOR AMSTERDAM NURSING HOME CORP.


ATTACHMENT “A”

Schedule of Coverage and Fees for Ancillary Services

BASIC SERVICES

THE FOLLOWING ITEMS AND SERVICES ARE AVAILABLE TO ALL RESIDENTS AND ARE INCLUDED IN THE MEDICARE PART A, BASIC MEDICAID, AND THE PRIVATE PAY ROOM AND BOARD RATE:

• Board, including therapeutic or modified diets as prescribed by a physician (excluding enteral andparenteral feeding), and including Kosher food provided upon the request of a Resident who as amatter of religious belief wishes to follow Jewish dietary laws

• Lodging; a clean, healthful, sheltered environment, properly outfitted• 24-hours-per-day professional nursing care• Use of all equipment, medical supplies and modalities for everyday care, such as catheters*,

dressings*, pads, etc.• Fresh bed linen, changed at least twice weekly, or as often as required for incontinent Residents• Hospital gowns or pajamas as required by the Resident’s clinical condition, unless the Resident,

next of kin or sponsor elects to furnish them; and laundry services for these and other launderablepersonal clothing items

• General household medicine cabinet supplies, such as non-prescription medications; routine hairand skin care materials; oral hygiene materials; except for specific items that are medically indicatedand needed for exceptional use for a specific Resident

• Assistance and/or supervision, when required, with activities of daily living, including but not limitedto toileting, bathing, feeding, and ambulation assistance

• Services, in the daily performance of their assigned duties, by Facility staff members responsiblefor Resident care

• Use of customarily stocked equipment, including crutches, walkers, wheelchairs or other supportiveequipment, including training in their use when necessary, unless such items are prescribed by aphysician for regular and sole use by a specific Resident. “Customarily stocked equipment”excludes prosthetics

• Therapeutic recreation (Activities) program, including but not limited to a planned schedule ofrecreational, motivational, social and other activities; together with the necessary materials andsupplies to make the Resident’s life more meaningful

• Social Services as needed• Complete dental examination upon admission and annually thereafter

* If these items or services are necessary for other than routine treatment, they may not be included in thebasic Medicaid and Private Pay room and board rate and may be billable to the Resident, Medicare PartB or other third party insurance (see chart below).

IF YOU HAVE ANY QUESTIONS REGARDING CHARGES AND BILLING, PLEASE FEEL FREE TO CONTACT THE BUSINESS OFFICE AT (212) 531- 7824.


ADDITIONAL CLINICAL SERVICES

THE FOLLOWING ADDITIONAL CLINICAL SERVICES ARE AVAILABLE TO ALL RESIDENTS. THE CHART BELOW DESCRIBES MEDICARE, MEDICAID AND PRIVATE RATE COVERAGE OF THESE SERVICES.

Services Medicare Part A Medicare Part B Medicaid Private Pay (When Not Covered by Medicare or Medicaid)

Attending Physician Not Covered Covered Covered Physician Bills Patient Physical Therapy Restorative Covered Covered (4) Covered Medicare Fee Schedule Physical Therapy Maintenance Covered Not Covered Covered Medicare Fee Schedule Occupational Therapy Restorative Covered Covered (4) Covered Medicare Fee Schedule Occupational Therapy Maintenance Covered Not Covered Covered Medicare Fee Schedule Speech Therapy Restorative Covered Covered (4) Covered Medicare Fee Schedule Speech Therapy Maintenance Covered Not Covered Covered Medicare Fee Schedule Ophthalmology Services Varies (5) Varies (5) Varies (5) Billed Direct to Patient Audiology Services Varies (5) Varies (5) Varies (5) Audiologist Bills Patient Dental Not Covered Not Covered Covered Not Included Pharmaceuticals Covered Not Covered Covered Not Included Oxygen Covered Not Covered Covered Included Oxygen Supplies Covered Not Covered Covered Included Enteral Nutrition – Supplements Not Covered Covered (1, 4) Covered Medicare Fee Schedule (2) Enteral and Parenteral Supplies Covered Covered (1, 4) Covered Medicare Fee Schedule (2) Primary Surgical Dressings Covered Covered (1, 4) Covered Medicare Fee Schedule (2) Urological Supplies Covered Covered (1, 4) Covered Medicare Fee Schedule (2)

Tracheostomy Supplies Covered Covered (1, 4) Covered Medicare Fee Schedule (2) Ostomy Supplies Covered Covered (1, 4) Covered Medicare Fee Schedule (2) Prosthetics and Orthotics Covered Covered (1, 4) Covered Medicare Fee Schedule (2) Laboratory Covered Covered (1, 4) Covered Medicare Fee Schedule (3)

X-Ray Covered Covered (1, 4) Covered Medicare Fee Schedule (3) EKG Covered Covered (1, 4) Covered Medicare Fee Schedule (3) EEG Covered Covered (1, 4) Covered Medicare Fee Schedule (3)

Ambulance Covered Covered (1, 4) Covered (1) Medicare Fee Schedule (3) Ambulette Not Covered Not Covered Varies (5) Fee Basis (3) If your stay is covered under Medicare Part A: • Medicare will pay up to 100 days for your stay (assuming eligibility criteria are met and benefits are still available).• Co-insurance payments for 2019 are $170.50 per day for 21 to day 100.

** It is the responsibility of the Resident, Sponsor and/or Resident Representative to verify co-insurance coverage of any secondary insurance by contacting the insurance carrier and notifying the Business Office at (212) 531-7824.

If you are covered by Medicare Part B, for 2018: • Annual Medicare Part B Deductible is $183.00.• The average 2018 Medicare Part B Premium for those “held harmless” from any increase in premiums is $109.00. Beneficiaries not

subject to the “hold harmless” provision pay $134.00. Medicare Part B beneficiaries not subject to the “hold harmless” provision arethose not collecting Social Security benefits, those who enroll in Part B for the first time in 2018, dual eligible beneficiaries who havetheir premiums paid by Medicaid, and beneficiaries who pay an additional income-related premium.

• Co-Insurance payments are 20% of the approved Medicare Part B charge for all Part B covered services.• Occupational therapy benefits are capped at a total of $1,980 per year (including co-insurance).• Physical and speech therapy benefits (combined) are capped at a total of $1,980 per year (including co-insurance).• Beneficiary may qualify for Therapy Cap Exception Process. However, if your request for additional services above the

therapy is denied, you will be responsible for 100% of the Medicare Approved Charge once the cap is reached.

(1) May be billed by outside vendor to DMERC or Intermediary.(2) Billed by Facility.(3) Billed directly by Provider or Vendor.(4) Patient/Resident responsible for co-insurance and deductible.(5) Coverage depends on services provided.



ATTACHMENT “B” SPECIAL RULES REGARDING SELECTED PAYORS

PAYMENT FOR IN-PATIENT LONG TERM CARE SERVICES IS AN EXPENSIVE AND COMPLICATED PROCESS. THIS SUMMARY PROVIDES OUR RESIDENTS AND THEIR FAMILIES WITH BASIC INFORMATION WHICH SHOULD SIMPLIFY THE PROCESS. NOTHING HEREIN SHOULD BE CONSIDERED TO BE LEGAL ADVICE. WE URGE YOU TO CONSULT WITH AN INSURANCE AGENT, ATTORNEY AND/OR OTHER KNOWLEDGEABLE PROFESSIONAL(S) IN ORDER TO HELP MAXIMIZE AVAILABLE COVERAGE. FURTHER, AS THE INFORMATION PROVIDED BELOW IS BASED UPON STATUTE AND REGULATIONS, IT IS SUBJECT TO CHANGE WITHOUT NOTICE.

MEDICARE PART A PAYMENT Medicare Part A Hospital Insurance Skilled Nursing Facility coverage is generally available to qualified individuals 65 years

of age or older, and individuals under age 65 who have been disabled for at least twenty-four months, who meet the following five requirements: 1) The Resident requires daily skilled nursing or rehabilitation services that can be provided only in a skilled nursing facility; 2) The Resident was hospitalized for at least three consecutive days, not counting the day of discharge, before entering the skilled nursing facility; 3) The Resident was admitted to the facility within 30 days after leaving the hospital; 4) The Resident is admitted to the facility to receive treatment for the same condition(s) for which he or she was treated in the hospital; and 5) A medical professional certifies that the Resident requires skilled nursing care on a “daily basis.” A Resident requires skilled nursing or skilled rehabilitation services on a daily basis when services are medically necessary and provided seven (7) days a week. There is an exception if they are only provided by the facility for five (5) days per week, due to staffing levels at the facility. Additionally, there may be a one to two day break if the Residents needs require suspension of the services.

Where these five criteria are met, Medicare may provide coverage of up to 100 days of care in a skilled nursing facility (SNF): the first 20 days of covered services are fully paid for; and the next 80 days (days 21 through 100), of the covered services are paid for by Medicare subject to a daily coinsurance amount for which the Resident is responsible. For 2019, the Medicare Part A co-insurance amount is $170.50 per day.

Additionally, Medicare Residents requesting a leave of absence from the facility should be aware of the Medicare rules regarding leave of absence and transfer within thirty (30) days. Medicare treats a leave of absence, where a Resident leaves the facility on a particular day and does not return by twelve (12) midnight that day, as an uncovered day. Additionally, the day in which a Resident begins a leave of absence (i.e., hospitalization), where the resident is absent for more than 24 hours, is treated as a day of discharge.

Except for specifically excluded services, nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements. Residents must consult with the Facility before obtaining any services outside of the Facility.

Medicare also has a thirty (30) day transfer requirement. A Resident must be transferred from a hospital or other SNF within thirty (30) days of discharge and meet the skilled care requirements in order to be eligible for SNF coverage.

If a Resident meets the eligibility requirements for Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, Facility will bill Medicare directly for all Part A services provided to the Resident. Medicare will reimburse Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG IV guidelines. RUG is an acronym for Resource-based Utilization Groups. These guidelines are a measure of what type of care the Resident requires and what it costs health care providers to provide that care to a Resident. Members of our professional staff will evaluate the Resident’s health condition based on a standardized assessment form (called the MDS 3.0) provided by the Centers for Medicare and Medicaid Services (CMS). Information from the MDS 3.0 form will be used by Medicare to assign the Resident a RUG IV category.

The Resident will be responsible for the daily co-insurance amount determined by Medicare. This amount is subject to increase each calendar year. With limited exceptions, a Resident who requires more than 100 days of SNF care in a benefit period will be responsible for private payment of all charges beginning with the 101st day. A new benefit period may begin when the Resident has either not been in a facility or has not been receiving a covered level of care in a skilled nursing facility for at least 60 days, returns to the hospital for another three-day stay, and then re-enters the SNF. A SNF may not request private payment until the Resident has received an official initial determination from Medicare that “skilled nursing” benefits are no longer available. While a SNF may make a determination of non-coverage, beneficiaries have a right to request an official Medicare determination of coverage (called a “Demand Bill”), which can be appealed.


MEDICARE PART B PAYMENT

Individuals who pay monthly premiums to enroll in Medicare Part B will be charged according to Facility’s or the service providers’ stated charge schedule for services they receive at Facility. Medicare Part B pays for a wide range of additional services beyond Part A coverage. Part B may cover some of a Residents care regardless of whether they are eligible for Part A benefits. Part B covers eighty (80%) percent of the Medicare approved charge for a specific service and the individual is responsible for the additional twenty (20%) percent. In general, Part B covers medical services and supplies. Part B covers such services as: physical, occupational and speech therapy, physician services, durable medical equipment, ambulance services and certain out-patient and clinical laboratory services. However, Part B benefits have limitations. For example, for 2018, there is an annual $183.00 deductible applicable to Medicare Part B benefits. Additionally, physical therapy (including speech-language pathology services) and occupational therapy are each subject to an annual limitation. The therapy financial limitations or “caps” are indexed by the Medicare Economic Index (MEI) each year. For 2018, the indexed amounts for physical therapy (including speech-language pathology services) and occupational therapy are $1,980.00 each, including co-insurance. Beneficiaries may be eligible for the Therapy Cap Exception Process. Both therapy limitations are still subject to the 80% - 20% coverage limitation in that the individual will be responsible for the 20% co-insurance payments. The Resident is responsible for private payment of all therapy charges and any other ancillary charges above the Medicare Part B coverage limitations. The Facility can bill and receive payment if the Resident fills out a Medicare assignment of benefits form. If the Resident completes an assignment of benefits form, a health care provider cannot charge the Resident above the Medicare approved charge. In order to determine the Resident’s Part B coverage you should contact the Social Security Administration.

In addition, Medicare Advantage programs and other alternatives may increase available Medicare benefits. To receive additional information about Medicare and Medicare Advantage programs, call the Social Security Administration at 800-772- 1213 or the Centers for Medicare and Medicaid Services at 1-800-MEDICARE.

MEDICARE PART D - PRESCRIPTION DRUG COVERAGE

Individuals eligible for Medicare Part A or enrolled in Medicare Part B and who do not have prescription drug coverage from a privately operated health plan or a Medicare Advantage-PD plan are eligible to enroll in Medicare Part D for prescription drug coverage. Medicare Part D through the selected PDP will provide reimbursement for prescription drugs listed in the PDP’s formulary subject to applicable premiums, deductibles and co-payments. Eligible individuals interested in obtaining prescription drug coverage through Medicare Part D must enroll in a PDP approved in the region. Upon admission to a skilled nursing home, individuals enrolled in a PDP in the community are permitted to continue with, or switch to a different PDP in the region.

Dual eligible Medicare/Medicaid beneficiaries are automatically enrolled in, and assigned to an approved benchmark prescription drug plan (“PDP”) in the region. As of January 1, 2006, Medicaid no longer pays for prescription drug cost for dual eligibles. Dual eligibles in nursing homes will receive prescription drug coverage through Medicare Part D for the drugs listed on the selected PDP’s formulary. As long as dual eligibles are enrolled in benchmark plans in their region, they will not be responsible for premiums, deductibles and cost sharing obligations.

Please call 800-633-4227 or contact www.medicare.gov/pdphome.asp to obtain enrollment information.

MANAGED CARE

Residents who are members of a managed care benefit plan that is under a contract with the Facility to provide specified services to plan members will receive those services with full coverage so long as the Resident meets the eligibility requirements of the managed care benefit plan. To the extent the Resident meets the eligibility requirements of the managed care benefit plan, he or she will be financially responsible only for the required deductibles and co-insurance and for those services that are not included in the list of covered services. Residents who have not received a list of covered services and eligibility requirements from their managed care benefit plan are advised to contact their social worker and/or managed care benefit plan.

PRIVATE INSURANCE

Residents who are covered by a private insurance plan that does not have a contract with the Facility must exhaust all available insurance coverage before seeking Medicare or Medicaid coverage. Where the insurance proceeds under the private plan are insufficient to cover the cost of care, the Resident will be responsible for any difference. The coverage requirements for nursing home care vary depending on the terms of the insurance policy. Questions regarding private insurance coverage should be directed to the social work staff and/or the Resident’s insurance carrier or agent.


http://www.medicare.gov/pdphome.asp

NO-FAULT INSURANCE

No-fault insurance coverage must be maintained by all automobile owners in New York State. When a driver or passenger suffers “serious injury” in an automobile accident, regardless of fault, the injured party is entitled to compensation under the owner’s no-fault policy for “basic economic loss.” Under the New York State Insurance Law, “serious injury” includes permanent limitation of use of a body part or body function, or a non-permanent injury which prevents an individual from performing “substantially all of the material acts which constitute such person’s usual and customary daily activities” for at least 90 days during the 180 days immediately following the accident. By statute, the “basic economic loss” recoverable under a no-fault policy is limited to medical expenses and lost earnings up to $50,000. The injured party ordinarily assigns to the nursing home his or her benefits under the no-fault policy. It is advisable to consult with an experienced attorney when pursuing a no-fault claim. For further information, contact your automobile insurance carrier.

MEDICAID

Medicaid is a publicly-funded program of assistance that covers nursing home Residents who can demonstrate financial need. To qualify for Medicaid, an individual may have only limited assets. For example, in 2018, the individual resource limit is $14,850 (subject to annual increases); plus any funds held in an “irrevocable burial trust” arrangement or up to $1,500 under a revocable burial account. Generally, most of the Resident’s monthly income must be paid to the Facility, except for a $50 monthly “personal needs allowance” and the monthly cost of retaining a private health insurance policy. This monthly income obligation, called the NAMI (Net Available Monthly Income), is determined by the Medicaid agency. If the Resident has a spouse in the community, the spouse might be entitled to a contribution from the Resident’s monthly income. During 2018, the “community spouse” is entitled to a minimum monthly income of $3,090.00 and resources of $74,820 or one-half the couple's resources as of the date of institutionalization to a maximum of $123,600 (these figures are subject to increase each calendar year); increases beyond these amounts are possible, but a Department of Social Services Fair Hearing or Family Court support proceeding may be required. The Resident’s home may be exempt for Medicaid eligibility purposes if the equity value is less than $750,000.00 or if the spouse or disabled or minor child resides there. Upon application, Medicaid looks back at financial transactions or transfers of assets made within a sixty (60) month period of time from the date on which the person was institutionalized and applied for Medicaid coverage. A Resident or spouse who makes a transfer within those periods may create a period of Medicaid ineligibility. Private-pay Residents should apply for Medicaid about three months before their funds are depleted. A Medicaid application must include proof of the Resident’s identity, U.S. citizenship or legal alien status, and past and present financial status. Medicaid recipients are required to recertify eligibility each year in order to retain benefits. Medicaid is a complex program and a knowledgeable professional can advise Residents and their families as to their rights under the Medicaid program. To receive information about Medicaid, individuals can call their local Department of Social Services in the county in which the Resident resides.

WORKERS’ COMPENSATION

Workers’ Compensation benefits are available for an employee’s work-related injuries. Benefits, including direct payments to a health care provider, are paid by the employer’s insurance carrier. Workers’ Compensation will provide primary coverage of nursing home care, as long as it is established that the nursing home care is necessitated solely by the Workers’ Compensation injury. Claim forms must be submitted to the local Workers’ Compensation Board Office within two years of the date of injury. It is advisable to consult with an attorney practicing in the Workers’ Compensation area when pursuing a claim. For further information, you can contact your local Workers’ Compensation Board office.

VETERANS’ BENEFITS

Veterans with certain service-related conditions, former prisoners of war, Medicaid-eligible veterans, or veterans receiving pension benefits may be eligible to receive Veterans’ Administration (VA) nursing home benefits. VA nursing home benefits are available for Residents in private non-VA facilities if: (i) the veteran requires nursing care for a service-connected disability following a stay at a VA hospital; (ii) the Resident is an Armed Services member who requires an extended period of nursing care and who will become a veteran upon discharge; (iii) a veteran who requires nursing home care for a service-connected disability, even where no hospital stay is first required; and (iv) a veteran who had been discharged from a VA hospital and is receiving VA hospital-based home health services. Generally, the VA will not authorize nursing home benefits for more than six months, except for veterans requiring care for a service-related disability. This six-month period can in some cases be extended when the veteran is: (i) awaiting Medicaid payment; (ii) planning to pay privately but there are obstacles to arranging the private payments; or (iii) terminally ill and expected to expire within six months. For further information, contact the Department of Veterans’ Affairs at 1-800-827-1000.


AMSTERDAM NURSING HOME CORPORATION (1992)

ADDENDUM XIV

BINDING ARBITRATION

The obligation to arbitrate applies equally to the Resident and/or Responsible Party(ies) (hereafter referred to as “you”) and the Facility. We each agree that the mutual obligation is valid and sufficient consideration for waiving the right to a trial by jury or a judge in a court of law. The agreement to arbitrate governs any and all past, present or future disputes between you and the Facility, whether arising from the terms of the Admission Agreement or as a matter of state or federal law, with the exception of payment disputes.

Any dispute, claim or controversy arising out of, or relating to your stay at the Facility, the care provided to you by the Facility, the Admission Agreement or the breach, termination, enforcement, interpretation or validity thereof, shall be determined as follows:

1. Recognizing that the benefit of arbitration in providing a faster and less costlyprocedure for the resolution of disputes is not necessary for claims within thejurisdiction of Small Claims and Commercial Small Claims Courts, any claim orcontroversy meeting the jurisdictional requirements for such courts under theConsolidated Laws of the State of New York shall be heard exclusively in suchSmall Claims or Commercial Claims Court.

2. All other claims or controversies between you and the Facility, with the exceptionof claims for unpaid charges, shall be submitted to binding arbitration administeredby National Arbitration and Mediation (“NAM”) pursuant to its comprehensiverules and procedures in effect at the time the arbitration is commenced. Thearbitration shall take place at the NAM office located in a mutually convenientlocation to the parties to the dispute within the State of New York. All disputesinvolving claims/counterclaims seeking in total $1 million or less shall be decidedby one (1) neutral Arbitrator and disputes involving claims/counterclaims seekinggreater than that amount shall be decided by a panel of three (3) neutral Arbitrators.If the NAM minimum standards governing consumer cases are in effect whenarbitration is commenced, the fees payable by you shall be limited to the amountspecified in such minimum standards. Additional information regarding NAM, itsrules and procedures can be obtained at www.namadr.com.

3. Should NAM be unwilling or unable to arbitrate a claim or controversy betweenthe parties, such claim or controversy shall be submitted to JAMS and all referencesin paragraph 2 to NAM shall be read as if it referred to JAMS. Additionalinformation regarding JAMS, its rules and procedures can be obtained atwww.jamsadr.com.



4. If neither NAM nor JAMS is willing or able to arbitrate a claim or controversybetween the parties, such claim or controversy shall be submitted to an Arbitratoror Arbitrators, in accordance with the terms set forth above, appointed by the NewYork Supreme Court, in Suffolk County or in a different county which constitutesa mutually convenient location for the parties to this dispute within the State ofNew York. Each party agrees to personal jurisdiction of, and venue in, this Courtfor purposes of such proceeding. The rules and procedures used shall be the NAMcomprehensive rules and procedures in effect at the time the arbitration iscommenced, without regard to any NAM rule that would otherwise bar arbitrationbetween the parties.

5. The prevailing party in the arbitration shall be entitled to an award of the arbitrationfees it paid, or will be required to pay, NAM, JAMS or the court-appointedArbitrator.

Either party shall be entitled to any remedies that would otherwise be available to him/her/it under applicable federal, state, or local laws. The Arbitrator(s) shall be neutral and selected according to the applicable arbitration rules and procedures. Each party shall, subject to the applicable arbitration rules and procedures, be entitled to the exchange of non-privileged information relevant to the claims or controversies submitted to arbitration. Each party shall undertake to keep confidential all awards and orders in the arbitration, as well as all information and materials in the arbitral proceedings not otherwise in the public domain, unless disclosure is required by law or is reasonably necessary for the enforcement of a party’s legal rights. Either party may, without inconsistency with this agreement to arbitrate, seek from a court any provisional remedy to protect such confidentiality.

This Agreement is intended to inure to the benefit of the Facility’s employees or agents and shall be enforceable by such employees or agents as third-party beneficiaries. This Agreement shall also be binding upon any agent, assign, estate or heir of either party. The Arbitrator(s) shall decide the dispute in accordance with the substantive law of the State of New York. Any award of the Arbitrator(s) is final and binding, and may be entered as a judgment in any court of competent jurisdiction.

Because the Facility is engaged in interstate commerce, these arbitration provisions are governed by the Federal Arbitration Act, 9 U.S.C. § 1 et. seq. The Arbitrator, and not any federal, state or local court or agency, shall have exclusive authority to resolve any dispute relating to the interpretation, applicability, enforceability or formation of this Agreement including, but not limited to, any claim that all or any part of this Agreement is void or voidable.



Nothing contained herein shall be construed to prohibit or discourage any party to this Agreement from communicating with federal, state, or local officials, including federal and state surveyors, other federal or state health department employees, and representatives of the Office of the State Long-Term Care Ombudsman regarding any matter concerning the Resident’s care or any other grievances or concerns.

This Agreement to arbitrate is being entered into with the understanding that it is not a condition of admission to the Facility, nor are you required to enter into this Agreement in order for the Resident to continue to receive care at the Facility. You may rescind your agreement to arbitrate within thirty (30) calendar days of the date of this agreement should you wish to do so. You may desire to seek the advice of a lawyer before you execute this Agreement.

By signing this Agreement, the Resident and the Resident’s Representative(s)/Responsible Party(ies) acknowledge and agree that this Agreement has been fully explained to you, and that you have personally reviewed and fully understand the terms of this Agreement. Furthermore, Undersigned acknowledges that he/she/they are waiving the right to a trial by jury or a judge in a court of law, except for small claims court matters and payment disputes, and have instead agreed to binding arbitration.

_________________________________________ ________________________ RESIDENT SIGNATURE DATE

___________________________________________ ________________________ DESIGNATED REPRESENTATIVE/ DATE RESPONSIBLE PARTY SIGNATURE



Consent for Use of Photographs

I, _________________________________________hereby agree that Amsterdam Nursing Home Corporation (1992) may take my photograph for facility identification purposes in connection with my residency and treatment. I, ________________________________________, hereby agree that Amsterdam Nursing Home Corporation (1992) may use my photograph or audio visual recordings of me during the normal routine of activities and/or events at the facility, which photographs and recordings may be used solely for the purposes of publicity to further enhance the facility’s image, with no form of compensation given to me. All such photographs, records, images and stories regarding such activities and/or events will be used and displayed with discretion by the facility carefully respecting my rights. I understand that this consent is voluntary and I may refuse to sign. My refusal to sign will not affect my ability to obtain treatment or eligibility for benefits. I understand that I may rescind this authorization at any time. _______________________________________ _______________________ Signature of Resident Date _______________________________________ _______________________ Signature of Designated Representative Date (if applicable)




Medicare Part A Resident Acknowledgement

I understand and agree that while I am a resident at Amsterdam Nursing Home (the “Facility”), my medical needs will be assessed and attended to by the Facility’s medical staff in accordance with a comprehensive care plan developed for me. To better coordinate my medical care, I agree to have all my medical needs organized and managed by the Facility’s medical staff during my stay. I make this commitment with the full knowledge that as a Medicare beneficiary I have the right to access medically necessary medical care at any time.

Upon my discharge from the Facility, I will resume being cared for by my community primary care physician or specialty physicians/providers.

In the event that I do schedule and attend medical appointments not ordered by the Facility’s medical staff, I acknowledge that the facility is not responsible for the costs of medical services furnished to me that have not been ordered by the Facility’s medical staff. I agree to arrange and pay for, as a personal expense:

(i) any associated transportation; and

(ii) an aide to accompany me, if required

Such charges will be billed to me by the Facility, and I acknowledge responsibility for these associated costs.

If for any reason the Facility is billed for any medical services, treatments, supplies or other services rendered to me during my stay and not ordered by the Facility’s medical staff, I will reimburse the Facility for these charges within 30 days of receipt of the Facility’s invoice.

I acknowledge and agree to the above:

_____________________________________________ Print Name

_____________________________________________ Resident Signature

____________________________ Date

_____________________________________________ Signature of Resident Representative







Amsterdam Admission Packet - Rev. 1/2018 Page 37 of 92Amsterdam Admission Packet Rev. 4/14/2020 Page 37 of 94




UNIFORM ASSIGNMENT AND RELEASE OF INFORMATION STATEMENTS

PATIENT/RESIDENT NAME: MED. RECORD # _________________

MEDICARE #: _______________________________

Authorization for Release of Information by Amsterdam Nursing Home Corporation (1992)

I hereby authorize and direct the above named medical facility, having treated me, to release to governmental agencies, insurance carriers or others who are financially liable for my medical care, all information needed to substantiate payment for such medical care and to permit representatives thereof to examine and make copies of all records relating to such care and treatment.

Assignment of Benefits to Provider of Services

I hereby assign, transfer and set over to the above named medical facility or other provider of service, sufficient monies and/or benefits to which I may be entitled from governmental agencies, insurance carriers, or others who are financially liable for my medical care to cover the costs of the care and treatment rendered to myself or my dependent in said Skilled Nursing Facility.

___________________________ ___________________________________ Date Signature of Resident/Resident Representative/

Sponsor

___________________________________ Relationship

MR. 151 revised 4/4/02 Uniform Assignment and Release of Information Statement

Finance



ACKNOWLEDGMENT OF RESTRAINT POLICIES

Resident Name: Date: _______________________

Admitting Diagnosis: _________________________________________________________

Amsterdam Nursing Home Corporation (1992), (ANHC), in accordance with federal and state laws, has a very stringent policy regarding the use of physical and chemical restraints on residents. Our philosophy of providing residents with the highest possible quality of care and life is reflective of our belief that it is essential for our residents to maintain their dignity and independence by being permitted to take “the normal risks of everyday life.” Restraints used in an attempt to remove these normal risks of living violate the rights of the resident, greatly reduces their quality of life, and present significant physical and psychological risks.

For these reasons and in accordance with federal and state laws, restraint use in our facility will only be considered to treat a medical symptom condition that endangers the physical safety of the resident or other residents and under the following conditions: 1) as a last resort measure after a trial period where less restrictive measures have been undertaken and proven unsuccessful; 2) with a physician order; 3) with the consent of the resident (or legal representative); 4) when the benefits of the restraint outweigh the identified risks. If restraint use is deemed necessary, the goal will be to use the least restrictive type of restraint for the shortest period of time possible.

Every resident at ANHC will be individually assessed upon admission regarding the need for appropriate safety measures and will be periodically reassessed as their needs change throughout their stay at our facility.

By virtue of my signature, I state that I have received, read and had an opportunity to discuss any questions I may have had concerning this restraint policy. Additionally, I state that I clearly understand and agree with this policy.

Resident Signature: __________________________________________ Date: __________________

(or Resident Representative/Sponsor)


AMSTERDAM NURSING HOME CORP.

NOTICE OF PRIVACY PRACTICES This notice describes the way medical information about you may be used and disclosed and how you or your personal representative (Health Care Proxy) can access your protected health information. Please review it carefully. This notice takes effect on September 23, 2014 and remains in effect until we replace it.

OUR PLEDGE REGARDING MEDICAL INFORMATION The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at Amsterdam Nursing Home. We need this record to provide you with quality care and to comply with legal requirements. This notice will tell you about the ways we may use and share medical information about you. We also describe your rights and certain duties we have regarding the use and disclosure of medical information.

OUR LEGAL DUTY Law Requires Us To:

• Keep your medical information private.• Give you notice describing our legal duties, privacy practices, and your rights

regarding medical information.• Follow the terms of this notice.

We Have The Right To: • Change our privacy practices and the terms of this notice at any time provided that

the changes are permitted by law.• Make changes in our privacy practices and the new terms of our notice effective

for all medical information that we keep, including information previously createdor received before the changes.

Notice of Change to Privacy Practices: Before we make an important change in our privacy practices, we will change this notice and make the new notice available upon request.

USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION The following section describes different ways that we use and disclose health information. Not every use or disclosure will be listed. However, we have listed all of the different ways we are permitted to use and disclose health information. We will not use or disclose your health information for any purpose not listed below, without your specific written authorization. Any specific authorization you provide may be revoked at any time by writing to us.

For Treatment: We may use health information about you to provide you with medical treatment or services. We may disclose health information about you to doctors, nurses, technicians, medical students, or other healthcare providers that may be consultants (not employees of our facility) to assist them in treating you.


Amsterdam Nursing Home Privacy Practice Notice (p.2)

For Payment: We may use and disclose your health information for payment purposes.

For Health Care Operations: We may use and disclose your health information for our health care operations. This might include measuring and improving quality, evaluating the performance of employees, conducting training programs, and getting the accreditation, certificates, licenses and credentials we need to serve you.

ADDITIONAL USES AND DISCLOSURES: In addition to using and disclosing your health information for treatment, payment, and health care operations, we may use and disclose medical information for the following purposes without authorization:

Facility Directory: Unless you notify us that you object, the following health information about you will be placed in our facilities directories: your name, location in the facility; your condition in general terms; your religious affiliation (if any). We may disclose this information to members of the clergy or, except for your religious affiliation, to others who contact us and ask for information about you by name.

Notification: Health information to notify or help notify: a family member, your personal representative, or another person responsible for your care. We will share information about your location, general condition or death. If you are present, we will get your permission if possible before we share, or give you the opportunity to refuse permission. In case of emergency, and if you are not able to give or refuse permission, we will share only the health information that is directly necessary for your health care, according to our professional judgment. We will also use our professional judgment to make decisions in your best interest about allowing someone to pick up medicine, medical supplies, x-ray or medical information for you.

Disaster Relief: Health information will be shared with a public or private organization or person who can legally assist in disaster relief efforts.

Fundraising: We may provide health information to one of our affiliated fundraising foundations to contact you for fundraising purposes. We will limit our use and sharing to information that describes you in general, not personal terms, and the dates of your health care. In any fundraising materials, we will provide you a description of how you may choose not to receive future fundraising communications. You have the right to opt-out from any and all fundraising communication.



Research in Limited Circumstances: Health information for research purposes in limited circumstances where the research has been approved by a review board that has reviewed the research proposal and established protocols to ensure the privacy of health information.

Funeral Director, Coroner, Medical Examiner: To help them carry out their duties, we may share the health information of a person who has died with a coroner, medical examiner, funeral director, or an organ procurement organization.

Specialized Government Functions: Subject to certain requirements, we may disclose or use health information for military personnel and veterans, national security, and intelligence activities, for protective services for the President and others, for medical suitability determinations for the Dept of State, for correctional institutions and other law enforcement custodial situations, and for government programs providing public benefits.

Court Orders and Judicial and Administrative Proceedings: We may disclose health information in response to a court or administrative order, subpoena, discovery request, or other lawful purpose under certain circumstances. Under limited circumstances, such as court order, warrant, or grand jury subpoena, we may share your health information with law enforcement officials. We may share limited information with a law enforcement official concerning the health information of a suspect, fugitive, material witness, crime victim, or missing person. We may share the health information of an inmate or other person in lawful custody with a law enforcement official or correctional institution under certain circumstances.

Public Health Activities: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, disability, or neglect. We may also disclose your health information to persons subject to jurisdiction of the Food and Drug Administration for purposes of reporting adverse events associated with product defects or problems, to enable product recalls, repairs, or replacements, to track products, or to conduct activities required by the Food and Drug Administration. We may also, when we are authorized by law to do so, notify a person who may have been exposed to a communicable disease or otherwise be at risk of contracting or spreading a disease or condition.

Victims of Abuse, Neglect, or Domestic Violence: We may disclose health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of their crimes. We may share your health information when necessary to help law enforcement officials capture a person who has admitted to being part of a crime or has escaped from legal custody.



Workers compensation: We may disclose health information when authorized and necessary to comply with laws relating to workers compensation or other similar programs.

Health Oversight Activities: We may disclose health information to an agency providing oversight for oversight activities authorized by law, including suits, civil, administrative or criminal investigations or proceedings, inspections, licensure or disciplinary actions, or other authorized activities.

Law Enforcement: Under certain circumstances, we may disclose health information to law enforcement officials. These circumstances include reporting required by certain laws (such as the reporting of certain types of wounds), pursuant to certain subpoenas or court orders, reporting limited information concerning identification and location at the request of a law enforcement official, reports regarding suspected victims of crimes at the request of a law enforcement official, reporting death, crimes on our premises, and crimes in emergencies.

USES AND DISCLOSURES THAT REQUIRE AUTHORIZATION We must obtain authorization from you prior to using and disclosing your health information for any reason not listed above and including the following:

Marketing Purposes Sale of Personal Health Information Release of Psychotherapy Notes (where appropriate)

YOUR INDIVIDUAL RIGHTS You Have A Right To:

• Look at or get copies of your health information. You may request that we providecopies in a format other than photocopies. We will use the format you requestunless it is not practical for us to do so. You must make your request in writing.You may get the form to request copies of your health information or to requestaccess to your health information from your Social Worker or the Privacy Officer inthe Health Information Management Department. Copies are .75 cents per pageand upon payment, copies will be mailed to you.

• Receive a list of all times we or our business associates shared your healthinformation for purposes other than treatment, payment and health care operationsand other specified exceptions.

• Request that we place additional restrictions on our use or disclosure of your healthinformation. We are not required to agree to these additional restrictions, but if wedo, we will abide by our agreement (except in case of an emergency).



• Request that we restrict certain disclosures of health information to a healthplan when such individual pays out of pocket in full for the health care itemor service.

• Request that we communicate with you about your health information bydifferent means or to different locations. Your request that we communicateyour health information to you by different means or at different locationsmust be made in writing to the Privacy Officer (listed at the end of thisnotice).

• Request that we change your health information. We may deny your requestif we did not create the information you want changed or for certain otherreasons. If we deny your request, we will provide you a written explanation.You may respond with a statement of disagreement that will be added tothe information you wanted changed. If we accept your request to changethe information, we will make reasonable efforts to tell others, includingpeople you name, of the change and to include the changes in any futuresharing of that information.

• You have the right to be notified following a breach of unsecured healthinformation.

QUESTIONS AND COMPLAINTS: If you have any questions about this notice or if you think that we may have violated your privacy rights, please contact the Amsterdam Nursing Home Privacy Officer at 212-316-7769 or write to:

Privacy Officer/Director of Health Information Management Amsterdam Nursing Home

1060 Amsterdam Ave. N.Y., N.Y. 10025

You may also submit a written complaint to the U.S. Dept of Health and Human Services.

We will not retaliate in any way if you choose to file a complaint.



PRIVACY PRACTICES ACKNOWLEDGMENT

I have received the Notice of Privacy Practices and have been provided with an opportunity to review it. Additional copies may be obtained from the Social Services Department.

Please sign and return to the Social Services Department.

Resident Name

Room # Date of Birth

Resident Signature

Print Name

Date

OR

Signature of Resident Representative

Print Name

Relationship

Date




EMERGENCY & DISASTER PREPAREDNESS FORM

Resident Name ____________________________________

The safety of our residents is our number one priority. This is especially true when emergencies occur that may affect our facility. We want you to know that we have an Emergency Management Plan which addresses emergencies of all kinds; including, but not limited to loss of power, water, severe storms, active shooter and other emergencies. There is a plan to safely evacuate residents if that becomes necessary. Residents will be accounted for in such an event. They may be moved to another facility or they may go home to family members if that is feasible. Our Emergency Management Plan is reviewed and updated at least annually and we evaluate the plan after any activation. Our staff is trained at least annually. In the event of an emergency that may create a need to evacuate residents, please check one of the following: _____ I am; _____ I am not able to bring my family member to my home. ______ _______________________________ _____________________________ Date Your Signature Print Your Name


NOTIFICATION OF BENEFITS AND SERVICES TO VETERANS AND SPOUSES OF VETERANS

Amsterdam Nursing Home Corporation (1992). (ANHC) in accordance with Executive Law and Public Health Law, section 2805-O, which became effective May 25, 2004 is required to advise in writing Veterans and spouses of Veterans residing in Nursing Homes about the services of The Division of Veteran’s Affairs and the Local Veteran’s Service Agency.

If you are a Veteran of spouse of a Veteran residing at Amsterdam Nursing Home please be advised of the following information:

1) NYS Division of Veteran’s Affairs 2) NY CityVA New York Harbor Health Care Center Mayors Office of Veterans AffairsAttn: NYSDVA 346 Broadway423 East 23rd Street – Room 9144-N New York, NY 10001New York, NY 10010 (212) 442-4171(212) 686-7500 Ext. 7086(212) 951-5961 Fax1-888-838-7697www.veterans.state.ny.us

Local Veteran’s Centers:

Manhattan Vet Center Staten Island Vet Center 32 Broadway 2nd Floor – suite 200 60 Bay Street New York, NY 10004 Staten Island, NY 10301 (212) 951-6866 or (877) 927-8387 (718) 816-4499 or (877) 927-8387

Brooklyn Vet Center Bronx Vet Center 25 Chapel Street – suite 604 2471 Morris Avenue – suite 1-A Brooklyn, NY 11201 Bronx, NY 10468 (718) 630-2830 or (877) 927-8387 (718) 367-3500 or (877) 927-8387

Queens Vet Center Harlem Vet Center 75-10B 91st Avenue 2279 3rd Avenue – 2nd floor Woodhaven, NY 11421 New York, NY 10035 (718) 296-2871 or (877) 927-8387 (646) 273-8139 or (877) 927-8387


http://www.veterans.state.ny.us/


MEDICARE MINIMUM DATA SET (MDS) AND THE PRIVACY ACT OF 1974 STATEMENT

THIS FORM PROVIDES YOU WITH THE ADVICE REQUIRED BY THE PRIVACY ACT OF 1975. THIS FORM IS NOT A CONSENT FORM TO RELEASE OR USE HEALTH CARE INFORMATION PERTAINING TO YOU.

1. AUTHORITY FOR COLLECTION OF INFORMATION, INCLUDING SOCIAL SECURITY NUMBER ANDWHETHER DISCOSURE IS MANDATORY OR VOLUNTARY

Medicare and Medicaid pertaining to long term care facilities are required to conduct comprehensive, accurate, standardized and reproducible assessments of each resident’s functional capacity and health status. To implement this requirement, the facility must obtain information from every resident. This information also is used by the Federal Health Care Financing Administration (HCFA) to ensure that the facility meets quality standards and provides appropriate care to all residents. For this purpose, as of June 22, 1998, all such facilities are required to establish a database of resident assessment information, and to electronically transmit this information to the HCFA contractor in the State government, which in turn transmits the information to HCFA. Because the law requires disclosure of this information to Federal and State sources as discussed above a resident does not have the right to refuse consent to these disclosures. These data are protected under the requirements of the Federal Privacy Act of 1974 and the MDS Long Term Care System of Records.

2. PRINCIPAL PURPOSES FOR WHICH INFORMATION IS INTENDED TO BE USED

The information will be used to track changes in health and functional status over time for purposes of evaluating and improving the quality of care provided by nursing homes that participate in Medicare or Medicaid. Submission of MDS information may also be necessary for the nursing homes to receive reimbursement for Medicare services.

3. ROUTINE USES

The primary use of this information is to aid on the administration of the survey and certification of Medicare/Medicaid long-term care facilities and to improve the effectiveness and the quality of care given to those facilities. This system will also support regulatory, reimbursement, policy and research functions. This system will collect the minimum amount of personal data needed to accomplish its stated purposes.

The information collected will be entered into the Long Term Care Minimum Data Set (LTCMDS) system of records, System No. 09-701616. Information from this system may be disclosed, under specific circumstances, to (1) a congressional office from the record of an individual in response to an inquiry from the congressional office made at the request of the individual; (2) the Federal Bureau of Census; (3) the federal Department of justice; (4) an individual or organization for a research, evaluation or epidemiological project related to the prevention of disease or disability, or the restoration of health; (5) contractors working for HCFA to carry out Medicare/Medicaid functions, collating or analyzing data, or to detect fraud or abuse; (6) an agency of a State government for purposes of determining, evaluation and or assessing overall or aggregate costs, effectiveness, and/or qualify of health care services provided in the State; (7)


another Federal agency to fulfill a requirement of a Federal statute that implements a health benefits program funded in whole or in part with the Federal funds or to detect fraud or abuse; (8) Peer Review Organizations to perform Title XI or Title XVIII functions; (9) another entity thatmakes payment for or oversees administration of health care service for preventing fraud orabuse under specific conditions.

4. EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION

The information contained in the Long Term Care Minimum Data Set is generally necessary for the facility to provide appropriate and effective care to each resident. If a resident fails to provide such information, for example in their medical history, inappropriate and potentially harmful care may result. Moreover payment for such services by third parties, including Medicare and Medicaid, may not be available unless the facility has sufficient information to identify the individual and support a claim for payment.


Deciding AboutA

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New York State Department of Health

Health Care


IntroductionWho should read this guide?

ThisguideisforNewYorkStatepatientsandforthosewhowillmakehealthcaredecisionsforpatients.Itcontainsinformationaboutsurrogatedecision-makinginhospitalsandnursinghomes.ItalsocoversDNRordersinahealthcarefacility,orinthecommunity.Becausethisguideisabouthealthcaredecision-making,theword“patient”isusedtorefertoanyonereceivingmedicalcare.Thisincludesanursinghomeresident.Thisguidedoesnot includethespecialrulesforhealthcaredecisionsmadebylegalguardiansofpersonswithdevelopmentaldisabilities.

Can the patient or other decision maker find out about the patient’s medical condition and proposed treatment?

Yes.Patientsorotherdecisionmakershavearighttobefullyinformedbyadoctorabouttheirmedicalconditionandthedoctor’sproposedtreatment.Patientsmustgiveinformedconsentbeforeanynon-emergencytreatmentorprocedure.Informedconsentmeansthatafterinformationisgivenaboutthebenefitsandrisksoftreatment(aswellasalternativestothetreatment)permissionisgiventogoaheadwiththetreatment.

Adult Patients Who Have the Ability to Make Informed DecisionsDo adult patients have a right to make their own health care decisions?

Yes.Adultpatientshavetherighttomaketreatmentdecisionsforthemselvesaslongastheyhavedecision-makingcapacity.

What is “decision-making capacity”?

“Decision-makingcapacity”istheabilitytounderstandandappreciatethenatureandconsequencesofproposedhealthcare.Thisincludesthebenefitsandrisksof(andalternativesto)proposedhealthcare.Italsoincludestheabilitytoreachaninformeddecision.

What if it’s unclear whether or not a patient has decision-making capacity? Who decides whether or not the patient has capacity?

Healthcareworkerswillassumepatientshavedecision-makingcapacity,unlessacourthasappointedalegalguardiantodecideabouthealthcare.Adoctorwillexaminethepatientifthereisgoodreasontobelievethepatientlackscapacity.Adoctormustmakethedeterminationthatapatientlackstheabilitytomakehealthcaredecisions.Anotherpersonwillmakehealthcaredecisionsforthepatientonlyafterthepatient’sdoctormakesthisdetermination.

Do family members always make health care decisions whenever patients lack decision-making capacity?

No.Sometimespatientshavealreadymadeadecisionaboutaprocedureortreatmentbeforetheylosetheabilitytodecide.Forexample,apatientcanconsenttosurgerythatinvolvesgeneralanesthesiabeforereceivinganesthesia,whichwouldcausethemtolosetheabilitytodecide.Othertimes,ahealthypersonmaysuddenlylosecapacity.Inthiscase,healthcaremayneedtobegivenrightawaywithoutconsent.Forexample,apersonmaybeknockedunconsciousduringanaccident.Healthcareproviderswillprovideemergencytreatmentwithoutconsentunlesstheyknowthatadecisionhasalreadybeenmadetorefuseemergencytreatment.

A G U I D E F O R P A T I E N T S A N D F A M I L I E S1

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A G U I D E F O R P A T I E N T S A N D F A M I L I E S 2

Advance Directives/Health Care ProxiesWhat is an advance directive?

Advancedirectivesarewritteninstructionsabouthealthcaretreatmentmadebyadultpatientsbeforetheylosedecision-makingcapacity.InNewYorkState,thebestwaytoprotectyourtreatmentwishesandconcernsistoappointsomeoneyoutrusttodecideabouttreatmentifyoubecomeunabletodecideforyourself.Byfillingoutaformcalledahealthcareproxy,thispersonbecomesyour“healthcareagent.”

Beforeappointingahealthcareagent,makesurethepersoniswillingtoactasyouragent.Discusswithyouragentwhattypesoftreatmentsyouwouldorwouldnotwantifyouwereinthehospitalandhadalife-threateningillnessorinjury.Makesureyourhealthcareagentknowsyourwishesaboutartificialnutritionandhydration(beingfedthoughafeedingtubeorIVline).Youcangetmoreinformationabouthealthcareproxiesat:http://www.health.state.ny.us/professionals/patients/health_care_proxy/index.htm.

Somepatientsalsoexpressspecificinstructionsandchoicesaboutmedicaltreatmentsinwriting.Awrittenstatementcanbeincludedinahealthcareproxy,oritcanbeinaseparatedocument.Somepeoplerefertothistypeofadvancedirectiveasa“livingwill.”

How do health care agents make decisions under a health care proxy?

Healthcareagentsmakedecisionsjustasifthehealthcareagentwerethepatient.Thehealthcareagentmakeshealthcaredecisionsaccordingtothepatient’swishes,includingdecisionstowithholdorwithdrawlife-sustainingtreatment.Ifthepatient’swishesarenotreasonablyknown,healthcareagentsmakehealthcaredecisionsinaccordancewiththepatient’sbestinterests.

Can a health care agent decide to withhold or withdraw artificial nutrition or hydration (through a feeding tube or an IV line)?

Healthcareagentscanonlymakedecisionstowithholdorwithdrawartificialnutritionandhydrationunderthehealthcareproxyiftheyknowthepatient’swishesaboutthetreatment.But,thehealthcareagentmayalsobeabletomakethistypeofdecisioninahospitalornursinghomeasasurrogatefromthesurrogatelistsetforthinlaw.

Health Care Decision-Making in Hospitals and Nursing HomesHow do adult patients with decision-making capacity make decisions in hospitals and nursing homes?

Patientsmayexpressdecisionsverballyorinwriting.Ahospitalpatientornursinghomeresidentmaynotverballymakeadecisiontowithholdorwithdrawlife-sustainingtreatmentunlesstwoadultswitnessthedecision.Oneoftheadultsmustbeahealthcarepractitioneratthefacility.Ifapatientdoesnotnowhavecapacitytomakeadecision(butmadeadecisioninthepastabouttheproposedhealthcare),thehospitalornursinghomewillactbasedonthepatient’spreviouslymadedecision.Thisistrueunlesssomethingoccursthatthepatientdidnotexpectandthedecisionnolongermakessense.

How are health care decisions made for a hospital patient or nursing home resident who does not have capacity?

Ifthepatienthasahealthcareproxy,thehealthcareagentnamedintheproxymakesdecisions.Ifapatientdoesnothaveahealthcareproxy,alegalguardian(orthepersonhighestinpriorityfromthesurrogatelist,knownas“thesurrogate”)makesdecisions.

What is the surrogate list?

Belowisthesurrogatelist.Thepersonwhoishighestinpriorityislistedatthetop.Thepersonwiththelowestpriorityisatthebottom.

• Thespouse,ifnotlegallyseparatedfromthepatient,orthedomesticpartner;

• Asonordaughter18orolder;

• Aparent;

• Abrotherorsister18orolder;and

• Aclosefriend.

What is a “domestic partner”?

A“domesticpartner”isapersonwho:

• hasenteredintoaformaldomesticpartnershiprecognizedbyalocal,stateornationalgovernment.Or,thispersonhasregisteredasadomesticpartnerwitharegistrymaintainedbythegovernmentoranemployer;or,thisperson


• iscoveredasadomesticpartnerunderthesameemploymentbenefitsorhealthinsurance;or,thisperson

• sharesamutualintenttobeadomesticpartnerwiththepatient,consideringallthefactsandcircumstances,suchas:

– Theylivetogether.

– Theydependoneachotherforsupport.

– Theyshareownership(oralease)oftheirhomeorotherproperty.

– Theyshareincomeorexpenses.

– Theyareraisingchildrentogether.

– Theyplanongettingmarriedorbecomingformaldomesticpartners.

– Theyhavebeentogetherforalongtime.

Who cannot be a domestic partner?

• Aparent,grandparent,child,grandchild,brother,sister,uncle,aunt,nephewornieceofthepatientorthepatient’sspouse.

• Apersonwhoisyoungerthan18.

Who qualifies as a “close friend”?

A“closefriend”isanyperson,18orolder,whoisafriendorrelativeofthepatient.Thispersonmusthavemaintainedregularcontactwiththepatient;befamiliarwiththepatient’sactivities,health,andreligiousormoralbeliefs;andpresentasignedstatementtothateffecttotheattendingdoctor.

What if a surrogate highest in priority is not available to make the decision?

Ifthishappens,thenextavailablesurrogatewhoishighestinprioritymakesthedecision.

What if a surrogate highest in priority is unable or unwilling to make the decision?

Inthiscase,anotherpersonfromthesurrogatelistwilldecide.Thesurrogatehighestinprioritymaydesignateanyotherpersononthelisttobesurrogate,aslongasnoonehigherinprioritythanthedesignatedpersonobjects.

Can patients or other decision makers change their minds after they make a treatment decision?

Yes.Decisionsmayberevokedaftertheyaremadebytellingstaffatthehospitalornursinghome.

Decisions to Withhold or Withdraw Life-Sustaining Treatment in Hospitals and Nursing HomesWhat is “life-sustaining treatment”?

“Life-sustainingtreatment”meansthattheattendingdoctorbelievesthepatientwilldiewithinarelativelyshorttimeifthepatientdoesnotgetthemedicaltreatmentorprocedure.CPRisalwaysconsideredtobelife-sustainingtreatment.

What is CPR?

CPR(cardiopulmonaryresuscitation)referstomedicalproceduresthattrytorestartapatient’sheartorbreathingwhenthepatient’sheartstopsand/orthepatientstopsbreathing.CPRmaybeginwithsomethinglikemouth-to-mouthresuscitationandforcefulpressureonthechesttotrytorestarttheheart.Thismaynotwork,soCPRmayalsoinvolveelectricshock(defibrillation);insertionofatubedownthethroatintothewindpipe(intubation);andplacingthepatientonabreathingmachine(ventilator).

What is a decision to withhold or withdraw life-sustaining treatment?

Adecisiontowithholdlife-sustainingtreatmentisdecidingtorefuseatreatmentbeforeitisprovided.Adecisiontowithdrawlife-sustainingtreatmentisdecidingtorefusetreatmentalreadybeingprovided.Everyadultpatienthastherighttorefusemedicineandtreatmentafterbeingfullyinformedof(andunderstanding)theprobableconsequencesofsuchactions.

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How would a hospital or a nursing home carry out a decision to withhold or withdraw life-sustaining treatment?

Thedoctormightdirectstaffnottoprovide,ortostopproviding,certainmedicines,treatmentsorprocedures.Thismayresultinthepatientdyingwithinarelativelyshorttime.Forexample,thedoctormightorderthataventilator,whichisenablingapatienttobreathe,beturnedoff.

Inordertowithholdlife-sustainingtreatment,thedoctormightissueamedicalordersuchasa:

• DoNotResuscitate(DNR)Order:thismeansdonotattemptCPRwhenthepatient’sheartstopsand/orthepatientstopsbreathing.

• DoNotIntubate(DNI)Order:thismeansdonotplaceatubedownthepatient’sthroatorconnectthepatienttoabreathingmachine(ventilator).

Adecisioncouldalsobemadetostop(ornottostart)artificialnutritionandhydrationthroughafeedingtubeoranIV.Thismeansthefacilitywillnotgivethepatientliquidfoodorfluidsthroughatubeinsertedinthestomach– orbyatubecalledacatheterinsertedintothepatient’sveins.Patientswillalwaysbeofferedfoodtoeatandfluidstodrinkbymouthiftheyareabletoeatanddrink.

Otherkindsofdecisionstolimitmedicines,treatmentsorprocedurescouldalsobefollowed(forexample,stoppingdialysis).

Will a hospital or a nursing home ever withhold all treatment?

No.EvenifapatienthasaDNRorderorothermedicalordertowithholdlife-sustainingtreatment,thepatientshouldreceivemedicalcareandtreatmenttorelievepainandothersymptomsandtoreducesuffering.Comfortcare,alsoknownaspalliativecare,shouldbeavailabletoallpatientswhoneedit.

When should a patient get a DNR order?

Anyadultwithdecision-makingcapacitymayrequestaDNRorder.However,patientsandfamiliesmustconsultwithadoctorabouttheirdiagnosisandthelikelyoutcomeofCPR.OnlyadoctorcansignaDNRorder.ADNRorderinstructshealthcareprofessionalsnottoprovideCPRforpatientswhowanttoallownaturaldeathtooccuriftheirheartstopsand/oriftheystopbreathing.Forexample,apatientwhoisexpectingtodiefromaterminalillnessmaywantaDNRorder.

Whensuccessful,CPRrestoresheartbeatandbreathing.ThesuccessofCPRdependsonthepatient’soverallmedicalcondition.AgealonedoesnotdeterminewhetherCPRwillbesuccessful.ButillnessesandfrailtiesthatgoalongwithageoftenmakeCPRlesseffective.Whenpatientsareseriouslyill,CPRmaynotworkoritmayonlypartiallywork.Thismightleavethepatientbrain-damagedorinaworsemedicalstatethanbeforehisorherheartstopped.AfterCPR(dependingonthepatient’smedicalcondition),thepatientmaybeabletobekeptaliveonlyonabreathingmachine.

Does a DNR order affect other treatment?

No.ADNRorderisonlyadecisionaboutCPR–chestcompression,intubationandmechanicalventilation– anddoesnotrelatetoanyothertreatment.Donotresuscitatedoes not meandonottreat.

What happens if the patient is transferred from the hospital or nursing home to another hospital or nursing home?

Medicalorders,includingaDNRorder,willcontinueuntilahealthcarepractitionerexaminesthepatient.Ifthedoctoratthenewfacilitydecidestocancelthemedicalorder,thepatientorotherdecisionmakerwillbetoldandheorshecanaskthattheorderbeenteredagain.

Decision-Making Standards for Legal Guardians and Surrogates in Hospitals and Nursing HomesHow are health care decisions made by surrogate decision makers, including legal guardians?

Thesurrogatemustmakehealthcaredecisionsinaccordancewiththepatient’swishes,includingthepatient’sreligiousandmoralbeliefs.Ifthepatient’swishesarenotreasonablyknown,thesurrogatemakesdecisionsaccordingtothepatient’s“bestinterests.”Tofigureoutwhatisinthe“bestinterests”ofthepatient,thesurrogatemustconsider:thedignityanduniquenessofeveryperson;thepossibilityofpreservingthepatient’slifeandpreservingorimprovingthepatient’shealth;reliefofthepatient’ssuffering;andanyotherconcernsandvaluesapersoninthepatient’scircumstanceswouldwishtoconsider.Inallcases,whatmattersisthepatient’swishesandbestinterests,notthesurrogate’s.

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Healthcaredecisionsshouldbemadeonanindividualbasisforeachpatient.Again,decisionsmustbeconsistentwiththepatient’svalues,aswellasreligiousandmoralbeliefs.

Do surrogates always have authority to consent to needed treatments?

Yes.

Do surrogates always have authority to make decisions to withhold or withdraw life-sustaining treatment?

No.Alegalguardianorasurrogateinahospitalornursinghomemaydecidetorefuselife-sustainingtreatmentforapatientonlyinthefollowingcircumstances:

• Treatmentwouldbeanextraordinaryburdentothepatientand:

– thepatienthasanillnessorinjurywhichcanbeexpectedtocausedeathwithinsixmonths,whetherornottreatmentisprovided;or

– thepatientispermanentlyunconscious;

or

• Theprovisionoftreatmentwouldinvolvesuchpain,sufferingorotherburdenthatitwouldreasonablybedeemedinhumaneorextraordinarilyburdensomeunderthecircumstancesandthepatienthasanirreversibleorincurablecondition.Inanursinghome,anethicsreviewcommitteemustalsoagreetodecisions(otherthanDNR)basedonthisbullet-point.Inahospital,theattendingdoctorortheethicsreviewcommitteemustagreetoadecisiontowithholdorwithdrawartificialnutritionandhydrationbasedonthisbullet-point.

How are decisions about life-sustaining treatment made for minors in a hospital or nursing home?

Theparentorguardianofapatientunder18makesdecisionsaboutlife-sustainingtreatmentinaccordancewiththeminor’sbestinterests.Theytakeintoaccounttheminor’swishesasappropriateunderthecircumstances.Foradecisiontowithholdorwithdrawlife-sustainingtreatment,theminorpatientmustalsoconsentifheorshehasdecision-makingcapacity.Itisassumedthatanunmarriedminorlacksdecision-makingcapacityunless

adoctordeterminesthatthepatienthasthecapacitytodecideaboutlife-sustainingtreatment.Minorswhoaremarriedmaketheirowndecisions,thesameasadults.

What if an unmarried minor patient has decision-making capacity and he or she is a parent? What if he or she is 16 or older and living independently from his or her parents or guardian?

Suchminorscanmakedecisionstowithholdorwithdrawlife-sustainingtreatmentontheirowniftheattendingdoctorandtheethicsreviewcommitteeagree.

Resolving Disputes in Hospitals and Nursing HomesWhat if there are two or more persons highest in priority and they cannot agree? For example, what if the adult children are highest in priority and they disagree with one another?

Inthiscase,thehospitalornursinghomestaffcantrytoresolvethedisputebyinformalmeans.Forexample,moredoctors,socialworkersorclergycoulddiscussthedecision.Also,everyhospitalandnursinghomemusthaveanethicsreviewcommittee.Thecasemaybereferredtotheethicsreviewcommitteeforadvice,arecommendation,andassistanceinresolvingthedispute.Thehospitalornursinghomemustfollowthedecisionofthesurrogatethatisbasedonthepatient’swishes,iftheyareknown.Ifthepatient’swishesarenotreasonablyknown,thehospitalornursinghomemustfollowthedecisionthatisinthepatient’sbestinterests.

What if a person connected with the case does not agree with the surrogate’s treatment decision? This could be the patient, a health care worker treating the patient in the hospital or nursing home or someone lower in priority on the surrogate list.

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Again,thehospitalornursinghomestaffcantrytoresolvethedisputebyinformalmeans.Ifthatisnotsuccessful,thepersonwhodisagreescouldrequesthelpfromtheethicsreviewcommittee.Thepersonchallengingthedecisionmakercanaskthattheethicsreviewcommitteetrytoresolvethedispute.Thispersoncouldpresentinformationandopinionstothecommittee.Theethicsreviewcommitteecanprovideadviceandmakearecommendation,andcanprovideassistanceinresolvingthedispute.

Are the recommendations and advice of the ethics review committee binding?

No,therecommendationsandadviceoftheethicsreviewcommitteeareadvisoryandnon-binding,exceptforthreeveryspecifictypesofdecisions.Theethicsreviewcommitteemustagreewiththedecisioninthefollowingthreesituations:

• Asurrogatedecidestowithholdorwithdrawlife-sustainingtreatment(otherthanCPR)fromapatientinanursinghome.Thepatientisnotexpectedtodiewithinsixmonthsandisnotpermanentlyunconscious.Inthissituation,theethicsreviewcommitteemustagreetothefollowing.Thepatienthasaconditionthatcan’tbereversedorcured.Also,theprovisionoflife-sustainingtreatmentwouldinvolvesuchpain,sufferingorotherburdenthatitwouldreasonablybedeemedinhumaneorextraordinarilyburdensomeunderthecircumstances.

• Asurrogatedecidestowithholdorwithdrawartificialnutritionandhydrationfromapatientinahospital.Theattendingdoctorobjects.Thepatientisnotexpectedtodiewithinsixmonthsandisnotpermanentlyunconscious.Inthissituation,theethicsreviewcommitteemustagreetothefollowing.Thepatienthasaconditionthatcan’tbereversedorcured.Also,artificialnutritionandhydrationwouldinvolvesuchpain,sufferingorotherburdenthatitwouldreasonablybedeemedinhumaneorextraordinarilyburdensomeunderthecircumstances.

• Inahospitalornursinghome,anethicsreviewcommitteemustapprovethedecisionofanunmarried,emancipatedminortowithholdorwithdrawlife-sustainingtreatmentwithouttheconsentofaparentorguardian.

Inthesethreesituations,life-sustainingtreatmentwillnotbewithheldorwithdrawnunlesstheethicsreviewcommitteeapproves.

What does it mean when the recommendations and advice of the ethics review committee are advisory and non-binding?

Thismeansthatthesurrogatehighestinprioritycanmakealegalhealthcaredecision.Heorshecandothisevenifanotherpersonlowerinpriorityonthesurrogatelistorotherscontinuetodisagreewiththesurrogatedecisionmaker.

What if the hospital or nursing home has a policy based on religious or moral beliefs that prevents the facility from honoring a health care decision?

Whenpossible,thefacilitymustinformpatientsorfamilymembersofthispolicybeforeoratadmission.Whenthedecisionismade,thefacilitymustcooperateintransferringthepatienttoanotherfacilitythatisreasonablyaccessibleandwillingtohonorthedecision.Meanwhile,thefacilitymusthonorthedecision,unlessacourtrulesotherwise.Ifthedecisiongoesagainstonehealthcarepractitioner’sreligiousormoralbeliefs,thepatientmustbepromptlyputunderthecareofanotherhealthcarepractitioner.

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StateofNewYorkDepartmentofHealth

5/101503

DNR Orders Outside the Hospital or Nursing HomeIf a patient is not in a hospital or nursing home, how can the patient get a DNR order or DNI order?

Thepatient’sdoctorcanwriteaDNRorderonastandardformthathasbeenapprovedbytheNewYorkStateDepartmentofHealth:DOH-3474(NonhospitalOrderNottoResuscitate).AdoctorcanalsosignanonhospitalDNIorderinadditiontothenonhospitalDNRorderusingtheDOH-5003formcalledMOLST(MedicalOrdersforLife-SustainingTreatment).EMS,homecareagenciesandhospicesmusthonortheseorders.

If the patient is at home with a nonhospital DNR order, or MOLST orders, what happens if a family member or friend calls an ambulance?

IfthepatienthasanonhospitalDNRorderanditisshowntoemergencypersonnel,theywillnottrytoresuscitatethepatientortakethepatienttoahospitalemergencyroomforCPR.Theymaystilltakethepatienttothehospitalforotherneededcare,includingcomfortcaretorelievepainandreducesuffering.

What happens to a DNR order issued in the hospital or nursing home if the patient is transferred from the hospital or nursing home to home care?

Theordersissuedforthepatientinahospitalornursinghomemaynotapplyathome.ThepatientorotherdecisionmakermustgetanonhospitalDNRorderontheDOH-3474formortheDOH-5003MOLSTform.IfthepatientleavesthehospitalornursinghomewithoutanonhospitalDNRorder,itcanbeissuedbyadoctorathome.

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Health Care ProxyAppointing Your Health Care Agent in New York State

The New York Health Care Proxy Law allows you to appoint someone you trust — for example, a family member or close friend – to make health care decisions for you if you lose the ability to make decisions yourself. By appointing a health care agent, you can make sure that health care providers follow your wishes. Your agent can also decide how your wishes apply as your medical condition changes. Hospitals, doctors and other health care providers must follow your agent’s decisions as if they were your own. You may give the person you select as your health care agent as little or as much authority as you want. You may allow your agent to make all health care decisions or only certain ones. You may also give your agent instructions that he or she has to follow. This form can also be used to document your wishes or instructions with regard to organ and/or tissue donation.


About the Health Care Proxy FormThis is an important legal document. Before signing, you should understand the following facts:

1. This form gives the person you choose as youragent the authority to make all health caredecisions for you, including the decision toremove or provide life-sustaining treatment,unless you say otherwise in this form. “Healthcare” means any treatment, service orprocedure to diagnose or treat your physical ormental condition.

2. Unless your agent reasonably knows yourwishes about artificial nutrition and hydration(nourishment and water provided by a feedingtube or intravenous line), he or she will not beallowed to refuse or consent to those measuresfor you.

3. Your agent will start making decisions for youwhen your doctor determines that you are notable to make health care decisions for yourself.

4. You may write on this form examples of thetypes of treatments that you would not desireand/or those treatments that you want tomake sure you receive. The instructions maybe used to limit the decision-making powerof the agent. Your agent must follow yourinstructions when making decisions for you.

5. You do not need a lawyer to fill out this form.

6. You may choose any adult (18 years of age orolder), including a family member or closefriend, to be your agent. If you select a doctoras your agent, he or she will have to choosebetween acting as your agent or as yourattending doctor because a doctor cannotdo both at the same time. Also, if you are apatient or resident of a hospital, nursing homeor mental hygiene facility, there are special

restrictions about naming someone who works for that facility as your agent. Ask staff at the facility to explain those restrictions.

7. Before appointing someone as your health careagent, discuss it with him or her to make surethat he or she is willing to act as your agent.Tell the person you choose that he or she willbe your health care agent. Discuss your healthcare wishes and this form with your agent. Besure to give him or her a signed copy. Youragent cannot be sued for health care decisionsmade in good faith.

8. If you have named your spouse as your healthcare agent and you later become divorcedor legally separated, your former spouse canno longer be your agent by law, unless youstate otherwise. If you would like your formerspouse to remain your agent, you may notethis on your current form and date it orcomplete a new form naming your formerspouse.

9. Even though you have signed this form, youhave the right to make health care decisionsfor yourself as long as you are able to do so,and treatment cannot be given to you orstopped if you object, nor will your agent haveany power to object.

10. You may cancel the authority given to youragent by telling him or her or your health careprovider orally or in writing.

11. Appointing a health care agent is voluntary.No one can require you to appoint one.

12. You may express your wishes or instructionsregarding organ and/or tissue donation onthis form.


Frequently Asked QuestionsWhy should I choose a health care agent? If you become unable, even temporarily, to make health care decisions, someone else must decide for you. Health care providers often look to family members for guidance. Family members may express what they think your wishes are related to a particular treatment. Appointing an agent lets you control your medical treatment by:

• allowing your agent to make health caredecisions on your behalf as you would wantthem decided;

• choosing one person to make health caredecisions because you think that person wouldmake the best decisions;

• choosing one person to avoid conflict orconfusion among family members and/orsignificant others.

You may also appoint an alternate agent to take over if your first choice cannot make decisions for you.

Who can be a health care agent?Anyone 18 years of age or older can be a health care agent. The person you are appointing as your agent or your alternate agent cannot sign as a witness on your Health Care Proxy form.

How do I appoint a health care agent? All competent adults, 18 years of age or older, can appoint a health care agent by signing a form called a Health Care Proxy. You don’t need a lawyer or a notary, just two adult witnesses. Your agent cannot sign as a witness. You can use the form printed here, but you don’t have to use this form.

When would my health care agent begin to make health care decisions for me? Your health care agent would begin to make health care decisions after your doctor decides that you are not able to make your own health care decisions. As long as you are able to make health care decisions for yourself, you will have the right to do so.

What decisions can my health care agent make?Unless you limit your health care agent’s authority, your agent will be able to make any health care decision that you could have made if you were able to decide for yourself. Your agent can agree that you should receive treatment, choose among different treatments and decide that treatments should not be provided, in accordance with your wishes and interests. However, your agent can only make decisions about artificial nutrition and hydration (nourishment and water provided by feeding tube or intravenous line) if he or she knows your wishes from what you have said or what you have written. The Health Care Proxy form does not give your agent the power to make non-health care decisions for you, such as financial decisions.

Why do I need to appoint a health care agent if I’m young and healthy?Appointing a health care agent is a good idea even though you are not elderly or terminally ill. A health care agent can act on your behalf if you become even temporarily unable to make your own health care decisions (such as might occur if you are under general anesthesia or have become comatose because of an accident). When you again become able to make your own health care decisions, your health care agent will no longer be authorized to act.

How will my health care agent make decisions? Your agent must follow your wishes, as well as your moral and religious beliefs. You may write instructions on your Health Care Proxy form or simply discuss them with your agent.

How will my health care agent know my wishes?Having an open and frank discussion about your wishes with your health care agent will put him or her in a better position to serve your interests. If your agent does not know your wishes or beliefs, your agent is legally required to act in your best interest. Because this is a major responsibility for the person you appoint as your health care


agent, you should have a discussion with the person about what types of treatments you would or would not want under different types of circumstances, such as:

• whether you would want life support initiated/continued/removed if you are in a permanentcoma;

• whether you would want treatments initiated/continued/removed if you have a terminalillness;

• whether you would want artificial nutritionand hydration initiated/withheld or continuedor withdrawn and under what types ofcircumstances.

Can my health care agent overrule my wishes or prior treatment instructions?No. Your agent is obligated to make decisions based on your wishes. If you clearly expressed particular wishes, or gave particular treatment instructions, your agent has a duty to follow those wishes or instructions unless he or she has a good faith basis for believing that your wishes changed or do not apply to the circumstances.

Who will pay attention to my agent? All hospitals, nursing homes, doctors and other health care providers are legally required to provide your health care agent with the same information that would be provided to you and to honor the decisions by your agent as if they were made by you. If a hospital or nursing home objects to some treatment options (such as removing certain treatment) they must tell you or your agent BEFORE or upon admission, if reasonably possible.

What if my health care agent is not available when decisions must be made? You may appoint an alternate agent to decide for you if your health care agent is unavailable, unable or unwilling to act when decisions must be made. Otherwise, health care providers will make health care decisions for you that follow instructions you gave while you were still able to do so. Any instructions that you write on your Health Care Proxy form will guide health care providers under these circumstances.

What if I change my mind?It is easy to cancel your Health Care Proxy, to change the person you have chosen as your health care agent or to change any instructions or limitations you have included on the form. Simply fill out a new form. In addition, you may indicate that your Health Care Proxy expires on a specified date or if certain events occur. Otherwise, the Health Care Proxy will be valid indefinitely. If you choose your spouse as your health care agent or as your alternate, and you get divorced or legally separated, the appointment is automatically cancelled. However, if you would like your former spouse to remain your agent, you may note this on your current form and date it or complete a new form naming your former spouse.

Can my health care agent be legally liable for decisions made on my behalf? No. Your health care agent will not be liable for health care decisions made in good faith on your behalf. Also, he or she cannot be held liable for costs of your care, just because he or she is your agent.

Is a Health Care Proxy the same as a living will?No. A living will is a document that provides specific instructions about health care decisions. You may put such instructions on your Health Care Proxy form. The Health Care Proxy allows you to choose someone you trust to make health care decisions on your behalf. Unlike a living will, a Health Care Proxy does not require that you know in advance all the decisions that may arise. Instead, your health care agent can interpret your wishes as medical circumstances change and can make decisions you could not have known would have to be made.

Where should I keep my Health Care Proxy form after it is signed?Give a copy to your agent, your doctor, your attorney and any other family members or close friends you want. Keep a copy in your wallet or purse or with other important papers, but not in a location where no one can access it, like a safe

Frequently Asked Questions, continued


deposit box. Bring a copy if you are admitted to the hospital, even for minor surgery, or if you undergo outpatient surgery.

May I use the Health Care Proxy form to express my wishes about organ and/or tissue donation?Yes. Use the optional organ and tissue donation section on the Health Care Proxy form and be sure to have the section witnessed by two people. You may specify that your organs and/or tissues be used for transplantation, research or educational purposes. Any limitation(s) associated with your wishes should be noted in this section of the proxy. Failure to include your wishes and instructions on your Health Care Proxy form will not be taken to mean that you do not want to be an organ and/or tissue donor.

Frequently Asked Questions, continued

Can my health care agent make decisions for me about organ and/or tissue donation?Yes. As of August 26, 2009, your health care agent is authorized to make decisions after your death, but only those regarding organ and/or tissue donation. Your health care agent must make such decisions as noted on your Health Care Proxy form.

Who can consent to a donation if I choose not to state my wishes at this time?It is important to note your wishes about organ and/or tissue donation to your health care agent, the person designated as your decedent’s agent, if one has been appointed, and your family members. New York Law provides a list of individuals who are authorized to consent to organ and/or tissue donation on your behalf. They are listed in order of priority: your health care agent; your decedent’s agent; your spouse, if you are not legally separated, or your domestic partner; a son or daughter 18 years of age or older; either of your parents; a brother or sister 18 years of age or older; or a guardian appointed by a court prior to the donor’s death.


Item (1) Write the name, home address and telephone number of the person you are selecting as your agent.

Item (2) If you want to appoint an alternate agent, write the name, home address and telephone number of the person you are selecting as your alternate agent.

Item (3) Your Health Care Proxy will remain valid indefinitely unless you set an expiration date or condition for its expiration. This section is optional and should be filled in only if you want your Health Care Proxy to expire.

Item (4) If you have special instructions for your agent, write them here. Also, if you wish to limit your agent’s authority in any way, you may say so here or discuss them with your health care agent. If you do not state any limitations, your agent will be allowed to make all health care decisions that you could have made, including the decision to consent to or refuse life-sustaining treatment.

If you want to give your agent broad authority, you may do so right on the form. Simply write: I have discussed my wishes with my health care agent and alternate and they know my wishes including those about artificial nutrition and hydration.

If you wish to make more specific instructions, you could say:

If I become terminally ill, I do/don’t want to receive the following types of treatments....

If I am in a coma or have little conscious understanding, with no hope of recovery, then I do/don’t want the following types of treatments:....

If I have brain damage or a brain disease that makes me unable to recognize people or speak and there is no hope that my condition will improve, I do/don’t want the following types of treatments:....

Health Care Proxy Form Instructions I have discussed with my agent my wishes about____________ and I want my agent to make all decisions about these measures.

Examples of medical treatments about which you may wish to give your agent special instructions are listed below. This is not a complete list:

• artificial respiration• artificial nutrition and hydration

(nourishment and water provided by feedingtube)

• cardiopulmonary resuscitation (CPR)• antipsychotic medication• electric shock therapy• antibiotics• surgical procedures• dialysis• transplantation• blood transfusions• abortion• sterilization

Item (5) You must date and sign this Health Care Proxy form. If you are unable to sign yourself, you may direct someone else to sign in your presence. Be sure to include your address.

Item (6) You may state wishes or instructions about organ and /or tissue donation on this form. New York law does provide for certain individuals in order of priority to consent to an organ and/or tissue donation on your behalf: your health care agent, your decedent’s agent, your spouse , if you are not legally separated, or your domestic partner, a son or daughter 18 years of age or older, either of your parents, a brother or sister 18 years of age or older, a guardian appointed by a court prior to the donor’s death.

Item (7) Two witnesses 18 years of age or older must sign this Health Care Proxy form. The person who is appointed your agent or alternate agent cannot sign as a witness.


Health Care Proxy(1) I, ___________________________________________________________________________________

hereby appoint ________________________________________________________________________(name, home address and telephone number)

_____________________________________________________________________________________

_____________________________________________________________________________________

as my health care agent to make any and all health care decisions for me, except to the extent that Istate otherwise. This proxy shall take effect only when and if I become unable to make my own healthcare decisions.

(2) Optional: Alternate AgentIf the person I appoint is unable, unwilling or unavailable to act as my health care agent, I hereby

appoint _____________________________________________________________________________(name, home address and telephone number)

_____________________________________________________________________________________

_____________________________________________________________________________________

as my health care agent to make any and all health care decisions for me, except to the extent that Istate otherwise.

(3) Unless I revoke it or state an expiration date or circumstances under which it will expire, this proxy shallremain in effect indefinitely. (Optional: If you want this proxy to expire, state the date or conditionshere.) This proxy shall expire (specify date or conditions): _____________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

(4) Optional: I direct my health care agent to make health care decisions according to my wishes andlimitations, as he or she knows or as stated below. (If you want to limit your agent’s authority to makehealth care decisions for you or to give specific instructions, you may state your wishes or limitationshere.) I direct my health care agent to make health care decisions in accordance with the followinglimitations and/or instructions (attach additional pages as necessary): __________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

In order for your agent to make health care decisions for you about artificial nutrition and hydration(nourishment and water provided by feeding tube and intravenous line), your agent must reasonablyknow your wishes. You can either tell your agent what your wishes are or include them in this section.See instructions for sample language that you could use if you choose to include your wishes on thisform, including your wishes about artificial nutrition and hydration.


(5) Your Identification (please print)

Your Name ___________________________________________________________________________

Your Signature _________________________________________________ Date ________________

Your Address __________________________________________________________________________

(6) Optional: Organ and/or Tissue Donation

I hereby make an anatomical gift, to be effective upon my death, of:(check any that apply)

■ Any needed organs and/or tissues

■ The following organs and/or tissues ____________________________________________________

___________________________________________________________________________________

■ Limitations ________________________________________________________________________

If you do not state your wishes or instructions about organ and/or tissue donation on this form, it will not be taken to mean that you do not wish to make a donation or prevent a person, who is otherwise authorized by law, to consent to a donation on your behalf.

Your Signature ___________________________ Date _______________________________________

(7) Statement by Witnesses (Witnesses must be 18 years of age or older and cannot be the health careagent or alternate.)

I declare that the person who signed this document is personally known to me and appears to be ofsound mind and acting of his or her own free will. He or she signed (or asked another to sign for him orher) this document in my presence.

Date ____________________________________ Date _______________________________________

Name of Witness 1 Name of Witness 2 (print) __________________________________ (print) _____________________________________

Signature _______________________________ Signature __________________________________

Address _________________________________ Address ____________________________________

________________________________________ ___________________________________________

1430 11/15

Departmentof Health









Resident Rights

(a) Residents 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,including those specified in this section.

(1) A facility must treat each resident with respect and dignity and care for each residentin a manner and in an environment that promotes maintenance or enhancement of hisor her quality of life, recognizing each resident’s individuality. The facility must protectand promote the rights of the resident.(2) The facility must provide equal access to quality care regardless of diagnosis, severityof condition, or payment source. A facility must establish and maintain identical policiesand practices regarding transfer, discharge, and the provision of services under theState plan for all residents regardless of payment source.

(b) Exercise of rights. The resident has the right to exercise his or her rights as a resident of thefacility and as a citizen or resident of the United States.

(1) The facility must ensure that the resident can exercise his or her rights withoutinterference, coercion, discrimination, or reprisal from the facility(2) The resident has the right to be free of interference, coercion, discrimination, andreprisal from the facility in exercising his or her rights and to be supported by the facilityin the exercise of his or her rights as required under this subpart.(3) In the case of a resident who has not been adjudged incompetent by the state court,the resident has the right to designate a representative, in accordance with State lawand any legal surrogate so designated may exercise the resident’s rights to the extentprovided by state law. The same-sex spouse of a resident must be afforded treatmentequal to that afforded to an opposite-sex spouse if the marriage was valid in thejurisdiction in which it was celebrated.

(i) The resident representative has the right to exercise the resident’s rights tothe extent those rights are delegated to the resident representative.(ii) The resident retains the right to exercise those rights not delegated to aresident representative, including the right to revoke a delegation of rights,except as limited by State law.

(4) The facility must treat the decisions of a resident representative as the decisions ofthe resident to the extent required by the court or delegated by the resident, inaccordance with applicable law.(5) The facility shall not extend the resident representative the right to makedecisions on behalf of the resident beyond the extent required by the court ordelegated by the resident, in accordance with applicable law.(6) If the facility has reason to believe that a resident representative is makingdecisions or taking actions that are not in the best interests of a resident, thefacility shall report such concerns in the manner required under State law.


(7) In the case of a resident adjudged incompetent under the laws of a State by a courtof competent jurisdiction, the rights of the resident devolve to and are exercised by theresident representative appointed under State law to act on the resident’s behalf. Thecourt-appointed resident representative exercises the resident’s rights to the extentjudged necessary by a court of competent jurisdiction, in accordance with State law

(i) In the case of a resident representative whose decision-making authority islimited by State law or court appointment, the resident retains the right to makethose decision outside the representative’s authority.(ii) The resident’s wishes and preferences must be considered in the exercise ofrights by the representative.(iii) To the extent practicable, the resident must be provided with opportunitiesto participate in the care planning process.

(c) Planning and implementing care. The resident has the right to be informed of, andparticipate in, his or her treatment, including:

(1) The right to be fully informed in language that he or she can understand of his or hertotal health status, including but not limited to, his or her medical condition.(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to:

(i) The right to participate in the planning process, including the right to identifyindividuals or roles to be included in the planning process, the right to requestmeetings and the right to request revisions to the person centered plan of care.(ii) The right to participate in establishing the expected goals and outcomes ofcare, the type, amount, frequency, and duration of care, and any other factorsrelated to the effectiveness of the plan of care.(iii) The right to be informed, in advance, of changes to the plan of care.(iv) The right to receive the services and/or items included in the plan of care.(v) The right to see the care plan, including the right to sign after significantchanges to the plan of care.

(3) The facility shall inform the resident of the right to participate in his or her treatmentand shall support the resident in this right. The planning process must—

(i) Facilitate the inclusion of the resident and/or resident representative.(ii) Include an assessment of the resident’s strengths and needs.(iii) Incorporate the resident’s personal and cultural preferences in developinggoals of care.

(4) The right to be informed, in advance, of the care to be furnished and the type of caregiver or professional that will furnish care.(5) The right to be informed in advance, by the physician or other practitioner orprofessional, of the risks treatment and treatment alternatives or treatment options andto choose the alternative or option he or she prefers.(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuseto participate in experimental research, and to formulate an advance directive.


(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.(8) Nothing in this paragraph should be construed as the right of the resident to receivethe provision of medical treatment or medical services deemed medically unnecessaryor inappropriate.

(d) Choice of attending physician. The resident has the right to choose his or her attendingphysician.

(1) The physician must be licensed to practice, and(2) If the physician chosen by the resident refuses to or does not meet requirementsspecified in this part, the facility may seek alternate physician participation in to assureprovision of appropriate and adequate care and treatment.(3) The facility must ensure that each resident remains informed of the name,Specialty and way of contacting the physician and other primary care professionalsresponsible for his or her care.(4) The facility must inform the resident if the facility determines that the physicianchosen by the resident is unable or unwilling to meet requirements specified in this partand the facility seeks alternate physician participation to assure provision of appropriateand adequate care and treatment. The facility must discuss the alternative physicianparticipation with the resident and honor the resident’s preferences, if any, amongoptions.(5) If the resident subsequently selects another attending physician who meets therequirements specified in this part, the facility must honor that choice.

(e) Respect and dignity. The resident has a right to be treated with respect and dignity,including:

(1) The right to be free from any physical or chemical restraints imposed for purposes ofdiscipline or convenience, and not required to treat the resident’s medical symptoms.(2) The right to retain and use personal possessions, including furnishings, and clothing,

as space permits, unless to do so would infringe upon the rights or health and safety ofother residents.(3) The right to reside and receive services in the facility with reasonableaccommodation of resident needs and preferences except when to do so wouldendanger the health or safety of the resident or other residents.(4) The right to share a room with his or her spouse when married residentslive in the same facility and both spouses consent to the arrangement.(5) The right to share a room with his or her roommate of choice when practicable,when both residents live in the same facility and both residents consent to thearrangement.(6) The right to receive written notice, including the reason for the change,before the resident’s room or roommate in the facility is changed.(7) The right to refuse to transfer to another room in the facility, if the purpose of thetransfer is:


(i) To relocate a resident of a SNF from the distinct part of the institution that is aSNF to a part of the institution that is not a SNF, or(ii) to relocate a resident of a NF from the distinct part of the institution thatis a NF to a distinct part of the institution that is a SNF.(iii) solely for the convenience of staff.

(8) A resident’s exercise of the right to refuse transfer does not affect the resident’seligibility or entitlement to Medicare or Medicaid benefits.

(f) Self-determination. The resident has the right to and the facility must promote and facilitateresident self determination.

(1) The resident has a right to choose activities, schedules (including sleeping andwaking times), health care and providers of health care services consistent with his orher interests, assessments, plan of care and other applicable provisions of this part.(2) The resident has the right to make choices about aspects of his or her life in thefacility that are significant to the resident.(3) The resident has a right to interact with members of the community and participatein community activities both inside and outside the facility.(4) The resident has a right to receive visitors of his or her choosing at the time of his orher choosing, subject to the resident’s right to deny visitation when applicable, and in amanner that does not impose on the rights of another resident.

(i) The facility must provide immediate access to any resident by—(A) Any representative of the Secretary,(B) Any representative of the State,(C) Any representative of the Office of the State long term careombudsman(D) The resident’s individual physician,(E) Any representative of the protection and advocacy systems, asdesignated by the state, Any representative of the agency responsiblefor the protection and advocacy system for individuals with a mentaldisorder(G) The resident representative.

(ii) The facility must provide immediate access to a resident by immediate familyand other relatives of the resident, subject to the resident’s right to deny orwithdraw consent at any time;(iii) The facility must provide immediate access to a resident by others who arevisiting with the consent of the resident, subject to reasonable clinical and safetyrestrictions and the resident’s right to deny or withdraw consent at any time;(iv) The facility must provide reasonable access to a resident by any entity orindividual that provides health, social, legal, or other services to the resident,subject to the resident’s right to deny or withdraw consent at any time; and(v) The facility must have written policies and procedures regarding thevisitation rights of residents, including those setting forth any clinicallynecessary or reasonable restriction or limitation or safety restriction orlimitation, when such limitations may apply consistent with the requirements


of this subpart, that the facility may need to place on such rights and the reasons for the clinical or safety restriction or limitation. (vi) A facility must meet the following requirements:

(A) Inform each resident (or resident representative, where appropriate)of his or her visitation rights and related facility policy and procedures,including any clinical or safety restriction or limitation on such rights,consistent with the requirements of this subpart, the reasons for therestriction or limitation, and to whom the restrictions apply, when he orshe is informed of his or her other rights under this section.(B) Inform each resident of the right, subject to his or her consent, toreceive the visitors whom he or she designates, including, but not limitedto, a spouse (including a same-sex spouse), a domestic partner (includinga same-sex domestic partner), another family member, or a friend, andhis or her right to withdraw or deny such consent at any time.(C) Not restrict, limit, or otherwise deny visitation privileges on the basisof race, color, national origin, religion, sex, gender identity, sexualorientation, or disability.(D) Ensure that all visitors enjoy full and equal visitation privilegesconsistent with resident preferences.

(5) The resident has a right to organize and participate in resident groups in the facility.(i) The facility must provide a resident or family group, if one exists, with privatespace; and take reasonable steps, with the approval of the group, to makeresidents and family members aware of upcoming meetings in a timely manner.(ii) Staff, visitors, or other guests may attend resident group or family groupmeetings only at the respective group’s invitation.(iii) The facility must provide a designated staff person who is approved by theresident or family group and the facility and who is responsible for providingassistance and responding to written requests that result from group meetings.(iv) The facility must consider the act promptly upon the grievances andrecommendations of such groups concerning issues of resident care and life inthe facility.

(A) The facility must be able to demonstrate their response and rationalefor such response.(B) This should not be construed to mean that the facility mustimplement as recommended every request of the resident or familygroup.

(6) The resident has a right to participate in family groups.(7) The resident has a right to have family member(s) or other resident representative(s)meet in the facility with the families or resident representative(s) of other residents inthe facility.(8) The resident has a right to participate in other activities, including social, religious,and community activities that do not interfere with the rights of other residents in thefacility.


(9) The resident has a right to choose to or refuse to perform services for the facility andthe facility must not require a resident to perform services for the facility. The residentmay perform services for the facility, if he or she chooses, when—

(i) The facility has documented the resident’s need or desire for work in the planof care;(ii) The plan specifies the nature of the services performed and whether theservices 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.

(10) The resident has a right to manage his or her financial affairs. This includes the rightto know, in advance, what charges a facility may impose against a resident’s personalfunds.

(i) The facility must not require residents to deposit their personal funds with thefacility. If a resident chooses to deposit personal funds with the facility, uponwritten authorization of a resident, the facility must act as a fiduciary of theresident’s funds and hold, safeguard, manage, and account for the personalfunds of the resident deposited with the facility, as specified in this section.(ii) Deposit of funds.

(A) the facility must deposit any residents’ personal funds in excess of$100 in an interest bearing account (or accounts) that is separate fromany of the facility’s operating accounts, and that credits all interestearned on resident’s funds to that account. (In pooled accounts, theremust be a separate accounting for each resident’s share.) The facilitymust maintain a resident’s personal funds that do not exceed $100 in anoninterest bearing account, interest bearing account, or petty cashfund.(B) Residents whose care is funded by Medicaid: The facility must depositthe residents’ personal funds in excess of $50 in an interest bearingaccount (or accounts) that is separate from any of the facility’s operatingaccounts, and that credits all interest earned on resident’s funds to thataccount. (In pooled accounts, there must be a separate accounting foreach resident’s share.) The facility must maintain personal funds that donot exceed $50 in a non-interest bearing account, interest-bearingaccount, or petty cash fund.

(iii) Accounting and records.(A) The facility must establish and maintain a system that assures a fulland complete and separate accounting, according to generally acceptedaccounting principles, of each resident’s personal funds entrusted to thefacility on the resident’s behalf.(B) The system must preclude any commingling of resident funds withfacility funds or with the funds of any person other than anotherresident.(C) The individual financial record must be available to the residentthrough quarterly statements and upon request.


(iv) Notice of certain balances. The facility must notify each resident that receivesMedicaid benefits—

(A) When the amount in the resident’s account reaches $200 less thanthe SSI resource limit for one person(B) That, if the amount in the account, in addition to the value of theresident’s other nonexempt resources, reaches the SSI resource limit forone person, the resident may lose eligibility for Medicaid or SSI.

(v) Conveyance upon discharge, eviction, or death. Upon the discharge, eviction,or death of a resident with a personal fund deposited with the facility, the facilitymust convey within 30 days the resident’s funds, and a final accounting of thosefunds, to the resident, or in the case of death, the individual or probatejurisdiction administering the resident’s estate, in accordance with State law.(vi) Assurance of financial security. The facility must purchase a surety bond, orotherwise provide assurance satisfactory to the Secretary, to assure the securityof all personal funds of residents deposited with the facility.

(11) The facility must not impose a charge against the personal funds of a resident forany item or service for which payment is made under Medicaid or Medicare (except forapplicable deductible and coinsurance amounts). The facility may charge the residentfor requested services that are more expensive than or in excess of covered services inaccordance with § 489.32 of this chapter. (This does not affect the prohibition on facilitycharges for items and services for which Medicaid has paid. See § 447.15 of this chapter,which limits participation in the Medicaid program to providers who accept, as paymentin full, Medicaid payment plus any deductible, coinsurance, or copayment required bythe plan to be paid by the individual.)

(i) Services included in Medicare or Medicaid payment. During the course ofa covered Medicare or Medicaid stay, facilities must not charge a resident forthe following categories of items and services:

(A) Nursing services.(B) Food and Nutrition services(C) An activities program(D) Room/bed maintenance services.(E) Routine personal hygiene items and services as required to meet theneeds of residents, including, but not limited to, hair hygiene supplies,comb, brush, bath soap, disinfecting soaps or specialized cleansing agentswhen indicated to treat special skin problems or to fight infection, razor,shaving cream, toothbrush, toothpaste, denture adhesive, denturecleaner, dental floss, moisturizing lotion, tissues, cotton balls, cottonswabs, deodorant, incontinence care and supplies, sanitary napkins andrelated supplies, towels, washcloths, hospital gowns, over the counterdrugs, hair and nail hygiene services, bathing assistance, and basicpersonal laundry.(F) Medically-related social services(G) Hospice services elected by the resident and paid for under theMedicare Hospice Benefit or paid for by Medicaid under a state plan.


(ii) Items and services that may be charged to residents’ funds. The facility maycharge to residents’ funds if they are requested by a resident, if they are notrequired to achieve the goals stated in the resident’s care plan, if the facilityinforms the resident that there will be a charge, and if payment is not made byMedicare or Medicaid:

(A) Telephone, including a cellular phone.(B) Television/radio, personal computer or other electronic device forpersonal use.

with RULES2 (C) Personal comfort items, including smoking materials, notions and novelties, and confections. (D) Cosmetic and grooming items and services in excess of those forwhich 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) Cost to participate in social events and entertainment outside thescope of the activities program(J) Non-covered 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 generally prepared by thefacility, as required

(1) The facility may not charge for special foods and meals,including medically prescribed dietary supplements, ordered bythe resident’s physician, physician assistant, nurse practitioner, orclinical nurse specialist(2) when preparing foods and meals, a facility must take into

consideration residents’ needs and preferences and the overallcultural and religious make-up of the facility’s population.

(iii) Requests for items and services.(A) The facility can only charge a resident for any non-covered item orservice if such item or service is specifically requested by the resident.(B) The facility must not require a resident to request any item or serviceas a condition of admission or continued stay.(C) The facility must inform, orally and in writing, the resident requestingan item or service for which a charge will be made that there will be acharge for the item or service and what the charge will be.


(g) Information and communication.(1) The resident has the right to be informed of his or her rights and of all rules andregulations governing resident conduct and responsibilities during his or her stay in thefacility.(2) The resident has the right to access personal and medical records pertainingto him or herself.

(i) The facility must provide the resident with access to personal and medicalrecords pertaining to him or herself, upon an oral or written request, in the formand format requested by the individual, if it is readily producible in such formand format (including in an electronic form or format when such records aremaintained electronically); or, if not, in a readable hard copy form or such otherform and format as agreed to by the facility and the individual, within 24 hours(excluding weekends and holidays); and(ii) The facility must allow the resident to obtain a copy of the records or anyportions thereof (including in an electronic form or format when such recordsare maintained electronically) upon request and 2 working days advance noticeto the facility. The facility may impose a reasonable, cost based fee on theprovision of copies, provided that the fee includes only the cost of:

(A) Labor for copying the records requested by the individual, whether inpaper or electronic form;(B) Supplies for creating the paper copy or electronic media if theindividual requests that the electronic copy be provided on portablemedia;(C) Postage, when the individual has requested the copy is mailed.

(3)The facility must ensure that information is provided to each resident in a form andmanner the resident can access and understand, including in an alternative format or ina language that the resident can understand.(4) The resident has the right to receive notices orally (meaning spoken) and in writing(including Braille) in a format and a language he or she understands, including;

(i) Required notices as specified in this section. The facility must furnish toeach resident a written description of legal rights which includes—

(A) A description of the manner of protecting personal funds(B) A description of the requirements and procedures for establishingeligibility for Medicaid, including the right to request an assessment ofresources.(C) A list of all pertinent State regulatory and informational agencies,resident advocacy groups.

New York State Department of Health 875 Central Avenue Albany, NY 12206 (888)201-4563


Office of Professional Discipline 163 West 125thf Rm 819 New York, NY 10027 (212)961-4369

80 Wolf Road, Suite 204 Albany, NY12205 (518)485-9350

NYS Long-term care Ombudsman Program 11 Park Place New York, NY 10007 (212)812-2901

New York State Commission of Quality of Care and Advocacy for Persons with Disabilities 401 State Street Schenectady, NY 12305 (800)624-4143

The New York Association of Independent Living 155 Washington Ave, Suite 208 Albany, NY12210 (518)465-4650

NYS Office of the Medicaid Inspector General 800 North Pearl Street Albany, NY 12204 [email protected] 1-877-873-7283

(D) A statement that the resident may file a complaint with the StateSurvey Agency concerning any suspected violation of state or federalnursing facility regulations, including but not limited to resident abuse,neglect, exploitation, misappropriation of resident property in the facility,noncompliance with the advance directives requirements and requestsfor information regarding returning to the community.

(ii) Information and contact information for State and local advocacyorganizations, including but not limited to the State Survey Agency, the StateLong-Term Care Ombudsman and the protection and advocacy system(iii) Information regarding Medicare and Medicaid eligibility and coverage;(iv) Contact information for the Aging and Disability Resource Centeror other No Wrong Door Program


mailto:[email protected]/

(v) Contact information for the Medicaid Fraud Control Unit;NYS Office of the Medicaid Inspector General 800 North Pearl Street Albany, NY 12204 [email protected] 1-877-873-7283

(vi) Information and contact information for filing grievances or complaintsconcerning 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, noncompliance with theadvance directives requirements and requests for information regardingreturning to the community.

(5) The facility must post, in a form and manner accessible and understandable toresidents, and resident representatives:

(i) A list of names, addresses (mailing and email), and telephone numbers ofall pertinent State agencies and advocacy groups, such as the State SurveyAgency, the State licensure office, adult protective services where state lawprovides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, homeand community based service programs, and the Medicaid Fraud Control Unit;and(ii) A statement that the resident may file a complaint with the State SurveyAgency concerning any suspected violation of state or federal nursing facilityregulations, including but not limited to resident abuse, neglect, exploitation,misappropriation of resident property in the facility, noncompliance with theadvance directives requirements and requests for information regardingreturning to the community.

(6) The resident has the right to have reasonable access to the use of a telephone,including TTY and TDD services, and a place in the facility where calls can be madewithout being overheard. This includes the right to retain and use a cellular phone at theresident’s own expense.(7) The facility must protect and facilitate that resident’s right to communicate withindividuals and entities within and external to the facility, including reasonable accessto:

(i) A telephone, including TTY and TDD services;(ii) The internet, to the extent available to the facility; and(iii) Stationery, postage, writing implements and the ability to send mail.

(8) The resident has the right to send and receive mail, and to receive letters,packages and other materials delivered to the facility for the resident through ameans other than a postal service, including the right to:

(i) Privacy of such communications consistent with this section; and(ii) Access to stationery, postage, and writing implements at the resident’sown expense.


mailto:[email protected]/

(9) The resident has the right to have reasonable access to and privacy in their use ofelectronic communications such as email and video communications and for Internetresearch.

(i) If the access is available to the facility(ii) At the resident’s expense, if any additional expense is incurred by thefacility to provide such access to the resident.(iii) Such use must comply with state and federal law.

(10) The resident has the right to—(i) Examine the results of the most recent survey of the facility conductedby Federal or State surveyors and any plan of correction in effect with respectto the facility; and(ii) Receive information from agencies acting as client advocates, and beafforded the opportunity to contact these agencies.

(11) The facility must—(i) Post in a place readily accessible to residents, and family members and legalrepresentatives of residents, the results of the most recent survey of the facility.(ii) Have reports with respect to any surveys, certifications, and complaintinvestigations made respecting the facility during the 3 preceding years,and any plan of correction in effect with respect to the facility, available for anyindividual to review upon request; and(iii) Post notice of the availability of such reports in areas of the facility thatare prominent and accessible to the public.(iv) The facility shall not make available identifying information aboutcomplainants or residents.

(12) The facility must comply with the Advance Directives.(i) These requirements include provisions to inform and provide writteninformation to all adult residents concerning the right to accept or refusemedical or surgical treatment and, at the resident’s option, formulate anadvance directive.(ii) This includes a written description of the facility’s policies to implementadvance directives and applicable State law.(iii) Facilities are permitted to contract with other entities to furnishthis information but are still legally responsible for ensuring that therequirements of this section are met.(iv) If an adult individual is incapacitated at the time of admission and is unableto receive information or articulate whether or not he or she has executed anadvance directive, the facility may give advance directive information to theindividual’s resident representative in accordance with State law.(v) The facility is not relieved of its obligation to provide this information tothe individual once he or she is able to receive such information. Follow-upprocedures must be in place to provide the information to the individualdirectly at the appropriate time.

(13) The facility must display in the facility written information, and provide to residentsand 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. (14) Notification of changes.

(i) A facility must immediately inform the resident; consult with the resident’sphysician; and notify, consistent with his or her authority, the residentrepresentative(s), when there is—

(A) An accident involving the resident which results in injury and has thepotential for requiring physician intervention;(B) A significant change in the resident’s physical, mental, or psychosocialstatus (that is, a deterioration in health, mental, or psychosocial status ineither life threatening conditions or clinical complications);(C) A need to alter treatment significantly (that is, a need to discontinueor change an existing form of treatment due to adverse consequences, orto commence a new form of treatment); or(D) A decision to transfer or discharge the resident from the facility.

(ii) When making notification, the facility must ensure that all pertinentinformation) is available and provided upon request to the physician.(iii) The facility must also promptly notify the resident and the residentrepresentative, if any, when there is—

(A) A change in room or roommate assignment as specified in(B) A change in resident rights under Federal or State law or regulations

(iv) The facility must record and periodically update the address (mailing andemail) and phone number of the resident representative(s).

(15) Admission to a composite distinct part. A facility that is a composite distinct partmust disclose in its admission agreement its physical configuration,including the various locations that comprise the composite distinct part, and mustspecify the policies that apply to room changes between its different locations under(16) The facility must provide a notice of rights and services to the resident prior to orupon admission and during the resident’s stay.

(i) The facility must inform the resident both orally and in writing in a languagethat the resident understands of his or her rights and all rules and regulationsgoverning resident conduct and responsibilities during the stay in the facility.(ii) The facility must also provide the resident with the State-developed noticeof Medicaid rights and obligations, if any.(iii) Receipt of such information, and any amendments to it, must beacknowledged in writing;

(17) The facility must—(i) Inform each Medicaid-eligible resident, in writing, at the time of th RULESadmission to the nursing facility and when the resident becomes eligible forMedicaid of—

(A) The items and services that are included in nursing facility servicesunder the State plan and for which the resident may not be charged;


(B) Those other items and services that the facility offers and for whichthe resident may be charged, and the amount of charges for thoseservices; and

(ii) Inform each Medicaid-eligible resident when changes are made to theitems and services

(18) The facility must inform each resident before, or at the time of admission, and periodically during theresident’s stay, of services available in the facility and of charges for those services, including any charges forservices not covered under Medicare/Medicaid or by the facility’s per diem rate.

(i) Where changes in coverage are made to items and services covered by Medicare and/or by theMedicaid State plan, the facility must provide notice to residents of the change as soon as isreasonably possible.(ii) Where changes are made to charges for other items and services thatthe facility offers, the facility must inform the resident in writing at least 60 days prior toimplementation of the change.(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, thefacility must refund to the resident, resident representative, or estate, as applicable, any deposit orcharges already paid, less the facility’s per diem rate, for the days the resident actually resided orreserved or retained a bed in the facility, regardless of any minimum stay or discharge noticerequirements.(iv) The facility must refund to the resident or resident representative any and all refunds due theresident within 30 days from the resident’s date of discharge from the facility.(v)The terms of an admission contract by or on behalf of an individual seeking admission to thefacility must not conflict with the requirements of these regulations.

(19) The facility must -(i) Not request or require residents or potential residents to waive their rights as set forth in theNew York State Operations Manual, Appendix PP, and in applicable state, federal or local licensing orcertification laws, including but not limited to their rights to Medicare or Medicaid; and(ii) Not request or require oral or written assurance that residents or potential residents are noteligible for, or will not apply for, Medicare or Medicaid benefits.(iii) Not request or require residents or potential residents to waive potential facility liability forlosses of personal property.

(20) Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or herpersonal and medical records.

(1) Personal privacy includes accommodations, medical treatment, written and telephonecommunications, personal care, visits, and meetings of family and resident groups, but this does notrequire the facility to provide a private room for each resident.(2) The facility must respect the residents right to personal privacy, including the right to privacy inhis or her oral (that is, spoken), written, and electronic communications, including the right to sendand promptly receive unopened mail and other letters, packages and other materials delivered to thefacility for the resident, including those delivered through a means other than a postal service.(3) The resident has a right to secure and confidential personal and medical records.

(i) The resident has the right to refuse the release of personal and medical records(ii) The facility must allow representatives of the Office of the State Long-Term CareOmbudsman to examine a resident’s medical, social, and administrative records inaccordance with State law.


(i) Safe environment. The resident has a right to a safe, clean, comfortable and homelikeenvironment, including but not limited to receiving treatment and supports for daily livingsafely. The facility must provide—

(1) A safe, clean, comfortable, and homelike environment, allowing the resident to usehis or her personal belongings to the extent possible.

(i) This includes ensuring that the resident can receive care and servicessafely and that the physical layout of the facility maximizes residentindependence and does not pose a safety risk.(ii) The facility shall exercise reasonable care for the protection of theresident’s property from loss or theft.

(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly,and comfortable interior;(3) Clean bed and bath linens that are in good condition;(4) Private closet space in each resident room(5) Adequate and comfortable lighting levels in all areas;

(6) Comfortable and safe temperature levels. Facilities initially certified afterOctober 1, 1990 must maintain a temperature range of 71 to 81 °F; and(7) For the maintenance of comfortable sound levels.

(j) Grievances.(1) The resident has the right to voice grievances to the facility or other agency or entitythat hears grievances without discrimination or reprisal and without fear ofdiscrimination or reprisal. Such grievances include those with respect to care andtreatment which has been furnished as well as that which has not been furnished, thebehavior of staff and of other residents; and other concerns regarding their LTC facilitystay.(2) The resident has the right to and the facility must make prompt efforts by the facilityto resolve grievances the resident may have, in accordance with this paragraph.(3) The facility must make information on how to file a grievance or complaint availableto the resident.(4) The facility must establish a grievance policy to ensure the prompt resolution of allgrievances regarding the residents’ rights contained in this paragraph. Upon request,the provider must give a copy of the grievance policy to the resident.

(k) Contact with external entities. A facility must not prohibit or in any way discourage aresident from communicating with federal, state, or local officials, including, but not limitedto, federal and state surveyors, other federal or state health department employees, includingrepresentatives of the Office of the State Long-Term Care Ombudsman, and any representativeof the agency responsible for the protection and advocacy system for individuals with mentaldisorder (established under the Protection and Advocacy for Mentally Ill Individuals Act of 2000regarding any matter, whether or not subject to arbitration or any other type of judicial orregulatory action.

Effective 12/1/16


ADDENDUM IX

BED RESERVATIONS

BED RESERVATIONS FOR PRIVATE-PAYING RESIDENTS, INCLUDING THOSE RECEIVING MEDICARE BENEFITS. Private paying residents and those non-Medicaid residents covered by Medicare and/or their sponsors and agents may hold a resident’s bed at the prevailing daily basic rate for as long as they wish, if it is expected that the resident will return to Amsterdam Nursing Home from the hospital or from a leave of absence and if the resident’s payment obligations under the Residency Agreement are not in arrears. Amsterdam Nursing Home requires prior written authorization for such bed reservation. During the resident’s absence from the facility, the daily basic rate remains payable under the Residency Agreement until the resident or the resident’s agent cancels the reservation.

Subject to the above conditions, the resident or responsible party and/or sponsor under the Residency Agreement may authorize, in advance, a three-day bed reservation in the event of hospitalization, to be billed at the private pay rate, with the understanding that during such three-day period, the reservation may be continued for as long as needed, or may be canceled.

BED RESERVATION FOR MEDICAID RESIDENTS

The Medicaid program will pay for a bed reservation under the following conditions: For Medicaid residents who are twenty-one (21) years of age or older and are not on hospice, Amsterdam Nursing Home will reserve a bed for any such Medicaid resident on a therapeutic leave of absence from the facility for a maximum of ten (10) days (per 12-month period). At no time will Medicaid pay for a bed-retention period that exceeds ten (10) days for such residents. If such a resident remains on therapeutic leave from Amsterdam Nursing Home for more than ten (10) days, he or she will be officially discharged from Amsterdam Nursing Home and his or her bed will be made available to someone else, unless the bed is reserved at the prevailing private pay rate. However, such resident shall be given priority readmission to Amsterdam Nursing Home. For Medicaid residents who are twenty-one (21) years of age or older and on hospice, Amsterdam Nursing Home will reserve a bed for such resident for up to fourteen (14) days (per 12-month period). At no time will Medicaid pay for a bed-retention period that exceeds fourteen (14) days for such residents. If such a resident remains outside of Amsterdam Nursing Home for more than fourteen (14) days, he or she will be officially discharged from Amsterdam Nursing Home and his or her bed will be made available to someone else, unless the bed is reserved at the prevailing private pay rate. However, such resident shall be given priority readmission to Amsterdam Nursing Home. For Medicaid residents who are less than twenty-one (21) years of age, Amsterdam Nursing Home shall reserve a bed for any such Medicaid resident for hospital, therapeutic and hospice leaves of absences without limitation, pursuant to current Medicaid regulations. The Resident and responsible party and/or sponsor under the Residency Agreement agree to pay promptly all amounts due to Amsterdam Nursing Home (such as NAMI) during any bed hold period.



ADDENDUM IX

BED RESERVATIONS (Continued)

If the Medicaid resident is ineligible for a reserved bed or if the bed reservation expires, the resident and responsible party and/or sponsor, if applicable, have the option to pay to reserve the bed at the prevailing private pay rate. Such a privately reserved bed will be immediately available to the resident upon his/her return to Amsterdam Nursing Home. If the bed is not reserved privately, Amsterdam Nursing Home will release the bed but will give priority readmission for the next available semi-private bed to that resident over the individuals referred to Amsterdam Nursing Home for their first admission. This policy shall be subject to future changes to applicable Department of Health regulations pertaining to Medicaid bed hold policies. The Facility shall reserve the right to incorporate further revisions to this policy that shall be effective as of the date of corresponding revisions to Department of Health regulations, including those implemented retroactively by the Department of Health.
