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Please note: The following sample disclosure form is provided for informational purposes
only. It is not, nor is it intended to be, a substitute for legal advice. You should consult an
attorney for advice regarding your individual situation. We invite you to contact us to learn
more about our services at:
Johnson Flodman Guenzel & Widger Law Firm
1227 Lincoln Mall
Lincoln, NE 68508
Office: (402) 475-4240
Fax: (402) 475-0329
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*Name of Facility*
Disclosure Statement
Overall Philosophy and Mission Statement:
(The overall philosophy and mission statement must reflect the needs of residents
afflicted with Alzheimer’s disease, dementia, or a related disorder).
*Name of Facility* will provide a home for those individuals who are no longer able to live
independently as a result of Alzheimer’s disease, dementia, or a related disorder. *Name of
Facility*’s mission is to ________________________.
Admission Criteria:
(The process and criteria for placement in, transfer to, or discharge from the unit).
Each individual resident’s needs will be screened by ____________________, to ensure those
needs can be met by *Name of Facility*’s staff. Following are requirements for occupancy in
*Name of Facility*/Special Care Unit:
1.
All residents of will have an established diagnosis of Alzheimer’s or related
dementia disorder.
2.
(Add other requirements as may be relevant. If an assisted living facility, you may
want to consider the level of ADLs the facility will handle and whether you will
accept complex nursing interventions with a negotiated risk agreement).
Discharge / Transfer Criteria:
(The process and criteria for placement in, transfer to, or discharge from the unit).
If an assisted living facility: *Name of Facility* reserves the right to discharge any
resident who’s needs cannot be met or their condition does not meet the criteria for placement
in *Name of Facility*. The resident’s responsible party will be given a thirty (30) day written
notice when discharge from the facility is planned, unless immediate discharge is appropriate
to ensure the safety of the resident, the safety of the other residents, or to meet the needs of
acute medical conditions. The final decision regarding discharge from the facility will be the
administrators. Discharge may be necessary when the following occur:
1.
(Identify areas for discharge).
If a nursing facility: *Name of Facility* reserves the right to move a resident back to the
general elderly population when the resident’s condition deteriorates to where the resident
requires additional skilled nursing care. *Name of Facility* will follow the admission /
discharge criteria as set forth in federal and state regulation.
Plan of Care:
(The process used for assessment and establishment of the plan of care and
its implementation, including the method by which the plan of care evolves
and is responsive to changes in condition).
If an assisted living facility: *Name of Facility* evaluates each resident at the time of
admission and negotiates a written service agreement with the resident. Each resident will
have a current service agreement in his or her chart at all times. The service agreement is
initiated at the time of admission. Any time a change has been noted by the administrator or
the administrator’s designee, the resident service agreement will be updated with input from
the family and/or responsible party. Any time the responsible party wishes to change any item
or items in the service agreement, this change will be between the administrator or the
administrator’s designee and the responsible party. The frequency of services provided will be
listed on the resident service agreement, and if there is an update to the service agreement, it
will shared immediately with the direct care staff.
If a nursing facility: Each resident will have a current plan of care in his or her chart at
all times. *Name of Facility* recognizes the importance of a current plan of care and will
reassess the resident and modify the plan of care, if appropriate, on a quarterly basis, or when
there is a substantial change in the resident’s condition. The plan of care is generally prepared
as follows:
1.
At the time of admission, the resident is assessed and a plan of care is completed
and placed in the resident’s chart.
2.
The plan of care will be reviewed on a quarterly basis following a meeting of the
care planning team. The care planning team includes the family and the resident.
The care plan will be updated and placed in the resident’s chart.
3.
Any time there is a substantial change in condition, the care plan team, including
the family and resident, will discuss whether changes are needed to the care plan.
4.
Prior to the care plan meeting, input will be collected from the chart and from staff.
Staff Training and Continuing Education Practices:
(Staff training and continuing education practices which shall include, but not be limited to,
four hours annually for direct care staff. Such training shall include topics pertaining to the
form of care or treatment set forth in the disclosure described in this section. The requirement
in this subdivision shall not be construed to increase the aggregate hourly training
requirements of the Alzheimer’s special care unit).
*Name of Facility* provides orientation and training to allow each staff member to meet
the needs of each resident. Education will include four hours annually of topics pertaining to
the form of care or treatment for the resident with dementia. The topics will include:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Resident rights;
Service agreements / Plans of care;
Advance directives;
Emergency procedures;
Resident special care needs;
Abuse, neglect, and misappropriation of money or property;
Disaster preparedness;
Care tactics;
Infection control;
OSHA standards; and
Dementia disease processes.
Physical Environment and Design Features:
(The physical environment and design features appropriate to support the
functioning of cognitively impaired adult residents).
*Name of Facility* was created and designed to support the functioning of cognitively
impaired adult residents. The design features include (identify your facility’s design features
specific to the cognitively impaired resident).
Resident Activities:
(The frequency and types of resident activities).
The activity programming at *Name of Facility* is designed to meet the interest and
lifestyles of each resident. Activities consist of music, exercise, crafts, sensory stimulation and
the like. Residents are allowed to function at their own pace and to participate in only the
activities they choose. (Add additional information as needed).
Family Involvement:
(The involvement of families and the availability of family support programs).
*Name of Facility* recognizes the importance of, and encourages, family involvement.
Families are asked to participate in preparation of the service agreement/plan of care, activity
programs, meals, and other areas as may be appropriate.
Family support programs such as education, encouragement, emotional support, and
training, are available from *Name of Facility* staff as needed to provide cares for the resident
in accordance with the resident service agreement/plan of care.
Cost:
(The cost of care and any additional fees).
*Name of Facility* charges $___ (outline your basic charges).
If a nursing facility: Identify the level of care. Identify that each individual’s charge is
based on a level of care as identified by the MDS assessment.