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Forms > 02 Admissions (70 docs)

02 Admissions (70 docs)

Free Forms, caregiving, nursing forms, policies, Licensing, Training, Case Management, Home Care, Assisted Living, DD, MI, HCBS

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Documents in 02 Admissions (70 docs) (70)

The Admission Agreement is a legal and binding contract that spells out the terms and services for both the resident and the facility.  The resident and/or responsible party and a representative of the facility will need to accept the terms of the agreement. Acceptance of the Terms of this Agreement
This is a checklist of ADDENDA TO THIS AGREEMENT - Check list of various addendums for Admission
This is a Sample Agreement and does not include every subject that may need to be included in a particular facility's agreement.  Modify this agreement where necessary to ensure compliance with your state law and with the advice of your company attorney.  Years of work and modifications have went into this agreement.  We feel ProvidersWeb has one of the best admission agreements in the nation. This sample admission agreement is used with the Resident Handbook - Welcome to Our Home and the Care Service Handbook. Admission Agreement - Private
Admission agreements are a legal and binding business contract.  The admission agreement legally specifies the specific services which will be provided and/or made available, and at what cost.  The language used is extremely important.  This form is designed to assist you in making sure the essential points are covered in your admission agreement. Admission Agreement Worksheet
This checkoff list is helpful to Residential Care Homes, Assisted Living Centers and Nursing Facilities to help check off documents and steps to be taken when admitting a resident to a facility.  This is a great admission check list form. Admission Check Off List
This quiz is used to test the knowledge of the Admission Coordinator regarding the admission process.  It covers the essentials every Admission Coordinator should at least know.  When an admission agreement is executed it is a legal and binding contract therefore it is important for the care business owner to ensure the admission process is completed properly. Admission Coordinator Quiz
The statutory advance health care directive form is as follows: ADVANCE HEALTH CARE DIRECTIVE (California Probate Section 4701) Explanation You have the right to give instructions about your own health care. You also have the right to name someone else to make health care decisions for you. This form lets you do either or both of these things. It also lets you express your wishes regarding donation of organs and the designation of your primary physician. If you use this form, you may complete or modify all or any part of it. You are free to use a different form. Part 1 of this form is a power of attorney for health care. ADVANCE HEALTH CARE DIRECTIVE FORM
This NEW wonderful from help the caregiver review problem areas, challenges, best approaches and more! This form not only provides an initial assessment to help you determine if the resident is suitable for your care services and admission,  it also provides a vehicle for assessing ongoing needs and tracking abilities, challenges, problem areas and symptoms.  ( 8 page Assessment used for pre-admission, admission, retention and history) More questions, easy to use, address falls, assaultive behavior and more. Alzheimer's & Dementia Assessment Pre-Admission, Admission/Retention/History
This form used by a Residential Care or Assisted Living facility to assist in assessing a resident's behavior.  Tool for Case Management Assessment for Behaviors  It should be used with the Mini-mental exam and other assessments forms to determine the resident's behavior care needs. Behavioral Assessment, Case Management Assessment for Behaviors
This is a great care facility resident retention plan on how to keep your current residents.  The care home Administrator can use this as a tool for quality assurance purposes, which can help the care facility retain residents in the facility longer.   A lot of residents move from one facility to another.  If you don't want to lose your residents, you need to have a retention plan. Care Facility Resident Retention Plan
This good sample Care Service Handbook is addendum number 2 to the admission agreement.  It details the various care services the facility would provide.

This handbook describes our Care Services.

We want you to fully understand how we provide care services at our Facility.   It is our responsibility to care for all the residents, and provide a safe working environment for the staff.  This manual contains narrative information about the care services we provide and our reasonable care service Care Service Handbook
Care Video & Media Release Form - to use when recording a resident's condition or behavior for health care or social care purposes. Care Video & Media Release Form
Points to consider when deciding whether to charge residents board and care fees on a monthly or daily basis. Charging by the Day
Sample Addendum to the Admission Agreement regarding a care facility or care business's complaint policy. Complaint Policy - Addendum for Residential Care, Community Care and Assisted Living Homes
A form signed by the responsible party to authorize medical treatment and emergency care of the resident if necessary. For community based care and home care. Consent for Medical Treatment Emergency Care
A great form used by residential care and assisted living staff to keep track of an individual resident's controlled medications.  Controlled Medications are medications like pain pills and sedatives.  One reason they should be controlled in a care facility is that staff have been known to steal these medications.  This form was developed to help prevent staff from stealing medications and to keep a better count of the controlled medications that the facility is responsible for. Controlled Medication Tracking Form
If not prohibited by state law you may obtain a Credit Application for Residency and Services.  This type of form is typically used by community based care facilities, assisted living facilities and nursing homes. Credit Application for Residency and Services
ALF & RCFE Example Addendum to the Admission Agreement regarding the use of a delayed egress system or secured perimeter in a residential care or assisted living type facility. Delayed Egress - Addendum for Residential Care and Community Based Facilities
This form was developed to document when a resident leaves a community care facility or nursing home.  It is important to properly document where the resident went to after they leave for various reasons. Discharge Summary for Care Facilities
This is a sample of a statement the resident and/or responsible party and the staff person completing the admission should sign indicating they have read and understand the house policy or rules of the care community. Ending Resident Handbook Statement Sample
This sample form was developed to be used as an eviction notice from a community care facility to a resident. Can also be used by HCBS facilities in conjunction with state laws. Eviction Notice (Form)
A form used by a Residential Care or Adult Assisted Living Facility to communicate with the home health nurse or physician's nurse regarding any changes in a resident's condition. Facility to Nurse Notes
A form used by a Residential Care or Adult Assisted Living Facility to correspond with the resident's physician regarding any changes in a resident's condition. Facility to Physician Notes
Fall Risk Statement Example for Residential Care and Assisted Living Facilities, check with state law and your legal advisor before using a Fall Risk Addendum.

An example of a Fall Risk Addendum made part of an Admission Agreement.

Fall Risk Addendum
This free document contains links to various fall risk assessments that are commonly used to help determine a person's fall risk level. Resident Fall Assessments include:
Dynamic Gait Index  - 
Tinetti Performance Oriented Mobility Assessment (POMA) 
VA's Get Up and Go Test  
Berg Balance Scale (BBS) 
Activities-specific Balance Confidence (ABC) Scale 

Other Helpful ProvidersWeb Documents: Resident Fall Prevention Care Plan,  Post Fall Management Plan Fall Risk Assessments - For Community Based Care
A form used by a care facility to document the financial information for a resident requesting a discounted rate for residency and services due to financial hardships. Financial Statement for Discounted Residency and Services
An addendum to the admission agreement between resident and care facility regarding food service. Food Service Agreement - Addendum for Community Based Home Care
The Tinetti assessment tool is an easily administered task-oriented test that measures an older adult's gait and balance abilities. Free Tinetti Performance Oriented Mobility Assessment
This newly designed form is completed at the time of admission to a residential care facility.  It contains vital resident identifying and emergency information such as:  name, address, birth date, responsible party, insurance information, etc.  It also contains the resident's emergency information to be used by emergency personnel, physicians, hospitals, etc. General Identification and Emergency Information Residential Care Assisted Living
This Levels of Care Assessment Form was designed to assist the caregiver or admission coordinator to help determine the level of care a resident may need.  This form is simple to use - any assisted living staff could complete it.  Upon admission, the resident will be assessed for the Level of Care Service that needs to be provided.  After admission, if there are increases or decreases in the Level of Care this form can be updated and the corresponding Level of Care Rate can be applied. Levels of Care Assessment Form for Residential Care, Assisted Living & all types of Case Managers
A good form used by Care Facility staff - to be completed by the resident's physician when there is a change in how a medication is to be distributed. Medication Direction Change Doctor's Form
The word Medication Disposition Record
This good form is used by the facility to document medication information when admitting a resident.  It is important to log in the medication the resident brought to the facility upon admission and find out why the resident is taking each medication. Medication Intake Form
A free packet includes mental health assessments. Mental Health Assessment
This form is used by community-based care facilities to help assess a resident's mental status.  It is a layman's tool only and it is not to be used to make a medical diagnosis. Used by Assisted living homes and residential care facilities. Mini-Mental Worksheet for Non-Medical Facilties
Before a resident is allowed to operate a mobility scooter in your facility you should complete the Operation Check List making sure that the person is able to operate the mobility scooter safely. Mobility Scooter Operation Check List for Assisted Living and Community Based Care Homes
More and more people are using a mobility scooter.  As a care facility you need to protect the safety of all individuals.  One good way is to establish an Operation Policy for all individuals who operate a mobility scooter or motorized cart. This great document includes safety and operation, maintenance, and recommendations.   


Our Recommendations
We strongly recommend that you install mobility scooter safety mirrors on each side.

If you decide to take your scooter out into the public, it is best to have a horn, lights, safety mirrors, reflectors and a cell phone in case you break down.

For safety reasons we feel it is best to not... Mobility Scooter Operation Policy - Motorized Carts
A form used by a community-based care facility to assess a resident's nutritional intake.  List of areas to monitor, medical problems related to eating and nutrition, and common signs of malnutrition. RCFE, ALF, RCF, ARF Case Manager, Care Coordinator, Wellness Coordinator Nutritional Assessment Form for Community Based Care, Case Management
Addendum to the Admission Agreement regarding optional services provided by the care facility to the resident. Optional Service Agreement - Addendum
The date the payment is due is a required part of an agreement. The due date is usually the first of the month.  By enforcing late payment charges (as allowed by law), this helps to insure that payments are received by the due date. Payment, Due Date, Late Charges
This consent form is to get permission to use and reproduce of any photograph, digital video, multi-media format or other audio-visual materials for residents, staff and volunteers. For residential care and assisted living facilities. Photograph & Media Release Form for Community Based Care Homes
A great form that is completed by the resident's physician prior to admission to a Residential Care Facility.  This form is more detailed than the usual state's form, and most likely will help the care provider better assess the resident's potential for admission. Physician's Report (Form)
One of the most important forms to complete prior to accepting a resident for care.  This form works well for all types of care facilities.  This form has been developed over a 20 year period of time, with great updates added.  This form is a great tool for assisted living staff assessment and residential care facilities to help evaluate and assess a resident's health and care service needs prior to admittance to the facility.  

We cannot stress enough how important it is to assess a potential resident correctly, prior to accepting them for admission.  Facilities need to make sure they can handle all the resident's care needs.

This multi-page detailed form is an excellent tool for caregiving staff to assist in the pre-admission process. See Levels of Care Form.  Skilled Nursing Facilities typical follow Medi-Care criteria. Pre-Admission Appraisal Assessment Form
A form used as an addendum to the Admission Agreement for a Residential Care, Assisted Living or Nursing Home Facility regarding the pre-admission fee that may be charged if allowed by state law. Pre-Admission Fee Agreement - Addendum
This form is designed to help determine what level of Protective Supervision Assessment Form - Case Management
The best of ProvidersWeb's Evaluations and Assessments Forms in an eBook.  ISBN 1-889226-29-7 ProvidersWeb's "Evaluations and Assessments" Forms eBook - ISBN 1-889226-29-7
The best of ProvidersWeb's Record Review Forms in an eBook.  ISBN 1-889226-27-0 ProvidersWeb's "Record Review" Forms eBook - ISBN 1-889226-27-0
This form is designed to be a tool to explain to residents and responsible parties of the facility's types of rate increases.  It is used as an addendum to the admission agreement. ALF, RCFE, ARF, RCF Rate Increase Agreement - Addendum - For Community Care Facilities
This form was developed for the purpose of assisting care facilities in developing a relocation plan for their residents when necessary. Relocation Plan Form
This sample Resident-Pharmacy Agreement is used to specify which pharmacy the resident and/or responsible party has elected.  It also contains other important pharmacy agreement information. Resident - Pharmacy Agreement
Example Addendum to the Admission Agreement regarding the resident and or responsible party's responsibilities at a residential care facility for the elderly, assisted living facility, or adult residential home. Resident and Responsible Party Responsibilities - Addendum
The document contains a linked list of over 40 resident assessments. Accepting the wrong resident can destroy a business.  One resident who is inappropriate for your facility could for example: harm another resident; need more care than the facility can handle which could lead to a negligent liability lawsuit; wander away from the facility; start a fire; go into a diabetic coma, etc.. Resident Care Assessments for Care Businesses over 40 assessments Case Management
The resident handbook is a set of house rules that govern everyday living actions at the care facility.  This form is used as an acknowledgment for the resident or responsible party to sign that they received a copy of the resident handbook upon admission to a nursing home, residential care facility, or assisted living facility. Resident Handbook (House Rules)
Resident Inquiry Form - this form is used to track a potential resident admission, and to check on your marketing program's effectiveness. Resident Inquiry Form
This great form is used to take the staff step-by-step to ensure new residents are properly orientated to their new assisted living community or community based care home.  It includes proper training on how to use the facility services, call button, other services and safety training. Resident Orientation Form
This form is used to authorize access to a resident's confidential records kept by the Community Based Care Facility and must be signed by the resident or their responsible party. Resident Records Access and Release Form
This form is used to do a roll call in the event of an emergency.  It is helpful to use during drills, and contains the essential basic resident information.  This form is for use by residential care homes for the elderly, developmentally disabled, group homes for kids, secured perimeter facilities for Alzheimers and Dementia residents, nursing homes, RCFE, ALF, ARF and assisted living facilities. Resident Roster Form
A form used by a residential care facility to list the resident's personal property valued at $25 or less, such as clothing. Resident's Clothing and Property List
This great form document contains an example of the order that the resident's records can be kept.  It is a great way to organize the resident's record and can be used as a check-off list to make sure the resident's record contains everything it should.  This is an excellent tool for board and care facilities, assisted living facilities, and even nursing homes. Resident's Record Order Form
A form used to document a resident's cash form in the care facility's possession. Used in all types of community based care homes. Resident's Safeguarded Cash Record Form
This good check list is used to make sure the care facility has all of the needed documentation when admitting a resident for short-term or respite care. Case Management and Facility Administration. Respite Care Check List - Case Management
A good form used by care facilities to conduct and document a Skin and Body Assessment of the resident upon admission, and upon re-admission (even from the hospital). It is essential to document any bedsores, wounds, scars, bruises, rashes or other visble skin conditions, to safeguard the resident's health and to make sure the facility is not blamed for a pre-exsisting condition. Skin and Body Assessment (Form) for Community Care Case Managers & Staff
This form insures the resident know of their rights to medical record privacy.

The federal law protects the Right to Privacy.  The Medical Records Confidentiality Act of 1995 ensures that all 50 states adopt a uniform policy for protecting the confidentiality of medical records. State's Authority to Review the Resident's Record
This form is used by Care Facility Staff to have the resident authorize a request so that the facility can obtain specially protected information.  This form must be signed by the resident or their responsible party. Super Confidential Information Release Form
Addendum to the Admission Agreement regarding the assisted living community or residential care facility's theft and loss policy. Theft and Loss Policies - Addendum
A form that should be signed upon admission as an acknowledgment of the Theft and Loss Policies for community care facilities. Theft and Loss Policies (Form)
Third Party Providers are other care and service providers who provide services to a resident at a community based care facility. This agreement has been designed to help ensure the Third Party Providers follow some important rules pertaining to the services they provide for the resident. Third Party Provider Rules & Policies - Facility Administration & Case Management
Visitor Rules for Care Homes, Care Communities and care facilities. Visitor's Rules
This form was developed as a warning notice to residents when they violate the house rules of a care facility. Warning Notice Violation of House Rule
A great sample Resident Handbook. This booklet contains reasonable House Rules and Policies that have been established to help create a comfortable environment for everyone.  The Resident Handbook has been developed and updated over a 25 year period of time and covers many important rules all residents should follow. Welcome to our Home: Resident Handbook
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