Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 113 - Regulations Governing the Licensing and Functioning of Assisted Housing Programs (includes Assisted Living Programs, Residential Care Facilities, and Private Non-Medical Institutions) (formerly 10-149 Ch. 113) › Level IV - Private Non-Medical Institutions › Appendix 144-113-IV-113-IV-A - Licensed Assisted Housing Program Standard Contract

Current through 2024-29, July 17, 2024
This contract is entered into between
					 _________________________________ (hereinafter "the Provider") and you,
					 _________________________________.This contract describes your financial
					 obligations, as well as other responsibilities and rights. It also describes
					 the rights and obligations that apply to the Provider in the course of
					 providing services to you.
This contract is a standard contract required for use in
					 the State of Maine. Providers may add additional provisions to the standard
					 contract in a customized addendum but these additional provisions may not
					 conflict with or replace the use of the standard contract. The intent of having
					 a standard contract in Maine is to permit you to compare costs and services
					 among providers. Providers are required to disclose their contracts and
					 rates.
In consideration of the payment and promises made in
					 this contract, you and the Provider agree as follows:
I.
STANDARDS
The Provider will help to further your independence and
					 respect your privacy and personal choices, including your choice to continue to
					 reside here for as long as the Provider and program, as it is fundamentally
					 designed, is able to meet your needs. The Provider's programs will be consumer
					 oriented and meet professional standards of quality at all times.
This means that if your needs exceed the Provider's ability
					 to provide services, the Provider will assist you in making other arrangements
					 including moving somewhere else, if necessary.
II.
PROVIDER
				  LICENSE
The Provider is licensed in conformity with the
					 requirements of the State of Maine. The type of provider is stated on the
					 license issued by the Maine Department of Human Services and posted for public
					 inspection in the ____________. This Provider is licensed as follows (check
					 one):
[] Level I Residential Care Facility
[] Level II Residential Care Facility
[] Level III Residential Care Facility
[] Level IV Residential Care Facility
[] Level I PNMI Residential Care Facility
[] Level II PNMI Residential Care Facility
[] Level III PNMI Residential Care Facility
[] Level IV PNMI Residential Care Facility
[] Type I Assisted Living Program
[] Type II Assisted Living Program
[] This box will be checked if you rent your unit from a
					 separate entity (referred to in this contract as the "Landlord') that is not
					 the Provider. The Landlord is responsible for enforcing the terms and
					 conditions of the lease. The Provider is responsible for assuring that the
					 terms and conditions of your lease agreement with the Landlord do not conflict
					 with this contract. The State of Maine has reviewed the separate lease
					 agreement and has determined that it complies with all laws and regulations
					 related to the provision of assisted living services. A copy of this lease is
					 attached for reference as Appendix F to this contract. Even though you have a
					 lease with separate landlord, you have the same rights as you would have if the
					 landlord and provider were one and the same.
III.
APPENDICES
The following Appendices are attached and made a part of
					 this contract:
[]
Appendix A: Admissions Policy
[] Appendix B: Your Rights
[] Appendix C: Grievance Policy
[] Appendix D: Tenancy Obligations (check if this
					 applies)
[] Appendix E: Additional terms in Customized Addendum
					 (check if this applies)
[] Appendix F: Applies only if you rent your unit from an
					 entity (the "Landlord") that is not the Provider
IV.
ADMISSION POLICY
There is an Admission Policy that meets the requirements of
					 the State of Maine that describes who can be admitted and the types of services
					 provided. A copy of this policy is attached as Appendix A.
V.
SERVICES PROVIDED DIRECTLY OR
				  INDIRECTLY BY PROVIDER INCLUDED IN THE DAILY/MONTHLY RATE
A. You agree to purchase:
[] Housing and Services.
[] Housing Only.
B. You agree to pay the following current
				  rate to the Provider:
[] Daily rate of $________
[] Monthly rate of $________
[] The amount you pay will be determined by the MaineCare
					 Program.
C. If you rent
				  your unit from a landlord that is a different entity from the Provider, you
				  understand that:
The landlord
					 is________________________________________.
The amount of your current monthly rent is
					 ___________.
D. Certain
				  basic services must be provided in all licensed assisted housing programs. If
				  you have decided to purchase assisted living services, these basic services are
				  provided under the daily/monthly rate you pay for your care. This means the
				  Provider must act in accordance with the regulations to:
1. Observe and assess how you function and/or
				  your individual behaviors for the purpose of enhancing your health and safety
				  or the health and safety of others;
2. Protect you from environmental hazards by
				  mitigating risk in the physical environment to prevent unnecessary injury or
				  accident; and
3. Identify your
				  needs and strengths, develop a service plan and arrange for and monitor service
				  delivery.
E. There is a
				  wide range of services available. Those services and their costs are listed in
				  Appendix E. What you actually receive for services will be based on whether you
				  are purchasing assisted living services, and on your individual assessment and
				  service plan.
If checked below, the service is offered by the Provider
					 as part of your current daily/monthly rate and there is no additional charge to
					 you if it becomes part of your service plan:
1. Personal Supervision.
[] Even though you may travel independently in the
					 community, the Provider will keep track of your general whereabouts
[] Staff will accompany you to medical appointments
[] The Provider provides an escort for regular
					 travel
[] The Provider has qualified staff in the building
					 24-hours/day
[]
					 Other____________________________________________
[] Additional provisions: See Appendix E
2. Assistance with activities of daily
				  living. (These are tasks that you may routinely need assistance with in order
				  to maintain your best level of physical function.)
[] Walking
[] Changing position in bed
[] Transferring from place to place
[] Dressing
[] Eating
[] Using the bathroom
[] Bathing
[] Personal hygiene, such as help washing your hair
[] Other
					 ____________________________________________
[] Additional Provisions: See Appendix E
3. Incidental activities of daily living.
[] Using the telephone
[] Handling your finances
[] Banking
[] Shopping
[] Light housekeeping
[] Heavy housekeeping
[] Getting to appointments
[] Barber/beautician services
[] Other
					 ____________________________________________
[] Additional Provisions: See Appendix E
4. Medication assistance.
[] Obtaining medications from the Pharmacy of your choice:
					 ______________________________________.
[] Ordered by Provider
[] Delivered by the Pharmacy
[] Ordered by you/family member
[] Picked up by Provider
[] Picked up by you/family member
[] Provide qualified staff to help you take your
					 medications (such as reading the container labels, watching while you take a
					 medication, checking the correct dosage, removing the dosage from the
					 container, administering prescribed dosage, filling a syringe, administering
					 any medication as allowed by applicable licensing regulations)
[] Maintaining an individual medication administration
					 record for you that will include all the medications and treatments that your
					 physician orders for you, and a record that includes, for example, information
					 that they have been administered at the right time and in the right dose
[] Other
					 ___________________________________________
[] Additional Provisions: See Appendix E
5. Food Service.
[] Meal preparation (including the cost of food) _____
					 times each day
[] Meal preparation (food purchased separately by you)
					 _________ times each day
[] Nutritious between-meal snacks __________ times each
					 day
[] Special diets ordered by your physician as follows:
					 _____________________________________________________
[] Shopping for groceries you purchase
[] Meal planning
[] Other
					 ___________________________________________
[] Additional Provisions: See Appendix E
6. Transportation services.
[] Arranging transportation (cost of transportation
					 included) ________miles roundtrip
[] Arranging transportation (cost of transportation not
					 included)
[] Transportation without escort to medical appointments
					 within ________ miles roundtrip
[] Transportation with escort to medical appointments
					 within ________ miles roundtrip
[] Other _________________________________________
7. Nursing services. Some
				  providers provide the services of a registered professional nurse. Others use
				  registered professional nurses to coordinate the services and oversee staff who
				  are not nurses. The following nursing services are part of your daily/monthly
				  rate:
[] None
[] Skilled nursing services provided by a registered
					 professional nurse.
[] Registered professional nurse who oversees staff and
					 coordinates your health care needs.
8. Housing Costs. These costs include those
				  associated with your housing instead of your services, and may include things
				  such as heat, lights, cable TV, telephone, your unit and other costs. Check all
				  that apply:
[] All housing costs (there will be no extra
					 charges)
[] All housing costs except:
______________________________________________________
______________________________________________________
______________________________________________________
[] Semi-private room
[] Shared bathroom
[] Private room
[] Private bathroom
[] Efficiency apartment
[] One Bedroom Apartment
[] Two Bedroom Apartment
[] Other
[] Additional Provisions: See Appendix E
[] You have a lease agreement with a landlord other than
					 the Provider: See Appendix F
9. Equipment and supplies. The Provider will
				  supply the following equipment and supplies, as needed, as part of the daily
				  cost that you pay:
[] None
[] Non-prescription analgesics and antacids
[] Bedroom furnishings:
					 ___________________________________
____________________________________________________
[] Pillows, sheets, linens, towels
[] Laundry supplies and equipment
[] Laxatives
[] Thermometers
[] Non-prescription skin creams/lubricants
[] Mouthwash
[] Toothpaste
[] Other non-prescription
					 ointments:_______________________
[] Shampoo
[] Soap
[] Facial tissue
[] Toilet tissue
[] Paper towels
[] Incontinence supplies
[]
					 Other:______________________________________________
10. Additional Services
[] See Appendix E