Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 110 - REGULATIONS GOVERNING THE LICENSING AND FUNCTIONING OF SKILLED NURSING FACILITIES AND NURSING FACILITIES › Appendix 144-110-A - STANDARDIZED NURSING FACILITY ADMISSIONS CONTRACT

Current through 2024-29, July 17, 2024
This contract is between
				  ____________________________________________ (the "Facility)" and
				  ________________________________ (the "Resident"). It will be signed by the
				  Resident or someone authorized to sign for the Resident (the Resident's
				  Agent*). It describes the Resident's financial obligations, as well as other
				  responsibilities and rights. It also describes the rights and obligations that
				  apply to the Facility in the course of providing care to the Resident.
In consideration of the payment and promises made in
				  this contract, the Resident and the Facility agree as follows:
*
An individual who signs this contract as an
				  Agent may or may not be able to make health care or other decisions on behalf
				  of the Resident. The extent of the Agent's authority depends on the nature of
				  the legal relationship between the Agent and the
				  Resident.
1.
Rates and
				  Charges
A. Generally
The Resident agrees to pay with his or her own funds
				  ("private pay") and/or through a third party payor (for example, Medicare,
				  Medicaid or other insurance) for all items and services provided to the
				  Resident by the Facility. Some services will be included in the Facility's
				  daily rate; some may be provided at the Resident's request by the Facility at
				  an additional charge; and some may be provided at the Resident's request by
				  third parties not employed by the Facility. These charges are described further
				  on in this contract.
B. Services and Items That Are Included in the
				  Daily Rate
The current daily rate at this Facility is
				  $______________.This daily rate includes a semi-private room []/ private room
				  [] and includes meals and snacks that meet the daily nutritional and special
				  dietary needs of the Resident, usual and customary nursing services and other
				  services and items as listed in Attachment A.
C. Items and Services Provided by the Facility
				  for an Extra Charge
The Resident will be charged separately for additional items
				  and services which the Resident or the Resident's physician, with the
				  Resident's approval, requests and which are not included in the Facility's
				  daily rate. These items and services may be provided by the Facility or by
				  third parties. The cost of these items or services may or may not be covered by
				  the Resident's insurer, if any. Many of the ordinary items and services for
				  which the Resident may be charged are listed in Attachment B. Costs for certain
				  items and services may be determined in advance, whereas others may vary
				  depending on the needs of the Resident and may not be able to be determined at
				  this time. When the Resident requests an item or service provided by the
				  Facility that is not included in the daily rate, the Resident will be notified
				  of the cost as soon as practicable.
2.
Paying for the Resident's
				  Care
A. Who Can Be Required to Pay for the Resident's
				  Care
Payment for the Resident's care is the responsibility of the
				  Resident. However, a Resident may have insurance, public benefits and/or other
				  third party payors to assist the Resident with the payment of this
				  obligation.
No other person, regardless of whether they are a
				  family member, friend, neighbor, legal agent or guardian (even if they sign
				  this document as an Agent for the Resident), can be required to pay for the
				  Resident's care from his or her own funds unless that person knowingly and
				  voluntarily agrees to pay for the cost of the Resident's care.
Other than amounts required under this contract, the Facility
				  may not charge, solicit, accept or receive any gift, money, donation or other
				  consideration as a precondition of the Resident's admission or to expedite the
				  Resident's admission or to continue the Resident's stay once the Resident is
				  admitted to the Facility.
The Facility requires the Resident or any other person
				  responsible for making payments on the Resident's behalf to pay for the
				  Resident's care under the terms of this contract within _______ days of receipt
				  of the Facility's monthly bill. The Facility may not hold the Resident
				  responsible for the payment of attorneys' fees or any other cost of collecting
				  payment.
It is anticipated that the resident's care will be paid for
				  by one or more of the following:
[] The Medicare Program; (If the Resident is responsible for
				  a co-pay, it will be explained to the Resident.)
[] The Medicaid Program; (If the Resident is responsible for
				  a Cost of Care, it will be explained to the Resident.)
[] Other insurance coverage(s); Please list:
______________________________________
[] The Resident, with the Resident's own funds;
[] Another person, with the Resident's funds;
Name: _____________________________________
Address: _____________________________________ Phone:
				  _____________________________________
Legal Authority:
				  _____________________________________
[] Another person who has voluntarily agreed to pay with
				  his/her own funds.
Name: _____________________________________
Address: _____________________________________
Phone: _____________________________________
The Resident agrees to provide all information requested by
				  the Facility about the Resident's health and financial status in an accurate
				  and timely manner and to update this information while the Resident is a
				  resident at the Facility.
It is understood that Medicare and Medicaid will make the
				  determinations concerning the Resident's medical and financial eligibility for
				  payment by those programs. The Facility is not permitted to require the
				  Resident to waive any rights to Medicare or Medicaid or require the Resident to
				  give written or oral assurances that the Resident is not eligible for, or will
				  not apply for Medicare or Medicaid benefits. The Resident is entitled to apply
				  for Medicare or Medicaid at any time.
B. Increases in Charges and Fees
Any time the Facility makes any changes in rates or charges,
				  responsibilities, services to be provided or any other items included in this
				  contract, the Facility will provide the Resident with at least thirty (30) days
				  advance notice.
3.
Limitations on
				  Liability
The Facility is obligated to take reasonable precautions to
				  provide the Resident and the Resident's personal belongings with security,
				  including providing a reasonable amount of space for the Resident's belongings.
				  The Facility, however, is not responsible for any loss or damage to the
				  Resident's personal belongings, including eye glasses and dentures, unless that
				  loss or damage is caused by the negligent or willful action of the Facility
				  staff.
4.
Rights as a
				  Resident
As a resident of this Facility, the Resident has many rights
				  under Federal and State law. These rights are included as part of this
				  contract. The Facility is required to attach to this contract a complete copy
				  of the state licensing rules establishing the Resident's rights. The Resident
				  must sign a written acknowledgement that the Resident has been informed of
				  these rights. No provision in this agreement may negate, limit or otherwise
				  modify the rights listed in those rules. Some of these rights are described
				  below.
A. Selection of a Doctor or Other Health Care
				  Provider
The Resident may select his or her own doctor and other
				  health care providers, provided that the Resident's doctor or other health care
				  providers comply with any applicable rules or laws concerning the provision of
				  care to the Resident and with the reasonable policies of the Facility.
B. Selection of a Pharmacy
The Resident has the right to obtain medication from the
				  pharmacy of his or her choice, provided that the pharmacy complies with any
				  applicable State rules and Federal regulations and with the reasonable policies
				  of the Facility concerning procurement of medication.
C. The Resident's Personal Property and Financial
				  Affairs
The Facility may not require the Resident to let the Facility
				  manage, hold or otherwise control the Resident's money or property. The
				  resident may, however, choose any person to manage his or her funds, including
				  the Facility. Any of the Resident's funds that are managed by the Facility will
				  not be commingled with Facility funds.
D. The Resident's Right to Make
				  Complaints
The Resident may make complaints about his or her care in the
				  Facility and the Resident may also suggest changes in the policies and services
				  of the Facility. The Resident will not be harassed for making a complaint or
				  suggesting a change in policy or service. The Resident may present his or her
				  complaints orally or in writing to the Facility staff or the Facility
				  administration. If the Resident prefers to make a complaint or suggestion to
				  someone other than the Facility, the Resident may do so orally or in writing to
				  one of the following agencies:
Long Term Care Ombudsman Program
61 Winthrop Street
Augusta, Maine 04332-0126
Telephone and TTY: (207) 621-1079
Toll Free: 1-800-499-0229
Legal Services for the Elderly
Toll Free and TTY: 1-800-750-5353
Division of Licensing and Certification
41 Anthony Avenue
11 State House Station
Augusta, Maine 04333-0011
Toll Free: 1-800-383-2441
TTY: (207) 624-5512
Office of Aging and Disability Services
41 Anthony Avenue
11 State House Station
Augusta, Maine 04333-0011
Toll Free: 1-800-262-2232
TTY: 1-888-720-1925
E. Holding the Resident's Bed if the Resident
				  Leaves the Facility
If Medicaid pays for part or all of the Resident's nursing
				  facility care and the Resident is hospitalized, the Facility will hold the
				  Resident'' bed for up to a maximum number of days in accordance with State
				  regulation. If the Resident is paying privately, or if the Resident's care at
				  the Facility is covered by Medicare, the Facility will hold the Resident's bed
				  at the Resident's option for as long as the Resident pays for it from his or
				  her own funds at the Facility's then current rate.
F. Transfer and Discharge
The Resident has the right to remain here at the Facility and
				  the Resident may not be transferred or discharged against the Resident's will,
				  except for the following reasons:
(1) the Resident's condition has improved so that the
				  Resident no longer needs the services the Facility provides; (2) the transfer
				  or discharge is necessary for the Resident's welfare and the Resident's needs
				  cannot be met by this Facility; (3) the health or safety of another individual
				  in the Facility is endangered; (4) the Resident, after reasonable and
				  appropriate notice, has failed to pay (or through his or her insurer[s] has
				  failed to pay) for a stay at the Facility; or (5) the Facility ceases to
				  operate.
The Facility will notify the Resident and the Resident's
				  family member, guardian or legal representative in writing thirty (30) days in
				  advance of the transfer or discharge except in the following circumstances: (1)
				  the health or safety of another individual in the Facility is endangered; (2)
				  the Resident's health improves sufficiently to allow a more immediate transfer
				  or discharge; (3) an immediate transfer or discharge is required by urgent
				  medical needs; or (4) the Resident has not resided in the Facility for thirty
				  (30) days. Notice in these situations will be provided as soon as
				  practicable.
The notice will contain the reasons for the transfer or
				  discharge and its effective date, the location to which the Resident will be
				  transferred or discharged, and the Resident's rights regarding transfer or
				  discharge. The notice will also tell the Resident how the resident can appeal
				  the Facility's decision to transfer or discharge the Resident, by requesting a
				  hearing, and will tell the Resident what agencies the Resident can call for
				  assistance. The Resident has the right to receive sufficient preparation and
				  orientation to ensure safe and orderly transfer from the Facility. This
				  includes a post-discharge plan of care developed with the participation of the
				  Resident and his or her family, if available. If the Resident is to be
				  discharged involuntarily, the Facility will comply with current law in making
				  discharge or transfer arrangements.
5.
The Resident's Right to End This
				  Contract
This contract terminates when the Resident is discharged from
				  the Facility or if the Resident dies while residing at the Facility. The
				  Resident's bill becomes due and payable ________ days from the date of the
				  Resident's discharge from the Facility. Should the Resident die, the Resident's
				  bill becomes due and payable ________ days after the Resident's death.
In the event the Resident dies while a resident of this
				  Facility, please state whom the Facility should contact:
Family/Friend:______________
Funeral Home:______________
Unless the Resident has instructed the Facility otherwise,
				  the Facility will immediately contact the individual(s) listed above to make
				  funeral arrangements. If the Facility is unable to reach the individual(s), the
				  Facility will contact the funeral home directly.
6.
Identification
				  Photo
The Facility may require a photograph of the Resident solely
				  for the use of the Facility and its employees for the purpose of
				  identification. The Resident consents to the use of such individual photographs
				  of the Resident for identification purposes only. Photographs may not be used
				  for any other purpose without the permission of the Resident for each specific
				  use.
7.
Changes in
				  Law
Any provision of this Agreement that is found to be invalid
				  or unenforceable as a result of a change in Federal or State law or regulation
				  will not invalidate the remaining provisions of this contract and it is agreed
				  that, to the extent possible, the Resident and the Facility will continue to
				  fulfill their respective obligations under this contract consistent with the
				  law.
IN WITNESS WHEREOF,
the parties have executed
				  this contract on this _______ day of _________________, ___________.
This contract signed for admission may not require or
				  encourage anyone other than the Resident to obligate himself or herself for the
				  payment of the Resident's expenses. If anyone other than the Resident informs
				  the Facility that he or she voluntarily wishes to guarantee payment of the
				  Resident's expenses, he or she can only do so in a separate written
				  agreement.
___________________________________
				  _______________________________________
(Nursing Facility) (Resident)
_______________________________________
(Resident's Agent)
Name:
__________________________
Address:
__________________________
Phone:
__________________________
Rider(s) Attached: [] Yes [] No