RESIDENCE AGREEMENT | Columbine Commons Assisted Living
Columbine Commons Assisted Living
RESIDENCE AGREEMENT
This Agreement is between Columbine Commons Assisted Living (hereafter referred to as “We,” “Our,”
or “Us”)
and (hereafter referred to as “You”).
Columbine Commons Assisted Living is a licensed assisted living residence located at
1475 Main Street, Colorado, 80550. We provide room and board,
housekeeping, limited transportation, activities, medication administration, and
some assistance with activities of daily living to persons who do not require
24-hour medical or nursing care, depending on the level of care assessed.
This Agreement provides a statement of the services that we furnish. This Agreement
also sets forth your legal obligations to us, both financial and non-financial. Additional
appendices to this agreement, included hereto and incorporated herein, include:
• Appendix A – Levels of Care
• Appendix B – Charges for Additional Services
• Appendix C – Additional Acknowledgments and Consents signature page
• Appendix D – Medication/Emergency Procedures and charges
• Appendix E – Pet Policy and Agreement ( Applicable Not applicable)
• Appendix F – Personal Funds Account
• Appendix G - Notice of Privacy Practices
• Appendix H - Lift Policy
• The Resident & Family Handbook, this includes:
1. Fire Alarm & Evacuation Procedures
2. House Rules
3. Grievance Procedures
4. Resident Rights
5. Activities
6. Staffing
This lease agreement is for a month-to-month tenancy. The lesser shall not require
the forfeiture of rent beyond a thirty-day period if the lessee moves due to a
medical condition or dies during the term of the lease.
You agree to abide by the rules, regulations, policies, and principles, as amended from
time to time. Any violations of the terms of the Resident Handbook or this
Agreement are grounds for termination of this Agreement.
RESIDENCE AGREEMENT | Columbine Commons Assisted Living
I. Basic Ser vices
Beginning on , we will provide you
with the following Basic Services subject to the terms of this
Agreement. These services are included in your Monthly Fee
unless otherwise indicated. Charges for services and supplies
not included in the Basic Services Rate are listed in Appendix B.
Your Apartment . You may occupy and use apartment
subject to the terms of this Agreement and
the Resident Handbook as they may be amended from
time to time. You are responsible for furnishing your own
apartment and providing your own linens. You are free
to decorate your apartment as you wish, provided that
you comply with our safety rules. You may not make any
structural or physical changes to your apartment unless
expressly approved in writing by us. Because of health
and safety guidelines, bedside commodes, space heaters
and electric blankets, extension cords, and area rugs are
not permitted. Power strips, one per room, may be used
in place of extension cords subject to our prior approval.
You release us from all liability for other electrical devices/
appliances that you use, such as irons, curlers, razors,
televisions, radios, lamps, etc.
Comm on Areas . Along with the other residents, you
may use common areas for their intended purposes, such
as the main dining room, private dining room, lounges,
activity rooms, meeting rooms, the beauty/barber shop, gardens, and other facilities. Some of
these rooms may require advanced reservations. We
may change or reconfigure the common areas at our
discretion for renovations.
Mea ls and Snac ks. We serve you with regular
meals in the dining room. Snacks are available 24-hours
per day. We provide the following therapeutic diets if
prescribed by your physician: (1) no concentrated sweets
(low sugar or no sugar dessert option); and (2) no added
salt (regular diet with no added salt). Other special
dietary arrangements must be negotiated in advance and
are not included in the Monthly Fee.
La undry . The laundering of personal laundry on a
weekly basis is included in the Monthly Fee. Laundry
service is provided once or twice a week as determined
by your Level of Care as outlined in Appendix A. We do
not provide dry cleaning services, but we will help you to
arrange for such services.
House kee ping . We will provide you with housekeeping
services as described in the Resident Handbook, including an
annual cleaning of all windows, and carpeting. Housekeeping
service is provided once or twice a week as determined by your
Level of Care as outlined in Appendix A. Additional carpet
shampooing in your apartment is available for the charge
provided in Appendix B.
Acti vities . We will provide a program of planned activities,
opportunities for community participation, and services
designed to meet your physical, social, and spiritual needs.
Trans portati on. We will make arrangements for or
provide transportation to you in order to meet your necessary
medical needs. Charges for transportation are provided in
Appendix B. All other transportation is your responsibility.
Obser vati on. We will intermittently observe your health
status to identify any changes in your physical, mental,
emotional, and social functioning. We will help you respond
to your dietary and health needs and needs for special
services. We do have a staff member in the facility, at all
times, that is certified in basic first aid. In the event of an
emergency, we will summon emergency medical services
to assist you by calling “911” or otherwise summoning
appropriate medical services personnel.
Plan of Care . We, together with you and your legal
representative (if you have one), interested family members
(with your consent), and your other health care providers,
will develop and carry out a written plan of care that
addresses your physical, mental, and social well-being
and functional capabilities. This plan of care will be
periodically reviewed and revised as necessary to meet your
needs. Your initial Care Plan is attached to this document.
Your Care Plan will be reviewed approximately 30 days after
admission and at least annually thereafter.
Hea lth Needs We Cann ot Meet . You hereby
acknowledge that we do not provide any medical or
nursing care. If medical attention is needed, you hereby
instruct us to contact your physician to arrange for
needed care. If we believe a medical emergency exists,
we will summon emergency medical services to assist you
by calling “911” or otherwise summoning appropriate
medical services personnel. We do not administer
emergency care including cardiopulmonary resuscitation.
Home health nursing services are available as ordered by
your physician. We will assist you with obtaining outside
services such as home health nursing, medical equipment,
and foot care. Please contact the Social Services Director
for more information or to arrange for such services.
RESIDENCE AGREEMENT | Columbine Commons Assisted Living
Anci llary Ser vices . Columbine Commons Assisted Living has a
responsibility for ensuring that all ancillary services are
delivered correctly to the residents. Columbine Commons Assisted Living
encourages residents to use the ancillary services provided
by Columbine Health Systems. Those services include:
Columbine Poudre Home Care, LLC, Market Centre
Medical Equipment, Inc., and Centre Pharmacy, Inc.
Emergency Contact . You designate
____________________________(name),
_______________________(relation), as the emergency
contact to be notified along with your primary physician in
case of an emergency or in the event of an accident or other
significant change in your physical, mental, or emotional status.
Assistance with Acti vities of Dai ly Li ving .
We will make available to you assistance, as needed, with
dressing, grooming, bathing, and other activities of daily
living, to the extent allowed by law.
Assistance with Storage and
Administrati on of Medicati ons . We will assist
you with storage and administration of your medications
and assistance in taking medications to the extent allowed by
law. If we determine that these services cannot properly be
provided to you because of any law, transfer to a higher level
of care outside of Columbine Commons Assisted Living may be required.
Hea lth Rec ords . We maintain a separate medical
record for each resident, which may contain medical and
other personal information. We will keep all information
in your clinical and administrative records confidential in
accordance with state and federal laws and your wishes. We
will not disclose the contents of your records without your
prior written consent except as allowed by law. Our Notice
of Privacy Practices is included as Appendix G.
Pers ona l Funds Acc ount . You hereby acknowledge
that we offer a Personal Funds Account to manage money
for your personal use. This account is subject to a monthly
handling fee by the facility of $2.00.
Excluded Ser vices . Except as otherwise expressly stated
in this Agreement and the Appendices attached hereto, you are
responsible for furnishing or paying for any of your health and
medical care services including, without limitation, hospital
services, physician services, nursing services including skilled
nursing facility charges, private duty personnel, medications,
over-the-counter medications, vitamins, foot care, eye glasses,
eye examinations, hearing aids, ear examinations, dental work,
dental examinations, orthopedic appliances, laboratory tests,
x-ray services, or any rehabilitative therapies.
II. Fees -- Pri vate Pay
Basic Ser vices Rate . You hereby agree to pay us the
amount of $________________ on or before the 5th day
of each month hereafter for the Basic Services. Accounts
which are past the due date of the 5th of the month shall be
subject to a late payment charge of $25. Accounts, which
remain past due by the 17th of the month, shall be subject
to an additional late payment charge of 1.5% of the unpaid
balance. If it becomes necessary for Columbine Commons Assisted Living Assisted Living,
to refer the resident’s account to an attorney, the
Resident and Financially Responsible Party, Legal Guardian,
Conservator, or Attorney-in-Fact, shall be obligated for
payment of Columbine Commons Assisted Living reasonable attorney’s fees
and court costs. In special circumstances, with the written
permission of the Administrator, the late fee may be waived.
Failure to make payment within 45 days of due date will result
in commencement of involuntary discharge proceedings.
Payment for any care from the date of this agreement to the
first of the next month will be prorated on the basis of the
monthly rate and will be due on the signing of this Agreement.
Additi ona l Ser vices . You hereby agree to pay us
for all Additional Services requested by you. The current
list of Charges for Additional Services is attached to this
Agreement as Appendix B.
Adjustments to Rates . We shall have the right,
upon 30 days prior written notice to you, to change your
Basic Services Rate and other fees and charges. The rate
for the apartment type you choose, plus the level of care
assessed, determines the monthly rate. The level of care
is determined by an assessment prior to admission and is
reassessed at Care Plan conferences or as determined by us.
The type of service and assistance necessary to meet your
individual needs determines the Care Level. We will notify
you and / or your legal representative if we determine that a
change in your Care Level is necessary.
Entrance Fee . Upon execution of this Agreement,
you shall pay a one time non-refundable Entrance Fee of
$___________. We do not require a security deposit to
reserve a room before moving in; however, you are required to
start paying the Basic Services Rate immediately. In the event
that Columbine Commons Assisted Living had to close the facility immediately
and was unable to provide a thirty days notice of such closure,
money collected from the resident, the resident’s family or
the resident’s legal representative to reserve a room, prior to
the resident moving in, would be returned to the resident, the
resident’s family, or the resident’s legal representative effective
the day of the facility closure.
RESIDENCE AGREEMENT | Columbine Commons Assisted Living
Absences and Room Hold Rate . If you are
admitted to another health care facility and you choose to
hold your room for your return, you will pay 100% of the
Basic Services Rate per day for the first 20 days you are
absent. Beginning on the 21st day and for the duration
of the hold, the rate to hold the room is 75% of the Basic
Services Rate. The Room Hold Rate will automatically
start upon your departure to another health care facility.
For any absences you incur other than for medical
reasons, you will pay 100% of the Basic Services Rate per
day for the duration of your absence. If possible, you
agree to notify us in advance of any absences.
III. Term and Terminati on
Term . This agreement shall begin on , and shall continue
until terminated in accordance with this Agreement.
Terminati on by You. You may terminate this
Agreement at any time, with or without cause, by giving
our Administrator or Social Services Director 30 days
prior written notice. Your notice must identify the date
when the termination shall become effective, which date
must be at least 30 days after the date of the notice. If you
discharge before the end of this 30-day notice period, you
remain responsible for all charges through the end of the
notice period. In all cases of discharge, our Social Services
Director will provide re-location assistance as needed.
Terminati on by Us . We may terminate this Agreement
at any time, with or without cause, by giving 30 days prior
written notice to you and/or your legal representative, if
applicable. It is our policy to terminate this Agreement for:
nonpayment and/or a finding by us that we cannot properly
care for you and/or your failure to comply with our written
policies and rules and/or when we cannot protect you from
harming yourself or others. Unless a shorter time period
is allowed by law, you and/or your legal representative will
receive 30 days prior written notice of discharge.
Terminati on Upon Your Death . This Agreement
shall terminate automatically upon your death. All amounts
due and payable under this Agreement shall become and
remain our property, and your estate shall be charged for
any unpaid bills. Your estate will pay the Basic Services Rate
until your apartment is vacated of all personal belongings.
RESIDENCE AGREEMENT | Columbine Commons Assisted Living
Refunds . If this Agreement is terminated with proper
notice given, and if you have paid in advance for services
beyond the termination date, such advance payments shall be
refunded to you within 30 days of your discharge. In the case
where we accept payment by Medicaid, advance payments
for Basic Services and the Supplemental Charge shall be
refunded to you following our receipt of the final payment by
Medicaid. The day of discharge will be included in the final
balance owed if you leave and all personal belongings are
removed. Possession of the apartment in any form, or benefit
to any services the day of discharge will result in a charge
for that day. We have the right to deduct money owed by
you as a result of charges incurred at any Columbine Health
Systems related entity from any refund due to you. Examples
of related charges include, but are not limited to, pharmacy
charges and charges for rehabilitation services. Refunds will
be mailed after final resolution of all claims and money owed.
V. Misce llane ous
Entry int o Your Apartment . We may enter your
apartment at reasonable times and for reasonable purposes,
including inspection, maintenance, and other services
described in this Agreement. We will make reasonable
efforts to notify you that our employee will enter or has
entered your room for non-routine events. Further, we are
licensed as an Assisted Living Residence by the State of
Colorado and, as such, a duly authorized agent may, after
providing proper identification and stating the purpose of
his or her visit, enter and inspect our community, including
your apartment, at any time without advance notice.
No Pr operty Interest . Your rights under this
Agreement are the rights and privileges expressly granted, and
do not include any property interest in Columbine Commons Assisted Living.
This Agreement gives you the right to live in our community
and to have as much freedom and choice regarding your life
here as possible. However, it does not give you the rights of a
“tenant” as that term is defined by state law. We reserve the
sole right to provide management of our community in the
best interests of all residents, including the right to make all
decisions concerning the admission, terms of admission, or
discharge of other residents consistent with state law.
Liabi lity for Damage . You agree to maintain your
apartment in a clean, sanitary, and orderly condition. You
shall reimburse us for the repair to your apartment and
for the repair or replacement of furnishings and fixtures
owned by us above and beyond ordinary wear and tear. In
addition, you shall reimburse us for any loss or damage to
our real or personal property outside of your apartment
caused either intentionally or negligently by you or by
persons on the premises with your permission.
Loss of Pr operty . We are not responsible for loss
of any property belonging to you due to theft or any
other cause unless such loss is caused by the negligent or
intentional acts of us or our employees. If you wish to
purchase insurance for the loss of your property, you are
responsible for purchasing and maintaining such insurance.
You release us and our employees from responsibility
for cash, credit cards, personal documents, photographs,
bridgework, dentures, eyeglasses, hearing aids, or other
valuables retained in your possession while living in our
facility. If you choose to change or add a locking device to
your room, you will first obtain our consent.
Anci llary Ser vices . The undersigned understands
that, generally speaking, ancillary services health care
providers will directly bill you, your health care insurance
company, or a government-supported program such as
Medicare, for the costs of their services. The
undersigned acknowledges and agrees that, if your health
care insurance company, or a government-supported
program fails to pay a valid bill from an ancillary services
health care provider, it may be necessary in some instances
for us to pay the bill on your behalf to guarantee your
continued receipt of proper health care and to avoid an
immediate threat to your health, safety, and welfare. If we
pay any such valid ancillary services bill on your behalf, you
agree that this amount will become an additional debt owed
to us and will appear on your monthly bill. You understand
that failure to promptly pay this additional debt once
invoiced may cause your involuntary discharge or transfer
from Columbine Commons Assisted Living for nonpayment. We may choose
not to pay any such ancillary services bill on your behalf
unless required to do so by federal or state law.
Sprin kler Systems . You acknowledge that we have
automatic sprinkler systems throughout the entire building,
including in your apartment.
RESIDENCE AGREEMENT | Columbine Commons Assisted Living
Indemni ficati on. You, on behalf of yourself, your heirs,
assigns, and any and all other persons who may claim through
or by you, do hereby indemnify, hold harmless, release, and
discharge us, our agents, officers, representatives, directors,
and employees, from any and all liability of any nature that has
arisen or that currently exists, or that may arise as a result of
the following: (1) any injury or damages of any sort that occur
while you are not on the premises owned and operated by us;
(2) any and all injuries resulting from your termination of this
Agreement; and (3) injuries or damages that may result from
your negligence or the negligence of any other person or entity,
except for our negligence.
Governing Law . This Agreement shall be governed by
and construed under the laws of the State of Colorado.
Amendment . This agreement may be amended by mutual
consent or by us giving 30 days written notice of the
amendment to you.
Wai ver of Breach . Our failure in one or more instances
to insist upon the strict performance, observance, or compliance
by you with any of the terms and provisions of this Agreement,
shall not be construed to be a waiver or relinquishment by us of
our rights to insist upon strict compliance by you with all of the
terms and provisions of this Agreement.
Assignment . This Agreement may not be assigned by you
without our prior written consent.
Att orney Fees . In the event any action is brought us to
enforce the terms of this Agreement, we shall be entitled to our
reasonable costs and attorney fees incurred therein, in addition
to such other relief as the court may deem appropriate.
Sta ffing . As required by the state, this facility will
divide and document the 24-hour day into two 12 hour
blocks which will be considered daytime and nighttime.
The daytime hours will be from 6:00am to 6:00pm. The
nighttime hours will be from 6:00pm to 6:00am. This
facility is staffed with awake PCP staff 24 hours a day.
Entire Agreement / Access to Funds . The
foregoing contains the parties’ entire agreement and is
mutually accepted and entered into by the parties whose
signatures appear below. The resident or person(s) signing
this Agreement certify that they have read and understand
this entire Agreement. The undersigned has legal access
to the resident’s income or resources and will pay bills,
charges, interest, and collection costs owed by the resident
to us from the resident’s income or resources.
Resident Signature Date Printed Name
Legal Representative(s) Signature Date Printed Name(s)
Columbine Commons Assisted Living Representative Signature Date Printed Name
Although we do not require personal guarantees as a condition of admission or continued stay, any
person may knowingly
and voluntarily agree to guarantee payment for the cost of your care from their assets. By signing below
as a “third party
guarantor,” such person guarantees payment for the cost of your care from their assets.
Third Party Guarantor(s) Signature Date Printed Name(s)
RESIDENCE AGREEMENT | Columbine Commons Assisted Living
Le vel 1 Le vel 2
Mobi lity Independent, but may use a
walker, wheelchair or cane.
Mobile but requires assistance
due to cognitive impairment, or
physical limitations.
Nutriti on Independent. May need verbal reminders and/
or help cutting food. Provide
daily assistance or reminders with
snacks or dietary supplements.
Hygiene Independent. Needs stand by assist, cueing or
minimal physical assistance with
bathing and personal grooming.
Dressing Independent to minimal
assistance with fasteners. May
require assistance picking out
clothing.
Requires reminders, cueing,
or physical assistance.
Continence Total control or independent
with using incontinence
products or catheter supplies.
May be incontinent. Needs
assistance with supplies or physical
assistance changing product or
catheter receptacles.
Menta l Stat us Oriented, may have
some forgetfulness.
May require direction,
reminders and cueing.
Beha viora l
Stat us
No problems. Appropriate
with others.
Moderate staff intervention to
cope with situational distress
and /or events.
Comm unicati on Able to make needs known. Able to make needs known
with some difficulty.
Medicati ons Managed by the facility Managed by the facility.
Requires additional assistance
with medications. Coumadin
therapy, scheduling lab draws, or
monitoring blood sugar testing.
Requires using a mail order
pharmacy service.
La undry Provided once a week. Provided twice a week.
House kee ping Provided once a week. Provided twice a week.
Le vels of Care Appendi x A
RESIDENCE AGREEMENT | Columbine Commons Assisted Living
Appendi x b
Ser vice Descri pti on COST
Guest Mea ls Normal guest meals (breakfast,
lunch, or dinner)
$6.00 per meal, per guest
Special holiday meals $10.00 per meal, per guest
$5.00 fee per room tray may be imposed if the residents continues to request room trays
House kee ping Additional carpet cleaning $50.00
Trans portati on Medical Appointments Drop-off and pick-up by van driver only
No Charge for immediate area
Medical Appointments Accompanied by staff member
$25.00 per hour, Loveland
and Fort Collins
Personal rides within city limits $7.95 per mile
Bea uty Shop /
Barber Shop
Ser vices
Additional charges apply See Beautician for rates
Telephone Monthly service fee $35.00
Unlimited Long distance No Charge
Cab le Televisi on Monthly service fee $25.00
Pet Charges Non refundable deposit $400.00
Pers ona l Funds
Acc ount
Monthly service fee $2.00
Apartment
Trans fer
Fee to move to another apartment
within the facility
$150.00
Power Stri ps Facility to remove multiple use outlets or
extension cords and replace with a power strip
$20.00 per Power Strip
Pharmacy
Ser vices
Use of pharmacy other than Centre Pharmacy
$250.00 per month
Dietary
Modified diets including mechical soft and pureed deits.
$200.00
Nursing
Nursing services that are needed for the resident and are within CC scope of practice and regulations.
Examples include, catheter changes, injections, blood glucose monintoring, wound care, etc
$12.50 a unit, units are calculated in 15 minute increments
Lost Pendant Fee to replace lost pendant $100.00 per pendant,
per occurrence
Charges for Additi ona l Ser vices
RESIDENCE AGREEMENT | Columbine Commons Assisted Living
Acknowledgements and Consents Appendi x C
Resident: _________________________________________ Apartment: ___________
Advance directi ves . Options for establishing
advanced directives have been explained to me and
I have received the pamphlet entitled “Your Right to
Make Health Care Decisions”.
I currently have the following advance directives and
have copies on file with Columbine Commons Assisted Living.
cal Power Of Attorney
My Legal Authority is:
Ph otogra phs . I consent to allow the staff or
others to photograph me while residing at Columbine
Commons. The prints or negatives can be used for
internal company purposes deemed appropriate.
My name and likeness may also be used in the
facility newsletter. If the company desires to use a
photograph for marketing purposes,
allow the company to do so.
Resident Handb ook. I hereby acknowledge that I
have received a copy of the COLUMBINE COMMONS ASSISTED LIVING
RESIDENT AND FAMILY HANDBOOK, and I agree
that I have read and become familiar with its contents,
or have had the contents read and explained to me.
Resident Rights . I acknowledge that I have read,
or had explained to me, Columbine Commons Assisted Living’ policy
on residents’ rights. I have also received a copy of the
Residents’ Rights.
Fire and Evac uati on Plan . Columbine Commons Assisted Living’
Fire and Evacuation Procedures and diagram were
explained to the resident within 48 hours of arrival.
(Provider initials and date:__________________)
Initia l Care Plan . I have been involved in
developing and have received a copy of the
initial care plan.
Acknowledgements and Consents
I have received, read, and understand the following
information provided by Columbine Commons Assisted Living:
n Procedures
Resident/Responsible Party Date Printed Name
Provider Date Printed Name
RESIDENCE AGREEMENT | Columbine Commons Assisted Living
Appendi x D
MEDICATION ADMINISTRATION. Unless
self-administered by a resident, medication, both
prescription and non-prescription (over-the-counter)
shall be administered by a Qualified Medication
Administration Person (QMAP) or a licensed nurse and only upon
the written order of a licensed physician or other
authorized practitioner. Per facility policy, if a
resident desires to self-administer medication,
either prescription or over-the-counter, there must
be documentation from a physician stating that the
resident may self-administer the medication.
Select preference:
Columbine Commons Assisted Living will secure and provide
administration of medications.
Columbine Commons Assisted Living will monitor and remind
resident to take their medications.
Upon admission to the facility residents will need
to bring all prescription and over-the-counter
medications and signed physician’s orders prior to
QMAP’s or Licensed Nurses administering medication. Any time the
resident visits a physician and receives new medication
orders, we must have written orders to administer
the medication.
CPR
In the event of an emergency, 911 will be called.
Columbine Commons staff members do not
provide emergency care but also cannot perform
CPR. Information regarding CPR directive, No
Resuscitation Orders, and other Advance Directives
are available from the Social Services Department.
Resuscitation Orders and other Advance Directives
are available from the Social Services Department.
PHARMACY AND OV ER THE COUNTER
MEDICATIONS. Residents may use the pharmacy
of their choice. Columbine Health Systems offers
a campus pharmacy that the Clinical Coordinator
and Medication Manager work closely with to see
that medications administered are in compliance
with the Department of Health regulations and
Columbine Commons Assisted Living’ policy and procedures. Centre
Pharmacy is a full service pharmacy that can deliver
both prescription and (over-the-counter) medications
routinely as well as on an urgent basis. Centre
Pharmacy uses the PAK-MED system for packaging
medication to help QMAP’s and Nurses administer medications
accurately and efficiently. If a resident chooses not to
use Centre Pharmacy for prescriptions and over the
counter medications, a monthly service fee of $250.00
will be charged. This fee covers the cost of the
additional time required for medication management
and administration of medications.
Select preference:
____________________________Pharmacy.
Resident will be charged a $250 monthly service fee.
Note: The responsible party must ensure all
medications are available at Columbine Commons Assisted Living at
all times.
MEDICATION AND EMERGENCY PROCEDURES
I have read and understand the Medication and Emergency Procedures.
Resident/Responsible Party Date Printed Name
Provider Date Printed Name
RESIDENCE AGREEMENT | Columbine Commons Assisted Living
Pet Policy and Agreement Appendi x E
We wi ll re view :
1) Animal type
2) Animal’s temperament
3) Appropriateness of animal type; may not be
considered appropriate because of the following:
a. Poisonous animal
b. Size
c. Age: Cats and Dogs must be
1 year old or older
The following documents must be made available:
1) Vet exams, vaccinations within the
last three months
2) Vet records validating the
good health of the animal
3) Current registration
4) New address tags
FEES. A non-refundable deposit of $400.00 is required.
Note . The Rabies vaccine is required by law for dogs
and cats. If given before the animal is a year old, it
must be repeated at one year, and then Larimer County
requires re-vaccination every three years. It is also
recommended, but not required, that dogs receive the
Distemper vaccine, and that cats receive both the Feline
Distemper and the Feline Leukemia vaccines.
Columbine Commons Assisted Living complies with local and state law,
and follows recommended guidelines.
TERMS.
• If the pet displays aggression, or is a threat to the
health and/or safety of the staff, visitors, residents,
or other pets, Columbine Commons Assisted Living will contact the
resident and/or their representative and have the
pet removed from the facility immediately.
• Food supplies and pet care are the sole
responsibility of the resident or the resident’s
family. The resident is responsible for exercising
the animal on a regular basis, and for the disposal
of all animal waste.
• The pet will not be allowed to stay at the facility
without the presence of the resident; this includes
resident illness, hospital stays, or vacation.
During these times, other arrangements are the
responsibility of the resident or the resident’s family.
• Pets will be quarantined when the facility concludes
it is needed, i.e. before integrating with other pets.
• Columbine Commons Assisted Living is not responsible for lost pets.
• If at any time a resident becomes abusive to their
pet, the pet will be removed immediately and
turned over to the primary responsible person.
• Upon discharge of the resident from Columbine
Commons, the pet will also be discharged.
I have read and understand Columbine Common’ pet policies. I agree to comply with their policies as
stated herein.
Resident/Responsible Party Date Printed Name
Witness Date Printed Name
Pets will be determined appropriate by Columbine Commons Assisted Living Admissions /Administration
.
RESIDENCE AGREEMENT | Columbine Commons Assisted Living
This Personal Funds Account Agreement is entered into by and between
,
hereinafter referred to as Resident, and Columbine Commons Assisted Living, a Colorado Corporation
and Assisted Living Facility, hereinafter called Facility.
This agreement allows Facility to maintain and manage funds
deposited for Resident while residing at Columbine Commons Assisted Living.
• Facility will manage funds up to, but not exceeding $500 at any given time.
• Monies will be available for Resident use upon request and during normal business hours.
• There will be a monthly service charge assessed at $2.00 per month.
• A quarterly accounting will be provided to the resident or responsible party at least quarterly.
I have read and understand Columbine Commons Assisted Living Personal Funds Account Agreement.
Resident/Responsible Party Date Printed Name
Witness Date Printed Name
Pers ona l Funds Agreement Appendi x F
RESIDENCE AGREEMENT | Columbine Commons Assisted Living
Appendi x G
THIS NOTICE DESCRIBES HOW MEDICAL
INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN ACCESS THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY.
We have summarized our responsibilities and your
rights on this first page. For a complete description of
our privacy practices, please review this entire notice.
Our Res ponsibi lities
Our Entity is required to:
• Maintain the privacy of your health information
• Provide you with this notice of our legal duties and
privacy practices with respect to information we
collect and maintain about you
• Abide by the terms of this notice
Your Rights
As a resident/client of our Entity, you have several rights
with regard to your health information, including the
following:
• The right to request that we not use or disclose
your health information in certain ways.
• The right to request to receive communications
in an alternative manner or location.
• The right to access and obtain a copy of your
health information.
• The right to request an amendment to your
health information.
• The right to an accounting of disclosures of
your health information.
We reserve the right to change our privacy practices and to
make the new provisions effective for all health information
we maintain. Should our privacy practices change, we will
post the changes in a prominent location in our Entity, as
well as on our web site. A copy of the revised notice will be
available after the effective date of the changes upon request.
We will not use or disclose your health information without
your authorization, except as described in this notice.
If you have questions and would like additional information,
you may contact our Entity’s Privacy Officer.
NOTICE OF PRIVACY PRACTICES 45 C.F.R. 164.520
Understanding Your Hea lth Rec ord /Informati on
Each time you receive services from an Entity, a record is made.
Typically, this record contains your symptoms, examination and
test results, diagnoses, treatment, and a plan for future care or
treatment. This information, often referred to as your health or
medical record serves as a:
• basis for planning your care and treatment
• means of communication among the many health
professionals who contribute to your care
• legal document describing the care you received
• means by which you or a third-party payer can verify that
services billed were actually provided
• a tool in educating health professionals (a source of data for
medical research)
• a source of information for public health officials who
oversee the delivery of health care in the United States
• a source of data for facility planning and marketing
• a tool with which we can assess and continually work to
improve the care we render and the outcomes we achieve
Understanding what is in your record and how your health
information is used helps you to: ensure its accuracy, better
understand who, what, when, where, and why others may access
your health information, and make more informed decisions when
authorizing disclosure to others.
How We Will Use or Disc lose
Your Hea lth Informati on
1) Treatment. We will use or disclose your health information
for treatment purposes, including for the treatment activities of
other health care providers. For example, information obtained
by a nurse, physician, or other member of your healthcare team
will be recorded in your record and used to determine the course
of treatment that should work best for you. Your physician will
document in your record his or her expectations of the members
of your healthcare team. Members of your healthcare team will
then record the actions they took and their observations. In
that way, the physician will know how you are responding to
treatment. We will also provide your physician or a subsequent
healthcare provider with copies of various reports that should
assist him or her in treating you once your discharged from our
nursing facility.
2) Payment. We will use or disclose your health information
for payment, including for the payment activities of other
health care providers or payers. Skilled nursing facilities
are required to submit resident assessment information to
governmental agencies for payment purposes. For example,
a bill may be sent to you or a third-party payer, including
Medicare or Medicaid. The information on or accompanying
the bill may include information that identifies you, as well
as your diagnosis, procedures, and supplies used.
RESIDENCE AGREEMENT | Columbine Commons Assisted Living
3) Health Care Operations. We will use or disclose your
health information for our regular health care operations.
For example, members of the medical staff, the risk or
quality improvement manager, or members of the quality
improvement team may use information in your health
record to assess the care and outcomes in your case
and others like it. Governmental agencies continually
compile data based on resident information and return
it to the facility for quality assessment and improvement
activities. This information will then be used in an effort
to improve the quality and effectiveness of the health care
and service we provide.
In addition, we will disclose your health information
for certain health care operations of other entities.
However, we will only disclose your information under
the following conditions: (a) the other Entity must have,
or have had in the past, a relationship with you; (b)
the health information used or disclosed must relate
to that other Entity's relationship with you; and (c) the
disclosure must only be for one of the following purposes:
(i) quality assessment and improvement activities; (ii)
population-based activities relating to improving health
or reducing health care costs; (iii) case management and
care coordination; (iv) conducting training programs; (v)
accreditation, licensing, or credentialing activities; or (vi)
health care fraud and abuse detection or compliance.
4) Business Associates. There are some services provided
in our organization through the use of outside people
and entities. Examples of these "business associates"
include our accountants, consultants and attorneys. We
may disclose your health information to our business
associates so that they can perform the job we have asked
them to do. To protect your health information, however,
we require the business associates to appropriately
safeguard your information.
5) Directory. Unless you notify us that you object, the follow
may occur. We may use your name, location in the facility,
and religious affiliation for directory purposes. This
information may be provided to members of the clergy
and, except for religious affiliation, to other people who
ask for you by name. We may also use your name on a
nameplate next to or on your door in order to identify your
room. We may also use your personal health information
on a wristband.
6) Notification. We may use or disclose information to
notify or assist in notifying a family member, personal
representative, or another person responsible for your
care, of your location and general condition. If we
are unable to reach your family member or personal
representative, then we may leave a message for them
at the phone number that they have provided us, for
example, on an answering machine.
7) Communication with Family. We may disclose to a
family member, other relative, close personal friend or
any other person involved in your health care, health
information relevant to that person's involvement in your
care or payment related to your care.
8) Research. We may disclose information to researchers
when certain conditions have been met.
9) Transfer of Information at Death. We may disclose
health information to funeral directors, medical
examiners, and coroners to carry out their duties
consistent with applicable law.
10) Organ Procurement Organizations. Consistent with
applicable law, we may disclose health information to organ
procurement organizations or other entities engaged in the
procurement, banking, or transplantation of organs for the
purpose of tissue donation and transplant.
11) Marketing. We may contact you regarding your treatment,
to coordinate your care, or to direct or recommend
alternative treatments, therapies, health care providers
or settings. In addition, we may contact you to describe a
health-related product or service that may be of interest to
you, and the payment for such product or service.
12) Food and Drug Administration (FDA). We may disclose to
the FDA, or to a person or Entity subject to the jurisdiction
of the FDA, health information relative to adverse events
with respect to prescription drugs, foods, supplements,
products and product defects, or post marketing
surveillance information to enable product recalls, repairs,
or replacements.
13) Workers Compensation. We may disclose health
information to the extent authorized by and to the
extent necessary to comply with laws relating to workers
compensation or other similar programs established by law.
14) Public Health. As required by law, we may disclose your
health information to public health or legal authorities
charged with preventing or controlling disease, injury,
or disability.
15) Correctional Institution. Should you be an inmate of a
correctional institution, we may disclose to the institution
or agents thereof health information necessary for your
health and the health and safety of other individuals.
16) Law Enforcement. We may disclose health information
for law enforcement purposes as required by law or in
response to a valid subpoena.
17) Reports. Federal law makes provision for your health
information to be released to an appropriate health
oversight agency, public health authority or attorney,
provided that a work force member or business associate
believes in good faith that we have engaged in unlawful
conduct or have otherwise violated professional or
clinical standards and are potentially endangering one or
more patients, workers or the public.
RESIDENCE AGREEMENT | Columbine Commons Assisted Living
Your Hea lth Informati on Rights
Although your health record is the physical property of the
nursing facility, the information in your health record belongs
to you. You have the following rights:
• You may request that we not use or disclose your health
information for a particular reason related to treatment,
payment, the Facility's general health care operations, and/or
to a particular family member, other relative or close personal
friend. We ask that such requests be made in writing on a
form provided by our facility. Although we will consider your
request, please be aware that we are under no obligation to
accept it or to abide by it. We will abide by your requests with
regard to the disclosure of your clinical and personal records
to anyone outside of the facility, except in an emergency, if
you are being transferred to another health care institution,
or if the disclosure is required by law.
• If you are dissatisfied with the manner in which or the
location where you are receiving communications from us
that are related to your health information, you may request
that we provide you with such information by alternative
means or at alternative locations. Such a request must be
made in writing and submitted to the Privacy Officer. We
will attempt to accommodate all reasonable requests.
• You may request to inspect and/or obtain copies of health
information about you, which will be provided to you in the
time frames established by law. You may make such requests
orally or in writing; however, in order to better respond to
your request we ask that you make such requests in writing
on our facility's standard form. If you request to have copies
made, we may charge you a reasonable fee.
• If you believe that any health information in your record
is incorrect or if you believe that important information
is missing, you may request that we correct the existing
information or add the missing information. Such requests
must be made in writing, and must provide a reason to
support the amendment. We ask that you use the form
provided by our facility to make such requests. For a request
form, please contact the Privacy Officer.
• You may request that we provide you with a written
accounting of all disclosures made by us during the time
period for which you request (not to exceed 6 years).
We ask that such requests be made in writing on a form
provided by our facility. Please note that an accounting
will not be provided for any of the following types of
disclosures: disclosures made for reasons of treatment,
payment or health care operations; disclosures made to
you or your legal representative, or any other individual
involved with your care; disclosures to correctional
institutions or law enforcement officials; and disclosures
for national security purposes. You will not be charged
for your first accounting request in any 12-month period.
However, for any requests that you make thereafter, you
may be charged a reasonable, cost-based fee.
• You have the right to obtain a paper copy of our
Notice of Privacy Practices upon request. You may also
access and print a copy of our notice from our website:
www.columbinehealth.com.
• You may revoke an authorization to use or disclose health
information, except to the extent that action has already been
taken. Such a request must be made in writing.
For More Informati on or to Report a Pr oblem
If you have questions and would like additional information,
you may contact our Entity’s Privacy Officer.
If you believe that your privacy rights have been violated,
you may file a complaint with us. These complaints must
be filed in writing on a form provided by our Entity. The
complaint form may be obtained from Privacy Officer and
when completed should be returned to the Privacy Officer.
You may also file a complaint with the secretary of the federal
Department of Health and Human Services. There will be no
retaliation for filing a complaint.
Acknowledgement of Recei pt of Notice of Pri vacy Practices
I hereby acknowledge that I have received Columbine Health Systems Notice of Privacy Practices. I
understand that this
Notice of Privacy Practices outlines my rights under the Health Insurance Portability and Accountability
Act (HIPAA).
If I have further questions regarding the Notice of Privacy Practices, I understand that I may contact the
Entity’s Privacy Officer.
The Privacy Officer of this Entity Contact number for the Privacy Officer
Signature of Resident/Client or Responsible party Date Printed Name
Provider
Signature of Entity Representative Date Printed Name
RESIDENCE AGREEMENT | Columbine Commons Assisted Living
LIF T POL ICY Appendi x H
Columbine Commons Assisted Living is a “no lift facility”. If a Resident falls and is unable to assist the
staff at Columbine Commons Assisted Living in getting themselves up, the staff will summon the local
Emergency Response Team (ERT). Other reasons that the staff may summon the ERT
when a Resident falls, include, but are not limited to: the Resident expresses pain with
or without movement; the Resident hits his/her head; a Resident is unable to rise with
minimal assistance from staff. Minimal assistance is helping lift 50 pounds or less.
Resident Signature Date Printed Name
Responsible Party Signature Date Printed Name
Facility Representative Signature Date Printed Name