Arkansas Elder Outreach of Little Rock, Inc.

An Arkansas Not for Profit Organization

Malvern Nursing Center Pleasant Valley Living Center
829 Cloud Rd. 12111 Hinson Rd.
Malvern, AR 72104 Little Rock, AR 72212

Spring Creek Living Center Three Rivers Nursing Center

804 North 2nd St. 33904 Hwy. 63
Cabot, AR 72023 Marked Tree, AR 72203

Willowbend at Marion
101 Brougham Ave.
Marion, AR 72364

Admission Agreement

Spring Creek Living Center and the responsible party or resident have discussed the
rights, releases and financial terms and arrangements providing for the medical, nursing,
and professional care of ________________________________________________.

Nursing Home Agreement

1. To furnish room, board, linens, bedding, nursing care, and such personal services
as may be required for health, safety, good grooming, and well being of the
resident.

2. To obtain the services of a licensed physician of the resident’s choice whenever

necessary or the services of another licensed physician if the personal physician is
not available, as well as request from the pharmacy such medications as the
physician may order.

3. To arrange for transfer of the resident to the hospital of the resident’s choice when
it is ordered by the attending physician, and immediately to notify the responsible
party of such transfer. (Ambulance memberships by Residents are neither
required nor encouraged by the facility. Residents who are Medicaid and
Medicare eligible should bear no out-of-pocket expense concerning covered
ambulance transfers).

4. To make refunds of all paid-in-advance funds, pro-rated on a daily basis and

computed by dividing the monthly rate by the number of days in the month.
Responsibility of Resident or Responsible Party

1. To provide such personal clothing and effects as needed or desired by the

resident.

2. To provide male residents with a good razor, preferably electric, for their own
personal use and to keep the razor in good repair.

3. To be responsible for non-covered hospital and transportation charges, if

hospitalization of the resident becomes necessary.

4. To be responsible for all physician’s fees, medications, and other treatments or

aids as ordered by the physician, and to provide transportation of the resident in
case of physician office visits or laboratory work. PHYSICIAN FEES AND
TREATMENT ARE NOT THE RESPONSIBILITY OF THE NURSING HOME.

5. To pay the basic rate agreed upon monthly, in advance, and by the 5th day of the
month.

6. To provide family cooperation with diets, treatments or orders specified by the

physician.

7. To reimburse the home for loss of income on therapeutic home visits or hospital
stays that do not meet the requirements of the Department of Human Services to
the extent they withhold funds from the home.

8. To pay for all necessary physician visits, and laboratory work as required by the
Department of Human Services.

Standard Admission Waiver

1. The management of this home has agreed to exercise such reasonable care toward
this person as his/her known condition may require, however, this home is in no
sense an insurer of his/her safety or welfare and assumes no liability as such.

2. Arkansas Elder Outreach of Little Rock is an Arkansas Not for Profit Corporation
and is registered as a 501(c)(3) charitable organization. Arkansas Elder Outreach
expressly claims charitable immunity in the State of Arkansas and specifically
claims immunity from suit and tort liability.

3. The management of this home will not be responsible for any valuables or money
left in the possession of this person while he/she is a resident at this home.

4. The management of this home will do personal laundry at no charge to the

resident and will exercise our best efforts in clothing care, however, in doing
laundry, Spring Creek Living Center assumes no liability for clothes that may be
 lost or ruined in washing. Dry cleaning of clothes shall be the responsibility of the
resident or family.

Chargeable Items

In addition to the basic monthly rate, Spring Creek Living Center may make charges for
the following items when used for the resident. Cost normally will be the cost of
purchase. Some of these items are ordered directly from the drug store for the resident
and will appear on the medication bill.

1. Over the counter medication items are not charged to Medicaid recipients.

2. Toothpaste, denture cleaners, personal deodorants, shave crèmes, powders,

Kleenex, and razors are available for Medicaid recipients.

3. Razor blades, and repairs to personal electric razors or appliances in the room.

4. Haircuts and beauty parlor services when provided by a licensed operator if

desired.

5. Private rooms, when available, at the request of the resident, will be provided at
an additional charge. Private rooms are only available to private pay residents.

6. Residents will be charged for deliberate breakage of equipment or facilities. They

will not be charged for normal wear and tear, but will be charged for the
repair/replacement cost on willful destruction.

Resident’s Bill of Rights

A copy of the Resident’s Bill of Rights was read and given to the resident or responsible
party.

Room Reassignment

It may be necessary for the nursing home to change room assignments in order to
accommodate new residents. We hope this occurs rarely, however, if requested to change
rooms, serious consideration will be given to the change.
Spring Creek Living Center reserves the right to make a room change if deemed
necessary by the Administrator and Director of Nursing. The resident or family will be
given notice.

Bed Hold Policy

During the course of the stay at the Nursing Facility, a patient may be transferred either
to a hospital for treatment or to home for therapeutic leave. For hospital and home leave,
private pay patients must pay to hold a bed at the Nursing Facility. For Medicaid Patients,
the Department of Human Services (DHS) provides only a limited payment for leave. To
hold a bed for eventual return to the Nursing Facility, the following Bed Hold Policy
applies:

a. For Private Pay Patients, the bed will be held for any single Hospital Leave or
Home Leave for a period up to 30 days provided the Nursing Facility receives full
reimbursement.
b. For Medicaid Patients, the Department of Human Services (DHS) will only pay
for up to 5 consecutive days of Hospital Leave. Thereafter, the bed will only be
held for the resident provided the Responsible Party pays the unpaid Medicaid
portion of the daily charge for Day 6 through the return day to the Nursing
Facility. DHS will pay for up to 14 consecutive days of Therapeutic Home Leave.
Thereafter, the Responsible Party must pay the unpaid Medicaid portion to hold
the bed until return.
c. If the Patients’ hospitalization or therapeutic leave exceeds the bed-hold period,
the Nursing Facility will discharge the Patient. Readmission will be permitted
only if a bed becomes available in a semi-private room and if the Patient:
i. Continues to require nursing facility services; and
ii. The Nursing Facility can meet the Patients needs.

Duration of Agreement

Either party may terminate this agreement on 14 days written notice. Otherwise, it will
remain in effect until a different agreement is executed or until the patient is discharged.
However, this does not mean that a resident will be forced to remain in the Nursing
Home against his will for any length of time. If a Resident leaves the Nursing Home
without prior notice to the home, the home may charge for 14 days (2 weeks) additional
care which would be the normal notice time. This is to allow the home to plan bed
occupancy to maintain quality care at low cost.
Financial Agreement

This resident or responsible party agrees to pay in advance $__________ per month for
room, board, and nursing services. This rate may be revised annually, and notice will be
served in the form of a letter.

This resident will be a Human Services Recipient (Medicaid) and will pay their Resident
Share of $_______, per month, (by the 5th). This is subject to change as raises occur,
Social Security, Retirement, etc.

This resident will be a Medicare patient upon admission. The resident and responsible
party agree to pay the 20% of charges not covered beginning on the 21st Medicare day
should the resident not have secondary insurance to cover the 20%. Also, Spring Creek
Living Center cannot guarantee that a long-term care bed will be available at the end of a
patient’s Medicare stay.

The Arkansas Department of Human Services will specify the amount paid by Medicaid
recipients Resident Share. Upon admission, the Administrator will estimate the Dept. of
Human Services Resident Share based on the financial information available. It is agreed
that this is an estimated budget, subject to revision upon receipt of exact figures from the
Department of Human Services. Upon receipt of the actual Resident’s Share, the
Administrator will notify the family and the account will be brought up to date the
following month, if money is due.

The responsible party has the right to handle the resident’s personal funds.
However, if you delegate this responsibility to the nursing home, we are required
by state regulation to handle these funds. Please, check one of the following
statements:

____1. I delegate _______________________ to handle this resident’s personal funds.

____2. The responsible party of the resident will handle this resident’s personal funds.

___________________________________ _____________________
Administrator Date

___________________________________
Responsible Party

___________________________________
Resident’s Name
 Resident Bill of Rights
The federal government has passed laws that establish the rights of nursing facility
residents. Arkansas has also passed laws that provide additional protection. Each person
admitted to a nursing home has the following rights, among others:

• To be fully informed of these rights and all rules and regulations governing
patient and conduct and responsibilities.
• To be fully informed of services available in the facility and of related charges of
theses services including any charged not paid by Medicaid or not included in the
basic rate per day.
• To be fully informed by a physician of his/her medical condition and to be given
the opportunity to participate in planning his/her medical treatment.
• To complete and advance directive.
• To refuse treatment.
• To be transferred or discharged only for medical reasons or for his/her stay
(except as prohibited by the Medicaid program); to be given reasonable advance
notice and the right to appeal.
• To voice grievances and recommend changes in policies and services to facility
staff and/or outside representatives of his/her choice, free from restraint,
interference, coercion, discrimination, or reprisal.
• To manage his/her personal financial affairs.
• To be free from mental and physical abuse, and to be free from chemical and
physical restraints, except as authorized in writing by a physician to protect the
resident from harming himself/herself.
• To confidential treatment of his/her personal and medical records.
• To be treated with consideration, respect, and full recognition of his/her dignity
and individuality, including privacy in treatment and care for his/her personal
needs.
• To not be forced to perform services for the facility.
• To associate and communicate privately with persons of his/her choice and to
send and receive his/her personal mail unopened.
• To meet with and participate in the activities of social, religious, and community
groups at his/her discretion.
• To retain and use his/her personal clothing and possessions.
• If married to be assured of privacy of visits by his/her spouse, and if both are
residents in the facility, to be permitted to share a room.
 Arkansas Elder Outreach
(An Arkansas Not for Profit Organization)

Policies and Procedures

Visiting Hours
Family and friends should feel free to visit at any reasonable hour. In order to have uninterrupted
visits with your Resident, you may want to view the activity calendar which is prominently
displayed in the facility.

Privacy
We ask that you not enter a Residents room when the door is closed. The Resident or roommate
may be receiving treatment and privacy is a right, which must not be violated. Please remember
to knock first.

Activity Programs
We offer a variety of daily activities for our Residents, including, but, not limited to: church
services, games, music, physical exercise group, bingo, arts and crafts, shopping trips, luncheon
buffets, field trips, cooking classes, and much, much more! Attendance is voluntary, however, we
do ask your support and cooperation in getting residents involved in activities.

Inventory of Personal Effects

It is the policy of Arkansas Elder Outreach Facilities to request an inventory of the resident’s
personal effects upon admission.
1. Resident/Responsible Party will be given an Inventory of Personal Effects Sheet to
complete upon admission.
2. All articles must have quantity, items of specific value (watches, rings, TV, radios, etc.)
must be listed.
3. All clothing must be marked with resident name.
4. Anything acquired after the initial admission must be listed on the Inventory of Personal
Effects which is located in the medical records chart at the nurses’ desk.
5. Anything taken out of the resident room after initial admission must be noted on the
Inventory of Personal Effects.
6. The Inventory of Personal Effects must be signed upon admission and discharge.
7. If an item becomes lost or misplaced, the facility will follow the Lost and Found Policy.
8. If an item is not on the Inventory of Personal Effects, the facility is not responsible for
any type of reimbursement.

Lost and Found

It is the policy of Arkansas Elder Outreach Facilities to receive reports of lost and found items
belonging to residents and to quickly work towards a reasonable and satisfactory conclusion. The
following is the lost and found procedure:
1. Logged in with Social, Nursing, or Administration staff and given to the Social Worker
for processing.
2. Report of lost item(s) made with description.
3. Incorporate other departments to help in search of lost item.
4. Look in lost/found area, which is the social office.
5. Search other rooms and areas throughout the facility.
6. If an item is not on the Inventory of Personal Effects, the facility is not responsible for
any type of reimbursement.
Family Meal Service
Arkansas Elder Outreach Facilities offer one meal to one family member free of charge. If more
than one family member wishes to eat with the resident, dietary services will charge $1.50 per
tray which should be paid to the business office during normal business hours or to dietary
services after normal business hours. Family members wanting to take advantage of the meal
service must notify social services, activity director, or dietary manager at least four (4) hours in
advance.

Special Diets
If the Resident is placed on a special diet by their Physician, the Dietary Manager or Director of
Nursing will explain the reason for the diet and what specific foods are allowed. Physician’s
orders will be followed. Please check with the LPN of RN before taking food from outside to a
Resident. Food must be brought in airtight containers. Some Residents may be refused certain
foods due to their diet. Always check with a Nurse before giving another Resident any type of
food.

Medication
Medication may be given ONLY by an LPN or RN. Medication is given at scheduled times based
on Physician orders. Under no circumstances may the Resident be allowed to have prescription or
over-the-counter medication in their room.

Baths/Showers
Baths and showers begin early each morning. This allows us to give some baths before breakfast.
Immediately following breakfast, baths and showers begin again. Most residents receive a
bath/shower at least three times a week, although we do have residents who take daily baths due
to medical issues. One reason we don’t bathe our residents everyday is that, with aging, skin
tends to dry more rapidly and frequent bathing intensifies this problem.

Bed Times
We do not have set bed times. Each resident usually sets his/her own scheduled. Most residents
tend to turn in early rather than late. We have a few who enjoy activities in the dining room late at
night. We also have an occasional resident who likes to sleep late and requests a late breakfast.
Although we lock or doors at night, you are welcome to visit anytime. If visiting after hours, we
ask that you respect other residents, especially roommates, and the staff by assisting us in
maintaining a quiet atmosphere. Overnight guests are discouraged.

Home Visits
We encourage family to take their Resident for a home visit or to an outside activity, if able and
approved by their physician. Anytime a Resident leaves the facility, the person taking them must
sign them out at the Nurses Station and back in upon return.

Care Plan Meetings

The “care plan” is a strategy by which the staff will help the resident with nursing care needs and
activities of daily living. A care plan can address any medical or non-medical issue involved in
caring for or assisting the resident. Each resident’s plan is tailored specifically for the resident.
Care plans are reviewed every three months, when the residents condition changes, or as needed.
We encourage family to attend care plan meetings and bring to our attention any ideas or
concerns about the resident’s care.
Resident Council
Resident Council gives residents the opportunity to work together towards a common goal and
share in planning and controlling their lives. An active council can do much to prevent, minimize,
and even eliminate some of the problems related to group living. Resident Council meets
regularly each month.

Family Council
Family Council is designed to give family members a voice in decisions that affect them and their
resident-loved ones and an opportunity to provide special support to one another. Issues may be
presented to the administrator and department heads as necessary. To become involved pleas
contact the administrator.

Please feel free to ask us any questions.

Administrator: Steve Hudgens

Director of Nursing: Jeff Pledger
Assistant Director of Nursing: Tosha Kirby
Social Worker/Admissions: Chelsea Baldwin
Dietary Manager: Morronica Covington
Activity Director: Iona Dorsey
Medical Director: Dr. Scott Simmons
Smoking Policy
Smoking poses serious risks to the resident’s health and safety, and is against medical
advice. However, we acknowledge and respect the individual’s right to smoke.

It is the policy of Arkansas Elder Outreach Nursing Facilities that all residents who
smoke will receive a full smoking assessment identifying the need for supervision. After
initial assessment each smoker will be reassessed yearly and PRN. Each resident will be
identified for need of supervision while smoking. All smokers will be care planned as
supervised or non-supervised with specific interventions in place. Consents and contracts
will be signed by the smoker and their responsible party. All Arkansas Elder Outreach
Facilities are Smoke Free. Smoking will be allowed in designated areas outside the
facilities.

Any resident assessed with permission to keep any type of lighting device for smoking
must sign a form indicating they will not light anyone’s cigarette but their own, nor will
they loan their lighter to anyone. Residents allowed to keep cigarettes and lighters must
put lighters that are not in use in a secure area, not accessible by other residents.
Example: purse, lock box, or bedside table with a safety lock.

______________________________ ________________________
Resident’s Signature Date

______________________________
Resident’s Name (printed)

______________________________
Responsible Party
 NO CPR
DO NOT
RESUSCITATE
DNR

State of Arkansas
Emergency Medical Services
DO NOT RESUSCITATE ORDER

Patient’s Full Name:_______________________________________________________

____________________________________________ _________________
Signature of Patient or Health Care Proxy/Legal Guardian Date

ATTENDING PHYSICAN’S ORDER

I, the undersigned, state that I am the physician for the patient named above.

I hereby direct any and all qualified Emergency Medical Services personnel, commencing on the
effective date noted below, to withhold cardiopulmonary resuscitation (cardiac compression,
endotracheal intubation and other advanced airway management, artificial ventilation,
defibrillation, administration of cardiac resuscitation medications, and related procedures) from
the patient in the event of the patient’s cardiac or respiratory arrest. I further direct such personnel
to provide to the patient other medical interventions such as intravenous fluids, oxygen, or other
therapies deemed necessary to provide comfort care or alleviate pain.

_______________________________________ ________________________________
Signature of Attending Physician Physician’s Telephone (emergency)

_______________________________________ ________________________________
Physician’s Printed Name Date Order Written
 FULL
CODE

State of Arkansas
Emergency Medical Services
FULL CODE ORDER

Patient’s Full Name:_______________________________________________________

____________________________________________ _________________
Signature of Patient or Health Care Proxy/Legal Guardian Date

ATTENDING PHYSICAN’S ORDER

I, the undersigned, state that I am the physician for the patient named above.

I hereby direct any and all qualified Emergency Medical Services personnel, commencing on the
effective date noted below, to perform cardiopulmonary resuscitation (cardiac compression,
endotracheal intubation and other advanced airway management, artificial ventilation,
defibrillation, administration of cardiac resuscitation medications, and related procedures) on the
patient in the event of the patient’s cardiac or respiratory arrest. I further direct such personnel to
provide to the patient other medical interventions such as intravenous fluids, oxygen, or other
therapies deemed necessary to provide comfort care or alleviate pain.
 *HIPPA CONSENT FORM
*HIPPA is the Health Insurance Portability and Accountability Act of 1966

Our Notice of Privacy Practices (NPP) provides information about how we may use and
disclose PHI about you. You have the right to review our NPP before signing this
consent. As provided in our NPP, the terms of our NPP may change, in accordance with
changes in Federal regulations. A current copy may be obtained by requesting a copy or
by viewing the notice on our website at: www.nursinghome.com.

You have the right to request that we restrict how PHI about you is used and disclosed.
We are not required to agree to this restriction, but if we do, we are bound by our
agreement.

By signing this form, you consent to our use and disclosure of PHI about you for
treatment, payment and healthcare operations. You have the right to revoke this consent,
in writing, except where we have already made disclosures in reliance on your prior
consent.

If you have any questions, you may contact our Privacy Officer/Ombudsman,. Herman
Estaun at (501)372-5300.

Patient’s Signature:____________________________________ Date:_____________

Responsible Party:____________________________________

Relationship to Patient:_________________________________
 ASSIGNMENT OF BENEFITS FORM
Patient’s Name:___________________________________________________________

Patient’s Medicare #:______________________________________________________

Patient’s Medicaid #:______________________________________________________

Other Insurance:__________________________________________________________

Insurance #:______________________________________________________________

Insurance Policy Subscriber Name:___________________________________________

I, _______________________________ request that payment of authorized Social

Security Administration, Medicare, Medicaid and/or other insurance benefits be made to

Spring Creek Living Center on my behalf for any service furnished to me.

I authorize any holder of medical or other information about me to release the Social

Security Administration, Medicare Program, Medicaid Program, and/or other insurance

carriers and their agents or intermediaries any information needed to determine

authorized benefits.

By signing below, I certify that the above information that I have provided is correct and

that I have read and understand the assignment of benefits to Spring Creek Living

Center.

_______________________________________ _____________________
Patient Name Date

_______________________________________ _____________________
Responsible Party Signature Relationship to Patient
 Medicare Admission Information
Resident Name:___________________________________________________________
Date of Birth:____________________________________________Age:_____________
Social Security Number:____________________________________________________
Primary Contact Person/Responsible Person:____________________________________
Name:_____________________________________Relationship:___________________
Address:________________________________________________________________
Home Phone:_______________________________Day Time Phone:_______________

The Medicare Program MAY provide up to 100 days. If the resident qualifies for
Medicare Services, Medicare will pay 100% of approved charges for the first 20 days.
Days 21 through 100, Medicare will pay approved charges with co-pay insurance or
private pay being responsible for _____ per day. It is important for you to know and
understand that even though the resident may initially qualify for Medicare Skilled
Services, he or she may be discharged at any time before the 100th day for any of the
following reasons (this is not an all inclusive list)

1. Resident refuses to participate.

2. Resident is unable to comprehend and/or follow instructions.
3. Resident meets his or her goals.
4. Resident reaches his or her maximum potential.
5. Resident no longer has a skilled nursing need.

Discharge Planning begins on the day of admission. Discharge Plans for this resident at
this time:
__________Place on waiting list for Long Term Bed at ________________
__________Discharge Home
__________Discharge to Assisted Living Environment
__________Discharge to another Long Term Care Facility
__________Other:______________________________________________

Please list your choices for placement at the time of discharge:

1.____________________________________________________________
2.____________________________________________________________

I have read and understand the Medicare Information above.

Signature:_________________________________________________
Date:_____________________________________________________

If you have any questions regarding the Medicare Program, Resident’s Progress,
Discharge Planning, or have any concerns, please contact ______________________at
Spring Creek Living Center.
 COVERED AND NON-COVERED SERVICES & CHARGES
MEDICARE

Medicare Part A Certified Section

Room and Board

Routine Nursing Care
Routine Supplies and Equipment

Medicare covers charges for the following ancillary services when approved:

Pharmacy Physical Therapy Radiology

Speech/Language Pathology Laboratory Occupational Therapy
Medical Supplies, Chargeable

Medicare does not cover charges for the following personal needs, items or services:

Personal Laundry Transportation Massage Therapy

Equipment Rental Private Room TV/Cable Hook-Up
Private Duty Nurse Beauty Shop Telephone

If the beneficiary meets the qualifying conditions, Medicare will pay 100% of the daily
room rate plus all covered ancillary charges for the first 21 days. You (the beneficiary)
are required to pay a portion of the charge for the 21st through the 100th day of coverage
for each benefit period. That portion is called co-insurance. The co-insurance is
established by the Federal government and presently is ______ per day. Medicare pays
the remaining portion. Some supplemental insurance will cover the coinsurance amount.

Medicare will not pay for personal items or services. You will be charged for personal
needs items and services.

When the beneficiary meeting qualifying conditions is no longer covered for Medicare
Part A inpatient services, Medicare Part B may pay 80% of the following ancillary
services and you (the beneficiary) will be billed 20% co-insurance.

Occupational Therapy Physical Therapy Speech/Language Pathology

Surgical Dressings Tube Feedings Radiology
Prosthetic Devices Laboratory

_________________________________________ ______________________
Beneficiary/Responsible Party Date

_________________________________________
Facility Representative
 MEDICARE BED HOLD

IF A RESIDENT IS ON MEDICARE AND SENT TO THE HOSPITAL

FOR ADMISSION, THE DAY THEY ARE SENT OUT, THEY ARE
DISCHARGED FROM Spring Creek Living Center.

IF THE FAMILY/RESPONSIBLE PARTY WISHES TO HOLD THE

BED UNTIL THE RESIDENT RETURNS FROM THE HOSPITAL,
THE PRIVATE RATE WILL BE PAID FOR BED HOLD. IF THE BED
HOLD IS NOT AGREED TO, THE RESIDENT WILL BE
DISCHARGED FORM THE FACILITY AND WILL NOT HAVE A BED
AVAILABLE UPON DISCHARGE FROM THE HOSPITAL.

THE PRIVATE RATE IS _______PER/DAY AND WILL BE

CALCULATED FOR BED HOLD.

I UNDERSTAND THE ABOVE POLICY AND AGREE TO IT.

RESIDENT/RESPON SIBLE PARTY: _________________________

FACILITY
REPRESENTATIVE:______________________________________

DATE:___________________