POLICIES AND SERVICES:
• Services provided in the basic rental fee.
• Rate increases are reviewed January 1 and July 1 of each year.
• Rate increases will change prior to above dates when health conditions change:
• Private or shared rooms
• Safe, clean environment
• Supervision as needed
• Personal assistance
- Bathing, hair care (shampoo & fix their hair weekly in our home)
• Medication monitoring and management
- All medications (including over the counter) are the client (s) expense.
- Medications (including over the counter) are kept under lock. We will be in charge of their daily distribution.
• Laundry services for personal clothing & bedding provided. (NO dry-cleaning)
• Daily housekeeping
• Scheduling of medical appointments
• Three nutritious meals plus snacks daily
• Transportation to doctor appointments
• Assistance calling proper transportation (Rainbow Rider, Medi-Van, Taxi, People’s Express, etc.) This cost for transportation is the client’s responsibility.
• Social activities
ADMISSION
• Douglas County Public Health Nurse or Family Physician must screen Resident.
• Provide a current physician’s report to include a detailed list of medications, degree of mobility, care and supervision needed.
• Be personally interviewed by Greg & Sue Odell
FINANCIAL
Private Pay or Financial Assistance (through Douglas County)
• Additional charges will be determined by each case depending on individual needs. If your monthly income does not meet the cost of the foster care, you may be eligible for financial assistance through the Douglas County Family Services at (320) 762-3876.
• Payment of monthly charges is due the first of every month
• Non-payment WILL result in discharge from this home. If health conditions require extended hospital or nursing home confinement and you desire to return to our home, there will be a monthly charge to reserve your room.
• In the event of a natural disaster or fire in the foster home where it would no longer be livable, other accommodations must be made at the client’s expense.
• Insurance on personal belongings (furniture, clothes, jewelry, etc), at clients expense.
• Personal cable/satellite television or telephone in your room, at clients expense.
• Resident and/or guardian will be responsible for purchasing the following items: Medications, medical equipment (walkers, canes, etc)
Special diet foods
Protective pads (attends, etc.)
Clothes (appropriate for the season)
Personal items (toothbrush, toothpaste, shampoo, lotion, etc.)
Doctor, ambulance and hospital bills
VISITORS
Visiting hours will be no earlier than 10 a.m. and no later than 8:30 p.m. A call is advisable to be sure the resident will be home.
FOOD AND MEALS
Three delicious home cooked meals and snacks daily.
Meals will be served:
• Breakfast 8:00 a.m. - 9:00 a.m.
• Lunch 12:00 p.m. - 1:00 p.m.
• Supper 5:30 p.m. - 6:30 p.m.
Snacks:
• Mid-morning
• Mid-afternoon
• Evening
If a client has their own snacks (candy, cookies, etc.) - it is advisable for us to keep them for the client and give out to them so that they don’t eat too much of it and either get sick or not want to eat the nutritious meals. We operate on a trust basis.
Provider would like advance notice if the resident would be out for meals. We will be having our meals and snacks together in the dining area. Proper table manners and courteous behavior is necessary for us to enjoy our meals together. We would require that each person wash his or her hands before meals – that’s a MUST.
SMOKING AND DRUGS
We are a non-smoking facility. This will not be allowed.
TELEPHONE
The client (s) will be able to use the phone at anytime but no longer than 15 minutes at one time. A private line can be installed in their room (at the client’s expense) if they wish, and then there would be no restrictions on phone usage. On our phone, there will be no long distance available – a client will need to purchase a phone card and use that for any long distance calls (we will help them with dialing the numbers if necessary).
TELEVISION AND AUDIO EQUIPMENT
Television and radio may be used so as not to disturb others. If a resident has a hearing disability, a headset must be used as needed. If a resident would like cable TV in their room, activation and monthly charges would be at their expense. (We will have cable TV provided in the living room.)
ACTIVITIES
We enjoy going out to lunch on occasion. We go to the park and enjoy other activities, which client(s) enjoy ... puzzles, games, etc.
TRIAL PERIOD
There will be a one-month trial period. If during that month the client (s) does not meet the care requirements, becomes uncooperative or unruly, is rude to the other clients, etc, that client will be asked to leave.
CONDITIONS
Management of the clients’ funds will be the responsibility of the client or person(s) responsible. Our home is unable to accommodate someone with advanced
Alzheimer/dementia or HIV positive. Our home has been made as safe for my clients as we could possibly make it. Therefore, we are not responsible for accidents.
DISCHARGE
Thirty day notice if resident voluntarily chooses to transfer from facility.
Payment of monthly charges is due the first of every month.
Non-payment will result in discharge from the home.
DISMISSAL
Thirty-day notice will be given before an involuntary discharge except:
• When resident is dismissed for behavior that is abusive physically or mentally to other residents of the home.
• In an emergency (illness of provider, family emergency, fire or damage to the home, etc.)
• Health care requires skilled facility.
I understand the above and agree with these terms.
x_____________________________________________________________________
Signature of Resident Print Name Date
x____________________________________________________________________
Signature of Legal Representative Print Name Date
x____________________________________________________________________
Signature of Provider Print Name Date
• Services provided in the basic rental fee.
• Rate increases are reviewed January 1 and July 1 of each year.
• Rate increases will change prior to above dates when health conditions change:
• Private or shared rooms
• Safe, clean environment
• Supervision as needed
• Personal assistance
- Bathing, hair care (shampoo & fix their hair weekly in our home)
• Medication monitoring and management
- All medications (including over the counter) are the client (s) expense.
- Medications (including over the counter) are kept under lock. We will be in charge of their daily distribution.
• Laundry services for personal clothing & bedding provided. (NO dry-cleaning)
• Daily housekeeping
• Scheduling of medical appointments
• Three nutritious meals plus snacks daily
• Transportation to doctor appointments
• Assistance calling proper transportation (Rainbow Rider, Medi-Van, Taxi, People’s Express, etc.) This cost for transportation is the client’s responsibility.
• Social activities
ADMISSION
• Douglas County Public Health Nurse or Family Physician must screen Resident.
• Provide a current physician’s report to include a detailed list of medications, degree of mobility, care and supervision needed.
• Be personally interviewed by Greg & Sue Odell
FINANCIAL
Private Pay or Financial Assistance (through Douglas County)
• Additional charges will be determined by each case depending on individual needs. If your monthly income does not meet the cost of the foster care, you may be eligible for financial assistance through the Douglas County Family Services at (320) 762-3876.
• Payment of monthly charges is due the first of every month
• Non-payment WILL result in discharge from this home. If health conditions require extended hospital or nursing home confinement and you desire to return to our home, there will be a monthly charge to reserve your room.
• In the event of a natural disaster or fire in the foster home where it would no longer be livable, other accommodations must be made at the client’s expense.
• Insurance on personal belongings (furniture, clothes, jewelry, etc), at clients expense.
• Personal cable/satellite television or telephone in your room, at clients expense.
• Resident and/or guardian will be responsible for purchasing the following items: Medications, medical equipment (walkers, canes, etc)
Special diet foods
Protective pads (attends, etc.)
Clothes (appropriate for the season)
Personal items (toothbrush, toothpaste, shampoo, lotion, etc.)
Doctor, ambulance and hospital bills
VISITORS
Visiting hours will be no earlier than 10 a.m. and no later than 8:30 p.m. A call is advisable to be sure the resident will be home.
FOOD AND MEALS
Three delicious home cooked meals and snacks daily.
Meals will be served:
• Breakfast 8:00 a.m. - 9:00 a.m.
• Lunch 12:00 p.m. - 1:00 p.m.
• Supper 5:30 p.m. - 6:30 p.m.
Snacks:
• Mid-morning
• Mid-afternoon
• Evening
If a client has their own snacks (candy, cookies, etc.) - it is advisable for us to keep them for the client and give out to them so that they don’t eat too much of it and either get sick or not want to eat the nutritious meals. We operate on a trust basis.
Provider would like advance notice if the resident would be out for meals. We will be having our meals and snacks together in the dining area. Proper table manners and courteous behavior is necessary for us to enjoy our meals together. We would require that each person wash his or her hands before meals – that’s a MUST.
SMOKING AND DRUGS
We are a non-smoking facility. This will not be allowed.
TELEPHONE
The client (s) will be able to use the phone at anytime but no longer than 15 minutes at one time. A private line can be installed in their room (at the client’s expense) if they wish, and then there would be no restrictions on phone usage. On our phone, there will be no long distance available – a client will need to purchase a phone card and use that for any long distance calls (we will help them with dialing the numbers if necessary).
TELEVISION AND AUDIO EQUIPMENT
Television and radio may be used so as not to disturb others. If a resident has a hearing disability, a headset must be used as needed. If a resident would like cable TV in their room, activation and monthly charges would be at their expense. (We will have cable TV provided in the living room.)
ACTIVITIES
We enjoy going out to lunch on occasion. We go to the park and enjoy other activities, which client(s) enjoy ... puzzles, games, etc.
TRIAL PERIOD
There will be a one-month trial period. If during that month the client (s) does not meet the care requirements, becomes uncooperative or unruly, is rude to the other clients, etc, that client will be asked to leave.
CONDITIONS
Management of the clients’ funds will be the responsibility of the client or person(s) responsible. Our home is unable to accommodate someone with advanced
Alzheimer/dementia or HIV positive. Our home has been made as safe for my clients as we could possibly make it. Therefore, we are not responsible for accidents.
DISCHARGE
Thirty day notice if resident voluntarily chooses to transfer from facility.
Payment of monthly charges is due the first of every month.
Non-payment will result in discharge from the home.
DISMISSAL
Thirty-day notice will be given before an involuntary discharge except:
• When resident is dismissed for behavior that is abusive physically or mentally to other residents of the home.
• In an emergency (illness of provider, family emergency, fire or damage to the home, etc.)
• Health care requires skilled facility.
I understand the above and agree with these terms.
x_____________________________________________________________________
Signature of Resident Print Name Date
x____________________________________________________________________
Signature of Legal Representative Print Name Date
x____________________________________________________________________
Signature of Provider Print Name Date