CONTRACT BETWEEN RESIDENTS AND BEL-WOOD NURSING HOME
This Agreement entered into this _____ day of ___________________, 20___, between
the County of Peoria, a unit of local government, hereinafter referred to as the “COUNTY”,
acting
by
and
through
the
Administrator
of
Bel-Wood
Nursing
Home
and
________________________________, hereinafter referred to as the “RESIDENT”.
WHEREAS, the COUNTY is the owner of a licensed nursing home, commonly known as
Bel-Wood Nursing Home located in the County; and
WHEREAS, the RESIDENT desires to enter into this Agreement in order to become a
RESIDENT of said nursing home; and
WHEREAS, the COUNTY is desirous of having the undersigned individual as a
RESIDENT of said nursing home.
NOW THEREFORE, for the reasons set forth above, the COUNTY and the RESIDENT
agree to enter into the contract as follows:
ARTICLE I. DEFINITIONS
1.01
The Act. This Agreement is subject to the provisions of the Illinois Nursing
Home Care Act (210 ILCS 45/1-101 et seq.), as amended (hereinafter the
“ACT”). All terms of this Agreement will have the same meaning as the terms
defined in the ACT unless otherwise defined herein.
1.02
Resident. _________________________________________________________
Social Security No. _________________________ will be the RESIDENT under
this Agreement. RESIDENT agrees to reside at Bel-Wood and the COUNTY
agrees to accept RESIDENT, under the terms and conditions of this Agreement.
1.03
Guardian.
For purposes of execution of this Agreement and for all other
purposes now or hereafter permitted under the ACT, ____________________ (if
applicable)
is
the
guardian
of
the
person
for
RESIDENT
and
______________________ (if applicable) is the guardian of the estate of
RESIDENT.
1.04
Guarantor.
The person executing this Agreement as guarantor agrees to
personally guarantee the timely and full payment of all fees and charges incurred
by or on behalf of RESIDENT hereunder. Guarantor also agrees to abide by all
applicable terms and conditions of this Agreement and hereby specifically
consents to any changes in the Basic Daily Fee and Additional Charges imposed
by the COUNTY. Guarantor represents to the COUNTY that he/ she will directly
benefit from RESIDENT’s admission to Bel-Wood and acknowledges that
COUNTY is entering into this Agreement in reliance upon the personal guarantee
of Guarantor. Guarantor’s guarantee hereunder will in all respects be continuing,
absolute and an unconditional guarantee, and will remain in full effect until all
indebtedness of RESIDENT created or existing hereunder will have been fully
paid and this Agreement has terminated. Guarantor’s liability hereunder will not
be affected or impaired by any act, commission or omission of the COUNTY,
except the COUNTY’s execution of an expressed written release of guarantor of
his/ her obligations hereunder.
The COUNTY shall not require any third party to guarantee the payments to the
COUNTY hereunder in the event that RESIDENT is a Medicaid recipient or
applicant or a Medicare beneficiary regarding items and services covered or paid
for under the Medicare or Medicaid programs as a condition of admission (or
expedited admission) to, or continued stay at Bel-Wood.
1.05
Responsible Parties. One or more persons who execute this Agreement as a
Responsible Party agree to act on behalf of RESIDENT. Except to the extent that
RESIDENT is covered by Medicare or Medicaid, a Responsible Party who
executes this Agreement acting in the capacity as Immediate Family Member,
Guardian, Attorney-in-Fact, and/ or Trustee (all as defined below) agrees to cause
payment to be made to COUNTY for fees and charges incurred by or on behalf of
RESIDENT from RESIDENT’s assets or estate. Additionally, each Responsible
Party hereby authorizes COUNTY to charge or withdraw from RESIDENT’s trust
funds and other accounts such amounts as may be necessary to cover
RESIDENT’s costs in connection with his or her participation in social events and
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activities planned or sponsored by COUNTY during the term hereof.
No
Responsible Party is required or requested by COUNTY to pay for any items or
services covered or paid by the Medicare or Medicaid Programs.
The
Responsible Party may act in more than one capacity and each agrees to honor the
applicable terms and conditions of this Agreement.
A.
Immediate Family Member. A person, who executes this Agreement as
an Immediate Family Member within the meaning of the ACT, agrees to
execute this Agreement on behalf of RESIDENT for all purposes
permitted under the ACT.
Immediate Family Members are not
responsible to pay fees and charges from their own assets or estates.
RESIDENT acknowledges and consents to persons executing this
Agreement as an Immediate Family Member and consents to this
procedure.
B.
Guardian. A person who executes this Agreement as a Guardian is either
(1) a guardian of the person for purposes of admitting RESIDENT to BelWood and making certain care decisions, or (2) a guardian of the estate for
purposes of handling RESIDENT’s finances, or (3) a guardian that serves
both functions, and has been appointed to do so by a court of competent
jurisdiction.
C.
Attorney-in-Fact.
A person who executes this Agreement as an
Attorney-in-Fact is acting under a validly executed Power of Attorney
under the Illinois Power of Attorney Act, Article II, Durable Powers of
Attorney. The resident must provide the document naming the Power of
Attorney.
D.
Trustee. A person who executes this Agreement as a Trustee represents
to COUNTY that he/ she is acting under a written trust agreement.
E.
RESIDENT’s Representative.
For purposes of execution of this
Agreement and for all other purposes now or hereafter permitted under the
ACT, _______________________ (if applicable) is the RESIDENT’s
Representative. RESIDENT shall provide Bel-Wood with a copy of the
written agreement between RESIDENT and RESIDENT’s Representative
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which authorizes RESIDENT’s Representative to inspect and copy
RESIDENT’s records and authorizes RESIDENT’s Representative to
execute this Agreement on behalf of RESIDENT.
F.
Signatories. As used in this Agreement, “Signatories to this Agreement”
refer to all persons signing the Agreement other than the Bel-Wood
Administrator or the Administrator’s designee.
1.06
COUNTY. For purposes of this Agreement, the term COUNTY and Bel-Wood
or Bel-Wood Nursing Home shall have the same meaning.
ARTICLE II. TERM
The initial term of this Agreement will commence as of the date set forth at the beginning
of this Agreement (the Effective Date) and will continue until terminated as provided herein.
ARTICLE III. DEPOSIT
3.01
Private Pay Residents. The deposit shall be paid upon admission to Bel-Wood.
All private pay RESIDENTS including RESIDENTS who have a pending
Medicaid application shall be required to pay a deposit. The deposit paid today
totals $____________.
Except as provided in Section 3.02, this deposit shall be
refundable subject to the deduction of any outstanding balances due hereunder to
the COUNTY.
The balance, if any, of the deposit shall be returned to the
RESIDENT, the appropriate family member, or guardian of the Resident when all
outstanding balances have been paid. The COUNTY shall provide an accounting
of any deductions taken from the deposit.
3.02
Medicaid. In the event that a RESIDENT’s Medicaid eligibility is established,
the COUNTY shall return the full amount of the deposit to the RESIDENT, the
appropriate family member or guardian of the RESIDENT’s person within 30
days of the establishment of Medicaid eligibility, unless the deposit must be
drawn upon or encumbered in accordance with Medicaid eligibility requirements
established by the Illinois Department of Healthcare and Family Services. The
deposit shall be delivered in person or sent by certified or registered mail or
Express Mail or similar overnight delivery service to the RESIDENT, appropriate
family member or guardian of the RESIDENT’s person.
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ARTICLE IV. SERVICES AND PAYMENT
4.01
Services. To the extent required by the Skilled Nursing and Intermediate Care
Facilities Code, Rules and Regulations (The Code) and the Illinois Department of
Public Health, as amended from time to time, in accordance with the policies of
Bel-Wood, the COUNTY will furnish the room, board, towels and linens, nursing
care, and such personal care services as may be reasonably necessary for the
health and safety of RESIDENT. The COUNTY will exercise reasonable care
towards RESIDENT and fulfill all of its duties to RESIDENT under the ACT.
However, the COUNTY is not an insurer of RESIDENT’s welfare and safety and
does not assume any liability as an insurer.
4.02
Basic Daily Fee. The initial Basic Daily Fee for the services provided by the
COUNTY to RESIDENT is listed in Exhibit A which is attached to this
Agreement and incorporated by reference herein. RESIDENT will be charged for
a full day of services hereunder on the day of admission.
4.03
Minimum Payment.
Except as otherwise set forth herein, RESIDENT and
Guarantor agree, jointly and severally, to pay the Basic Daily Fee in advance
from the date of admission to the end of the current month and in advance for
each month thereafter during the term hereof.
However, if RESIDENT is
admitted less than seven (7) days prior to the end of the month, the RESIDENT
will pay the Basic Daily Fee in advance from the date of admission to the end of
the subsequent month.
Moreover, if RESIDENT specifies in advance that
RESIDENT’s stay at Bel-Wood will be less than one (1) month, the RESIDENT
will pay the Basic Daily Fee in advance for that period of time in which
RESIDENT will be staying in Bel-Wood.
Notwithstanding anything contained herein to the contrary, RESIDENT will pay
the COUNTY for a minimum of seven (7) days of services hereunder at the Basic
Daily Fee.
If the RESIDENT is covered under Medicaid, the parties hereto acknowledge
that, in certain situations depending on RESIDENT’s financial condition, the
5
amount that the Illinois Department of Healthcare and Family Services
reimburses the COUNTY for services and products provided to RESIDENT
pursuant hereto may be less than the current Medicaid rate for such services and
products. In such situations, the parties hereto agree that RESIDENT shall be
liable to the COUNTY for, and shall immediately pay to the COUNTY, the
amount of such reimbursement deficiency. Nothing contained in this Section
4.03, however, shall be deemed to require RESIDENT or any Responsible Party
to pay to the COUNTY any amounts in excess of the applicable Medicaid rate for
any services or products provided pursuant to this Agreement.
4.04
Additional Charges. The Basic Daily Fee does not include certain services and
products which the COUNTY will furnish to RESIDENT for Additional Charges.
The general description of these services and products are listed in Exhibit B
which is attached to this Agreement. In addition, except to the extent covered by
Medicare or Medicaid, RESIDENT and Guarantor will be liable for any and all
costs and expenses incurred in connection with any special treatment ordered by a
physician for RESIDENT and not included within the services generally provided
to RESIDENTS of Bel-Wood.
4.05
Itemized Statement.
One (1) itemized statement of Additional Charges for
products and services provided by the COUNTY to RESIDENT will be sent each
month to RESIDENT including Room and Board, and Signatories to this
Agreement. It is agreed that this statement must be paid within ten (10) days of
the billing date of the itemized statement.
4.06
Change in Daily Fees and Additional Charges. The COUNTY reserves the
right to change the Basic Daily Fee and Additional Charges at any time. The
COUNTY will give RESIDENT or Signatories to this Agreement a minimum of
thirty (30) days written notice prior to a change in the Basic Daily Fee or
Additional Charges. RESIDENT or Signatories to this Agreement may either
consent to the change or choose to terminate this Agreement at any time within
thirty (30) days of receipt of said notice. Said notice shall become an addendum
to this Agreement. If the level of care for RESIDENT is changed, the Basic Daily
Rate will be changed on the date the level of care is changed.
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4.07
Late Payment Fee.
Except to the extent prohibited by applicable law, the
COUNTY has the right to charge a fee equal to one and one-half percent (1-1/2%)
per month for all payments of Basic Daily Fees and Additional Charges
outstanding as of the last day of each month.
The late fees must be paid
immediately upon notice of imposition of a late fee from the COUNTY.
4.08
Waiver of Fees and Charges. Upon the request of RESIDENT or a Signatory to
this Agreement, the COUNTY may, based upon and subject to the ability of
RESIDENT and Guarantor to pay, waive or reduce the Basic Daily Fee, one or
more Additional Charges or any other fees, charges or assignment of assets
charged by the COUNTY for services or products provided to RESIDENT
pursuant to this Agreement; provided, however, the RESIDENT or the Signatory
making such request must provide the COUNTY the documentation satisfactory
to the COUNTY evidencing such inability to pay.
4.09
Sources of Payment.
RESIDENT and the Responsible Parties represent to
COUNTY that, upon the effective date of this Agreement, RESIDENT is a:
(check one)
Medicare Beneficiary
Medicaid Recipient
Medicaid Applicant
Private Pay RESIDENT
Other (Specify):
__________________________________
All appropriate and valid sources of income available to the RESIDENT are:
RESIDENT’s assets
RESIDENT’s Pension Fund
Trust Funds
Social Security (to the full extent of payments made to or on
behalf of RESIDENT)
Other (specify): __________________________________
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4.10
Medicare and Medicaid. Under certain circumstances, the COUNTY accepts
RESIDENTS who are covered under either the Medicare or Medicaid Program.
However, the COUNTY does not make any assurance of any kind whatsoever
that a RESIDENT’s care will be covered by Medicare, Medicaid or any other
public assistance program, and each of the signatories to this Agreement hereby
releases the COUNTY, its representative, agents and employees from any liability
or responsibility in connection with RESIDENT’s or Signatory’s potential claim
of such coverage.
In the event that RESIDENT’s Medicare or Medicaid
payments are terminated, RESIDENT and Signatories to this Agreement, shall, to
the extent permitted under applicable law, be responsible for all payments due
hereunder that are not covered by Medicare or Medicaid.
With respect to items and services that are covered by Medicare or Medicaid, the
COUNTY shall not, during the period that RESIDENT is covered by the
Medicare or Medicaid Program, charge RESIDENT for amounts in excess of the
Medicare or Medicaid Program’s payment rate, notwithstanding the provisions of
Section 4.02, Section 4.04 and Section 4.06 above.
The COUNTY may not (1) charge, solicit, accept or receive, in addition to any
amount or otherwise required to be paid under the Medicare or Medicaid
Program, any gift, money, donation or other consideration, or (2) require a
Medicare or Medicaid RESIDENT to request any item or service, as a precondition of admitting (or expediting the admission of) a Medicare or Medicaid
RESIDENT to Bel-Wood or as a requirement for such RESIDENT’s continued
stay at Bel-Wood.
Notwithstanding the foregoing, nothing contained herein shall be construed as
preventing the COUNTY from charging the Medicare or Medicaid RESIDENT
for items or services that such RESIDENT has requested and received and which
are not covered or paid for under the Medicare or Medicaid Program. In addition,
the COUNTY shall be permitted to impose a charge against the personal funds of
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a Medicare or Medicaid RESIDENT for applicable deductible and co-insurance
amounts.
ARTICLE V. MEDICAL
5.01
RESIDENT’s Responsibility for Services and Equipment. RESIDENT and
Signatories to this Agreement, will secure, at their expense, except to the extent
covered by Medicare or Medicaid, and with the prior approval of the COUNTY,
all medical services, equipment and supplies necessary for RESIDENT’s personal
use except for services, equipment and supplies provided by COUNTY,
including, without limitation, the services, equipment and supplies listed in
Exhibit B which the COUNTY will provide at additional charges. In the event
RESIDENT or any third party provides equipment for RESIDENT’s personal use,
RESIDENT and Signatories to this Agreement shall assume all risk and liability
associated with such equipment and use. The COUNTY reserves the right to
inspect and approve or reject the use or placement of any and all equipment. No
medicines, treatments or special diets will be given to RESIDENT except as
ordered by RESIDENT’s physician or physician selected by COUNTY. Except
to the extent covered by Medicare or Medicaid, RESIDENT and Signatories to
this Agreement shall be and remain liable for any all fees and expenses incurred
in connection with a physician and other costs of medical care and goods and
services not directly provided by COUNTY. RESIDENT and Signatories to this
Agreement authorize COUNTY to use for RESIDENT’s benefit at RESIDENT’s
sole cost, the pharmacist, laboratory and other outside services provided as may
be deemed necessary or appropriate by COUNTY.
5.02
Personal Physician. The COUNTY will admit and cooperate with health care
professional selected by RESIDENT or Responsible Party, provided that such
professional complies with the policies and rules of Bel-Wood and applicable
governmental laws and regulation. The COUNTY recognizes that RESIDENT
has the right to select his or her own physician. As of the date of this Agreement,
RESIDENT’s personal physician is _____________________________________
__________________________________________________________________
(name, address and telephone number). If the RESIDENT’s physician or the
9
address or telephone number of such physician changes, RESIDENT will
immediately give Bel-Wood written notice of the change.
Prior to treating
RESIDENT, RESIDENT’s physician must submit to COUNTY a copy of his/ her
license, evidence of hospital affiliations and malpractice insurance in a form and
in an amount acceptable to the COUNTY. RESIDENT authorizes COUNTY to
provide a physician for RESIDENT in the event RESIDENT’s physician is not
available, fails to comply any policies and rules of Bel-Wood or any applicable
governmental laws and regulations or in the event that RESIDENT does not
inform Bel-Wood of RESIDENT’s physician.
5.03
Physician Policy. Bel-Wood’s policy is that RESIDENT’s personal physician or
that physician’s designee must be available at all times for notification of
significant changes in RESIDENT’s clinical condition in order to direct
appropriate action. No later than at the time of admission, the physician will
provide Bel-Wood with a current written history and physical of RESIDENT, as
well as all other orders for medications, diet and treatments required by
RESIDENT, and will subsequently provide timely visits to RESIDENT and
modify any such orders previously written or directed, as required by the
condition of RESIDENT and all applicable governmental laws and regulations.
For purposes hereof, “current history and physical” means the history and
physical conducted within five (5) days of admission of RESIDENT.
As
provided above, except as otherwise covered by Medicare or Medicaid,
RESIDENT and Signatories to this Agreement shall be solely liable for payment
of any and all services provided by the physician, including a physician chosen by
COUNTY in accordance with Section 5.02 herein.
5.04
Plan of Care. RESIDENT and Responsible Parties will assist Bel-Wood’s staff
in development and implementation of individualized plan of care, and further
agree to assist and cooperate with Bel-Wood in the implementation of such plan
including, without limitation, participation in those activities and treatment
programs as may be prescribed therein.
5.05
Food Stuff, Medicines. No food stuff, liquids, or medicines may be brought into
Bel-Wood by or for RESIDENT without prior approval of Bel-Wood’s
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Administrator or the nurse supervising RESIDENT. In the event such consent is
obtained, all food stuff, liquids or medicines will be stored in sealed containers as
specified by Bel-Wood. All medicines which are necessary or appropriate for
RESIDENT’s use will be prescribed by RESIDENT’s physician, or by BelWood’s medical director. This restriction includes items normally sold over the
counter. RESIDENT will not store or otherwise maintain any medications in
RESIDENT’s room or possession unless there is an order from the RESIDENT’s
physician or Bel-Wood’s medical director stating that RESIDENT is allowed to
self-administer his or her medication. All other medications will be kept locked
and supervised by Bel-Wood’s nursing staff.
5.06
Transfer to Hospital. Except in the event of emergency, the COUNTY will
arrange for transfer of RESIDENT to the hospital of RESIDENT’s choice when
such transfer is ordered by RESIDENT’s physician or any physician selected by
Bel-Wood. Except as otherwise covered by Medicare or Medicaid, all transfer,
transportation and other costs will be paid by RESIDENT or Signatories to this
Agreement.
5.07
Emergency. RESIDENT and all other signatories to this Agreement authorize
the COUNTY to provide to RESIDENT any emergency care deemed necessary
by Bel-Wood or its physicians and to transfer RESIDENT to a hospital or other
facility for purposes of providing emergency or other necessary care.
5.08
DNR Procedures. Unless a copy of a properly executed written document that
conforms with the Illinois Living Will Act or Powers of Attorney for Health Care
Law is attached to this Agreement, RESIDENT and all other Signatories to this
Agreement represent to Bel-Wood that no agreement or understanding exists
which could require the denial or cessation of medical treatment or procedures
necessary to prolong the natural life of RESIDENT. Unless Bel-Wood receives a
copy of such a document, it is understood that Bel-Wood is authorized but not
required to take every step necessary to extend the natural life of RESIDENT by
whatever means are necessary.
RESIDENT and other signatories of this
Agreement hereby release and hold harmless the COUNTY, its elected and
appointed officials, officers, employees, agents and representatives from any and
11
all actions taken or claims made pursuant to Section 5.07 above and this Section
5.08.
5.09
Not Agent of Bel-Wood.
RESIDENT’s physician and other health care
professionals described above will be retained solely at the request of RESIDENT
or one (1) or more Responsible Parties. It is expressly acknowledged by all
parties that no physician or other health care professional is the employee or agent
of COUNTY with respect to personal services rendered to RESIDENT, that
COUNTY expressly disclaims any responsibility for any actions of such persons
acting in such capacity, and that no action or statement by employees of
COUNTY may be interpreted to change this policy.
ARTICLE VI.TERMINATION
6.01
Termination Generally.
(a)
If the RESIDENT is compelled by a change in physical or mental health to
leave Bel-Wood, this Agreement and all obligations hereunder shall
terminate upon seven (7) days prior written notice.
(b)
No prior notice of termination of this Agreement shall be required in the
case of the RESIDENT’s death.
(c)
RESIDENT may terminate this Agreement pursuant to Section 4.06
“Change in Daily Fees and Additional Charges.”
(d)
In all situations other than those set forth in Sections 6.01(a), (b), and (c)
above, RESIDENT may terminate this Agreement upon thirty (30) days
prior written notice to the COUNTY.
(e)
In addition to Section 6.01(a) above, the COUNTY may terminate this
Agreement for any of the reasons in Section 6.04, “Temporary Absences,”
or Section 6.05, “Involuntary Transfer and Discharge,” provided that the
procedures in Section 6.06, “Discharge Notice” are followed.
6.02
Termination Consequences.
All fees and charges except the RESIDENT’s
deposit as provided in Article III, will be prorated to the date of termination. If
payment of any fees or charges has been made in advance, any excess will be
refunded to RESIDENT or signatories to this Agreement respectively if such
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parties originally paid such fees and charges in advance. Notwithstanding the
termination of this Agreement, all obligations of RESIDENT and signatories to
this Agreement for fees, charges and other liabilities incurred prior to the date of
termination will survive this termination.
6.03
Level of Care Change. If RESIDENT’s physical or mental condition changes
such that RESIDENT requires a higher level of personal care than is initially
provided under this Agreement, COUNTY may, at its option, provide RESIDENT
such higher level of care as it deems advisable. Any additional fees and charges
will be paid by the parties liable pursuant to Article IV hereof, except that charges
deemed necessary under this Section shall not be considered either a change in
Daily Fee or an Additional Charge referred to in Section 4.06.
6.04
Temporary Absences.
A.
Private Pay. In the event that a private pay RESIDENT is to be absent
from Bel-Wood for any period of time due solely to a medical necessity,
COUNTY will, at its option, hold accommodations available for
RESIDENT, provided no request to the contrary has been made by
RESIDENT or Responsible Party before or at the time RESIDENT leaves
the facility. During the time when RESIDENT is absent due to a medical
necessity, a Reservation Fee equal to ninety percent (90%) of the Basic
Daily Fee will be charged to RESIDENT’s account. The Reservation Fee
will be equal to one hundred percent (100%) of the Basic Daily Fee in the
event the RESIDENT’s absence is for any reason other than a medical
necessity. If these procedures are not followed, COUNTY may, at the
time prior to the readmission of RESIDENT, declare this Agreement
immediately terminated and may treat RESIDENT’s bed as immediately
open and available.
B.
Medicaid RESIDENT.
In the event that a Medicaid RESIDENT is
hospitalized and therefore to be absent from Bel-Wood, COUNTY will
hold accommodations available for such RESIDENT for up to ten (10)
consecutive days. In the event that a Medicaid Resident is to be absent
from Bel-Wood due to any reason other than a medical necessity, the
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COUNTY will, at its option, hold accommodations available for such
RESIDENT for up to seven (7) consecutive days, provided that such bedhold is (1) requested by RESIDENT or a Responsible Party and (2)
authorized in accordance with all applicable IDPA rules and regulations.
If a Medicaid RESIDENT’s hospitalization exceeds a period of ten (10)
days or if an absence that is not medically necessitated exceed seven (7)
days, COUNTY may, at any time prior to the readmission of RESIDENT,
declare
this
Agreement
immediately
terminated
and
may
treat
RESIDENT’s bed as immediately open and available.
6.05
Involuntary Transfer or Discharge.
(A)
COUNTY reserves the right and is hereby authorized to involuntary
transfer or discharge a RESIDENT for the following reasons: (1) for
medical reasons; (2) for RESIDENT’s physical safety or the physical
safety of other residents, the staff of Bel-Wood or visitors to Bel-Wood;
(3) for late payment or non-payment of fees and charges; except as may be
prohibited by Title XVIII or Title XIX of the Federal Social Security Act
or due to a Medicare or Medicaid RESIDENT’s failure to have payment
made under Title XVIII or Title XIX of the Federal Social Security Act or
under the Illinois Public Aid Code; or (4) for any other reason permitted
under the ACT. COUNTY will discuss such transfer or discharge with
RESIDENT and Responsible Parties, and the discussion will be
documented in RESIDENT’s clinical record as to the substance of the
discussion and the parties present.
(B)
For purposes of Section 6.05 (A)(3) “late payment or non-payment of
fees,” if payment is not received within 45 days after submission of a bill,
Bel-Wood may send notice by certified mail to the RESIDENT and
Signatories to this Agreement requesting payment within 30 days. If
payment is not received within said 30 days, Bel-Wood may, at its option,
institute transfer or discharge proceedings pursuant to Section 6.06. The
RESIDENT and Signatories to this Agreement shall have the right to pay
the amount of the bill in full up to the date of transfer or discharge. Such
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payment in full shall terminate any transfer or discharge proceedings.
This section does not apply to those residents whose care is provided
under the Illinois Public Aid Code.
6.06
Discharge Notice. COUNTY will also provide RESIDENT and Signatories to
this Agreement with at least thirty (30) days written notice, sent by certified mail,
prior to RESIDENT’s involuntary transfer or discharge. However, written notice
may be given as soon as practicable before an involuntary transfer or discharge if
(1) an immediate transfer or discharge is ordered by the RESIDENT’s attending
physician because of the RESIDENT’s health care needs or (2) the transfer or
discharge is mandated by the physical safety of other residents, the staff of BelWood or visitors to Bel-Wood as documented in RESIDENT’s clinical record.
6.07
Death. This Agreement will terminate in the event of RESIDENT’s death. In
case of death, authorization is given to COUNTY as RESIDENT’s physician’s
orders or permits, to remove the body of RESIDENT at any time. RESIDENT
hereby designates _____________________________________ as a funeral
home to which his/ her body is to be removed. COUNTY will have no liability
for financial obligations arising out of the death of RESIDENT. All funeral
expenses will be paid by the estate of RESIDENT, by Responsible Parties, and/ or
by funds made available by other persons or by law.
In the event of
RESIDENT’s death, COUNTY is authorized to enter into RESIDENT’s living
quarters in order to inventory, secure and store any property of RESIDENT for a
reasonable time until delivery of property to the appropriate persons. If the
property remains unclaimed for a period of longer than twenty (20) days,
COUNTY is authorized to donate such property to a charity or a charitable thrift
shop.
Article VII.
7.01
PERSONAL MATTERS
Other Personal Items. RESIDENT and Responsible Parties will provide, mark
and be responsible for all items for RESIDENT’s personal use, including, but not
limited to, clothing, toiletry equipment and supplies and personal amenities and
will also provide sufficient spending money as may be necessary or appropriate
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for the RESIDENT’s well being. If COUNTY provides such personal items, the
costs of such items will be included in the Additional Charges.
7.02
RESIDENT’s Property. The COUNTY will not be responsible for loss or
damage of any property brought into Bel-Wood by RESIDENT, relatives or
friends of RESIDENT, or otherwise belonging to RESIDENT including
RESIDENT’s personal clothing, dentures, hearing aids and affects, unless they
are specifically delivered for safe keeping to Bel-Wood’s administration and a
written receipt for such property is issued. Bel-Wood will accept for safe keeping
only small items of minimal value. RESIDENT will have access to such items
upon reasonable request.
7.03
RESIDENT’s Funds. Unless RESIDENT otherwise directs, RESIDENT and
Responsible Parties authorize COUNTY to accept and hold funds of RESIDENT
in a non-interest bearing resident trust fund. Such funds may be withdrawn by
RESIDENT upon written request in accordance with Bel-Wood’s procedures
which will reasonably insure that RESIDENT’s funds are readily available for
RESIDENT. The balance held in this fund on behalf of RESIDENT shall not
exceed One Hundred Dollars ($100.00) at any time. Any RESIDENT’s funds in
excess of One Hundred Dollars ($100.00) will be delivered to RESIDENT or
Responsible Party or deposited in an interest-bearing account that is separate from
any of Bel-Wood’s operating accounts and that credits all interest earned on
RESIDENT’s account to his or her account.
7.04
Living Quarters. RESIDENT will initially occupy the living quarters designated
as _______________________________________________.
However, Bel-
Wood reserves the right to transfer RESIDENT to other living quarters if required
to do so by law or for efficient management as determined in its sole discretion.
Bel-Wood will provide basic maintenance to RESIDENT’s living quarters as
required under the ACT. COUNTY will give RESIDENT advance notice of any
room transfer or change of roommate.
7.05
Indemnification. RESIDENT and Signatories to this Agreement will indemnify
and hold COUNTY harmless from and against any and all liabilities, claims,
actions, damages, costs and expenses, including, without limitation, Attorney fees
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and costs of investigation, incurred by the COUNTY arising out of (1) any
property damage caused by RESIDENT, including costs incurred for repair or
replacement of property of Bel-Wood or the COUNTY, the staff or other
residents, (2) any physical injuries to any member of the staff, other residents or
any third party caused by RESIDENT, or (3) any breach by RESIDENT, or
Signatories to this Agreement of any of the terms of this Agreement, including,
without limitation, any costs and Attorney fees incurred for actions taken by
COUNTY in connection with the enforcement of this Agreement.
ARTICLE VIII. GENERAL MATTERS.
8.01
Documentation Acknowledgment. It is acknowledged that:
A.
RESIDENT and Signatories to this Agreement each have received a copy
of this Agreement as executed; and
B.
RESIDENT and any other party requesting it have received a written
statement of RESIDENT’s rights and responsibilities under the ACT, a
copy of which is attached hereto and incorporated by reference herein as
Exhibit C; and
C.
RESIDENT and any other party requesting it have received a written
statement of Bel-Wood’s policy concerning RESIDENT Grievance
Procedures; and
D.
If applicable, RESIDENT and RESIDENT’s spouse have each received a
written statement explaining their spousal impoverishment rights, as
required under the ACT and as specifically defined in Section 5-4 of the
Code. (305 ILCS 5/5-4).
8.02
Attachments. The documents identified in this preceding Section 8.01 above are
incorporated by reference in this Agreement and form a part of this Agreement.
RESIDENT and Signatories to this Agreement as applicable, hereby agree to
abide by the terms and conditions set forth in the documents identified above and
by all rules and regulations of Bel-Wood as may be established from time to time,
including, without limitation, the rule against smoking in unauthorized areas of
Bel-Wood.
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8.03
Guardianship.
If in the sole discretion of COUNTY, it is necessary or
appropriate that a Guardian be appointed by an appropriate court with respect to
RESIDENT’s person or estate, Responsible Parties agree that they will, at their
sole costs and expense, petition the appropriate court to appoint a Guardian for
the RESIDENT if no Guardian has previously been appointed.
The parties
acknowledge that COUNTY will have no responsibility to undertake
guardianship proceedings unless required under the ACT nor will COUNTY be
responsible for any injury or loss to RESIDENT caused by failure to undertake
such proceedings.
8.04
Release of RESIDENT’s Records. Bel-Wood will respect the confidentiality of
RESIDENT’s records, and will release such records only to those persons
authorized by law to inspect and copy RESIDENT’s records in accordance with
State and Federal laws and only upon the signed release for such records. In the
event that RESIDENT or a Responsible Party, or any third party on behalf of
RESIDENT or a Responsible Party, request one or more photocopies of
RESIDENT’s records, RESIDENT must immediately reimburse Bel-Wood for
any and all costs, charges, and expenses incurred in fulfilling such request.
8.05
Notice. Any notice, election, request, demand, designation, consent, agreement
or communication given or required to be given under this Agreement shall be in
writing and signed on or on behalf of the party giving it, and except as otherwise
provided in Sections 6.05(B) and 6.06, shall be personally delivered to the
persons who are signatories to this Agreement below or sent by first class mail,
postage prepaid, or by Express Mail or similar private overnight delivery service
addressed to the signatories of this Agreement or to such other address or person
as a party shall have previously designated in writing.
8.06
Notice Delivery. Any notice, election, request, demand, designation, consent,
agreement or communication shall be considered given and received on the first
of the following to occur.
a.
The date of personal delivery; or
b.
Two (2) days after the postmarked date; or
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c.
One (1) day after the date appearing on the shipping invoice of Express
Mail or similar overnight delivery service; or
d.
Actual receipt.
However, any notice sent by certified mail shall be considered given and received
on the day the return receipt is signed.
8.07
Failed Notice. Rejection or refusal to accept or inability to deliver because of
change in address for which no notice has been received shall constitute receipt.
8.08
Change of Address. Any party requested to furnish an address below will give
notice to Bel-Wood within 10 days of any change of address or telephone
number.
8.09
Interpretation. This Agreement constitutes the entire Agreement between the
parties and may not be amended except in writing executed by the parties hereto.
8.10
Counterparts. This Agreement may be executed in one or more counterparts,
each of which will be deemed an original but all of which will constitute one
instrument.
8.11
Governing Law. This Agreement will be governed by the laws and regulations
of the State of Illinois and will be binding upon the parties hereto and their
respective heirs, representatives and assigns.
8.12
Severability. In the event any provision of this Agreement is declared invalid or
unenforceable by a court of competent jurisdiction, or is in violation of any local,
state or federal law, the remaining terms of this Agreement will be unaffected and
remain in full force and effect.
8.13
Consent.
The undersigned acknowledges that each of them have read and
understands this Agreement, and that each of them voluntarily consents to all of
its terms. The liabilities of RESIDENT and Guarantor hereunder shall be joint
and several.
8.14
Third Party Responsibility. This Agreement is not intended to create any thirdparty rights or obligations to any party not a signatory to this Agreement other
than to its assigns and successors of Bel-Wood.
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8.15
Discussions. The parties shall each have the right to request conferences with the
other to be scheduled at regular intervals for the purpose of interpreting and
discussing this Agreement and any extensions thereof.
8.16
Amendments and Renewal.
This Agreement may be amended by mutual
agreement of the parties, evidenced in writing, executed by the parties and affixed
to this Agreement. No other written or verbal agreement shall have any affect.
8.17
Waiver. No delay or omission by any party in exercising any right, power or
privilege hereunder shall impair such right, power or privilege, nor shall any
single or partial exercise of any such right, power or privilege preclude any
further exercise thereof or the exercise of any other right, power or privilege.
8.18
Integration.
This Agreement constitutes the entire Agreement between the
parties and contains all agreements between the parties with respect to the subject
matter hereof. This Agreement supersedes all other agreements, either in writing
or oral, between the parties hereto with respect to the same or similar subject
matter.
The undersigned acknowledge that each of them have read and understand this
contract, and that each of them voluntarily consent to all of its terms.
THE COUNTY OF PEORIA
RESIDENT
________________________________________
Bel-Wood Administrator or Designee
________________________________________
(Print Name)
Title: ___________________________________ ________________________________________
Signature
________________________________________
Signature
Date: ___________________________________ Date: ___________________________________
Phone: _________________________________
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Address:
Prior Address:
________________________________________
________________________________________
________________________________________
________________________________________
RESPONSIBLE PARTY
GUARANTOR
________________________________________
(Print Name)
________________________________________
(Print Name)
________________________________________
Signature
________________________________________
Signature
Date: ___________________________________ Date: ___________________________________
Address:
Address:
________________________________________
________________________________________
________________________________________
________________________________________
Telephone: ______________________________
Telephone: ______________________________
Relation to Resident (check as appropriate)
Immediate Family Member
Attorney-in-Fact
Trustee
Guardian of the person
Guardian of the estate
Resident’s Representative
Guarantor
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