Skilled Nursing and Rehabilitation

Transcription

1 Skilled Nursing and Rehabilitation 400 N County Farm Road, Wheaton, IL (630) Admission Department (630) Admission Dept. Fax (630) Admission to a Skilled Nursing Facility is a significant change to the individual entering the facility and also for their family. It is generally a more positive experience when the applicant is involved in making the choice. We therefore request that the applicant be informed of plans for admission to DPCC as soon as possible. Important Note: A Pre-Admission Screening/Determination of Need interview is required for any person entering a Nursing Home in the State of Illinois. This screening may be completed by one of the following agencies: Applicants over age 60 (sixty) DuPage County Department of Senior Services (630) Applicants with illness or injury occurring after age 21 (twenty-one) and before age 60 (sixty) Department of Rehabilitation Services (DORS) (630) Applicants with illness or injury occurring before age 21 (twenty-one) PACT, Inc. (630) A Financial Review Meeting to discuss the Financial Affidavit will be scheduled after the medical review is complete and applicant is clinically approved. This meeting must be prior to admission. You have the right to ask if any resident of the facility is an Identified Offender. **In accordance with Illinois State law, the DuPage Convalescent Center will be running a criminal background check on all persons prior to admission to this facility. By completion and submission of this application, you are giving consent for a criminal background check to be conducted electronically. DPCC IS A SMOKE-FREE FACILITY AS WELL AS THE ENTIRE DPC CAMPUS, NEW RESIDENTS MAY NOT SMOKE. NEW RESIDENTS MAY NOT SMOKE INSIDE OR OUTSIDE OF THE FACILITY. A COPY OF THIS POLICY IS AVAILABLE UPON REQUEST PRIOR TO ADMISSION

2 PERSONAL INFORMATION Name: Sex: Phone: City: State: Zip: How long at this address: SSN: Birthdate: Birthplace (include city, state & county) : Occupation (prior to retirement): Name applicant prefers: Religion: Level of Education: Place of Worship: Race & Ethnicity: Marital Status: Maiden Name: Fathers Name: Mothers Maiden Name: **Has applicant ever been convicted of a felony? Y/N Veteran: Applicant Spouse Language: Interpreter Needed? YES NO *Primary Care Physician Name & Phone: Primary Dentist Name & Phone: *Residents may continue to see an outside physician at their own expense for transportation; they will be assigned a DPCC physician for routine physical and emergency needs. Funeral Home Name & Phone: A funeral home should be listed for each resident in order to comply with state regulations. FAMILY / REPRESENTATIVE CONTACT INFORMATION 1.) Name: Relationship: Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) 2.) Name: Relationship: Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) 3.) Name: Relationship: Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Contacts may be added at any time by contacting the Admissions Department or your Social Service Coordinator. By supplying address, contact elects to receive electronic newsletters, fundraiser information and correspondence from DPCC. You may opt-out at any time by contacting your Social Service Coordinator. For Office Use Only: Admit Date & Time: From: MR: Unit: Room No: Pay Source:

3 ADVANCE DIRECTIVES PLEASE PROVIDE WRITTEN DOCUMENTATION WHERE APPLICABLE: Living Will Power of Attorney for Health Care Power of Attorney for Property Court Appointed Guardian Surrogate Decision Maker Please provide copies of all Advance Directives, including Do Not Resuscitate orders. Paperwork must be valid and on file to be honored. HEALTH INSURANCE INFORMATION Medicare Number: Part A: Part B: Medicaid Information: Has Medicaid been applied for? Y/N Recipient Number: Case Number: - - Pending Case Number: - - Effective November 1, 2014, new applications must be completed on-line; please go to for details on how to apply. Health Insurance: (Please include Supplemental, Secondary or Long Term Care insurance) Insurance Name: Phone No: Policy / Group No. Claim Health Insurance: (Please include Supplemental, Secondary or Long Term Care insurance) Insurance Name: Phone No: Policy / Group No. Claim Prescription Drug Coverage: (Please include Medicare D and discount coverage) Insurance Name: Phone No: Policy Name & Phone of the Pharmacy you are currently using: Please provide copies of the front and back of all cards that apply. ACTIVITIES OF DAILY LIVING, TEMPERAMENT AND PERSONAL PREFERENCES In order for out staff to assess the applicant for appropriate placement and to establish a plan of care, the following information is required. Please place a check mark next to all assistance that the applicant requires or applies. Dressing: Bathing: Eating: Standing: Walking: Use Walker: Wheelchair: Transferring to Chair/Wheelchair: Bed: Uses Motorized W/C*: *Please note that DPCC retains the right to evaluate resident s abilities with an electric mobility device prior to the use of one in this facility. DPCC will provide a manual wheelchair when appropriate. Able to manage own finances: Y/N List other activities with which applicant requires assistance: Sociable: Y / N Forgetful: Y / N Mentally Alert: Y / N Verbally aggressive: Y / N Timid: Y / N Confused: Y / N Grouchy: Y / N Physically aggressive: Y / N Independent: Y / N Suspicious: Y / N Anxious: Y / N Strikes out: Y / N Withdrawn: Y / N Cries easily: Y / N Wanders off: Y / N Prefers being alone: Y / N Prefers groups: Y / N Depressed: Y / N Chronic complainer: Y / N What temperature do you prefer in your room? Hot Warm Cold What time to you like to go to bed? Early Late Do you like to watch TV? Y / N What time do you like to watch? Morning Afternoon Evening Late All Night Rooms are assigned according to medical necessity. Residents may request a room change after admission. Special care is taken when assigning rooms; cognitive abilities and compatibility are taken into consideration whenever possible; however, it is not always possible to meet all personal preferences for each resident.

4 Please attach copies of current bank statements, real estate tax bill / mortgage statement and investment statements to support the information provided. Please include any other information that you believe may assist with this application. FINANCIAL STATEMENT Regular Monthly Income Applicant Spouse Social Security $ $ Pension $ $ Dividends $ $ Interest $ $ Mortgage/Rental Income $ $ IRA Income $ $ Trust Income $ $ Other (Identify source) $ $ TOTAL MONTHLY INCOME $ $ Assets Are any assets in a TRUST? If yes, please indicate type of TRUST: Cash Savings: Bank: Balance $ Checking: Bank: Balance $ CD s: $ Money Market: $ Stocks: $ Bonds: $ IRA s: $ Annuities: $ Home/Condo: $ Trust Fund: $ Life Ins: $ Other: $ Liabilities / Expenses Primary Residence: $ Second Residence: $ Auto 1: $ Auto 2: $ Loan Guarantees $ $ $ Other Monthly Liabilities Gas $ Electric $ Phone $ Cable $ Water $ Sewer $ Disposal $ $ AFFIDAVIT OF APPLICANT I, the undersigned, hereby certify that the answers to the foregoing questions are true, correct and complete, and that I have not knowingly or intentionally withheld any facts or circumstances, which would, if disclosed, unfavorably affect my application for admission. I hereby authorize a full investigation of any statements contained in this application by DPCC. I understand that misrepresentation or omission of facts or information requested will be considered sufficient cause for denial of my application for residency at DPCC. Signed: Signed: DPCC Rep.: Applicant Representative

5 DuPage Convalescent Center Application for Long Term Care Admission PRE ADMISSION MEDICAL EXAMINATION FORM TO BE COMPLETED & SIGNED BY A PHYSICIAN Patient Name: (Last) (First) (Middle) (Age) Reason for placement: MEDICAL INFORMATION Physical Description: Height: Weight: Major Diagnoses: Psychiatric/Psychosocial Problems (Please include dates, placement, treatment mode, medications used: Fractures in the last 18 months, include dates: Psychiatric hospitalizations or problems, include dates: History of alcohol abuse: Y/N : List treatment: History of substance abuse: Y/N: List treatment: History of TB or (+) test: Y/N: If yes, explain: Current smoker? Y/N: Type & Frequency: History of infection during hospitalization: MRSA VRE ESBL Other: History of communicable disease: Allergies: Please note current policy prohibits any new residents from smoking at DPCC. MEDICATIONS (By statute, each medication must be supported by Diagnosis) May attach a Medication List signed by physician Medication Diagnosis Dosage Frequency Continued on Reverse

6 PRE ADMISSION MEDICAL EXAMINATION FORM Continued WOUND CARE THERAPY MOST RECENT LABORATORY / X-RAY RESULTS Chest X-Ray CBC Mantoux Step 1 Step 2 Pneumonococcal Pneumonia Vaccination Flu Vaccination Culture Data (if completed within the last 30 days): Sputum: Urine: Blood: Other: FUNCTIONAL LEVEL (PLEASE CHECK ALL THAT APPLY) I-INDEPENDENT A-ASSISTANCE NEEDED U-UNABLE TO PERFORM I A U I A U I A U I A U BED ACTIVITY Turns Sits PERSONAL HYGEINE Face, Hair Arms Trunk/ Perineum Lower Extremity Bowel Program Bladder Program Upper Extremity Bowel Program DRESSING Appliance/Splint Upper Extremity Trunk Lower Extremity FEEDING TRANSFERS Sitting/Standing Tub Toilet MOBILITY Wheelchair Walking Stairs PATIENT USES Appliance Cane Wheelchair Walker Prosthesis Colostomy Catheter Indwelling External Other BEHAVIOR Noisy Belligerent Alcoholic Withdrawn Suspicious Verbally Aggressive Strikes Out Other SAFETY MENTAL STATUS May wander off Requires secured unit Alert Confused Forgetful Confused Alert Forgetful COMMUNICATION ABILITY Primary Language: Speaks Writes Understands Speaking Writing DIET General Special G-Tube RESPIRATORY BiPAP CPAP O2 L/min. via: Nebs Suction X Physician Signature Date Physician s Address, City, State, Zip & Telephone Number Please return this form to the DuPage Convalescent Center, Admissions, 400 N. County Farm Road, Wheaton, IL 60187; or fax it to (630) Your assistance is greatly appreciated.