Lodge Application Package

Transcription

1 Lodge Application Package Rosealta Lodge, Camrose S:\Stoney Rosealta\Admin\WORD\LODGEINFO(APPLICATIONPKG&RESIDENT HDBK)\ Rosealta Lodge Application Package.doc Page 1 of 17

2 I n f o r m a t i o n Housing and Community Services SENIORS LODGE The mandate of the Seniors Lodge Program is to provide subsidized accommodation for independent, healthy seniors whose needs were limited to the provision of meals and housekeeping. In recognition of the changing needs of residing residents, the mandate was amended to allow access to community-based services for functionally independent seniors. The Lodge Priority Rating System was implemented to standardize lodge entrance criteria across Alberta. Through an application and interview process, the applicant s eligibility is assessed. Consideration will be given to low to moderate income seniors 65 years or older. Under the authority of Alberta Seniors and Community Supports and the Camrose and rea Lodge Authority, The Bethany Group operates as a management body for two lodges in Camrose. Rosealta Lodge Street Camrose Lodges provide the privacy and comfort of home while offering a community environment where an active, carefree life-style is encouraged. Core services provided by the lodge include: basic room furnishings (if required) weekly housekeeping services three meals per day, as well as daily snacks building security 24 hour non-medical staffing access to community-based services opportunities for life enriching activities to enhance physical, emotional, social, spiritual, and intellectual well-being To find out more about the lodge program, please feel free to contact the Lodge Manager at the telephone number listed above. S:\Stoney Rosealta\Admin\WORD\LODGEINFO(APPLICATIONPKG&RESIDENT HDBK)\ Rosealta Lodge Application Package.doc Page 2 of 17

3 Lodge Criteria The Bethany Group The following information and conditions are presented to help lodge applicants and their family members make plans for appropriate housing choices. Listed below are areas that need to be considered when choosing the appropriate facility. Where the manager or coordinator feels that the applicant s needs may not be met with confidence and safety, alternate housing options will be discussed. An applicant must meet and maintain the following minimum standard of wellness as an entrance requirement to the Lodge: Is able to participate in the activities of the lodge and to benefit from the lodge environment and lifestyle (e.g., can: negotiate long hallways; participate in family style dining; manage personal laundry; live with independence and safety in the lodge setting; understand and follow instructions for evacuation in case of a fire; etc.). Has stable health, and any medical conditions are manageable within a lodge setting (making use of available community support systems, etc.). Is willing and able to maintain personal care and hygiene. He/She is also able to handle his/her own toileting without help, and if there is some degree of incontinence, is willing and able to manage that incontinence without help. Is able to move about independently or with the use of mechanical aids, and can move from lying down to sitting to standing without help. Is not in need of extensive guidance and direction from others to get through the day (i.e., is not suffering from dementia, etc.). Is not assessed by Home Care as requiring designated assisted living level 3 or higher (e.g., long term care). Has regular dietary needs. Please note that specialty diets which require close supervision cannot be met in the lodge setting. Is willing to live in a lodge and abide by the lodge rules and regulations. Agrees to a trial period of six weeks. Within that period, either party has the right to withdraw from the agreement if companionable living arrangements cannot be made. A notice period of one month is required. S:\Stoney Rosealta\Admin\WORD\LODGEINFO(APPLICATIONPKG&RESIDENT HDBK)\ Rosealta Lodge Application Package.doc Page 3 of 17

4 M o n t h l y R a t e s Housing and Community Services SENIORS LODGE Rates are set by the Camrose and Area Lodge Authority. The Services Charge (which is not available to the residents in the H-Units) includes all meals and snacks, weekly housekeeping, linen laundry, annual suite cleaning, activities/recreation, and 24-hour security and emergency response. The Rent Charge (which is based on 30% of income) includes bed/sitting room (furnished, with a private bathroom), utilities (Note: cable, parking, and telephone are extra), and the repairs, maintenance, and cleaning of the common areas of the lodge. Effective July 1, 2015, the monthly rates* are: Rosealta Lodge Services Charge for Singles... $ Rent Charge for Singles... 30% of income (up to a max. of $800) Services Charge for Couples in Adjoining Rooms... $ Rent Charge for Couples in Adjoining Rooms... 30% of income (up to a max. of $1600) Parking - per space... $8.00 Cable TV... $12.00 Fridge... $5.00 Cottage Units Per Unit... 30% of income (up to a max. of $700) Cable TV... $12.00 Meals...Fee per meal Parking.... $9.00 *All rates are subject to change. If you are low- to moderate-income, please ensure that you are receiving both the Alberta Seniors Benefit (ASB) and the Guaranteed Income Supplement (GIS) before moving into the lodge (if applicable). If you wish to find out if you are already receiving these benefits (or if you need to apply for them), please call ASB at and GIS at S:\Stoney Rosealta\Admin\WORD\LODGEINFO(APPLICATIONPKG&RESIDENT HDBK)\ Rosealta Lodge Application Package.doc Page 4 of 17

5 LODGE APPLICATION FORM (Please note that unless you are applying for accommodation as a couple, you may disregard the Co-Applicant information sections) Applicant s Name: Mr. Mrs. Ms. Miss Date of Birth: Phone Number: Current Address (including postal code): In case we are not able to contact you, please list an alternate contact person (including their phone number and their relationship to you): Co-Applicant s Name: Mr. Mrs. Ms. Miss Date of Birth: Phone Number: Current Address (including postal code): In case we are not able to contact you, please list an alternate contact person (including their phone number and their relationship to you): Please answer all of the questions in the following pages. This information is required by the Alberta Housing Act and will be used to establish your circumstances and level of need. Applications will be placed on as waiting list in order of priority and need, based on your responses to the questions. Your application cannot be reviewed unless all of the questions have been answered, the medical report form has been filled out by your doctor, and a copy of your latest tax return Notice of Assessment has been included with your completed application. S:\Stoney Rosealta\Admin\WORD\LODGEINFO(APPLICATIONPKG&RESIDENT HDBK)\ Rosealta Lodge Application Package.doc Page 5 of 17

6 An application for lodge residency does not guarantee that you will be accepted for lodge accommodation. Lodges are not a substitute for Continuing Care; however, people who receive support and assistance from community supports (such as Home Care) may be eligible. The process for potential admittance to the lodges is as follows: 1. An application form is completed, and a copy of a current Notice of Assessment is included. The completed application is then either mailed or faxed to: Rosealta Lodge Street Camrose, AB T4V 4G3 Fax: (780) Phone: (780) or (780) The application(s) will then be rated and placed on the waiting list in order of the point scoring system. 3. When a room at the lodge is available, the most appropriate applicant(s) will be contacted. The Lodge Manager will set up a tour and interview. An additional medical form which is to be completed by a physician may be required at that time (if requested by the Lodge Manager). The applicant(s) may also be required to provide written consent for the exchange of pertinent information between the Lodge Manager and the applicant s service provider(s) (e.g., Home Care, Mental Health, etc.). 4. Once the interview(s) have been conducted, the room will be offered to the most suitable candidate. S:\Stoney Rosealta\Admin\WORD\LODGEINFO(APPLICATIONPKG&RESIDENT HDBK)\ Rosealta Lodge Application Package.doc Page 6 of 17

7 If applying as a couple, please note that both the Applicant and the Co-Applicant columns must be completed in their entirety (i.e., there must be a complete set of Yes or No answers for EACH individual applying); if applying as a single, only the Applicant column needs to be completed. Thank you. Lodge Application Form Questionnaire Applicant Co-Applicant 1. Do you (or your partner) cook full-sized, nutritious meals on a regular basis? Yes or No Yes or No 2. Do you (or your partner) cook regularly, but often stick to easy foods such as soup and sandwiches? Yes or No Yes or No 3. Do you (or your partner) cook some of your own meals, but get assistance from other individuals for the remainder of your meals? Yes or No Yes or No 4. Do you get all of your meals from Meals-on-Wheels, family, and/or other sources? Yes or No Yes or No 5. Would you like to move into a lodge at this time because you are lonely and feel a need for activities, recreation, and friends? Yes or No Yes or No 6. Have you been limiting your leisure/social activities (e.g., participating in a recreation group/club, attending church, etc.) due to your lack of mobility and/or frailty? Yes or No Yes or No 7. Have you been limiting your leisure/social activities (e.g., participating in a recreation group/club, attending church, etc.) because you live too far away and/or have transportation problems? Yes or No Yes or No 8. Do you have an emergency situation (e.g., an impending eviction, a lack of financial resources, etc.) which may be helped by your move to a lodge? Yes or No Yes or No If yes, please explain: Applicant: Co-Applicant: S:\Stoney Rosealta\Admin\WORD\LODGEINFO(APPLICATIONPKG&RESIDENT HDBK)\ Rosealta Lodge Application Package.doc Page 7 of 17

8 If applying as a couple, please note that both the Applicant and the Co-Applicant columns must be completed in their entirety (i.e., there must be a complete set of Yes or No answers for EACH individual applying); if applying as a single, only the Applicant column needs to be completed. Thank you. Lodge Application Form Questionnaire 9. Would a lodge be better for you because of issues such as your forgetfulness, your personal safety (e.g., risk of falling, a lack of proper household security, etc.), or Applicant Co-Applicant another similar situation? Yes or No Yes or No If yes, please explain: Applicant: Co-Applicant: 10. Are there any other situations in your life (such as abuse) where a move to a lodge would help alleviate and/or eradicate the problem? Yes or No Yes or No If yes, please explain: Applicant: Co-Applicant: 11. Do you handle all of your own personal care and hygiene, without any assistance? Yes or No Yes or No 12. Do you handle most of your own bathing, minor cleaning, etc., but get help with some of the more difficult tasks? Yes or No Yes or No If yes, please list the tasks you require assistance with: Applicant: Co-Applicant: 13. Do you get Home Care and/or others to do most (or all) of your laundry, cleaning, and personal care? Yes or No Yes or No S:\Stoney Rosealta\Admin\WORD\LODGEINFO(APPLICATIONPKG&RESIDENT HDBK)\ Rosealta Lodge Application Package.doc Page 8 of 17

9 If applying as a couple, please note that both the Applicant and the Co-Applicant columns must be completed in their entirety (i.e., there must be a complete set of Yes or No answers for EACH individual applying); if applying as a single, only the Applicant column needs to be completed. Thank you. Lodge Application Form Questionnaire Applicant Co-Applicant 14. Do you need help getting in and/or out of your bed? Yes or No Yes or No 15. At this time, do you live in a building with others (e.g., an apartment building, etc.)? Yes or No Yes or No 16. Does the thought of living closely with other seniors appeal to you? Yes or No Yes or No 17. Do you like to be left alone and live independently? Yes or No Yes or No 18. Do you generally get around your home without much help from others? Yes or No Yes or No 19. Do you limit how much you get around (both inside and outside of your home) due to fear of falling and/or other physical problems? Yes or No Yes or No If yes, please explain: Applicant: Co-Applicant: 20. Do you need help to get around outside of your home (e.g., to go shopping, to get to appointments, etc.)? Yes or No Yes or No 21. Do you have family nearby who can help and support you when you need it? Yes or No Yes or No 22. Do you have friends nearby who can help and support you when you need it? Yes or No Yes or No 23. Do you want to move to a lodge because you feel that there is no other accommodation that is suitable for you? Yes or No Yes or No If yes, please explain why you feel that lodge accommodations will suit your needs: Applicant: Co-Applicant: S:\Stoney Rosealta\Admin\WORD\LODGEINFO(APPLICATIONPKG&RESIDENT HDBK)\ Rosealta Lodge Application Package.doc Page 9 of 17

10 If applying as a couple, please note that both the Applicant and the Co-Applicant columns must be completed in their entirety (i.e., there must be a complete set of Yes or No answers for EACH individual applying); if applying as a single, only the Applicant column needs to be completed. Thank you. Lodge Application Form Questionnaire Applicant Co-Applicant 24. Do you need to leave your present accommodation because the rent is beyond your means or the residence is being sold? Yes or No Yes or No 25. Do you wish to move from your current home because the maintenance, gardening, and/or general upkeep is getting to be too much work for you? Yes or No Yes or No 26. Is your present home not suitable due to accessibility issues (e.g., steps, etc.)? Yes or No Yes or No 27. Do you need to move because your present living arrangement is not suitable anymore (due to issues such as overcrowding, living with family, etc.)? Yes or No Yes or No 28. Have you been assessed as requiring designated assisted living 3 or higher? Yes or No Yes or No 29. Do you suffer incontinence to such a degree that you are not able and/or willing to manage it yourself? Yes or No Yes or No 30. Do you have an activated Personal Directive? Yes or No Yes or No If yes, please indicate your Named Agent and their phone number: Applicant s Named Agent: Co-Applicant s Named Agent: 31. Do you have a Legal Guardian? Yes or No Yes or No If yes, please indicate their name and phone number: Applicant s Legal Guardian: Co-Applicant s Legal Guardian: S:\Stoney Rosealta\Admin\WORD\LODGEINFO(APPLICATIONPKG&RESIDENT HDBK)\ Rosealta Lodge Application Package.doc Page 10 of 17

11 Lodge Application Form Questionnaire Lodge Application Form Questionnaire Applicant Co-Applicant 32. Please indicate if you currently use (or are scheduled to begin using) any of the following: Walker: Yes or No Yes or No Wheelchair: Yes or No Yes or No Motorized Scooter (NOTE: motorized scooters are prohibited in the lodges): Yes or No Yes or No Electric Wheelchair (NOTE: electric wheelchairs are prohibited in the lodges): Yes or No Yes or No 33. Are you currently receiving the Alberta Seniors Benefit (ASB)? Yes or No Yes or No 34. Are you currently receiving Assured Income for the Severely Handicapped (AISH)? Yes or No Yes or No 35. Are you currently receiving Canada Pension Plan/Old Age Security (CPP/OAS)? Yes or No Yes or No 36. Are you currently receiving a Guaranteed Income Supplement (GIS)? Yes or No Yes or No 37. Are you currently receiving a Veteran s Pension (DVA)? Yes or No Yes or No 38. Have you included a copy of your Notice of Assessment with this completed application? Yes or No Yes or No When would be the soonest that you would be able/willing to move into a lodge (starting from the date that you submitted your completed application to us)? Immediately 1 3 months 3 6 months 6 months 1 year more than 1 year Do you own your own home? Do you rent your home? Yes No Yes No S:\Stoney Rosealta\Admin\WORD\LODGEINFO(APPLICATIONPKG&RESIDENT HDBK)\ Rosealta Lodge Application Package.doc Page 11 of 17

12 Lodge Application Form Questionnaire Do you share your accommodations with anyone else (other than a co-applicant)? Yes No If yes, please explain: Please tell us a bit more about yourself and why you would like to move into a lodge. Do not worry about handwriting or spelling. If you require extra space, please attach a separate sheet of paper. S:\Stoney Rosealta\Admin\WORD\LODGEINFO(APPLICATIONPKG&RESIDENT HDBK)\ Rosealta Lodge Application Package.doc Page 12 of 17

13 APPLICANT S MEDICAL INFORMATION This medical information is required by The Bethany Group for all applicants wishing to obtain tenancy in the lodge. Please ensure that a physician completes all required sections (with the exception of the Authorization for Release of Information section, which is to be completed by the applicant). ****Any cost associated with the completion of this form is the responsibility of the applicant**** Authorization for Release of Information I, hereby authorize and instruct, to release (applicant) (name of physician completing report) the personal care information requested in this application. I understand that the information collected will be used to determine eligibility to the Lodge Seniors Housing Program with The Bethany Group. Date: Applicant s signature: Witness: Medical Information The mandate of the Seniors Lodge Program is to provide accommodation for independent, healthy seniors whose needs are limited to the provision of meals and housekeeping. Residents must be mentally and physically capable of performing daily skills independently, and have good judgment and decision making abilities. 1. Would this applicant require assistance with: a) Managing daily personal care (including dressing)? Yes No Unsure b) Bathing? Yes No Unsure c) Mobility (e.g., to dining room, activities)? Yes No Unsure d) Personal hygiene (e.g., continence, shaving)? Yes No Unsure e) Reminders and cueing? Yes No Unsure f) Taking medications? Yes No Unsure g) Following direction (e.g., fire drills, emergencies)? Yes No Unsure i) Social behaviors (e.g., eating, visiting)? Yes No Unsure 2. Are there signs of wandering? Yes No Unsure 3. Does applicant have any special dietary needs? Yes No Unsure If yes, are they capable of making wise food choices? Yes No Unsure Please explain: S:\Stoney Rosealta\Admin\WORD\LODGEINFO(APPLICATIONPKG&RESIDENT HDBK)\ Rosealta Lodge Application Package.doc Page 13 of 17

14 4. Is the applicant receiving Home Care supports? Yes No Unsure If yes, who is the contact for their Home Care supports? Name: Phone number: 5. Is the applicant receiving Mental Health support? Yes No Unsure If yes, who is the contact for their Mental Health support? Name: Phone number: 6. Is applicant showing signs of dementia? Yes No Unsure If yes, please explain: 7. Is the applicant showing signs of physical &/or verbal aggression? Yes No Unsure If yes, please explain: 8. How long has the applicant been your patient? 9. Additional Comments: Name and contact information of physician who completed this form: Name: (please print) Signature: Phone # Date: The information collected for this application is confidential and will only be used for the purpose of evaluating the applicant for accommodation. The Bethany Group may request additional information, or an updated report, if deemed necessary. S:\Stoney Rosealta\Admin\WORD\LODGEINFO(APPLICATIONPKG&RESIDENT HDBK)\ Rosealta Lodge Application Package.doc Page 14 of 17

15 CO-APPLICANT S MEDICAL INFORMATION This medical information is required by The Bethany Group for all applicants wishing to obtain tenancy in the lodges. Please ensure that a physician completes all required sections, with the exception of the Authorization for Release of Information section (which is to be completed by the co-applicant). ***Any cost associated with the completion of this form is the responsibility of the co-applicant*** Authorization for Release of Information I, hereby authorize and instruct, to release (co-applicant) (name of physician completing report) the personal care information requested in this application. I understand that the information collected will be used to determine eligibility to the Lodge Seniors Housing Program with The Bethany Group. Date: Co-applicant s signature: Witness: Medical Information The mandate of the Seniors Lodge Program is to provide accommodation for independent, healthy seniors whose needs are limited to the provision of meals and housekeeping. Residents must be mentally and physically capable of performing daily skills independently, and have good judgment and decision making abilities. 1. Would this applicant require assistance with: a) Managing daily personal care (including dressing)? Yes No Unsure b) Bathing? Yes No Unsure c) Mobility (e.g., to dining room, activities)? Yes No Unsure d) Personal hygiene (e.g., continence, shaving)? Yes No Unsure e) Reminders and cueing? Yes No Unsure f) Taking medications? Yes No Unsure g) Following direction (e.g., fire drills, emergencies)? Yes No Unsure i) Social behaviors (e.g., eating, visiting)? Yes No Unsure 2. Are there signs of wandering? Yes No Unsure 3. Does applicant have any special dietary needs? Yes No Unsure If yes, are they capable of making wise food choices? Yes No Unsure Please explain: S:\Stoney Rosealta\Admin\WORD\LODGEINFO(APPLICATIONPKG&RESIDENT HDBK)\ Rosealta Lodge Application Package.doc Page 15 of 17

16 4. Is the applicant receiving Home Care supports? Yes No Unsure If yes, who is the contact for their home care supports? Name: Phone number: 5. Is the applicant receiving Mental Health support? Yes No Unsure If yes, who is the contact for their mental health support? Name: Phone number: 6. Is applicant showing signs of dementia? Yes No Unsure If yes, please explain: 7. Is the applicant showing signs of physical &/or verbal aggression? Yes No Unsure If yes, please explain: 8. How long has the applicant been your patient? 9. Additional Comments: Name and contact information of physician who completed this form: Name: (please print) Signature: Phone # Date: The information collected for this application is confidential and will only be used for the purpose of evaluating the applicant for accommodation. The Bethany Group may request additional information, or an updated report, if deemed necessary. S:\Stoney Rosealta\Admin\WORD\LODGEINFO(APPLICATIONPKG&RESIDENT HDBK)\ Rosealta Lodge Application Package.doc Page 16 of 17

17 Thank you for your interest in our lodge. This checklist has been provided for your convenience so that you can ensure that you have provided us with all of the information necessary to begin processing your application. Please double-check your application package and ensure that you have: filled out all of the personal information on page 5 (for both the applicant and the co-applicant, if applying as a couple); completed the Lodge Application Form Questionnaire on pages 7 thru 11; answered all of the questions regarding accommodations on page 13; had a physician complete the Medical Information Form on pages (for both the applicant and the co-applicant, if applying as a couple); and included a copy of a current Notice of Assessment for each applicant. Once all portions have been completed, the Lodge Application Package can be mailed or faxed to: Rosealta Lodge Street Camrose, AB T4V 4G3 Fax: (780) Phone: (780) or (780) S:\Stoney Rosealta\Admin\WORD\LODGEINFO(APPLICATIONPKG&RESIDENT HDBK)\ Rosealta Lodge Application Package.doc Page 17 of 17