assisted+living+checklist

Erickson Resource Group – [email protected] / www.ericksonresource.com t: 514-795-7377 EST ©2009 Erickson Resource Group - All rights reserved. No content contained within this document may be reused without

prior written permission.

Assisted Living & Board and Care Checklist Assisted living homes are an option for an individual who wants to live in a home-like environment but requires minimal support to do so. It combines housing and supportive services in one location. It offers assistance with activities of daily living, such as housekeeping, meal assistance, medication management and basic personal care. Generally, they are not locked facilities. When searching for an assisted living facility, it is important to evaluate the services that are included, and those that require additional payment. Use this checklist as a guide. Residence Information:

1. Name of facility/address: ___________________________________________________________

2. Name of administrator:

___________________________________________________________

3. Name of owner (if private): ___________________________________________________________

4. Management company:

___________________________________________________________

5. How many beds are in the facility? What is the ratio of staff to residents? ___________________________________________________________

6. Grievance process:

_________________________________________________________________________________________________________________________________________________________________________________

7. Supervising physician or nurse:

______________________________________________________________________________________________________________________

THIS

IS A

DEMO



8. Is there a supervising physician available; and if so, how often does the

supervising physician visit the facility and/or how often is the nurse available? ______________________________________________________________________________________________________________________

9. How does my loved one schedule an appointment with the nurse or

supervising physician? ______________________________________________________________________________________________________________________

10. Does my loved one see his/her own physician? Who makes my loved one’s doctor’s appointments? If I book them, can you help with transportation? _________________________________________________________________________________________________________________________________________________________________________________

11. Is there a pharmacy located on-site? Or, do you have a pharmacy that makes deliveries? ______________________________________________________________________________________________________________________

12. If there is a medical emergency, what is the process? How am I notified if my loved one needs to be hospitalized? _________________________________________________________________________________________________________________________________________________________________________________

13. What constitutes a medical emergency?

_________________________________________________________________________________________________________________________________________________________________________________

14. Is this a smoking facility? Where can residents smoke?

___________________________________________________________

15. Additional staffing (nurse, nurse’s aide, social worker, occupational therapist, recreation therapist/activities director, physical therapist, physician, pharmacist, etc.): ___________________________________________________________ ___________________________________________________________

THIS

IS A

DEMO



Fees:

1. Rate structures:

a. Flat monthly fee that is all inclusive: _____________________________________________________

b. Tiered rate based on the type and amount of services:

_____________________________________________________

c. Flat daily rate that is all inclusive: _____________________________________________________

d. Fee for a second person (couple):

_____________________________________________________

e. Social security rate, if applicable: _____________________________________________________

f. Private Insurance accepted and rate:

_____________________________________________________

2. Additional fees:

a. Application fee: _____________________________________________________

b. Assessment fee :

_____________________________________________________

c. Security deposit: _____________________________________________________

d. Community fee:

_____________________________________________________

e. Another facility specific fee: _____________________________________________________

THIS

IS A

DEMO



3. Third party payments:

a. Medicare or Medicaid program: _____________________________________________________

b. Private insurance program:

_____________________________________________________

c. Programs for low income applicants or if applicant’s funds are exhausted: _____________________________________________________

d. Social security program:

_____________________________________________________

4. Contract:

a. What type of contract do I sign (monthly, yearly)? _____________________________________________________

b. What are the penalties for breaking the contract?

_____________________________________________________

c. Are the penalties different if my loved one needs to leave because they need a higher level of care? __________________________________________________________________________________________________________

d. What is the process if I need to break a contract?

__________________________________________________________________________________________________________

Make sure to ask whether these fees are refundable if you change your mind or leave the facility before the intended date.

Unit Type and Cost per month: Ask if each type have a private or shared bathroom.

1. Private:____________________________________________________ 2. Studio: ____________________________________________________

THIS

IS A

DEMO



3. One bedroom: ______________________________________________

4. Two bedroom: ______________________________________________

5. Half bathroom (toilet and sink): _________________________________

6. Fully furnished: _____________________________________________

7. Floors of unit availability: ______________________________________

8. Access to elevator: __________________________________________

9. Can you bring your own furniture? Paint the walls? Hang pictures? _________________________________________________________________________________________________________________________________________________________________________________

Transportation:

1. Parking space: ______________________________________________

2. Shuttle service (van/bus) to common services: _____________________

3. Van/bus handicap accessible (lift, etc.): ___________________________

4. Fee for shuttle: ______________________________________________

5. Scheduling process for shuttle: _________________________________

6. Personal transportation: _______________________________________ Meals:

1. Breakfast: __________________________________________________ 2. Lunch:_____________________________________________________

3. Dinner: ____________________________________________________

4. Snacks: ____________________________________________________

THIS

IS A

DEMO



5. Dining hall: _________________________________________________ 6. Room delivery: ______________________________________________

7. Guest meals: ________________________________________________

8. Fees: ______________________________________________________

Housekeeping:

1. Included in daily rate a. _______ times a week

2. Not included in daily rate a. Fee: _____________

Laundry service:

1. Included in daily rate:

a. Linens: _______________________________________________

b. Personal items: ________________________________________

c. Towels: _______________________________________________

d. ______ times a week

2. Not included in rate:

a. Linens fee: __________________

b. Personal items fee: ____________

c. Towels fee: __________________ Amenities:

Included / Not included 1. Emergency response system: � � 2. Gas � � 3. Electric � �

THIS

IS A

DEMO



Included / Not included 4. Water � � 5. Window treatments � � 6. Cable TV hookup � � 7. Basic cable � � 8. Local phone service � � 9. Refrigerator � � 10. Stove � � 11. Microwave oven � � 12. Dishwasher � � 13. Carpeting � � 14. Lockable doors � � 15. Furnished � � 16. Television � �

Medication management:

1. Included in daily rate:

a. Details and process: __________________________________________________________________________________________________________

2. Not included in daily rate

a. Fees: ________________________________________________ b. Details and process:

_______________________________________________________________________________________________________________________________________________________________

Additional paid services:

1. Shopping: _________________________________________________

2. Respite: ___________________________________________________

3. Beauty shop/barber: _________________________________________

4. Companion for outings: _______________________________________ 5. Supplies (toiletries, incontinence care, etc.): _______________________

THIS

IS A

DEMO



Personal care: Provided Not provided Frequency Fee (# per week)

1. Bathing � � _____ _____ 2. Ambulation � � _____ _____ 3. Dressing � � _____ _____ 4. Grooming � � _____ _____ 5. Eating � � _____ _____ 6. Toileting � � _____ _____

Ask the following:

1. If my loved one becomes ill, or I have concerns about his/her health or level of functioning, who do I inform? ______________________________________________________________________________________________________________________

2. Does my loved one receive assistance with transportation to and from the

hospital and/or medical appointments? ______________________________________________________________________________________________________________________

3. What are the criteria for eligibility into this home?

______________________________________________________________________________________________________________________

4. What happens if my loved one needs more care? Does he/she have to

move? Is there another floor that he/she can transfer to that offers more assistance? Is there assistance with this process? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. How do you involve the children and spouse in my loved one’s care? __________________________________________________________________

__________________________________________________________________

__________________________________________________________________

THIS

IS A

DEMO



6. What does my loved one do if he/she wants to go out for a walk or leave the facility with my family? Does he/she have to notify anyone and if so, who? _________________________________________________________________________________________________________________________________________________________________________________

7. How do you care for residents with Dementia/Alzheimer’s who may be at

risk of wandering? _________________________________________________________________________________________________________________________________________________________________________________

Your impressions: Good Fair Poor

1. Interaction between staff and the residents � � � 2. Cleanliness � � � 3. Public areas � � � 4. Rooms � � � 5. Quietness � � � 6. Dining area/food � � � 7. Activity availability � � � 8. Residents look clean and groomed � � � Additional comments, questions, concerns: ________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

THIS

IS A

DEMO

Documents

assisted+living+checklist