Form 4662 – Fill Out and Use This PDF

U niform Disclosure Statement

June 2019, D H MH Form 4662

M aryland Assisted Living Program

U niform D isclosure Statement

What is the Purpose of the D isclosure Statement?

The purpose of the Disclosure Statement is to empower consumers by describing an assisted living program’s policies and services in a uniform manner. This format gives prospective residents and their families consistent categories of information from which they can compare programs and services.1

It is important to note that the Disclosure Statement is not intended to take the place of visiting the program, talking with residents, or meeting one-on-one with staff. Nor is the statement a binding contract or substitute for the Resident Agreement. Rather, it serves as additional information for making an informed decision about the services provided in each program.

If you have any questions about any issue raised in the Disclosure Statement or in the Resident Agreement provided by an assisted living program, please seek clarification from that program’s manager or administrator.

What is Assisted Living?

Assisted living is a way to provide care to people who are having difficulty living independently. Assisted living providers furnish a place to live, meals, and assistance with daily activities such as dressing, bathing, eating, and managing medications. Assisted living programs also tend to have a less institutional look than nursing homes. However, these facilities are not as highly regulated by the State as nursing homes. There are a wide variety of assisted living programs in Maryland. They range from large, corporate-managed facilities where hundreds of people live in their own apartments to small, private homes.

Assisted living programs may differ in many ways including, but not limited to: size, staff qualifications, services offered, location, fees, sponsorship, whether they are freestanding or part of a continuum of care, participation in the Medicaid Waiver, ability to age in place, and visiting hours. Therefore, consumers should try to have a general idea of what type of setting, services, and price range they may want before contacting an assisted living program, as well as having questions prepared to ask the program manager or administrator. Consumers may find the Maryland Department of Aging’s publication entitled, “Assisted

Living in Maryland: What You Need to Know,” helpful when they are contemplating assisted living. The publication may be downloaded from the Department of Aging’s Web site. (https://aging.maryland.gov/documents/ALGuide.pdf)

In addition, the Office of Health Care Quality (OHCQ) encourages consumers to verify the licensure status of any assisted living

program that they are considering. A list of licensed assisted living programs is available online. (https://health.maryland.gov/ohcq/Pages/Licensee-Directory.aspx)

Where can I find the Assisted Living Licensure Standards?

The Assisted Living Licensure Standards are found in the Code of Maryland Regulations (COMAR) 10.07.14, available at public libraries, or online at http://www.dsd.state.md.us/Publications.html. A copy of the most recent survey report of an assisted living

program may be obtained from the program’s manager or administrator.

1Assisted Living providers are not required to provide all of the services listed in the Disclosure Statement—regulatory requirements may be found in COMAR 10.07.14.

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U niform Disclosure Statement

June 2019, D H MH Form 4662

1) Assisted Living Program Contact Information:

Facility Name

License No.	No. of Licensed Beds	Level of Care at which Facility is
		Licensed
Address (Street, City, State, Zip)
Phone Number	Fax Number
E-Mail Address (optional)	Operator/Management Company
Manager	Contact Information
Delegating Nurse	Contact Information
Alternate Manager	Contact Information
Completed By	Title	Date Completed

2) What sources of payment are accepted?

Assisted living programs differ in what types of sources they may accept for payment, e.g. private insurance, Medicaid, private pay, SSI/SSDI, etc. What sources of payment are accepted at this program?

3) What are levels of care?

The levels of care correspond with how much assistance residents need. The level of care designation, therefore, reflects the complexity of the services required to meet the needs of a resident. The State of Maryland recognizes three levels of care, and they are as follows: Level 1 is low level of care required, Level 2 is moderate level of care required, and Level 3 is high level of care required.

A resident’s level of care is determined by the Resident Assessment Tool, which collects essential information about a resident’s physical, functional, and psychosocial strengths and deficits. There are two components to the assessment tool - a Health Care Practitioners Physical Assessment, to be completed or verified by a health care practitioner, and the Assisted Living Manager’s Assessment, to be completed by the Assisted Living Manager or designee. A resident’s score on the assessment tool determines his/her level of care (Level 1 = a total score of 0-20; Level 2 = a total score of 21-40; and Level 3 = a total score of 41 or higher).

Some assisted living programs may have elected to develop more than three levels of care. If an assisted living program has more than three levels of care, please describe the levels of care and how they correlate to the three levels of care recognized by the State. In addition, include program charges for each level of care.

Explanation: (You may attach materials as necessary)

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U niform Disclosure Statement

June 2019, D H MH Form 4662

4) What is a Resident Agreement?

The resident agreement is a legal contract, obligating a consumer to provide payment in return for services to be provided by the assisted living program. An assisted living program will provide a consumer with a Resident Agreement to review and sign prior to move-in. Prospective residents should feel free to request a copy of a sample resident agreement at any time.

The resident agreement is required by regulation to include, at a minimum, the information provided in COMAR 10.07.14.24(D) and 10.07.14.25(A), such as: the level of care the program is licensed to provide, a list of services provided by the program, an explanation of the program’s complaint or grievance procedure; admission and discharge policies and procedures; obligations of the program and the resident or the resident’s representative with regards to financial matters—handling resident finances, purchase or rental of essential or desired equipment; arranging or contracting for services not covered by the resident agreement; rate structure and payment provisions; identification of persons responsible for payment; notice provisions for rate increases; billing, payment, and credit polices; and terms governing the refund of any prepaid fees or charges in the event of a resident’s discharge or termination of the resident agreement.

5) What Services are Provided?

Consumers should expect assisted living programs to provide clear information regarding services and fees. Some programs may charge fees for services based on the resident’s assessed level of care, while others may provide an “a la carte” menu of services. Consumers should understand what is included in the base monthly rate, what services require an additional charge, circumstances under which fees may increase, and the refund policy. Below is a chart to help consumers better compare assisted living programs. This chart is not all-inclusive and providers may offer more or fewer services than listed below.

Nursing and Clinical Care:

24-Hour Awake Staff, Including Awake Overnight Staff

Nursing Review Every 45 Days (Required by COMAR)

On-site Licensed Nursing (_________ Hours/Week)

Physician Services

Bladder Incontinence Care

Bowel Incontinence Care

Catheter Care

Consultant pharmacist medication review (required in some cases)

Diabetes Care

End of Life Care

Home Health

Hospice Care

Incontinence Products

Infection Control Materials (e.g., gloves, masks, etc.)

Nutritional Supplements

Service Plan and Frequency _________(Required by COMAR at

least every 6 months)

Temporary use of wheelchair/walker

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U niform Disclosure Statement

June 2019, D H MH Form 4662

Personal Care:

Arrange/Coordinate Medical Appointments

Assistance with bathing

Assistance with dressing

Assistance with handling money

Assistance with incontinence

Assistance with preparing meals

Assistance with shopping for food or personal items

Assistance with toileting

Companion Services

Housekeeping

Mobility/Transfer Assistance

Personal Care Items

Environment:

Activities program (_____ days per week), specify programs or

attach calendar.

Alcohol Consumption

Barber/Beauty Shop

Cable TV

Fire Sprinklers (____ in all areas or _____in some areas), specify:

Internet Access

Linens/Towels

Chair Glide System

Dry Cleaning Services

Elevators

Emergency Call System

Emergency Generator

Fire Alarm System

Automatic Electronic Defibrillators (AEDs)

Handrails

Personal Laundry

Personal Phone

Pets Allowed, specify:

Ramps

Security Services, specify:

Smoking

Secured Areas

Sprinkler system

Transportation, specify

Visitation, specify hours and include the facility’s policies and procedures

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U niform Disclosure Statement

June 2019, D H MH Form 4662

Environment: (Continued)

Volunteer Services, specify and include the facility’s policies and procedures

Wander Guard or similar system, specify:

Dietary:

Meals (______ per day & snacks) (COMAR requires a minimum of

3 meals per day & additional snacks)

Special Diets, specify:

Family or Congregate Meals

Pharmaceuticals/Medications:

Durable Medical Equipment, specify:

Medication Administration

Medication Injections

Pharmaceuticals

Self Administration of Medications Permitted

Use of Outside Pharmacy Permitted

Use of Mail Order Pharmacy Permitted

Specialized Care or Services:

Behavior Management: Verbal Aggression

Behavior Management: Physical Aggression

Dementia Care

Intravenous Therapy

Mental Health Supports and Services, specify:

Ostomy Care

Oxygen Administration

Special Care Units, if there are additional charges for this type of care, please specify cost difference as well as how those services differ from the services provided in the rest of the program.

Services for persons who are blind

Staff who can sign for the deaf

Bilingual Services

Tube Feeding

Wound Care

Explanation: (opt ional)

Explanation:(opt ional)

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U niform Disclosure Statement

June 2019, D H MH Form 4662

6) What are the criteria for discharge or transfer?

The following is a list of situations that may necessitate the termination of the resident agreement and the transfer or discharge of a resident from an assisted living program. Consumers are encouraged to inquire about an assisted living program’s policies and procedures in the event that a resident must relocate. This list is not all-inclusive and criteria will differ depending upon the assisted living program’s ability to provide certain types of care. All transfers and discharges must comply with Maryland regulatory requirements, including notice requirements, and terms of the Resident Agreement.*

Criteria/Factor which may:	Cause	Cause	Require the use of external
	(temporary)	(permanent)	resources
	transfer	discharge
Medical condition requiring care exceeding that of which the
facility determines it can safely provide
Unacceptable physical, verbal, or sexual behavior
Medication stabilization
Danger to self or others
Inability to toilet
Non-ambulatory
Inability to eat/tube feeding
Must be hand fed
Inability to walk/bedfast
Others:
Mental health issues, specify:
Mobility changes
Needs skilled nursing care
Requires sitters
Medication injections
Behavior management for verbal or physical aggression
Bladder incontinence care
Bowel incontinence care
Intravenous (IV) therapy
Level of care change
Moderate or advanced dementia, specify:

*Under Maryland Regulations an assisted living program may not provide services to an individual who at the time of initial admission, as established by the initial assessment, requires: (1) More than intermittent nursing care; (2) Treatment of stage three or stage four skin ulcers; (3) Ventilator services; (4) Skilled monitoring, testing, and aggressive adjustment of medications and treatments where there is the presence of, or risk for, a fluctuating acute condition; (5)

Monitoring of a chronic medical condition that is not controllable through readily available medications and treatments; or (6)Treatment for a disease or condition which requires more than contact isolation. Exceptions to the conditions listed above are provided for individuals who are under the care of a licensed general hospice program.

Who makes the resident discharge or transfer decision?

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Explanat ion:(opt ional)

Explanat ion:(opt ional)

7) What are the requirements for staff training?

COMAR requires that assisted living programs provide initial and annual training for the alternate manager and staff in: (a) fire and life safety, including the use of fire extinguishers; (b) infection control, including standard precautions, contact precautions, and hand hygiene; (c) basic food safety; (d) emergency disaster plans; (e) basic first aid by a certified first aid instructor; and (f) cognitive impairment and mental illness training. Staff must have training or experience in: (a) the health and psychosocial needs of the population being served; (b) the resident assessment process; (c) the use of service plans; and (d) resident rights. A sufficient number of staff must also have initial and ongoing training in CPR training from a certified instructor. Consumers are encouraged to talk to the assisted living program manager about sources of staff training and their qualifications.

COMAR requires that assisted living program managers have sufficient skills, training, and experience to serve the residents in a manner that is consistent with the philosophy of assisted living. Managers must have verifiable knowledge in: (a) the health and psychosocial needs of the population being served; (b) the resident assessment process; (c) use of service plans; (d) cuing, coaching, and monitoring residents who self-administer medications with or without assistance; (e) providing assistance with ambulation, personal hygiene, dressing, toileting, and feeding; and (f) resident rights. Managers must receive initial and annual training in: (a) fire and life safety; (b) infection control, including standard precautions; (c) emergency disaster plans; and (d) basic food safety. Managers are required to have initial certification and recertification in: (a) basic first aid by a certified first aid instructor; and (b) basic CPR by a certified CPR instructor.

COMAR requires that assisted living program managers of programs licensed for five beds or more have completed an 80-hour manager’s training course. Some managers are exempt from this requirement.

Some assisted living programs may elect to require training for staff, managers, and alternate managers beyond these requirements.

Additional training provided:

8) What is the assisted living program’s staffing pattern?

COMAR requires assisted living programs to develop a staffing plan that includes on-site staff sufficient in number and qualifications to meet the 24-hour scheduled and unscheduled needs of the residents. The delegating nurse, based on the needs of a resident, may issue a nursing order for on-site nursing.

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U niform Disclosure Statement

February 2009, D H MH Form 4662

If staff do not work on a per-day basis, indicate the onsite hours per month.

Explanation:

9) How do I file a complaint?

Under Maryland regulations, assisted living programs are required to have an internal complaint or grievance procedure. An explanation of the assisted living program’s internal complaint or grievance procedure must be included in the resident agreement. Consumers should review this information and make sure that they understand how the internal complaint or grievance procedure operates. Consumers should direct any questions about the internal procedure to the assisted living program’s manager or administrator.

Consumers may also report concerns or file a complaint regarding an assisted living program to the Office of Health Care Quality. Complaints may be registered over the phone or through the OHCQ Web site. Complaints may be anonymous. For

more information regarding filing a complaint, please visit the Office of Health Care Quality’s Web site at https://health.maryland.gov/ohcq/Pages/Complaints.aspx or call (410) 402-8217 or 1-877-402-8218.

Maryland Department of H ealth

O ffice of H ealth Care Q uality

7120 Samuel Morse Drive

Columbia, Maryland 21046

Phone: (410) 402-8015 T oll Free: 1-877-402-8218

www.health.maryland.gov/ohcq

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