Bill of Residents Rights

Section * - Nursing

Rev. 03-01-12

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Bill of Residents Rights

Exercise of Rights:

1. You have the right to exercise your rights as a resident of the facility and as a citizen or resident of the United States.

2. You have the right to be free of interference, coercion, discrimination, or reprisal from the facility in exercising your rights.

3. If you are adjudged incompetent under the laws of this state by a court of competent jurisdiction, your rights will be exercised by the person appointed under state law to act on your behalf. 4. If you are not adjudged incompetent by a state court, any legal surrogate designated according to state law may exercise your rights, to the extent provided by state law. Notice of Rights and Services:

5. You have the right to be informed prior to or upon admission and during your stay both orally and in writing in a language you understand of your rights and all rules and regulations governing your conduct and responsibilities during your stay in the facility. 6. You have the right, upon oral or written request and 24-hour notice (excluding weekends and holidays), to have access to all records pertaining to you, and upon request and two working days advance notice, to purchase photocopies of all such records.

7. You have the right to be fully informed in language you understand of your total health status including, but not limited to, your medical condition.

8. You have the right to refuse treatment, to refuse to participate in experimental research, and to formulate and advance directive such as a living will or a durable power of attorney for health care, recognized under state law relating to the provision of health care when you are no longer able to make decisions. 9. You have the right to be informed in writing at the time of admission to the facility, or when you become eligible for Medicaid, of items and services that are included in nursing facility services under the Medicaid program in this state and for which you may not be charged. You also have the right to be informed of those other items and services that the facility offers and for which you may be charged, the amount of charges, and to be informed when changes are made to items and services paid for and not paid for by the Medicaid program in this state.

10. You have the right to be informed before or at the time of admission and periodically during your stay of services available in the facility and of charges for those services including any charges for services not covered under the Medicare program or by the facility’s per diem rate. 11. You have the right to file a complaint with the State Survey and Certification Agency concerning abuse, neglect, and misappropriation of property in the facility and non-compliance with the advance directive requirements.

12. You have the right to be informed of the name, specialty, and way of contacting the physician responsible for your care.

13. Except in a medical emergency or if you have been adjudged incompetent, you have the right to be informed immediately whenever

a. You are involved in an accident which results in injury and could require physician intervention. b. A significant change occurs in your physical, mental, or psychosocial status. c. There is a need to alter treatment significantly. d. A decision is made to transfer or to discharge you from the facility. e. A change in room or roommate assignment occurs. Bill of Residents Rights

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Rev. 03-01-12

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Bill of Residents Rights

f. There is a change in your rights under federal or state law or regulations. g. You also have the right to have your attending physician consulted regarding the above (except e and f) and to have your legal representative or interested family member notified promptly. Resident Funds:

14. You have the right to manage your financial affairs and the facility may not require that you deposit your personal funds with the facility. The facility may not impose a charge against your personal funds for any item or service for which payment is made under Medicare or Medicaid (except for applicable co-insurance and deductible amounts). The facility may charge you for requested items or services that are more expensive than or in excess of covered services. A description of the manner of protecting personal funds is contained in the Policy on Protection of Residents’ Funds which is incorporated into this document. Free Choice:

15. You have the right to choose a personal attending physician. 16. You have the right to be fully informed in advance about care and treatment and of any changes in the care or treatment that may affect your well-being and to participate in planning care and treatment or changes in care and treatment, unless you have been adjudged incompetent or found to be incapacitated under state law.

Privacy and Confidentiality:

17. You have the right to personal privacy and confidentiality of your personal and clinical records. Personal privacy includes privacy in accommodations, medical treatment, written and telephone communication, personal care, visits and meeting of family and resident groups, but this does not require facility to provide a private room.

18. You have the right to approve or refuse the release of personal and clinical records to any individual outside the facility except:

a. When you are transferred to another health care institution b. When record release is required by law.

Grievances:

19. You have the right to voice grievances with respect to treatment or care that is or fails to be furnished, without discrimination or reprisal for voicing the grievances. You have the right to prompt efforts by the facility to resolve grievances you may have, including those with respect to the behavior of other residents. Examination of Survey Results:

20. You have the right to examine the results of the most recent survey of the facility conducted by federal or state surveyors and any plan of correction in effect with respect to the facility. The facility will either post the results or a notice of their availability in a place readily accessible by you. 21. You have the right to receive information from agencies acting as client advocates and to be afforded the opportunity to contact these agencies.

Bill of Residents Rights

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Rev. 03-01-12

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Bill of Residents Rights

Work:

22. You have the right to refuse to perform services for the facility. You have the right to perform services for the facility if you choose to do so and agree to work arrangement described in the plan of care. The facility will document the need or desire for work in your plan of care. The plan will specify the nature of the services performed and whether voluntary or paid. Compensation will be at or above the prevailing rates. Mail:

23. You have the right to privacy in written communication including the right to send and promptly receive mail that is unopened and to have access to stationary, postage, and writing implements at your own expense. Access to Facility/Visitation Rights:

24. You have the right to receive visitors and the facility must allow access to you for any such visitors at any reasonable hour.

25. You have the right and the facility must provide immediate access to you by the following: a. Any representative of the Secretary of the Department of Health and Human Services. b. Any representative of the state.

c. Your individual physician.

d. The state long term care ombudsman.

e. The agency responsible for the protection and advocacy system for developmentally disabled individuals.

f. The agency responsible for the protection and advocacy system for mentally ill individuals. g. Immediate family or relatives, subject to your right to deny or withdraw consent at any time. h. Others, including any entity or individual that provides health, social, legal, or other services to you, subject to your right to deny or withdraw consent at any time. Telephone:

26. You have the right to reasonable access to the private use of a telephone. Personal Property:

27. You have the right to retain and use personal possessions, including some furnishings and appropriate clothing, as space permits, unless to do so would infringe upon the rights to health and safety of other residents.

Married Couples:

28. You have the right to share a room with your spouse if you live in the same facility and you both consent to the arrangement.

Self-Administration of Drugs:

29. You have the right to self-administer drugs if the interdisciplinary team has determined, for you individually, that this practice is safe.

Bill of Residents Rights

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Rev. 03-01-12

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Bill of Residents Rights

Admission, Transfer and Discharge Rights:

30. You have the right to remain in the facility and not be transferred (including transfers to a bed outside the certified facility) or discharged from the facility unless: a. The transfer or discharge is necessary for your welfare and your needs cannot be met in the facility. b. The transfer or discharge is appropriate because your health has improved sufficiently so you no longer need the services provided by the facility.

c. The safety or health of individuals in the facility is endangered. d. You have failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) your stay at the facility.

e. The facility ceases to operate.

31. When transfer or discharge occurs for any of the above referenced reasons, you have the right to have the reason for the transfer or discharge documented in your medical record (except 30e) and to have written notice of the reason given to you and your family member or legal representative in a language and manner you and they understand. This notice will include: the reason for the transfer or discharge, the effective date of the transfer or discharge, the location to which you are being transferred or discharged, a statement that you have the right to appeal the action to the state agency designated by the state for such appeals, and the name, address, and telephone number of the state long term care ombudsman. For residents with developmental disabilities, the notice will include the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act. For nursing home residents who are mentally ill, the notice will include the telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act.

You also have the right to be provided by the facility with sufficient preparation and orientation to ensure safe and orderly transfer or discharge from the facility. 32. You have the right, without affecting your eligibility or entitlement to Medicaid benefits, to refuse a transfer to another room within the facility, if the purpose of the transfer is to relocate you from: a. That part of the facility, if any, that is Medicare-certified to a noncertified part of the facility; or, b. That part of the facility that is not Medicare-certified to the Medicare-certified part of the facility (if any) Resident Behavior-Facility Practices:

33. Restraints: You have the right to be free from any physical restraints or psychoactive drugs which are used for the purpose of discipline or convenience and are not required to treat your medical symptoms. Restraints may only be imposed:

a. To ensure your physical safety or the physical safety of other residents. b. Only upon the written orders of a physician. The orders must specify the duration and circumstances under which restraints are to be used, except in emergency circumstances specified by the Secretary, until such order could reasonably be obtained.

34. Abuse: You have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion.

Bill of Residents Rights

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Rev. 03-01-12

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Bill of Residents Rights

Quality of Life:

35. Dignity/Self Determination and Participation: You have the right to receive care from the facility in a manner that is a safe environment and that promotes, maintains, or enhances your dignity and respect in full recognition of your individuality. You have the right to: a. Choose activities, schedules, and health care consistent with your interests, assessments, and plans of care.

b. Interact with members of the community both inside and outside the nursing facility. c. Make choices about aspects of your life in the nursing facility that are significant to you. Participation in Resident and Family Groups:

36. You have the right to organize and participate in resident groups in the facility and your family has the right to meet in the facility with the families of other residents in the facility. Participation in Other Activities:

37. You have the right to participate in social, religious, and community activities that do not interfere with the rights of other residents in the facility.

Accommodation of Needs:

38. You have the right to reside and receive services in the facility with reasonable accommodation of individual needs and preferences except when your health or safety of other residents would be endangered. 39. You have the right to receive notice before your room or roommate in the facility are changed. HIPAA Privacy Practices Statement

Section 1 - Culture

Rev. 03-01-12

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HIPAA Privacy Practices Statement

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSEDAND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

OUR RESPONSIBILITIES

This Healthcare Facility (hereinafter referred to as "Healthcare Center") takes the privacy of your health information seriously. We are required by law to maintain that privacy and to provide you with this Notice of Privacy Practices. This notice is provided to tell you about our duties and practices with respect to your information. HOW WE MAY USE AND DISCLOSURE YOUR HEALTH INFORMATION The following categories describe different ways that we use and disclose health information. For each category we explain what we mean and give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories. i For Treatment. We may use health information about you to provide you with treatment, care or services. We may disclose your health information to doctors, nurses, aids, technicians or other Healthcare Center employees who are involved in taking care of you at the Healthcare Center. For example your health information will be shared with vendors instrumental in providing you care such as the Pharmacy. i For Payment. We may use and disclose your health information to bill and collect for the treatment and services we provide to you. We may send your health information to an insurance company or a third party for the payment. For example, your health information will be provided to insurance companies for payment. i For Health Care Operations. We may use and disclose your health information for operations. These uses and disclosures are necessary to run the Healthcare Center and to make sure you receive quality care. We are also required to provide our residents' information to various governmental entities to maintain our license. For example, during survey’s, the state survey team will be looking at the information on your chart. i As Required By Law. We will disclose your health information when required to do so by federal, state or local law. i For Public Health Purposes. We may disclose your health information for public health activities. These activities generally include the following:

x to prevent or control disease, injury or disability; x to report births and deaths;

x to report defective medical devices or problems with medications; x to notify people of recalls of products they may be using; and x to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.

HIPAA Privacy Practices Statement

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HIPAA Privacy Practices Statement

i About Victims of Abuse. We may notify the appropriate government authority if we believe a resident has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

i Health Oversight Activities. We may disclose your health information to a health oversight agency for activities authorized by law. These oversight activities might include audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

i Judicial Purposes. We may disclose your health information in response to a court or administrative order. We may also disclose your health information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

i Law Enforcement. We may release health information if asked to do so by a law enforcement official: x In response to a court order, subpoena, warrant, summons or similar process; x To identify or locate a suspect, fugitive, material witness, or missing person; x About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;

x About a death we believe may be the result of criminal conduct; x About criminal conduct at the Healthcare Center; and In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

i Coroners, Medical Examiners and Funeral Directors. We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information about residents of the Healthcare Center to funeral directors as necessary to carry out their duties.

i Organ and Tissue Donation. We may release your health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

i To Avert a Serious Threat to Health or Safety. We may use and disclose your health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat. HIPAA Privacy Practices Statement

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HIPAA Privacy Practices Statement

i Military and Veterans. If you are a member of the armed forces, we may release your health information as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority. [A Healthcare Center that is a component of the Department of Veterans Affairs should also include the following: "We may use and disclose to components of the Department of Veterans Affairs health information about you to determine whether you are eligible for certain benefits."] i National Security and Intelligence Activities. We may release your health information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. i Protective Services for the President and Others. We may disclose your health information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

i Treatment Alternatives and Health-Related Benefits. We may use and disclose your health information to tell you about or recommend possible treatment alternatives or health-related benefits or services that may be of interest to you.

i Fundraising Activities. We may use your health information to contact you in an effort to raise money for the Healthcare Center and its operations. We may disclose health information to a foundation related to the Healthcare Center so that the foundation may contact you to raise money for the Healthcare Center. In these cases, we would release only contact information, such as your name, address and phone number and the dates you are at the Healthcare Center. If you do not want the Healthcare Center to contact you for fundraising efforts, you must notify in writing the person listed on the last page of this Notice. i Healthcare Center Directory. We may include certain limited information about you in the Healthcare Center directory while you are a resident at the Healthcare Center. This information may include your name, location in the Healthcare Center, your general condition (e.g., fair, stable, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or minister, even if they do not ask for you by name.

i Individuals Involved in Your Care or Payment for Your Care. We may release health information about you to your responsible party, friend or family member who is involved in your health care. We may also give information to someone who helps pay for your care. We may also tell your family or friends your condition and that you are at the Healthcare Center.

i Name on the Door of Your Room We will put your name on the door of your room in order to assure your safety in being easily identified in the event of an emergency. i Name used in the Course of Facility Activities The facility may place the resident’s name in the activity room in conjunction with some of the events and activities that take place on a daily basis. The facility may also disclose the resident’s name to third parties such as bus drivers, guides, or other individuals who may be responsible for the resident’s well-being while on an excursion outside of the facility. HIPAA Privacy Practices Statement

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HIPAA Privacy Practices Statement

i Conversations and Discussions concerning Resident Care Because of the nature of the healthcare centers environment, conversations about the resident’s condition or care could be overheard by third parties. The facility will institute safeguards to avoid such disclosures when possible. OTHER USES OF HEALTH INFORMATION

Other uses and disclosures of health information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you provide us authorization to use or disclose your health information, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made under the authorization, and that we are required to retain our records of the care that we provided to you.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

You have the following rights regarding health information we maintain about you: i Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to the Executive Director. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply.

i Right to Request Confidential Communications. You have the right to request that we communicate with you or your responsible party about health matters in an alternative way or at a certain location. To request confidential communications, you must make your request in writing to the Executive Director. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

i Right to Inspect and Copy. You have the right to inspect and copy health information that may be used to make decisions about your care. To inspect and copy health information that may be used to make decisions about you, you can submit your request in writing or orally. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. HIPAA Privacy Practices Statement

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HIPAA Privacy Practices Statement

i Right to Amend. You have the right to ask us to amend your health and/or billing information for as long as the information is kept by the Healthcare Center. To request an amendment, your request must be made in writing and submitted to the Executive Director. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: x Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;

x Is not part of the health information kept by or for the Healthcare Center; x Is not part of the information which you would be permitted to inspect and copy; or x Is accurate and complete.

i Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures that we have made of your health information. To request this list of disclosures, you must submit your request in writing to the Executive Director. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. i Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. You may obtain a copy of this Notice at our web site at www.trilogyhs.com. To obtain a paper copy of this Notice, you may request it at the Healthcare Center, by making a request in writing to the Executive Director.

WHO THIS NOTICE APPLIES TO

This Notice describes the Healthcare Center’s practices and those of: i Any health care professional authorized to enter information into or consult your Healthcare Center medical record. i All departments and units of the Healthcare Center. i Any member of a volunteer group we allow to help you while you are in the Healthcare Center. i All employees, staff and other Healthcare Center personnel. i All entities, sites and locations owned or managed by Trilogy Health Services, LLC and it’s subsidiaries, follow the terms of this Notice. In addition, these entities, sites and locations may share health information with each other for treatment, payment or operations purposes described in this Notice. HIPAA Privacy Practices Statement

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HIPAA Privacy Practices Statement

CHANGES TO THIS NOTICE

We reserve the right to change this Notice. We reserve the right to make the revised Notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice in the Healthcare Center. The Notice will contain on the first page, in the top right-hand corner, the effective date. In addition, if we revise the Notice, and you are still a resident of the Healthcare Center, we will offer you a copy of the current Notice in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with the Healthcare Center or with the Secretary of the Department of Health and Human Services. To file a complaint with the Healthcare Center, contact Trilogy Health Services, LLC at 303 N. Hurstbourne Parkway, Suite 200, Louisville KY 40222 ATTN: Privacy Officer. All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

If you have any questions about this notice, please contact: Trilogy Health Services, LLC

Privacy Officer

800-***-****, ext. 2800

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