1. Basic Rights.
Each Patient/Resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the Health Care Center.

2. Exercise of Rights.
Each Patient/Resident has the right to exercise his or her rights as a Patient/Resident of the Health Care Center and as a citizen or Patient/Resident of the United States without interference, coercion, discrimination and reprisal from the Health Care Center. Any Patient/ Resident who has a legal surrogate designated in accordance with State law has the right to have the surrogate exercise the Patient¹s/Resident¹s rights, and any Patient/Resident who has been adjudged incompetent has the right to have a person appointed under State law to act on the Patient¹s/Resident¹s behalf and exercise the Patient¹s/Resident¹s rights.

3. Notice of Rights.
Each Patient/Resident has the right to be informed both orally and in writing in a language the Patient/Resident understands of the Patient¹s/Resident¹s rights, including the State¹s notice of rights and obligations of Patients/Residents of nursing facilities under the Medicaid program. This notice must be given prior to or upon admission, and during the Patient¹s/Resident¹s stay.

4. Rules and Responsibilities.
Each Patient/Resident has the right to be informed both orally and in writing in a language the Patient/Resident understands of all rules and regulations governing Patient/Resident conduct and responsibilities during the Patient¹s/Resident¹s stay in the Health Care Center. This notice must be given both prior to or upon admission, and during the Patient¹s/Resident¹s stay.

5. Patient/Resident Access to Records.
Each Patient/Resident or the Patient¹s/Resident¹s legal representative has the right upon oral or written request to access all records pertaining to the Patient/Resident, including clinical records, within 24 hours and after receipt of the Patient/Resident¹s records for inspection, to purchase at a cost not to exceed the community standard photocopies of the records or any portion of them upon request and 2 working days¹ advance notice to the Health Care Center.

6. Refusal of Treatment.
Each Patient/Resident has the right to refuse treatment and to refuse to participate in experimental research; and to execute advance directives. The facility will not charge a resident (or his or her representative) for any item or service not requested by the resident. Further, the facility will not require the resident (or resident¹s representative) to request any item or service as a condition of admission or continued stay. The facility will inform the resident or a representative requesting an item or service for which there will be a charge and what the charge will be.

7. Health Care.
Each Patient/Resident has the right to choose a personal attending physician, to be fully informed in advance about care, treatment and any changes thereto, and total health status, and to participate in planning care and treatment, unless the Patient/Resident is adjudged incompetent or otherwise found to be incapacitated under state law.

8. Notice of Medicaid Covered Services and Items.
Each Patient/Resident who is or becomes entitled to Medicaid benefits has the right to be informed in writing of the items and services provided by the Health Care Center that are included in the State plan and for which the Patient/Resident may not be charged, and of those other items and services that the Health Care Center offers and for which the Patient/Resident may be charged, and the charges therefor. This notice must be provided by the Health Care Center at the time of admission or when the Patient/Resident becomes eligible for Medicaid.

9. Notice of Services.
Each Patient/Resident has the right to be informed, upon admission and periodically during the Patient¹s/Resident¹s stay, of the items and services provided by the Health Care Center and the charges therefore, including any which are not covered under Medicare or by the Health Care Center¹s daily rate.

10. Notice of Changes.
Each Patient/Resident has the right to be informed when changes are made to the items and services provided by the Health Care Center which are included in the State plan or that are covered by Medicare or the daily rate, and when changes are made to those other items and services that the Health Care Center offers and for which the Patient/Resident may be charged.

11. Covered Services.
The Health Care Center may not charge a Patient/Resident for any item or service for which payment is made under Medicare or Medicaid.

12. Freedom from Restraints.
Each Patient/Resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the Patient¹s/Resident¹s medical symptoms. Restraints may only be used in the case of an emergency or to ensure the physical safety of the Patient/Resident or other Patients/Residents if a physician has given a written order that specifies the duration and circumstances.

13. Privacy in Communications.
The Patient/Resident has the right to privacy in written communications including the right to send and promptly receive mail unopened and the right to have access to stationery, postage and writing implements at the Patient¹s/Resident¹s own expense. Each Patient/Resident has the right to have reasonable access to the use of a telephone where calls can be made without being overheard.

14. Privacy.
Each Patient/Resident has the right to privacy with regard to accommodations, treatment, communications, personal care, visits and meetings of family and Patient/Resident groups.

15. Record Release.
In most circumstances, each Patient/Resident has the right to confidentiality of all personal and clinical records, and to approve or refuse release of such records to individuals outside the Health Care Center.

16. Physician.
Each Patient/Resident has the right to be informed by the Health Care Center of the name, specialty and way of contacting the physician responsible for his or her care.

17. Medicare and Medicaid Information.
The Health Care Center must prominently display in the Health Care Center written information, and provide to Patients/Residents and applicants for admission oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits.

18. Notice of Changes in Condition.
The Health Care Center must immediately inform the Patient/Resident, consult with the Patient/Resident¹s physician, and if known, notify the Patient¹s/Resident¹s legal representative or interested family member when: an accident involving the Patient/Resident results in injury and has the potential for requiring physician intervention; the Patient¹s/Resident¹s physical, mental or psychosocial status significantly changes; it is necessary to alter treatments significantly; or, a decision is made to transfer or discharge the Patient/Resident from the Health Care Center.

19. Change of Room or Roommate.
The Health Care Center must promptly notify the Patient/Resident, and if known the Patient¹s/Resident¹s legal representative or interested family member before there is a change in room or roommate assignment. A Patient/Resident may refuse any room transfer if the purpose of such transfer is to move the Patient/Resident from one level of nursing care to another level of nursing care.

20. Change of Rights.
The Health Care Center must promptly notify the Patient/Resident and, if known, the Patient¹s/Resident¹s legal representative or interested family member when there is a change in Patient/Resident rights under Federal or State law, or a change in the rules and regulations governing Patient/Resident conduct. The Health Care Center will record and periodically update the address and telephone number at the resident¹s legal representative or interested family member.

21. Grievances.
A Patient/Resident has the right to voice grievances without discrimination or reprisal. Such grievances include those with respect to treatment, which has been furnished, as well as that which has not been furnished.

22. Resolution of Grievances.
A Patient/Resident has the right to prompt efforts by the Health Care Center to resolve grievances the Patient/Resident may have, including those with respect to the behavior of other Patients/Residents.

23. Filing Complaints.
Each Patient/Resident has the right to file a complaint with the State survey and certification agency concerning Patient/Resident abuse, neglect and misappropriation of Patient/Resident property. Also, each Patient/Resident has a right to lodge complaints regarding non-compliance with advance directives.

24. Participation in Patient/Resident and Family Groups.
Each Patient/Resident has the right to organize and participate in Patient/Resident groups. The Patient¹s/Resident¹s family also has the right, subject to reasonable restrictions, to meet in the Health Care Center with families of other Patients/Residents of the Health Care Center. The Health Care Center must provide the Patient/Resident group or family group, if one exists, with private space to meet. Staff or visitors may attend meetings at the group¹s invitation. The Health Care Center must provide a designated staff person responsible for providing assistance in responding to written requests that result from group meetings. When a Patient/Resident or family group exists, the Health Care Center must listen to the views and act upon the grievances and recommendations of Patient¹s/Residents and families concerning proposed policy and operational decisions affecting Patient/Resident care and life in the Health Care Center.

25. Accommodation of Needs.
A Patient/Resident has the right to reside and receive services in the Health Care Center with reasonable accommodation of individual needs and preferences, except when the health or safety of the individual or other Patients/Residents would be endangered.

26. Homelike Atmosphere.
Each Patient/Resident has the right to a safe, clean, comfortable and homelike environment, and to use his or her personal belongings to the extent possible. Each Patient/Resident has the right to housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior; clean bed and bath linens that are in good condition; private closet space in the Patient¹s/Resident¹s room; adequate and comfortable lighting levels in all areas; comfortable and safe temperature levels; and, comfortable sound levels.

27. Activities.
The Health Care Center must provide for an ongoing program of activities directed by a qualified professional and designed to meet, in accordance with the comprehensive assessment, the interests and physical, mental and psychosocial well being of each Patient/Resident.

28. Social Services.
The Health Care Center must provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well being of each Patient/Resident.

29. Participation in Other Activities.
Each Patient/Resident has the right to participate in social, religious and community activities that do not interfere with the rights of other Patients/Residents.

30. Examination of Survey Results.
Each Patient/Resident has the right to examine the results of the most recent survey of the Health Care Center conducted by federal or state surveyors and any plan of corrective action in place. The results must be made available for examination at the Health Care Center in a place readily accessible to Patients/Residents.

31. Receipt of Advocacy Information.
A Patient/Resident has the right to receive information from agencies acting as client advocates, and to be afforded the opportunity to contact these agencies.

32. Examination of Records by Ombudsman.
The Health Care Center must allow representatives of the State Ombudsman to examine a Patient's/Resident¹s clinical records with the permission of the Patient/Resident or the patient¹s/Resident¹s legal representative, and consistent with State law.

33. Access by Advocates.
Each Patient/Resident has the right to have the Health Care Center provide reasonable access to the Patient/Resident by any entity or individual that provides health, social, legal, or other services to the Patient/Resident, subject to the Patient¹s/Resident¹s right to deny or withhold consent at any time.

34. Access and Visitation Rights.
Each Patient/Resident has the right to receive visitors and the Health Care Center must provide immediate access to any Patient/Resident by the following:
(1) any representative of the Secretary of the (federal) Department of Health and Human Services;
(2) any representative the State;
(3) the Patient¹s/Resident¹s individual physician;
(4) the State Long-Term Care Ombudsman;
(5) the agency responsible for the protection and advocacy system for developmentally disabled individuals;
(6) the agency responsible for the protection and advocacy system for mentally ill individuals;
(7) (Subject to the Patient¹s/Resident¹s right to deny or withdraw consent at anytime) immediate family or other relatives of the Patient/Resident, and
(8) (Subject to reasonable restrictions and the Patient¹s/Resident¹s right to deny or withdraw his or her consent at any time) others who are visiting with the consent of the Patient/Resident.

35. Financial Affairs.
Each Patient/Resident has the right to manage his or her financial affairs, and the Health Care Center may not require any Patient/Resident to deposit any personal funds with the Health Care Center. However, if a Patient/Resident authorizes the Health Care Center in writing, the Health Care Center must hold, safeguard, manage and account for any personal funds that a Patient/Resident does deposit with the Health Care Center, using a system that assures a complete and separate accounting of the funds, provides that any funds in excess of $50.00 with bear interest on the Patient¹s/Resident¹s behalf, and precludes the commingling of a Patient¹s/Resident¹s personal funds with those of the Health Care Center or of any person other than another Patient/Resident.

The Health Care Center must purchase a surety bond or (as permitted by law) provide other assurance of the security of all personal funds of Patents/Residents deposited with the Health Care Center. A Patient/Resident¹s financial record will be made available through quarterly statements upon request. Upon the death of a resident with a personal account with the facility, the facility will convey the resident¹s funds, along with an accounting, to the individual or probate jurisdiction administering the resident¹s estate within 30 days.

36. Notice of Certain Balances.
Each Patient/Resident that receives Medicaid benefits has the right to be notified when the amount in a Patient¹s/Resident¹s personal account maintained by the health Care Center reaches $200.00 less than the SSI resource limit for one person, and to be notified that if the amount in the account, in addition to the value of the Patient's Resident¹s other nonexempt resources, reaches the SSI limit, the Patient/Resident may become ineligible for Medicaid or SSI.

37. Work.
Each Patient/Resident has the right to refuse to perform services for the Health Care Center, although the Patient/Resident may perform services for the Health Care Center if he or she so chooses when:
(a) the need or desire to work is documented in the plan of care;
(b) the plan of care specifies the nature of the services performed and whether the services are voluntary or paid;
(c) compensation paid is at or above the prevailing rate; and
(d) the Patient/Resident agrees to the work arrangement.

38. Personal Possessions.
The Patient/Resident has 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 or health and safety of other Patients/Residents.

39. Rooming with Spouses.
Each Patient/Resident has the right to share a room with a spouse when both reside in the Health Care Center and both consent to the arrangement.

40. Self-Administration of Drugs.
Each Patient/Resident may self-administer drugs if the interdisciplinary team has determined that this practice is safe for the individual Patient/Resident.

41. Continued Residence at the Facility.
The Health Care Center must permit each Patient/Resident to remain in the Health Care Center, and not transfer or discharge the Patient/Resident from the Health Care Center unless certain conditions have been met. The Patient¹s/Resident¹s clinical record must be documented whenever a Patient/Resident is so transferred or discharged. The Patient/Resident and, if known, a family member or legal representative of the Patient/Resident, must be notified before any such transfer or discharge of the impending transfer or discharge and the reasons for such action in writing and in a language and manner they understand. Except under certain circumstances, the notice of transfer or discharge must be made by the Health Care Center at least 30 days before the Patient/Resident is transferred or discharged. The Health Care Center must provide sufficient preparation and orientation to the Patient/Resident to ensure safe and orderly transfer or discharge from the Health Care Center.

42. Bed-Hold Policies.
Before the Health Care Center transfers a Patient/Resident to a hospital or allows a Patient/Resident to go on therapeutic leave and upon such transfer or leave, the Health Care Center must provide written information to the Patient/Resident, and a family member or legal representative that specifies the applicable bed-hold policies. The Health Care Center must establish and follow a written policy under which a Patient/Resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan is readmitted to the Health Care Center immediately upon the first availability of a bed in a semiprivate room, if the Patient/Resident requires the services provided by the Health Care Center and is eligible for Medicaid nursing facility services.

43. Discharge and Transfer Policies.
The Health Care Center must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all individuals regardless of the source of payment.

44. Guarantors.
The Health Care Center must not require a third party guarantee of payment to the Health Care Center as a condition of admission, or expedited admission, or continued stay in the Health Care Center and in the case of a person eligible for Medicaid, must not charge, solicit, accept, or receive, in addition to any amount otherwise to be paid under the State plan, any gift, money, donation or other consideration as a precondition of admission, expedited admission or continued stay in the Health Care Center.

45. Rights to Medicare or Medicaid.
The Health Care Center must not require Patients/Residents or potential Patients/Residents to waive their rights to Medicare or Medicaid and must not require oral or written assurance that Patients/Residents or potential Patients/Residents are not eligible, or will not apply for, Medicare or Medicaid benefits.

46. Freedom from Abuse.
Each Patient/Resident has the right to be free from verbal, physical, sexual and mental abuse, corporal punishment and involuntary seclusion.

47. Protection from Abuse.
The Health Care Center must develop and implement written policies and procedures that prohibit the mistreatment, neglect and abuse of Patients/Residents and misappropriation of Patient/Resident property. The Health Care Center must not employ individuals who have been found guilty of abusing, neglecting or mistreating individuals by a court of law or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of Patients/Residents or misappropriation of their property. The Health Care Center must report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse¹s aid or other Health Care Center staff to the State nurse aide registry or licensing authorities. The Health Care Center must ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of Patient/Resident property, are reported immediately to the administrator of the Health Care Center and to other officials including to the State survey and certification agency in accordance with State law. The Health Care Center must thoroughly investigate all alleged violations, prevent further potential abuse while the investigation in is progress, and take prompt remedial action if the alleged violation is verified.

48. Quality of Life.
The Health Care Center must care for its Patients/Residents in a manner and in an environment that permits maintenance or enhancement of each Patient¹s/Resident¹s quality of life.

49. Patient/Resident Dignity.
The Health Care Center must promote care for Patients/Residents in a manner and in an environment that maintains or enhances each Patient¹s/Resident¹s dignity and respect in full recognition of his or her individuality.

50. Self-Determination and Participation.
Each Patient/Resident has the right to choose activities, schedules and health care consistent with his or her interests, assessments and plans of care; interact with members of the community both inside and outside the Health Care Center; and make choices about aspects of his or her life in the Health Care Center that are significant to the Patient/Resident.

Signature of Patient/Resident or Responsible Party Printed Name Date

Signature of Health Care Center Representative Printed Name Date