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Assisted Living & Board and Care Checklist Assisted living homes are an option for an individual who wants to live in a homelike 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: ___________________________________________________________

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2. Name of administrator: ___________________________________________________________

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3. Name of owner (if private): ___________________________________________________________ 4. Management company: ___________________________________________________________

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

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6. Grievance process: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ 7. Supervising physician or nurse: ___________________________________________________________ ___________________________________________________________

Erickson Resource Group – stephanie@ericksonresource.com / www.ericksonresource.com t: 514-795-7377 EST Š2009 Erickson Resource Group - All rights reserved. No content contained within this document may be reused without prior written permission.


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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? ___________________________________________________________ ___________________________________________________________ ___________________________________________________________

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

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

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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.): ___________________________________________________________ ___________________________________________________________

Erickson Resource Group – stephanie@ericksonresource.com / 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.


1. Rate structures:

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Fees:

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): _____________________________________________________

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e. Social security rate, if applicable: _____________________________________________________ f. Private Insurance accepted and rate: _____________________________________________________

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2. Additional fees:

a. Application fee: _____________________________________________________

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b. Assessment fee : _____________________________________________________

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c. Security deposit: _____________________________________________________ d. Community fee: _____________________________________________________ e. Another facility specific fee: _____________________________________________________

Erickson Resource Group – stephanie@ericksonresource.com / www.ericksonresource.com t: 514-795-7377 EST Š2009 Erickson Resource Group - All rights reserved. No content contained within this document may be reused without prior written permission.


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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:

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

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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? _____________________________________________________ _____________________________________________________

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

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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: ____________________________________________________

Erickson Resource Group – stephanie@ericksonresource.com / 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.


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3. One bedroom: ______________________________________________ 4. Two bedroom: ______________________________________________ 5. Half bathroom (toilet and sink): _________________________________ 6. Fully furnished: _____________________________________________

7. Floors of unit availability: ______________________________________ 8. Access to elevator: __________________________________________

Transportation:

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

1. Parking space: ______________________________________________

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2. Shuttle service (van/bus) to common services: _____________________ 3. Van/bus handicap accessible (lift, etc.): ___________________________ 4. Fee for shuttle: ______________________________________________

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5. Scheduling process for shuttle: _________________________________ 6. Personal transportation: _______________________________________

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Meals:

1. Breakfast: __________________________________________________ 2. Lunch:_____________________________________________________ 3. Dinner: ____________________________________________________ 4. Snacks: ____________________________________________________

Erickson Resource Group – stephanie@ericksonresource.com / www.ericksonresource.com t: 514-795-7377 EST Š2009 Erickson Resource Group - All rights reserved. No content contained within this document may be reused without prior written permission.


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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: _____________

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Laundry service: 1. Included in daily rate:

a. Linens: _______________________________________________

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b. Personal items: ________________________________________ c. Towels: _______________________________________________ d. ______ times a week

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2. Not included in rate: a. Linens fee: __________________

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b. Personal items fee: ____________ c. Towels fee: __________________

Amenities: 1. Emergency response system: 2. Gas 3. Electric

Included   

/

Not included   

Erickson Resource Group – stephanie@ericksonresource.com / www.ericksonresource.com t: 514-795-7377 EST Š2009 Erickson Resource Group - All rights reserved. No content contained within this document may be reused without prior written permission.


Medication management:

Included             

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Not included             

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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

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1. Included in daily rate:

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a. Details and process: _____________________________________________________ _____________________________________________________ 2. Not included in daily rate

a. Fees: ________________________________________________

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b. Details and process: _____________________________________________________ _____________________________________________________ _____________________________________________________

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Additional paid services: 1. Shopping: _________________________________________________ 2. Respite: ___________________________________________________ 3. Beauty shop/barber: _________________________________________ 4. Companion for outings: _______________________________________ 5. Supplies (toiletries, incontinence care, etc.): _______________________ Erickson Resource Group – stephanie@ericksonresource.com / www.ericksonresource.com t: 514-795-7377 EST Š2009 Erickson Resource Group - All rights reserved. No content contained within this document may be reused without prior written permission.


Personal care:

1. 2. 3. 4. 5. 6.

Bathing Ambulation Dressing Grooming Eating Toileting

Ask the following:

     

Not provided

Frequency (# per week) _____ _____ _____ _____ _____ _____

Fee

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Provided

     

_____ _____ _____ _____ _____ _____

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

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2. Does my loved one receive assistance with transportation to and from the hospital and/or medical appointments? ___________________________________________________________ ___________________________________________________________

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

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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? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

Erickson Resource Group – stephanie@ericksonresource.com / 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.


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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        

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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

Fair        

Poor        

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Additional comments, questions, concerns: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

Erickson Resource Group – stephanie@ericksonresource.com / 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 and Board & Care Checklist