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ALZHEIMER'S / DEMENTIA SPECIAL CARE UNIT
State Form 48896 (12-98) / BAIS 0005

Required by Indiana Code 12-10-5.5

To comply with Indiana Code 12-10-5.5, this disclosure form must be returned in December of each year and should include data current as of December 1. Complete the attached Alzheimer's / Dementia Special Care Unit Disclosure form. Facilities with more than one Alzheimer's / Dementia Special Care Unit should complete a separate form for each program / unit in order to convey complete information about each program / unit. If all Special Care Units are identical - complete one form. Please limit your responses to the spaces provided. Do not include attachments. FAX copies will NOT be accepted. Mail form(s) to: MS21 Attention: Alzheimer's / Dementia Special Care Disclosure Division of Disability, Aging and Rehabilitative Services 402 West Washington Street, Room W-454 Indianapolis, IN 46204 Questions may be directed to (317) 232-7020 or 1-800-545-7763.

Please remove this cover sheet before mailing.

ALZHEIMER'S / DEMENTIA SPECIAL CARE UNIT
State Form 48896 (12-98) / BAIS 0005 Name of facility Check one:

For Profit
Name / Title of contact person completing form Telephone number

Non Profit

Address (number and street, city, state, ZIP code)

FAX number

E-mail address

County

Date (month, day, year)

Name of owner

Name of Alzheimer's / Dementia Special Care Program / Unit:

Total Number of Beds in Program / Unit

Number of Medicaid Certified Beds

Number of beds in balance of facility: Grand total number of beds in facility:
If you have more than one Alzheimer's / Dementia Special Care Program / Unit, have you submitted additional disclosure forms? Total number of disclosure forms submitted:

Yes
Does the Joint Commission on the Accreditation of Health Care Organizations (JCAHCO) accredit the program / unit?

No No

Yes 1. Mission / Philosophy

Does the Alzheimer's / Dementia Special Care Program / Unit have a mission or philosophy statement concerning the needs of residents with Alzheimer's Yes No If yes, please write the statement here: disease, a related disorder, or dementia?

2. Process and Criteria for Admission, Transfer, and Discharge Process Does the program / unit have a formal written process for: If yes, does the process include: Physician's evaluation / diagnosis Staff evaluation Psychiatric evaluation / diagnosis Family conference Appeal procedure Other - specify: Criteria / Factor which may: Needs skilled nursing care Needs care for a medical condition Incontinence Inability to toilet Non ambulatory Inability to walk /bedfast Must be fed Inability to eat / feeding tube Other diminished functional abilities Combative / Aggressive behavior Psychotic behavior Sexually inappropriate behavior Other unprovoked behavioral issues Doesn't have a guardian No durable power of attorney Inability to pay Other - specify: Page 1 Prevent Admission Yes No Cause Transfer Yes No Cause Discharge Yes No Admission Yes No Transfer Yes No Discharge Yes No

3. Plan of Care Does the care planning process for the Alzheimer's / dementia care program / unit differ form other programs / units of the facility? Yes No If yes, how? How frequently are care plans reviewed / revised? Monthly Quarterly As Needed Question:

Other Check one: Yes No

Does the care planning team include a variety of professionals with skills in medical and nursing, as well as in behavioral, emotional, and social needs? Do care plans include personal histories prior to dementia, such as skills, occupations, interests, hobbies, cultural / spiritual history, and daily routine? Are family members invited to care-planning meetings? If yes, are care-planning meetings scheduled to accommodate family members' schedules? Are family members encouraged to offer suggestions? Are family members' suggestions included in the final care plan when appropriate? 4. Staffing Patterns Please specify the ratio of direct care staff to patients for each shift. If you don't use ratios, you may enter NA. Day / Morning Program / unit Balance of facility Please specify the resident census and number of full time equivalent (FTE*) direct care staff for each shift of the dementia care program / unit: Resident census # = Number of Staff Day / Morning Afternoon / Evening Night Licensed practical nurse, LPN Registered nurse, RN Certified Nursing Assistant, CNA Qualified Medications Assistant, QMA Activity Director / Staff Social Worker Other - specify: Total * Please assume 1 FTE = 8 hours; .5 FTE = 4 hours; .25 FTE = 2 hours Are the same staff consistently assigned to the program / unit, rather than rotated? Yes No How is staff selected to work on the program / unit? What is the title and educational background of the program / unit director? What is the specialty and board certification of the medical director? Special Requirements for Initial Training and Continuing Education Does the staff of the program / unit receive Alzheimer's / dementia-specific training beyond the training Initial Training? received by the staff of other program / units? Yes No Yes No Continuing Education? Yes No Afternoon / Evening Night

If yes, please specify the type and amount of Alzheimer's / dementia-specific initial training and continuing education required / provided for the program / unit staff. Type of Training Required or Provided Alzheimer's disease, dementia, stages of disease Physical, cognitive, and behavioral manifestations Medications and side effects Creating an appropriate and safe environment Techniques for dealing with problem behaviors Techniques for communicating Using activities to improve quality of life Assisting with personal care and daily living Nutrition and eating / feeding issues Techniques for supporting family members Managing stress and avoiding burnout Other - specify: Total Page 2 Number of Hours (fill in number) Initial Training Cont. Educ. Per Year Training for (check one) All Staff Direct Care Staff only

5. Unit Design Features Unit Design Features Check one: Is the Alzheimer's / dementia care program in a separate unit(s)? If yes, is the unit newly constructed (versus renovated or adapted)? Is the unit locked? Does the unit provide special safety / security features? Is there a safe / secure outdoor area where residents can easily go without direct supervision if they wish? Do residents have supervised access to the outdoors? Are residents' rooms clearly identified by personal wayfinding cues? Are residents encouraged to personalize private space with pictures, furniture, etc.? Does the unit use multiple sensory cues - things to see, smell, hear, touch, and taste - to assist in wayfinding and orientation? Does the environment provide space for familiar activities such as cooking, cleaning, yard work, and gardening? Does the unit have a kitchenette accessible to residents? Are animals present on the unit? Other - specify: Other - specify: 6. Frequency and Types of Activities for Residents Question Is an activity director available to coordinate activities for the Alzheimer's / dementia care program / unit? Does the Alzheimer's / dementia care program / unit have activity staff dedicated exclusively to that program / unit? If yes, specify the number of hours and days of the week that the unit is staffed for activities: Specify number of hours Mon Fri Tues Weds Thurs Morning Afternoon Evening Are activities provided 24 hours a day for residents who need them? Yes No Which of the following therapeutic methods are used in the program / unit? Check one: Art therapy Exercise Recreational therapy Music therapy Other: 7. Family Support Question Does the program / unit have an Alzheimer's / dementia support group for family members? Does the program / unit refer family members to another organization's Alzheimer's / dementia support group? Does the program / unit have a family council? Are family members given written criteria for admission, transfer, and discharge? Are family members informed of procedures for registering, resolving, and appealing any complaints? Are end of life issues discussed with family members at the time of admission? Other - specify: 8. Guidelines for Use of Physical and Chemical Restraints Question Check one: Are written guidelines on the use of physical and chemical restraints available to consumers? Are the guidelines for using these restraints in the dementia program / unit different from other programs / units of the facility? Have state or federal officials cited the care program / unit or facility during the past twelve month for inappropriate use of physical or chemical restraints? If yes, has this been corrected? 9. Itemization of Fees and Charges Does the program / unit have an entrance fee for admission in addition to the base daily or monthly rate? If yes, please specify fee: Yes No Please specify the base daily rate for program / unit of the facility on December 1: Program / unit Private Base Daily Rate: $ Dementia care program / unit Please list any supplementary or optional services / fees not included in the base daily rate: Yes No Yes No Massage Pet therapy Reminiscence therapy Other: Check one: Yes No Check one: Yes No

Yes

No

Sat

Sun

Check one:

Yes

No

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10. Other Please describe any other features, services, or characteristics that distinguish this facility's program / unit from other facilities:

Consumers seeking additional information should contact:
Name

Address (number and street, city, state, ZIP code)

Telephone number E-mail address

FAX number

Verified by (signature)

Name (printed)

Title

Date (month, day, year)

Please return on or before December 31st to: MS21; Attention Alzheimer's / Dementia Special Care Disclosure; Division of Disability, Aging, and Rehabilitative Services; 402 West Washington Street, Room W-454, Indianapolis, Indiana 46204 Questions may be directed to: (317) 232-7020 or 1-800-545-7763

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