Nixon Assisted Living Admission Inquiry

You can either:

1. Download the forms from the provided links, fill them out in PDF Viewer/Editor and email them in.

2. Download the forms from the provided links, fill them out in PDF Viewer/Editor and print them out and bring them in.

3.  Download the forms from the provided links, print them out and fill them out by hand and bring them in.

4. Fill out this application below.

Enrollment Form

Resident Interest Activity Survey

Nixon Admission Inquiry

Nixon Admissions Family Profile Form

Advanced Directive Acknowledgement Form

DNR Status Form

Emergency Treatment Release Form

Consent for Emergency Medical Transportation Form

Admission Agreement

Financial Agreement

Resident Bill of Rights

TDADS Form 3100

DAHS Form

Disclosure and Acknowledgement Form

 

Nixon Adult Day Center respects the rights of all clients to make determinations regarding their medical care including Advance Directive. All of us from ages 18 to 108 regardless of our current health condition have a right to formulate an advance directive. Advance directives are medical instructions that state your health care wishes. By putting your wishes in writing, you make your decisions known and take the burden off your family and doctors in the event you can no longer make decisions for your self. Texas recognizes 4 types of Advance Directives:

1. A Directive to Physicians and Family or Surrogate (Living Will) - written instructions that list your medical wishes in the event you can not longer speak or communicate.

2. A Medical Power of Attorney - names the person or persons that you have chosen to make medical decisions for you in the future if because of illness or injury you can no longer make decisions for yourself.

3. An Out-of-Hospital Do Not Resuscitate Order - gives instructions if you are out-of-the hospital not to revive or resuscitate you if your heart stops beating and your breathing stops.

4. A Mental Health Treatment Declaration - states your wishes about treatment using medications or therapy that affects your mind or emergency medical treatment in case you are disabled.

Your Rights:

• To have an advance directive (living will and/or durable power of attorney for health care decisions)
• To obtain information regarding an advance directive
• To have your advance directive (if you have one) included in your medical record
• To have your advance directive followed to the extent that is medically appropriate and lawful

Please know the Advance Directive is for medical decisions that must be made only in the event that you can not make decisions for yourself.

NIXON ASSISTED LIVING OF HOUSTON

Please Note: Family has been given information regarding DNR status.

I give Nixon Adult Day Center permission to take my photograph and display it in the facility, as well as in the newspaper to record special events.

1. Facility's Responsibility The facility shall exercise such reasonable care toward the resident as his or her known condition may require, however, the facility is in no sense an insurer of the residents safety or welfare and assumes no liability as such.

The facility shall provide personal care on a nondiscriminatory basis so that all residents are admitted and receive benefits and services without regard to race, religion, color, national origin, age, sex or handicap.

The facility shall not be responsible or liable for the loss or damage of any money, jewelry, documents or any other personal property or possessions. All articles retained in the residents possession including dentures, eyeglasses, hearing aids, etc. shall be entirely the responsibility and liability of the resident.

Records pertaining to residents shall be treated as confidential and properly safeguarded and shall be made available only to authorized person and agencies. The facility shall be responsible for maintaining the home in compliance with Minimum Standards as outlined by the Texas Department of Health.

2. Residents Accepted:

A resident may: not have a disease endangering other residents; exhibit symptoms of emotional disturbance, but are not considered dangerous to himself\/herself or other residents; need occasional assistance with walking; require assistance with bathing, dressing and grooming; require occasional assistance with routine skin care, such as application of lotions, treatment of minor cuts and burns; need reminders to encourage toilet routine and prevent incontinence; require the occasional or temporary services by professional personnel, if provided by contact with the individual resident; need assistance with medications, supervision of self-medication, or administration of medication; require encouragement to eat or monitoring for brief periods of time due to social or psychological reasons of temporary illness; be hearing impaired or speech impaired; be incontinent without skin breakdown; requirea0established therapeutic diets; require self-help devices; occasionally require restraints with physicians orders.

3. Room Reservation

A "room reservation" charge will be considered the same as rent if the resident or legal guardian and responsible party elect to leave resident's personal belongings during an absence from the facility, for vacation or hospital stay.

4. Duties of Legal Guardian and Responsible Party:

The resident or legal guardian and responsible party shall:

A. Arrange for the services of the attending physician of choice and a designated alternate to be contacted in the event the attending physician is unavailable (as set forth in the Admission record completed by resident, legal guardian, or responsible party, reference to which is hereby for all purposes made). The arrangements will include a commitment to see the resident either by visitation in the facility or through office visits provided by the responsible party or legal guardian.

B. The resident shall have a physical examination within the period commencing 30 days prior to and ending 14 days after admission and annually thereafter.

C. Provide a written inventory of personal belongings, in duplicate upon forms furnished by the facility, properly signed by the responsible party, resident, or legal guardian at time of admission. The original copy shall be retained by the responsible party as a receipt and a copy she be kept with the resident's records.

D. Provide such spending money as needed by the resident.

E. Provide wash and wear clothing, properly labeled or marked, in sufficient quantities to keep the resident neatly dressed.

F. Be responsible for hospital charges and transportation to same, if hospitalization of the resident becomes necessary.

G. Be financially responsible for all physician's fees, medications, special equipment, oxygen and other services or aids ordered by attending physician.

H. Accept the requirement of the facility items that only one member of the family may have any jurisdiction over the admission, care or discharge of the resident.

I. Not bring into the facility items not allowed in the resident's room- according to list furnished by the facility's office.

J. Accept all financial and legal responsibility for any private nurses engaged for resident. All special duty nurses or sitters will be expected to follow the rules and regulations of the facility and will be subject to dismissal for violations.

K. Set-up charge account with pharmacy of choice, but must have delivery service

available.

5. Prescriptions:

All medications must be prescribed by a licensed physician. The cost will be assumed by the resident or legal guardian and responsible party. Arrangements for the purchase of medications will be made when the resident is admitted, from the pharmacy of their choice. All medications will be under security precaution as required by law. The facility is authorized to order all medications required by the resident from the resident's designated pharmacy. Medications, including controlled drugs will be released to the resident at discharge.

6. Grant of Authority:

The resident or legal guardian and responsible party hereby grant to the facility the authority to:

A. Have the resident visited by dentists, oral hygienists, podiatrists, physical therapists and any other person deemed necessary for the rendering of care to the resident by the attending physician upon written permission of the attending physician.

B. Allow the resident to participate in any activities within the scope of the residents mental and physical capabilities, as authorized by the attending physician; and the resident or legal guardian and responsible party release the facility from any responsibility for the resident during participation either within the facility or for any activity which takes the resident outside the facility.

C. Discharge resident if his/her lever of care progresses beyond the level this home is licensed to provide.

D. To permit the resident to be moved after proper notification to a different room, when it is deemed necessary for the welfare of the resident or other residents.

7. Other Rules and Regulations:

Resident or responsible party is responsible for all medical supplies and equipment, persanal toiletries, including Kleenex for their room, (we provide Kleenex for their use in the dining and living room areas vitamins or food supplements and unusual food items will be provided by the family.

8. Rate:

The monthly rate is based on the type and amount of care required by the resident as described in the application. Should the resident's condition change requiring more care, the monthly rate may increase or the resident may be required to move to another facility where more appropriate care is available.

 

If the resident is or ever shall receive governmental financial assistance, the resident or legal guardian hereby acknowledge that the governmental agency giving such financial assistance may adjust the monthly rate and the amount of the monthly rate for which such governmental agency is responsible, and the resident or legal guardian and responsible party hereby agree that when such government agency makes such adjustments, this agreement will then be automatically adjusted so that the resident or legal guardian and responsible party shall pay to the facility all portions of the monthly rate and any other sums for care, services and supplies furnished or rendered to the resident not paid by the governmental agency giving such financial assistance. If at any time or for any reason any governmental agency either denies payment to facility for care and services rendered and supplies furnished to the resident or requires that facility to repay any payments previously paid to the facility by such governmental agency for care and services rendered or supplies furnished to the resident, the resident or legal guardian and responsible party, jointly and severally, shall pay to the facility an amount of money equal to all such payment denied or required to be repaid so that the facility shall receive all sums due and owing to it for care and services rendered and supplies furnished to the resident, or legal guardian and responsible party, jointly and severally, shall pay all sums due to the facility at the office of the facility at the above address, including the monthly rate and all sums for other services or supplies. Should collection of any sums due hereunder be deferred to an attorney for collection, the resident or legal guardian and responsible party hereunder shall jointly and severally pay reasonable attorneys fees and collection expenses. The liability of the resident or legal guardian and responsible party hereunder shall be joint and several, direct and primary, for all obligations under this agreement. Thereafter the full amount is due on the first day of the month. A $25.00 late fee will be assessed if payment is received after the 5th day of the month.

The right to use the Personal Care Facility Services is not contingent upon contributions.

9. Refunds:

Residents desiring to move shall receive a refund of any uneared portion of the monthly rate to which they are entitled upon request, provided all terms of this agreement have been met and 14 days written notice given. All refunds will be made within 30 days following discharge.

10. Duration of Agreement:

Either party may, without cause, terminate this agreement on fourteen (14) days written notice. Such notice will not act as cancellation of financial responsibility until actual termination  date of this agreement. This does not mean that the resident will be forced to remain in the facility against his will, but the facility would appreciate time for planning discharge so it will be least traumatic for the resident. The legal guardian or responsible party shall, upon termination hereof, subsequent to the notice provided for in Paragraph 8, be responsible for and accept custody of the resident.

11. Services Provided:

The facility identifies the social and emotional needs of each resident and provides services or referrals to meet these needs. The home cares for the resident according to an Individual Service Care Plan that is agreed upon between the facility and the person arranging the care at the time of admission. In addition to the assistance of daily living activities included in the service care plan the home provides: Three nutritious meals per day, snacks, housekeeping, launder of washable items, clean comfortable bed, pillow and linens. The resident has the right to live under a legally enforceable agreement with protections equivalent to the landlord/tenant laws in the State of Texas. 

 

 

12. Operational Policy Acknowledgment:

The resident or legal guardian and responsible party acknowledge that each of them has been provided with access to a copy of the facility's operational policy, Minimum Licensing Standards and other rules and regulations of the home and each agrees to and shall be bound and abide by the terms and provisions thereof.

C. The Base Charges will accrue from date of bed consignment through the day of discharge, prorated by the number of days in the month

D. Unless prior arrangements are made:

1. Payment received after the 3rd of the month will be assessed a 10% late charge.

2. Payment received on/after 4th  of the month will be assessed 20% late charge.

3. Payment more than 30 days in arrears will warrant cancellation of agreement, and termination of the individual's residency.

All Base Charges and Deposits are non-refund and or subject to charge at the discretion of the management of Nixon Assisted Living of Houston in accordance with terms and conditions set forth in the admission agreement.

 

1. Each assisted living facility must post the Resident's Bill of Rights, as provided by the department. in a prominent place in the facility and written in the primary language of each resident. A copy of the Resident's Bill of Rights must be given to each resident.
2. A resident has all the rights, benefits, responsibilities and privileges granted by the Constitution and laws of this state and the Cinited States, except where lawfully restricted. The resident has the right to be free of interference, coercion, discrimination, and reprisal in exercising these civil rights.
3. Each resident in the assisted living facility has the right to:
A. be free from physical and mental abuse, including corporal punishment or physical and chemical restraints that are administered for the purpose of discipline or convenience and not required to treat the resident's medical symptoms. A provider may use physical or chemical restraints only if the use is authorized in writing by a physician or the use is necessary in an emergency to protect the resident or others from injury A physician's written authorization for the use of restraints must specify the circumstances under which the restraints may be used and the duration for which the restraints may be used. Except in an emergency, restraints may only be administered by qualified medical personnel:
B.participate in activities of social, religious, or community groups unless the participation interferes with the rights of others:
C. practice the religion of the resident's choice:
D. if mentally retarded, with a court-appointed guardian of the person. participate in behavior modification program involving use of restraints, consistent with subparagraph (A) of this paragraph, or adverse stimuli only with the informed consent of the guardian:
E. be treated with respect, consideration, and recognition of his or her dignity and individuality, without regard to race. religion, national origin, sex. age. disability, marital status. or source of payment. This means that the resident:
i. Has the right to make his/her own choices regarding personal affairs, care, benefits, and services:

ii. Has the right to be free from abuse, neglect, and exploitation; and

iii. If protective measures are required, has the right to designate a guardian or representative to ensure the right to quality stewardship of his/her affairs:

F. a safe and decent living environment:
G. not be prohibited from communicating in his or her native language with other residents or employees for the purpose of acquiring or providing any type of treatment, care, or services:
H. complain about the resident's care or treatment. The complaint may be made anonymously or communicated by a person designated by the resident The provider must promptly respond to resolve the complaint. The provider must not discriminate or take other punitive action against a resident who makes a complaint:
I. receive and send unopened mail, and the provider must ensure that the resident's mail is sent and delivered promptly:
J. unrestricted communication, including personal visitation with any person of the resident's choice, including family members and representatives of advocacy groups and community service organizations, at any reasonable hour:
K. make contacts with the community and to achieve the highest level of independence. autonomy, and interaction with the community of which the esi dent is capable:
L. manage his or her financial affairs. The resident may authorize in writing another person to manage his/her money. The resident may choose the manner in which his/her money is managed, including a money management program, a representative pavee program, a financial power of attorney a trust. or similar method, and the resident may choose the least restrictive of these methods. The resident must be given, upon request of the resident or the resident's representative, but at least quarterly, an accounting of financial transactions made on his or her behalf by the facility should the facility accept his or her written delegation of this responsibility to the facility in conformance with state law:
M. access the resident's records, which are confidential and may not be released without the resident's consent. except.
i. to another provider. if the resident transfers residence: or

ii. if the release is required by another law:

N. choose and retain a personal physician and to be fully informed in advance about treatment or care that may affect the resident's well being:
O. participate in developing his/her individual service plan that describes the resident's medical, nursing. and psychological needs and how the needs will be met:
P. be given the opportunity to refuse medical treatment or services after the resident:
i. is advised by the person providing services of the possible consequences of refusing treatment or services; and

ii. acknowledges that he/she understands the consequences of refusing treatment or services:

Q. unaccompanied access to a telephone at a reasonable hour or in case of an emergency or personal crisis:
R. privacy, while attending to personal needs and a private place for receiving visitors or associating with other residents. unless providing privacy would infringe on the rights of other residents. This right applies to medical treatment, written communications. telephone conversations. meeting with family. and access to resident councils. If a resident is married and the spouse is receiving similar services. the couple may share a room:
S. retain and use personal possessions, including clothing and furnishings. as space permits. The number of personal possessions may be limited for the health and safety of other residents:
T. determine his or her dress, hair style, or other personal effects according to individual preference, except the resident has the responsibility to mantain personal hygiene;
U. retain and use personal property in his or her immediate living quarters and to have an individual locked area (cabinet. closet. drawer, foot locker. etc.) in which to keep personal property:

V. refuse to perform services for the facility, except as contracted for by the resident and operator:
W. be informed by the provider no later than the 30th day after admission:
i. whether the resident is entitled to benefits under Medicare or Medicaid; and

ii. which items and services are covered by these benefits, including iters or services for which the resident may not be charged:

X. not be transferred or discharged unless:

i. the transfer is for the resident's welfare, and the resident's needs cannot be met by the facility:

ii. the resident's health is improved sufficiently so that services are no longer needed:

iii. the resident's health and safety or the health and safety of another resident would be endangered if the transfer or discharge was not made:

iv. the provider ceases to operate or to participate in the program that reimburses for the resident's treatment or care: or

v. the resident fails, after a reasonable and appropriate notice, to pay for services:

Y. not be transferred or discharged, except in an emergency, until the 30th day after the date the facility provides written notice to the resident. the resident's legal representative, or a member of the resident's family, stating:

i. that' the facility intends to transfer or discharge the resident:

ii. the reason for the transfer or discharge;

iii. the effective date of the transfer or discharge:

iv. if the resident is to be transferred, the location to which the resident will be transferred: and

v. any appeal rights available to the resident:

Z. leave the facility temporarily or permanently, subject to contractual or financial obligations:

AA. have access to the services of a representative of the state Long-term Care Ombudsman Program: and

BB. execute an advance directive, under the Advance Directives Act (Chapter 166, Health and Safety Code), or designate a guardian in advance of need to make decisions regarding the resident's health care should the resident become incapacitated.

 

Resident's Bill of Rights:

I understand that I have the right to have any visitors as I choose at anytime.

I understand that there will be a designated area where I may meet privately with my visitors to ensure confidentiality.

I understand that Nixon does not provide lodging or meals for my select visitors. Due to safety and health risks, visitors are discouraged from overnight stays with recipients.

I understand all visitors are required to sign in. Any visitor disruptions or disturbances will be strongly discouraged. Visitors with obvious health concerns will be asked to reschedule their visit.

I understand that restrictions may be enforced related to health or safety risks.

Nixon Assisted Living of Houston allows complete freedom for residents to leave and return to/from the facility at their discretion. Family and friends may visit as they wish at any time, curfews are not in place or enforced However, residents are asked to notify staff prior to leaving the property as well as what time they plan to return.

This allows staff time to coordinate medication schedules, perform patient care, meal preparation, infection control/universal precautions, environmental control and any pending appointments.

NIXON ASSISTED LIVING OF HOUSTON, INC.

6800 BLEKER STREET

HOUSTON, TEXAS 77016

THIS IS TO CERTIFY THAT I HAVE RECEIVED A COPY OF THE RESIDENTS BILL OF RIGHTS.

A resident or the resident's guardian or legal representative is entitled to conduct authorized electronic monitoring
(AEM) under Chapter 242 and 247 of the Health and Safety Code. To request AEM, you, your guardian or your legal
representative must:

1) complete the Request for Authorized Electronic Monitoring form (available from the facility);

2) obtain the consent of other residents, if any, in your room, using the Consent to Authorized Electronic Monitoring
form (available from the facility); and

3) give the form(s) to the facility manager or designee.

Who may request AEM?

1) The resident, if the resident has capacity to request AEM and has not been judicially declared to lack the required
capacity.

2) The guardian of the resident, if the resident has been judicially declared to lack the required capacity.

3) The legal representative of the resident, if the resident does not have capacity to request AEM
and has not been judicially declared to lack the required capacity.

Who determines if the resident does not have the capacity to request AEM?

The resident's physician will make the determination regarding the capacity to request AEM. When the resident's
physician has determined the resident lacks capacity to request AEM, a person from the following list, in order of
priority, may act as the resident's legal representative for the limited purpose of requesting AEM:

1) a person named in the resident's medical power of attorney or other advance directive;

2) the resident's spouse;

3) an adult child of the resident who has the waiver and consent of all other qualified adult children of the resident to
act as the sole decision- maker;

4) a majority of the resident's reasonably available adult children;

5) the resident's parents; or

6) the individual clearly identified to act for the resident by the resident before the resident became incapacitated or
the resident's nearest living relative.

Who may consent to AEM?

1) The other resident(s) in the room.

2) The guardian of the other resident, if the resident has been judicially declared to lack the required capacity.

3) The legal representative of the other resident, if the resident does not have capacity to sign the form, but has not
been judicially declared to lack the required capacity. The legal representative is determined by following the
procedure for determining a legal representative, as stated above, under "Who determines if the resident does not
have the capacity to request AEM?"

Can a resident be discharged or refused admittance for requesting AEM?
A facility may not refuse to admit an individual and may not discharge a resident because of a request to conduct
AEM. If either of these situations occur, you should report the occurrence to the local office of Long Term CareRegulatory, Texas Health and Human Services (HHS).

What about covert electronic monitoring?
A facility may not discharge a resident because covert electronic monitoring is being conducted by or on behalf of a
resident. A facility attempting to discharge a resident because of covert electronic monitoring should be reported to
the local office of Long Term Care-Regulatory.

What is required if a covert electronic monitoring device is discovered?

If a covert electronic monitoring device is discovered by a facility and is no longer covert as defined in 40 Texas
Administrative Code (TAC) §92.3 (relating to Definitions) the resident must meet all requirements for AEM before
monitoring is allowed to continue.

Is notice of AEM required?

Anyone conducting AEM must post and maintain a conspicuous notice at the entrance to the resident's room. The
notice must state that an electronic monitoring device is monitoring the room.

What is required for the installation of monitoring equipment?

The resident or the resident's guardian or legal representative must pay for all costs associated with conducting AEM,
including installation in compliance with life safety and electrical codes, maintenance, removal of the equipment,
posting and removal of the notice, or repair following removal of the equipment and notice, other than the cost of
electricity.

A facility may require an electronic monitoring device to be installed in a manner that is safe for residents, employees,
or visitors who may be moving about the room. A facility may also require that AEM be conducted in plain view.

The facility must make reasonable physical accommodation for AEM, which includes providing:

1) a reasonably secure place to mount the video surveillance camera or other electronic monitoring device; and

2) access to power sources for the video surveillance camera or other electronic monitoring device.

If the facility refuses to permit AEM or fails to make reasonable physical accommodations for AEM, you should report
the facility's refusal to the local office of Long Term Care-Regulatory.

Are Facilities subject to administrative penalties for violations of the electronic monitoring rules?

Yes, HHS may assess an administrative penalty (see 40 TAC §92.559 (relating to What is the administrative penalty
schedule?)) against a facility for each instance in which the facility:

1) refuses to permit a resident or the resident's guardian or legal representative to conduct AEM;

2) refuses to admit an individual or discharges a resident because of a request to conduct AEM;

3) discharges a resident because covert electronic monitoring is being conducted by or on behalf of the resident; or

4) violates any other provision related to AEM.

How does AEM affect the reporting of abuse and neglect?

40 TAC §92.102 (relating to Abuse, Neglect, or Exploitation Reportable), requires facility staff to report abuse or
neglect. If abuse or neglect has occurred, the most important thing is to report it. Abuse and neglect cannot be
addressed unless reported.

For purposes of the duty to report abuse or neglect, the following apply:

1) A person who is conducting electronic monitoring on behalf of a resident is considered to have viewed or listened
to a tape or recording made by the electronic monitoring device on or before the 14th day after the date the tape or
recording is made.

2) If a resident, who has capacity to determine that the resident has been abused or neglected and who is conducting
electronic monitoring, gives a tape or recording made by the electronic monitoring device to a person and directs
the person to view or listen to the tape or recording to determine whether abuse or neglect has occurred, the
person to whom the resident gives the tape or recording is considered to have viewed or listened to the tape or
recording on or before the seventh day after the date the person receives the tape or recording.

3) A person is required to report abuse based on the person's viewing of or listening to a tape or recording only if the
incident of abuse is acquired on the tape or recording. A person is required to report neglect based on the person's
viewing of or listening to a tape or recording only if it is clear from viewing or listening to the tape or recording that
neglect has occurred.

4) If abuse or neglect of the resident is reported to the facility and the facility requests a copy of any relevant tape or
recording made by an electronic monitoring device, the person who possesses the tape or recording must provide
the facility with a copy at the facility's expense. The cost of the copy cannot exceed the community standard.

5) A person who sends more than one tape or recording to HHS must identify each tape or recording on which the
person believes an incident of abuse or evidence of neglect may be found. Tapes or recordings should identify the
place on the tape or recording that an incident of abuse or evidence of neglect may be found.

What is required for the use of a tape or recording by an agency or court?

Subject to applicable rules of evidence and procedure, a tape or recording created through the use of covert
monitoring or AEM may be admitted into evidence in a civil or criminal court action or administrative proceeding. A
court or administrative agency may not admit into evidence a tape or recording created through the use of covert
monitoring or AEM or take or authorize action based on the tape or recording unless:

1) the tape or recording shows the time and date the events on the tape or recording occurred, if the tape or recording
is a video tape or recording;

2) the contents of the tape or recording have not been edited or artificially enhanced; and

3) any transfer of the contents of the tape or recording was done by a qualified professional and the contents were not
altered, if the contents have been transferred from the original format to another technological format.

Are there additional provisions of the law?
A person who places an electronic monitoring device in the room of a resident or who uses or discloses a tape or
other recording made by the device may be civilly liable for any unlawful violation of the privacy rights of another.

A person who covertly places an electronic monitoring device in the room of a resident or who consents to or
acquiesces in the covert placement of the device in the room of a resident has waived any privacy right the person
may have had in connection with images or sounds that may be acquired by the device.

DAHS Form

1. Resident/Provider Bill of Rights
2. Rights of Elderly
3. Privacy Notice (HIPPA)
4. Advance Directive/Living Will (Making Healthcare Decisions)
5. Confidentiality of Information
6. How to File a Complaint with DADS

 

By my signature, I certify that I have received information of the above material and that the information has been read or translated to me and that I understand the content.