Resident Handbook

Address: 94 South Avenue

Harrisonburg, VA 22801

Phone Number: 540-433-2791

Fax Number: 540-433-0109

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Table of Contents
Welcome to Avante Harrisonburg! ................................................................................................. 5
Our Mission ......................................................................................................................................................... 5
Our Commitment .............................................................................................................................................. 5
Our Values ........................................................................................................................................................... 5
Basic Rights ......................................................................................................................................................... 6
Admissions .............................................................................................................................................. 6
Admission Contract ...................................................................................................................................................... 6
Admissions Rights ............................................................................................................................................ 7
Room Rates and Billing Policy .......................................................................................................... 7
Room Rates ......................................................................................................................................................... 7
Billing Policy ....................................................................................................................................................... 7
Private Paying Residents ........................................................................................................................................... 7
Residents With Medicaid Coverage ....................................................................................................................... 7
Residents With Pending Medicaid Applications .............................................................................................. 7
Admittance During Last Seven Days of a Month .............................................................................................. 8
After the First Payment .............................................................................................................................................. 8
Payment Method ............................................................................................................................................... 8
Residents With Medicaid Coverage ....................................................................................................................... 8
Residents With Medicare Coverage....................................................................................................................... 8
Patient Trust Account.................................................................................................................................................. 8
Direct Deposit (EFT or Electronic Funds Transfer) ........................................................................................ 8
Money and Possession Rights....................................................................................................................... 9
Bed assignment and reservations ................................................................................................... 9
Bed assignment ................................................................................................................................................. 9
Bed reservation policy .................................................................................................................................... 9
Residents With Medicare, Veterans Administration or Private Pay Coverage .................................... 9
Residents With Medicaid Coverage ....................................................................................................................... 9
Living Accommodation Rights .................................................................................................................. 10
Moving In................................................................................................................................................ 10
What we Provide ............................................................................................................................................ 10
What to Bring .................................................................................................................................................. 11
Recommended Personal Clothing ........................................................................................................................ 11
Special items to Bring if Necessary ...................................................................................................................... 11
Personal Items Residents May Bring .................................................................................................................. 11
What not to Bring........................................................................................................................................... 12
Visitation ................................................................................................................................................ 12
Visiting Hours.................................................................................................................................................. 12
Meals for Visitors ........................................................................................................................................... 12
Transfer and Discharge..................................................................................................................... 13
Discharge Policy ............................................................................................................................................. 13
Notice ............................................................................................................................................................................... 13
Transfer........................................................................................................................................................................... 13
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 Personal Belongings................................................................................................................................................... 13
Refund Policy ................................................................................................................................................................ 13
Transfer and Discharge Rights ................................................................................................................. 13
Leave of Absence Policy .................................................................................................................... 13
Maximum Time Period ................................................................................................................................ 14
Leave Of Absence Requirements .............................................................................................................. 14
Resident Care Plan .............................................................................................................................. 14
Elopement risk assessment........................................................................................................................ 15
Medical Care and Treatment Rights........................................................................................................ 15
Avante Resident Concern and Grievance Policy....................................................................... 15
Scope of Policy ................................................................................................................................................ 15
Avante Resident Concern ............................................................................................................................ 16
Arbitration ............................................................................................................................................. 16
Definition .......................................................................................................................................................... 16
Purpose ............................................................................................................................................................. 16
Procedure ......................................................................................................................................................... 17
Limitations ....................................................................................................................................................... 17
Withdrawal of request ..................................................................................................................................... 17
Smoking Policy ..................................................................................................................................... 17
Regulations on Smoking Indoors ............................................................................................................. 17
Regulations on Smoking Outdoors .......................................................................................................... 18
Resident Smoking Regulations ................................................................................................................. 18
Professional Services ......................................................................................................................... 18
Physicians ......................................................................................................................................................... 18
Social Services ................................................................................................................................................. 19
Rehabilitation Services ................................................................................................................................ 19
Medication ........................................................................................................................................................ 19
Self-Administration of Medication ....................................................................................................................... 19
Personal Services ................................................................................................................................ 19
Resident Meals ................................................................................................................................................ 19
Laundry Services............................................................................................................................................ 19
Beauty and Barber Shop.............................................................................................................................. 20
Personal Mail and Newspapers ................................................................................................................ 20
Activities ................................................................................................................................................. 20
Resident Activities......................................................................................................................................... 20
Family Activities ............................................................................................................................................. 20
Resident Council............................................................................................................................................. 20
Activity Rights ................................................................................................................................................. 20
Frequently Asked Question ............................................................................................................. 21
Protecting Residents Rights ............................................................................................................ 22
Forms ....................................................................................................................................................... 23
EFT Authorization Agreement .................................................................................................................. 23
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Avante Residential Rights Agreement.................................................................................................... 26
HIPPA Notice of Privacy Practices for Personal Health Information .......................................... 27
Avante Resident Grievance Form............................................................................................................. 29
American Health Lawyers Association Alternative Dispute Resolution.................................... 30

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 Welcome to Avante Harrisonburg!
We are pleased you have chosen us to care for you or your
loved one. In order to acquaint you with the services we
provide we have created this resident handbook to familiarize
you with the facilities and assistance we offer, and to answer
many of the questions you may have. All contracts and forms
can be found at the end of this handbook.

Our Mission
To improve the quality of life for our residents, colleagues, and communities by exceeding
expectations one individual at a time

Our Commitment
To serve, to heal, to care. This isn’t just something we talk about; it’s something we make
apparent every day. We are highly committed to helping our residents reach and maintain the
greatest possible level of independence.

Our Values
At Avante, we have six core values that we use to guide us in providing the best care to you or
your loved ones.

Accountability Showing personal responsibility for acting with urgency, problem solving,
stewardship and integrity.
Visibility Demonstrating a passion for Avante's vision to be the best provider of resident
service and care by acting with sincerity, willingness and knowledge.

Achievement Stretching goals, driving for results and celebrating our successes.

Nurture Fostering a culture of humility, respect, dignity and compassion.

Teamwork Sustaining high performance teams through a spirit of collaboration and respect
for all colleagues.
Excellence Striving to exceed our residents and families' expectations by listening and
delighting our customers with great service and care.

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Basic Rights
As a resident of Avante Harrisonburg residents are entitled to protection under both state and
federal law. Residents or the resident’s representatives will be asked to sign the Residential
Rights Agreement within 24 hours of admission indicating that have received and read these
rights.

Patients have the right to…

 Respect and dignity in recognition of individuality and preferences when being treated by
staff

 Quality care and treatment that is fair and free from discrimination

 Necessary services to attain or maintain highest possible level of function

 Representation from a relative or a legal to act on the residents behalf and exercise these
rights when they are unable to do so themselves

 Voice complaints or grievances without fear of retaliation

o This can be done through a grievance form found at the end of the document

 Visit with family and friends as well as the right to contact and meet with agency
representatives or individuals who provide health, legal, social or other services

Admissions
Avante Harrisonburg is a fully licensed and skilled nursing facility. Our staff consists of trained
professionals who are dedicated to providing the highest quality of care and life for our residents.
Licensed nurses, certified nursing assistants and therapists provide 24-hour care, seven days a
week.
Admission Contract
At the time of admission, a contract must be signed by one of the following:
 Resident

 Resident's legal representative

 Any individual who has legal access to the resident's income or resources and is available
to pay for care

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Admissions Rights
 Residents must be informed of all rights in a language or manner that is understood.

 Residents must be informed of all of this facility's rules and regulations, including those
regarding transfer and discharge policies.

 Residents have the right to carefully review all contracts and agreements prior to signing;
Avante cannot require a cosigner for payment, but may require a relative or a legal
representative to ensure payment from income or resources.

Room Rates and Billing Policy

Room Rates
Private Room $250.00 per day
Semiprivate Room $215.00 per day

Room rates change periodically and residents receive notice in writing prior to any change.
Please contact Avante business office for current rates.

Billing Policy
Prior to admission, residents must pay according to their room type or insurance method.
Private Paying Residents
Private Paying Residents must pay for 30 days room and board in advance.
Residents With Medicaid Coverage
Residents who have been approved for Medicaid must pay one month in advance
at the time of admission. The amount of resident responsibility is determined by
the Department of Social Services. Monthly payments are due by the 5th of each
month thereafter.
Residents With Pending Medicaid Applications
If a resident has submitted a Medicaid application but has not been approved at the time of
admission, a 30-day advance payment is required. The resident must pay from the date of
admission until verification of Medicaid acceptance.

Residents have the right to apply for Medicare and Medicaid, and the right to information and
assistance in applying for those programs. Residents cannot be asked to give up or delay their
rights to these programs.

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Admittance During Last Seven Days of a Month
If a resident is admitted during the last seven days of a month, payment for the remaining days of
that month is required, in addition to the 30-day advance payment for the following month.
After the First Payment
Bills for each resident’s account are automatically generated at the end of each month for the
following month. Ancillary charges reflect all medical supplies provided from the previous
month through the date of billing. Pharmaceutical items are billed directly from the pharmacy
and are payable in accordance with the pharmacy billing policy.

Bills from Avante are payable upon receipt and are considered late after the 5th of the month.
Resident accounts with outstanding fees after this date may be subject to penalty. Please contact
the business office for further details at 540-433-2791.

Payment Method
Residents With Medicaid Coverage
Residents with Medicaid coverage who also receive Social Security and/or other pension checks
must submit these checks to Avante to cover any portion of the resident's room and board that is
not covered by Medicaid.
Residents With Medicare Coverage
Residents with Medicare coverage must provide Avante with a copy of the Medicare card and
supplemental insurance cards for billing claims. The resident or the resident's representative will
sign the admission contract to ensure payment of any portion of the billing not covered by
Medicare.
Patient Trust Account
All residents are provided with a Patient Trust Account (PTA) at the time of admission. The PTA
is used to manage monthly deposits and withdrawals of money used for care costs. The following
restrictions apply:

 Residents may withdraw any amount, up to the balance in their accounts, for personal
expenses.

 Cash deposits are not allowed, however, cash withdrawals may be made up to $40.
Withdrawals over $40 are issued as a check.

 All deposits require three days to process before withdrawals are made.
Direct Deposit (EFT or Electronic Funds Transfer)
Effective March 1, 2011, all federal payments, including social security checks, must be
deposited electronically. We accept direct deposits; also known as Electronic Funds Transfer
(EFT), for Social Security checks, as well as any other federal or state issued monthly payments
such as pension or retirement checks. EFT regulations and enrollment forms are located at the
end of this handbook.

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Money and Possession Rights
 Residents have the right to manage their own financial affairs or to have Avante manage
their personal money in accordance with specific requirements, which include periodic
accounting reports.

 Residents have the right to reasonable security of clothing and personal property. This
facility must maintain an inventory of residents clothing and other personal property and
make reasonable efforts to prevent theft or loss of these items.

Bed assignment and reservations

Our facility has a capacity for 117 residents in private or semi-private rooms. All rooms have
bathrooms and are furnished with comfortable beds, closet space, bedside cabinets, and dividing
privacy curtains. A nurse call bell is at each bedside and in all of the bathrooms. Residents are
encouraged to personalize their living area with whatever personal items space will
accommodate. Bed assignments are nondiscriminatory.

Bed assignment
 Avante reserves the right to assign or reassign beds in order to best utilize space and
accommodations for all residents. Every effort is made to fulfill resident’s requests and
consider their preferences.

 Avante reserves the right to change a bed assignment in accordance to a change in the
resident's medical condition or when there is a concern about compatibility between two
residents.

Bed reservation policy

Residents With Medicare, Veterans Administration or Private Pay Coverage
Medicaid coverage does not provide for beds to be held for residents. Medicare, Veteran's
Administration, and private pay residents may elect to hold a bed when transferred from the
facility to a hospital by paying the regular room rate. The Avante business office must receive
written notification to hold a bed. Upon notification, Avante will reserve the resident's bed
provided payment is made as if the resident were at the facility. The resident's bed will not be
held if payment is not received.
Residents With Medicaid Coverage
Medicaid coverage does cover the reservation of a bed when the Medicaid-only resident is
approved for the Institutional Care Program (ICP) at the time the resident is admitted to a
hospital or is placed on therapeutic leave. Avante will hold the resident's bed for a total of eight
days unless five percent or less of certified Medicaid beds are available. If a bed reservation is
not made, a resident wishing to return to Avante will be given the next available bed provided
their condition warrants readmission and there are no legally justifiable reason for denying
readmission.

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Living Accommodation Rights
 Residents have the right to express preferences with respect to their room and roommate
and notification prior to any changes.

 Residents have the right to a safe, clean and comfortable living environment.

 Residents have the right to receive care in a manner that promotes and enhances quality
of life, including enough quality food to meet their needs and preferences.

 Residents have the right to privacy in their room and during bathing, medical treatment
and personal care.

 Residents have the right to privacy during visits or meetings, in making telephone calls
and with mail.

Moving In
Moving to a nursing facility is a life-changing event and may require adjustment for both the
resident and their loved ones. We want to help make this transition as smooth and pleasant as
possible.

What we Provide
We provide the following for each Avante resident:

Bathroom Comfortable bed

Closet Space Bedside cabinet
Dividing privacy Curtin in semi-private rooms Cable television
Telephone Nurse call bell at each bedside and in each
bathroom

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What to Bring
Please provide sufficient personal clothing, labeled with the resident's name in permanent
marker.
Recommended Personal Clothing

Female Residents Male Residents

7 Washable dresses 7 washable shirts
7 Night gowns or dresses 7 pairs of pajamas
1 Pair or comfortable shoes 1 pair of comfortable shoes
1 Pair of house slippers 1 Pair of house slippers
2 House coats or robes 2 Robes
7 Sets of underclothes 7 Sets of underclothes
7 Pairs of socks 7 Pairs of socks

Please log all personal items brought to Avante at admission. In case of loss, Avante staff will
work closely with the resident and family to locate lost personal items, including filing a police
report for the loss of any large identifiable items.
Special items to Bring if Necessary
 Glasses
 Hearing Aids
 Dentures
Personal Items Residents May Bring
Residents are encouraged to personalize their living area with items from home as space allows.
In order to comply with the fire code, items may not be placed within ten inches of the ceiling.
Recommended items are listed below.

 Television  Pillows
 Clock  Afghan
 Bedspread  Recliner
 Radio  Small plants
 Pictures

Food and snack items are allowed as long as the following rules are adhered to:

 Covered, air-tight containers are necessary for storing food items.

 Approval by the head nurse is required before all food items are given to the resident.

 Compliance with the resident's dietary restrictions is essential for all food items.

 Limit the quantity of food items brought into the facility to avoid spoilage.

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What not to Bring
 Leave valuables such as expensive watches, rings, and necklaces at home.

 Limit the amount of cash left with the resident. A patient trust account can be opened in
the business office and money can be withdrawn as needed.

 Do not bring existing medications from home or the hospital. This includes over-the-
counter items such as Turns®, aspirin, eye drops and analgesics.

 Leave electric heating pads, extension cords and candles at home, they are prohibited by
the fire marshal.

 Avoid bringing throw rugs, as they are a tripping hazard for our residents and staff.

 Be aware that alcoholic beverages are not permitted in resident rooms.

o A physician’s order is required for a resident to consume alcohol. Alcohol

belonging to a resident will be secured at the nurse's station and dispensed by a
licensed nurse according to the physician’s orders.

Visitation
Avante respects the right of residents to have visitors, and encourages family and friends to
spend time with residents.

Visiting Hours
Visiting hours are 7a.m. to 8:30 p.m.. Residents are assisted to one of the common areas for the
duration of the visit in order to facilitate caregiving and/or protect the privacy of other residents.
Immediate family are not subject to visiting hour limitations, but may be asked to conduct the
visit in one of the common areas for the comfort and privacy of all residents.

Avante will provide immediate access, at any time, to any representative at the Secretary of the
Department of Health and Human Services, the Commonwealth of Virginia, the resident's
physician, the state long-term care ombudsperson and the Protection and Advocacy Agencies for
the mentally ill and mentally retarded. Contact information for these sources may be found on
page 22.

Meals for Visitors

Visitors are encouraged to eat meals with the residents. Guest meals are $2.50 per person. Those
interested must sign up at the information desk or notify the business office by 10 a.m. on the
day they wish to eat lunch or by noon. on the day they wish to eat dinner. Guest meals are not
provided at breakfast.

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Transfer and Discharge
Discharge Policy
Notice
Avante requires a five-day notice prior to discharge to give the facility time for proper discharge
planning. Charges may be assessed for failure to provide the five-day notice.
Transfer
In the event that a resident becomes aggressive to the point of endangering themselves or others
the Avante administrator will be notified. The administrator, under the directions of a certified
physician, may transfer and discharge the resident to another facility more suitable to the
residents needs.
Personal Belongings
All personal belongings must be removed from the facility within two weeks of discharge. If a
bed is reserved, personal items may remain; however, all valuables should be removed tor
security reasons. Personal property not removed from Avante within the required two weeks
following discharge becomes the property of Avante and will be disposed of at our discretion.
Please contact the Department of Social Services if help is needed making arrangements for the
removal of a resident's personal belongings within the two-week time period.
Refund Policy
If a refund is due upon discharge, payment of balance due will be processed within 30 days after
all charges have been submitted.

Transfer and Discharge Rights

 Residents have the right to be notified in writing before transfer or discharge from
Avante.

 Residents have the right to appeal any transfer or discharge decision.

 Residents have the right to return to Avante after a short-term transfer to a hospital or
after a therapeutic leave from the facility. Residents must be informed regarding the
policy on bed holds.

Leave of Absence Policy

A leave of absence (LOA) may be granted to Avante residents in accordance with the resident's
individual Care Plan. A nurse must provide a medication schedule if needed and resident and/or
caregiver must agree to follow all instructions exactly. Failure to follow a medication or dietary
plan while on a LOA may result in the denial of further LOA requests.

A LOA may be granted for the following reasons:

 A visit with relatives or friends

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  Participation by developmentally disabled residents in an organized summer camp for
developmentally disabled persons

Maximum Time Period

If the LOA is an overnight visit (or longer) to the home of relatives or friends, the time period is
restricted as follows:

 18 leave days per calendar year are allowed for non-developmentally disabled residents

 12 additional days of leave per year may be approved in increments of no more than two
consecutive days when the following conditions are met:

o The request for additional days of leave are in accordance with the Residents Care
Plan and appropriate to the physical and mental well-being of the resident

o At least five days of residency within the Avante facility must be provided
between each approved LOA

 Developmentally disabled residents must spend at least 73 days per calendar year within
the Avante facility

Leave Of Absence Requirements

A record of the resident's LOA must be logged and include the following:

 The address of the intended destination

 Dates of requested leave

 Specific date and time of expected return

If the Resident is unable to return at the documented date and time the facility MUST be
contacted immediately.

Resident Care Plan

Recognizing that each person is unique, Avante staff members design a care plan to address the
specific needs of each resident. The initial resident care plan meeting is scheduled at the time of
admission and is reviewed quarterly thereafter. Resident Care Plan meetings identify resident
needs, establish goals, and help the resident achieve maximum levels of functioning and
independence, thereby enhancing quality of life and well being. Family members or caregivers
are encouraged to attend and are reminded of the scheduled meeting through written
correspondence.

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Elopement risk assessment
An elopement risk assessment is administered within 24 hours of admission and updated
quarterly or following a significant change in condition or mental health state. This assessment
determines the eligibility of each resident to take a leave of absence either independently or with
an escort under the guidelines of the leave of absence policy.

Medical Care and Treatment Rights

 Residents have the right to participate in the design of the Resident Care Plan and
treatment.

 Residents have the right to refuse any plan of care, treatment or procedure.

 Residents have the right to make advance directives for treatment. This includes the right
to a power of attorney for health care and choices on health care decisions including
unwanted or life-sustaining treatment.

 Residents have the right to freedom from restraint and abuse. This includes the right to
refuse any bonds that limit mobility or drugs that affect their mind, except in an
emergency situation. In accordance with federal and state laws, any use of physical or
chemical restraint must be used to treat medical symptoms and not for the purpose of
discipline or staff convenience.

 Residents have the right to keep personal and health records confidential.

Avante Resident Concern and Grievance Policy

Avante affirms that all residents have the right to a dignified existence and to quality medical
care in conformance with a professional plan of care based on individual needs. It is the right of
every resident to have access to a forum to express dissatisfaction with the quality of life or
quality of care being provided by Avante without fear of reprisal.

Scope of Policy

Every Avante employee will be trained on regulations regarding resident concerns and
grievances. Training is required of each new employee hired by Avante. Contractors who have
direct contact or provide direct medical care to residents within the facility will be given a copy
of this policy and are expected to abide by it.

Each resident of Avante, or a legal representative, will be provided with a copy of this policy
upon admission. A copy of this policy must be posted and remain at all times accessible to all
Avante residents and their representatives.

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Avante Resident Concern

Any resident, family member, resident representative, or employee of Avante may file a resident
concern if it is believed that quality of life or quality of care for the resident is inappropriate. A
resident concern may be submitted verbally or in writing, however, it must contain the following
information:
 Notice that a resident concern is being filed.
 Date and time of the alleged incident.
 Circumstances surrounding the alleged incident or, if there was not one specific incident,
a general description of the nature of the concern.
 Location of the alleged incident.
 An account of the alleged incident as stated by the resident, the employee, any witnesses
or any other individuals involved.
 Recommendations for corrective action.
 A signature of the originator and the relationship to the affected resident.

If the resident concern is given verbally, it must be transcribed into writing before the concern
will be addressed by Avante. The concern originator must review the transcribed copy to
confirm with a signature that it is accurate and complete. A resident concern is considered to be
filed when a signed, written report is submitted by the originator. For convenience, a resident
concern form, containing all elements indicated above, will be available at the nurse's station
located on each wing of the facility; however, use of this form is not required.

If the originator of the resident concern is not satisfied with the response received from the
facility, a resident grievance may be initiated.

Arbitration
Definition

Arbitration is a method of resolving disputes by one or more neutral third parties known as the
arbiters. Arbiters are selected and agreed upon by both the resident and the facility. The arbiters
are experienced in healthcare issues and will listen to evidence from both sides and make a
decision that is enforceable.

Purpose

Arbitration is designed to expedite the settlement of disputes and avoid the delay and expenses
associated with a court lawsuit. Residents choosing arbitration must request the use of an
alternative dispute resolution service with the American Health Lawyers Association (AHLA).

Arbitration may be requested for but is not limited to any dispute or claim regarding the
following:

 Issues relating to improper, inappropriate or inadequate care.

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  Issues relating to the delivery of services or goods.
 Issues regarding personal endangerment or injury.
 Issues regarding pa3mients or management of resident funds.

Procedure

A resident or resident representative requesting arbitration must submit a completed AHLA

alternative dispute resolution form. Avante facilities are required to make copies of this form
available upon request.
A resident or resident representative who submits an alternative dispute resolution form is agreeing to sue in
arbitration instead of a traditional court of law.

A resident or resident representative requesting arbitration is agreeing to abide by the decision of

the arbiters.

Limitations
Arbitration may not be used for issues relating to the failure to pay the facility for care, services
or goods provided to the resident. Avante reserves the right to bring a court lawsuit to collect any
amount owed.

Withdrawal of request

Virginia law gives the resident or resident representative the right to withdraw from arbitration
for certain reasons relating to discharge, incapacity or death if 60 days' notice is given.

Smoking Policy
It is the policy of all Avante facilities to provide a smoke-free setting for all residents as well as
to provide a smoke-free place of employment for all employees. Residents who wish to smoke
must meet with the care plan team to create an individual plan designed to meet the resident's
needs while safeguarding the rights and safety of other residents. Smoking plans are reviewed
quarterly by the care plan team or more frequently if needed.

Regulations on Smoking Indoors

Smoking is prohibited in all enclosed areas of the facility. This includes, but is not limited to,
common work areas, resident rooms, hallways, stairs, lobby and reception areas, dining area,
lounges, elevators, restrooms, motor vehicles owned or leased by Avante and any other enclosed
areas specific to each facility.

"No Smoking" signs or the universal "No Smoking" symbol shall be clearly, sufficiently and
conspicuously posted at every entrance to the facility.

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Regulations on Smoking Outdoors
Avante at Harrisonburg provides an outdoor designated smoking area for both residents and
employees. This smoking area meets the following requirements:

 Located on the grounds of the facility

 Accessible to all residents and employees

 Protected from the elements

 Located at a distance outside of the facility to ensure that tobacco smoke does not enter
the enclosed areas through entrances, windows, ventilation systems, or by any other
means

Resident Smoking Regulations

Residents who wish to smoke must meet with the Care Plan team to create an individual plan
designed to meet the resident's needs while safeguarding the rights and safety of other residents.
Smoking plans are reviewed quarterly by the care plan team or more frequently if needed.

If a resident requires supervision in order to utilize the outdoor designated smoking area,
employees are given the choice whether they wish to supervise a resident and thereby be exposed
to secondhand smoke. Employees have the right to refuse to accompany a resident to and in the
outdoor designated smoking area.

If it is determined by the care plan team or an attending physician that smoking by a resident
poses a danger to him or herself or others, all smoking items will be confiscated and made
available for use by the resident only at specific times or under the supervision of Avante staff.

Professional Services
Physicians
Avante has a choice of physicians who have privileges to see our residents. If a family physician
is unable to provide care for the Avante resident after admission, the resident or resident’s
representative may choose one of the physicians available, who will contact the family physician
as needed. A current list of physicians and their contact information may be obtained from the
Avante business office.

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Social Services
Social Service providers play an important role in the adjustment of new residents. In an effort to
meet the resident's psychological, social and emotional needs, Social Service providers
coordinate interaction among residents, families and community resources.

At the time of admission to Avante, a family conference with a Social Service provider will be
scheduled. At this conference, the new resident and the resident's family or representative will
learn of services available to them and be introduced to available Avante staff members. A
Social Service provider will also discuss discharge planning and be available to schedule any
community resources that might be helpful at the time of discharge.

Rehabilitation Services
The Avante rehabilitation center offers superior rehabilitation services with measureable results.
Personalized programs are designed to help residents achieve their highest level of
independence. Physical, occupational and speech therapies are provided by licensed and certified
staff following surgery or illness, using state-of-the-art equipment and modalities to accelerate
the healing process.

Medication
Medication is provided by the Avante pharmacy provider. No outside medications, prescription
or over-the-counter, are allowed without orders from the attending or on-call physician.

Self-Administration of Medication
It is the policy of Avante that each resident be offered the opportunity to self-administer
medications. However, it is imperative that all residents are in a safe environment a t all times.
Each resident's cognitive, physical and visual ability will be assessed in order to determine his or
her capacity to self-administer medications in a safe manner. If it is determined, at any time that
the resident is unable to perform self-medication in a safe manner, this right will be withdrawn.

Personal Services
Resident Meals
Meals are prepared fresh daily by the Avante on-site dietary. Our menus are created in
conjunction with our registered dietitians. The Avante dietary staff makes every effort to assist
residents in meeting specific nutritional needs and to accommodate any special diet concerns.

Avante at Harrisonburg recognizes the importance of an enjoyable mealtime for our residents.
Every effort is made to establish compatible tablemates in order to encourage conversation and
socialization during meals. Physically able residents are encouraged to eat in the dining room.

Laundry Services
Laundry service is provided to all Avante residents at no charge. All clothing must be labeled or
marked with a permanent marker. Family members may opt to provide their own laundry
service; however, Avante requires that laundry items be collected a minimum of two times per
week.

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Beauty and Barber Shop
The Avante beauty and barber shop is open on Mondays unless otherwise posted. Please see the
schedule posted at the front desk for current pricing and hours.

Personal Mail and Newspapers

Personal mail is delivered unopened daily except on Sundays and holidays. Outgoing mail may
be left in the mailbox a t the nurse's station. Postage stamps are available for purchase in the
business office during normal business hours. Arrangements can be made to provide assistance
with reading and sending mail if needed.

Newspaper delivery arrangements can be made with the business office during normal business
hours. The resident is responsible for payment of the subscription.

Activities
Resident Activities
Avante offers a variety of both group and individual activities, designed to promote social and
physical interaction as well as mental stimulation. Participation is encouraged but not mandatory.
Residents are invited to continue to do activities they have enjoyed in the past, as well as to try
new activities. A variety of programs such as arts and crafts, physical activities, religious
programs, bingo, discussion groups and current event topics are offered on a daily, weekly or
monthly basis.

Family Activities
Family activities are held every month. A calendar of events, flyers on bulletin boards and
posters in the front lobby will notify you of these enjoyable events, which are planned by the
Avante activities department. Past activities have included cookouts, potluck suppers and
scheduled entertainment. Family and friends are invited to attend these activities with the
residents, as it provides an opportunity to share in a resident’s experiences, meet their new
friends and socialize on an informal basis.

Resident Council
Family activities are held every month. A calendar of events, flyers on bulletin boards and
posters in the front lobby will notify you of these enjoyable events which are planned by the
Avante activities department. Past activities have included cookouts, potluck suppers and
scheduled entertainment. Family and friends are invited to attend these activities with the
residents, as it provides an opportunity to share in a resident’s experiences, meet their new
friends and socialize on an informal basis.

Activity Rights
 Residents have the right to choose and participate in activities, including social, religious
and community activities.

 Residents have the right to organize and participate in resident groups.

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Frequently Asked Question
Q: May I plan a special birthday or anniversary celebration for my loved one?
A: Yes. Arrangements can be made for special events. Please contact the director of
social services or the director of activities to make arrangements.

Q: May I take loved ones out of the Avante facility for a meal or other activity?
A: Residents who are physically able and are not deemed an elopement risk may be
approved to leave the facility according to the rules of absence policy. The resident or escort will
sign out and sign in on a leave of absence log sheet, indicating the date and expected time of
return as well as purpose or destination. A nurse will instruct the resident on any necessary
medication needed during the leave of absence. If the resident is unable to return at the
designated time, the resident or escort must contact the facility immediately.

Q: Are gratuities accepted?

A: Gratuities are not necessary all staff is prohibited from accepting either tips or gifts. A
sincere thank you is the best reward.

Q: How do I file a grievance?

A: The Avante Resident Concern and Resident Grievance Policy as well as forms to fine
a grievance, can be found at the end of this handbook.

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Protecting Residents Rights
The following services are available at any time.
Center for Quality Health Care Services and Consumer Protection Virginia
Department of Health
3600 West Broad Street, Suite 216
Richmond, VA 23230
1-800-955-1819
Website: www.vdh.state.va.us

Virginia Office for Protection and Advocacy (VOFA)

1910 Byrd Ave., Suite 5
Richmond, VA 23230
1-800-552-3962
Website: www.vopa.state.va.us
Email: general.vopa.vopa.virginia.gov
Virginia Association of Area Agencies on Aging Office of
theState Long Term Care Ombudsperson
530 East Main Street, Suite 428
Richmond, VA 23219
1-800-552-3402
Website: http: / /www.vda.virginia.gov/ombudsman.asp
Local Long-Term Care Ombudsperson ProgramValley Program for Aging Services, Inc.
2137 Magnolia Avenue
Buena Vista, VA 24416
Phone: 540-261-2553 or 1-866-816-9020
Website: http://www.vaaaa.org/LTCOP/localombud.asp
Email: ItcotSvpas.info
Medicaid Fraud Control Unit of the Office of the Attorney General
900 East Main Street
Richmond, VA 23219
1-800-371-0824
Website:http://www.oag.state.va.us/Programs%20and%20Resources/Medicaid Fraud/index.html
Email: MFCU ma0(5)oag.state.va.us

Virginia Health Quality Center (VHQC)

9830 Maryland Drive, Suite J
Richmond, VA 23233
1-804-289-5330
Website: http://www.vhqc.org/

22
 Forms
EFT Authorization Agreement
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
Form Approved OMB
No. 0938-0626
Expires: 01/2020

ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENT

PART I: REASON FOR SUBMISSION
Reason for Submission:
New EFT Enrollment Check here if EFT payment is being made to
Individual Group the Home Office of the Chain Organization
(Attach letter Authorizing EFT payment to
Change to Current EFT Enrollment Chain Home Office)
(e.g. account or bank changes)
Cancel EFT Enrollment
Since your last EFT authorization agreement submission, have you had a:
Change of Ownership, and/or
Change of Practice Location?
If you checked either a change of ownership or change of practice location above, you must submit a
change of
information (using the Medicare enrollment application) to the Medicare contractor that services your
geographical area(s) prior to or accompanying this EFT authorization agreement submission.

PART II: ACCOUNT HOLDER INFORMATION

Provider/Supplier/Indirect Payment Procedure (IPP) Biller Legal Business Name

Chain Organization Name or Home Office Legal Business Name (if different from Chain

Organization Name) Account Holder’s Street Address

Account Holder’s City Account Holder’s State Account Holder’s Zip Code

Tax Identification Number (TIN) Designate TIN

SSN (enrolling as an individual) OR
EIN (enrolling as a group/organization/corporation
Medicare Identification Number (if issued) Health Plan Identifier (HPID) or Other Entity Identifier (OEID) (IPP Entities Only)

National Provider Identifier (NPI) National Provider Identifier (NPI) National Provider Identifier (NPI)

PART III: FINANCIAL INSTITUTION INFORMATION

Financial

Institution’s

Name

23
 Financial

Institution’s

Street

Address

Financial Institution’s City/Town Financial Institution’s State/Province Financial Institution’s Zip Postal Code

Financial Institution’s Telephone Number Financial Institution’s Contact Person (optional)

Financial Institution Routing Number (must be 9 digits)

Provider’s/Supplier’s/IPP Entity’s Account Number with Financial Institution (include all zeroes) Type of Account (check one)
Checking Account Savings Accoun
Please include a confirmation of account information on bank letterhead or a voided check. When submitting
the
documentation, it should contain the name on the account, electronic routing transit number, account
number and type. If submitting bank letterhead, the bank officer’s name and signature is also
required. This information will be used to verify your account number. NOTE: Starter checks are not
acceptable for EFT confirmations.
PLEASE NOTE: In accordance with section 1104 of the Affordable Care Act, enrollment
of electronic fund transfer (EFT) is for electronic fund transfer authorization only. EFT
enrollment does not constitute enrollment as a provider or supplier in the Medicare
program. PART IV: CONTACT PERSON
This is the person we will contact for any questions regarding this EFT.
Contact Person’s Name Contact Person’s Title

Contact Person’s Telephone Number Contact Person’s E-mail Address

PART V: AUTHORIZATION
I hereby authorize the Centers for Medicare & Medicaid Services (CMS) to initiate credit entries, and
in accordance with 31 CFR part 210.6(f) initiate adjustments for any duplicate or erroneous entries
made in error to the account indicated above. I hereby authorize the financial institution/bank
named above to credit and/or debit the same to such account. CMS may assign its rights and
obligations under this agreement to CMS’ designated fee-for-service contractor. CMS may change its
designated contractor at CMS’ discretion.
If payment is being made to an account controlled by a Chain Home Office, the Provider of
Services hereby acknowledges that payment to the Chain Office under these circumstances is still
considered payment to the Provider, and the Provider authorizes the forwarding of Medicare
payments to the Chain Home Office.
If the account is drawn in the Physician’s or Individual Practitioner’s Name, or the Legal Business
Name of the Provider/Supplier or IPP entity, the said Provider/Supplier or IPP entity certifies
that he/she has sole control of the account referenced above, and certifies that all arrangements
between the Financial Institution and the said Provider/Supplier or IPP entity are in accordance
with all applicable Medicare regulations and instructions.

24
 This authorization agreement is effective as of the signature date below and is to remain in full
force and effect until CMS has received written notification from me of its termination in such
time and such manner as to afford CMS and the Financial Institution a reasonable opportunity
to act on it. CMS will continue to send the
direct deposit to the Financial Institution indicated above until notified by me that I wish to
change the Financial Institution receiving the direct deposit. If my Financial Institution
information changes, I agree to submit to CMS an updated EFT Authorization Agreement.

SIGNATURE LINE
Authorized/Delegated Official Name (Print) Authorized/Delegated Official Telephone Number

Authorized/Delegated Official Title Authorized/Delegated Official E-mail Address

Authorized/Delegated Official Signature (Note: Must be original signature in black or blue ink.) Date

PRIVACY ACT ADVISORY STATEMENT

Sections 1842, 1862(b) and 1874 of title XVIII of the Social Security Act authorize the collection of this
information. The purpose of collecting this information is to authorize electronic funds transfers.
Per 42 CFR 424.510(e)(1), providers and suppliers are required to receive electronic funds transfer (EFT) at the time of
enrollment, revalidation, change of Medicare contractors or submission of an enrollment change request; and
(2) submit the CMS-588 form to receive Medicare payment via electronic funds transfer.
The information collected will be entered into system No. 09-70-0501, titled “Carrier Medicare Claims Records,” and
No. 09-70-0503, titled “Intermediary Medicare Claims Records” published in the Federal Register Privacy Act
Issuances, 1991 Comp. Vol. 1, pages 419 and 424, or as updated and republished. Disclosures of information from this
system can be found in this notice.
You should be aware that P.L. 100-503, the Computer Matching and Privacy Protection Act of 1988, permits the
government, under certain circumstances, to verify the information you provide by way of computer matches.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this information collection is 0938-0626. The time required to complete
this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard,
Baltimore, Maryland 21244-1850.
DO NOT MAIL THIS FORM TO THIS ADDRESS.
MAILING YOUR APPLICATION TO THIS ADDRESS WILL SIGNIFICANTLY DELAY PROCESSING.

25
Avante Residential Rights Agreement

As a resident of Avante, you are entitled to protection under both state and federal law as outlined in the
residential rights listed in this handbook. Upon satisfactory and full disclosure of these rights, please
complete the following:

I, ________________________________________________ , do hereby certify by my

signature that I have received a copy of the Avante residential rights. I have either read these or I have had
them read to me. I read, speak, and understand these rights in English. If not, these rights have been
provided for me in either oral or written form in an appropriate language that I know and understand.

Name of facility

Street address

City, State and zip code

Name of resident

Signature of resident

Date of signature

Signature of representative

Date of signature

Signature of witness

Date of signature

26
HIPPA Notice of Privacy Practices for Personal Health Information

Background
The HIPAA Privacy Rule gives individuals a fundamental new right to be informed of the
privacy practices of their health plans and of most of their health care providers, as well as to be
informed of their privacy rights with respect to their personal health information. Health plans
and covered health care providers are required to develop and distribute a notice that provides a
clear explanation of these rights and practices. The notice is intended to focus individuals on
privacy issues and concerns, and to prompt them to have discussions with their health plans and
health care providers and exercise their rights.

How the Rule Works

The Privacy Rule provides that an individual has a right to adequate notice of how a covered
entity may use and disclose protected health information about the individual, as well as his or
her rights and the covered entity’s obligations with respect to that information. Most covered
entities must develop and provide individuals with this notice of their privacy practices. The
Privacy Rule does not require the following covered entities to develop a notice:
• Health care clearinghouses, if the only protected health information they create or receive is
as a business associate of another covered entity. See 45 CFR 164.500(b)(1).
• A correctional institution that is a covered entity (e.g., that has a covered health care provider
component).
• A group health plan that provides benefits only through one or more contracts of insurance
with health insurance issuers or HMOs, and that does not create or receive protected
health information other than summary health information or enrollment or disenrollment
information. See 45 CFR 164.520(a).
Content of the Notice.
Covered entities are required to provide a notice in plain language that describes:
• How the covered entity may use and disclose protected health information about an
individual.
• The individual’s rights with respect to the information and how the individual may exercise
these rights, including how the individual may complain to the covered entity.
• The covered entity’s legal duties with respect to the information, including a statement that the
covered entity is required by law to maintain the privacy of protected health information.
• Whom individuals can contact for further information about the covered entity’s privacy
policies.
The notice must include an effective date. A covered entity is required to promptly revise and
distribute its notice whenever it makes material changes to any of its privacy practices.
Providing the Notice.
• A covered entity must make its notice available to any person who asks for it.
• A covered entity must prominently post and make available its notice on any web site it
maintains that provides information about its customer services or benefits.
• Health Plans must also:
Provide the notice to individuals then covered by the plan no later than April 14, 2003
(April 14, 2004, for small health plans) and to new enrollees at the time of enrollment.
Provide a revised notice to individuals then covered by the plan within 60 days of
a material revision.

27
 Notify individuals then covered by the plan of the availability of and how to
obtain the notice at least once every three years.
• Covered Direct Treatment Providers must also:
Provide the notice to the individual no later than the date of first service delivery (after
the April 14, 2003 compliance date of the Privacy Rule) and, except in an emergency
treatment situation, make a good faith effort to obtain the individual’s written
acknowledgment of receipt of the notice. If an acknowledgment cannot be obtained,
the provider must document his or her efforts to obtain the acknowledgment and the
reason why it was not obtained.
When first service delivery to an individual is provided over the Internet, through e-
mail, or otherwise electronically, the provider must send an electronic notice
automatically and contemporaneously in response to the individual’s first request for
service. The provider must make a good faith effort to obtain a return receipt or other
transmission from the individual in response to receiving the notice.
In an emergency treatment situation, provide the notice as soon as it is reasonably
practicable to do so after the emergency situation has ended. In these situations,
providers are not required to make a good faith effort to obtain a written
acknowledgment from individuals.
Make the latest notice (i.e., the one that reflects any changes in privacy policies)
available at the provider’s office or facility for individuals to request to take with
them, and post it in a clear and prominent location at the facility.
• A covered entity may e-mail the notice to an individual if the individual agrees to receive an
electronic notice.
Organizational Options.
• Any covered entity, including a hybrid entity or an affiliated covered entity, may choose to
develop more than one notice, such as when an entity performs different types of covered
functions (i.e., the functions that make it a health plan, a health care provider, or a health
care clearinghouse) and there are variations in its privacy practices among these covered
functions. Covered entities are encouraged to provide individuals with the most specific
notice possible.
• Covered entities that participate in an organized health care arrangement may choose to
produce a single, joint notice if certain requirements are met. For example, the joint
notice must describe the covered entities and the service delivery sites to which it applies.
If any one of the participating covered entities provides the joint notice to an individual,
the notice distribution requirement with respect to that individual is met for all of the
covered entities.

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Avante Resident Grievance Form

Name of resident: ________________________________

Room number: ______________________________
Name of originator: _______________________________
Relationship to resident: ________________________________
Date: _____________________________
Date and time event occurred:
Names of others involved: __________________________________
Describe the nature of the grievance (be specific):

What actions or recommendations do

you feel need to be taken?
Signature of originator: _________________________________________________
Received by: _______________________________________________

This form must be forwarded to the Avante facility risk manager within 48 hours of an Avante supervisory
employee receiving it.

Date received by risk manager:

Date(s) of investigation: _______________________________________________
Signature of resident: _______________________________________________
Signature of resident representative:
Signature of staff member: __________________________________________________
Signature of administrator: __________________________________________________

Is a completed grievance response form on file? □ Yes □ No

Was this grievance resolved to the satisfaction of the originator? □ Yes □ No

If no, a request for arbitration may be filed at the discretion of the originator.

29
American Health Lawyers Association Alternative Dispute Resolution

Name of party(ies) requesting

dispute resolution
Name of contact person
Street address
City, State, Zip Code
Telephone number E-mail address

Briefly describe the dispute, including any amounts in dispute and the extent of relief sought by the
parties. Please attach additional sheet(s) containing this information of necessary.

Has a court proceeding been commenced?

□ Yes □ No

If yes, please list the case name, the court, and the docket number and describe briefly the status of the
litigation.

By signing this document, I (i) agree to abide by the applicable rules of the AHLA Alternative Dispute
Resolution Service; (ii) verify that, to the best of my knowledge all information contained in this request is
true, correct and complete; (iii) believe in good faith that the dispute described is subject to resolution
under these rules; (iv) release AHLA, their directors, members of their governing boards and their
officers, employees, agents attorneys, consultants and representatives from any and all liability to that
requesting party or a person or entity claiming through that requesting party by reason of or in any way
relating to action taken or not taken with respect thereto.

Name of requestor
Signature of requestor or legal
representative
Date

30