BASIC SERVICES AGREEMENT

The Resident/Representative/Family confirm that Tolstoy Foundation Rehabilitation and Nursing Center Company, Inc. (TFRNC/the facility) has been provided with a complete list of the names of Resident’s current financial agents, and agree to inform the facility of future appointments or revocation of appointments of financial agents.

The Resident and the undersigned agree to provide the facility with copies of all Powers of Attorney, guardianship commissions or other documentation authorizing an agent to act for, or on behalf of, the Resident or who has access to the Resident’s assets.

The following services are provided under the private pay - daily basic rate:

• Resident’s room;
• Board, including therapeutic or modified diets as prescribed by a physician; Kosher food for those who follow Jewish dietary laws;
• Twenty-four hour skilled nursing care;
• Bed linens and towels;
• Hospital gowns or pajamas unless the Resident, family/friends/responsible party elects to furnish them;
• Laundry services for machine washable items; however, dry cleaning is not covered;
• General household medicine-cabinet non-prescription items, routine skin care, oral hygiene supplies, etc.
• Resident specific assistance and/or supervision with activities of daily living such as toileting, bathing, feeding and ambulation;
• Services of facility staff performing daily assigned patient care duties;
• Use of customarily stocked equipment such as crutches, walkers, wheelchairs or other supportive equipment, and training in their use, unless such items are prescribed for the sole use by a specific resident;
• Use of all equipment and modalities, notwithstanding the quantity usually used in the everyday care of the Resident such as catheters, hypodermic syringes and needles, irrigation outfits, dressings and pads, and so forth;
• Activities designed to meet Resident recreational, motivational and social needs. Activity programs follow a schedule which is enhanced by guest performances such as piano concerts, choir visits and ethnic entertainment - all geared to make the Residents' lives more meaningful;
• Social Services staff available for resident/family counseling, and Family and Resident Councils.

*Price Subject to change with 30 days notice.

 Physician and Ancillary Services Provided On a Fee For Service Basis:

Residents are only obliged to pay for those services, co-pays, and/or deductibles not covered by Medicare, Medicaid or private insurance and which are not included in the Daily Basic Rate.

The facility will arrange for ancillary services as medically necessary and pursuant to the orders of the Attending Physician. Properly credentialed practitioners, approved by the Home, will administer the services.

Items/Services NOT Covered In The Daily Basic Rate, Or by Medicaid, Medicare Or Private Insurance:

Certain items and services, such as those listed below, are made available by the Facility for the convenience of residents and must be paid for by the Resident, or charged against the Resident’s account when the cost is incurred:

• Barber and Beauty Parlor Services
• Private telephone costs in their entirety
• Personal television and/or radio
• Newspapers and periodicals
• Shoes and clothing
• Dry cleaning
• Transportation for personal occasions

Medicare will not pay for transportation costs to dialysis treatments or medical appointments unless there is a documented medical necessity justifying transportation by ambulance; ambulette transportation is not paid for by Medicare.

*Private Pay - Daily Basic Rate is subject to change and does NOT include the cost of pharmaceuticals/prescriptions.