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Phone: (973) 301-2121

Assisted Living Services

Assisted Living Services Application

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Facility
Address
Phone Number
Fax
TIN
Email
County
Total number of beds
Memory unit beds
Hospice beds
Other

Admission Information
Direct Admission from Physician's Office
- Yes
- No
Direct Admission from Home
- Yes
- No
Admission 7 Days/Week
- Yes
- No
Admission on Holiday
- Yes
- No
Other

Diagnostic Testing
Stat lab test with ≤ 8 hours
- Yes
- No
Stat x-rays with ≤ 8 hours
- Yes
- No
EKG
- Yes
- No
Ultrasound
- Yes
- No
Dopler
- Yes
- No
Swallow Studies
- Yes
- No
Other

Nursing Services
Vital signs every 4 hours
- Yes
- No
Intake and Output monitoring
- Yes
- No
Accuchecks at least every shift
- Yes
- No
Pulse Ox
- Yes
- No
Nebulizer treatments
- Yes
- No
Incentive Spirometry
- Yes
- No
Cpap
- Yes
- No
Oxygen
- Yes
- No
Foley Catheter Care
- Yes
- No
Ostomy Care
- Yes
- No
Restorative Nursing
- Yes
- No
Other

On-Site Therapies
Physical
- Yes
- No
Occupational
- Yes
- No
Speech
- Yes
- No

Social Services
Licensed Social Worker
- Yes
- No
Discharge Planner
- Yes
- No

Primary Care Oversight
RN on site 24 hours/day
- Yes
- No
Nurse on site 24 hours/day
- Yes
- No
At least one physician, NP or PA in the facility weekly
- Yes
- No
Other

On-Site Consultations
Psychiatry
- Yes
- No
Internal Medicine
- Yes
- No
Geriatrician
- Yes
- No
Psychologist
- Yes
- No
Wound Care
- Yes
- No
Dentist
- Yes
- No
Hospice/Palliative Care
- Yes
- No
Home Health
- Yes
- No
Dietition
- Yes
- No
Podiatry
- Yes
- No
Other

Interventions
IV Fluids
- Yes
- No
IV antibiotics
- Yes
- No
Isolation
- Yes
- No
Surgical drain management
- Yes
- No
Analgesic Pumps
- Yes
- No
Automatic Defibrillator
- Yes
- No
Others

Pharmacy Services
New medications filled within 8 hours
- Yes
- No
Pharmacist medication utilization audit
- Yes
- No
Other
Additional Information/Comments
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