Thank you for your interest in Victoria Home, one of the premiere state-certified, not-for-profit skilled nursing facilities in the Hudson Valley.

Please read the Admission Policies information below before downloading the application form.

The admission policies and procedures of Victoria Home, Inc. are established in accordance with Federal and State codes, rules and regulations.

Information regarding admission policies, the application process and the Home’s services will be provided to anyone on request. Area referral agencies and hospitals will be provided with copies for their routine use in the discharge planning process.

ANTI-DISCRIMINATION POLICY

All written information regarding services of the facility will include the anti-discrimination policy statement. Candidates and/or their designated representatives will be informed verbally at the time of application and interview of the anti-discrimination policy; and the Home will periodically publish this anti-discrimination policy in the Westchester/Rockland Newspaper.

PRE-ADMISSION INQUIRIES
All admission inquiries are handled by the Victoria Home Admission Coordinator(s). The Admission Coordinator will explain all the services of Victoria Home and the requirements for admission. If the inquirer decides to make a formal application to the Home, the Admission Coordinator will provide the applicant with an admission packet.

APPLICATION PROCESS
Victoria Home will admit a resident, only after approval for admission by the Home’s Admission Committee. To be considered for admission by the committee, applicants must submit the following:
• Current PRI and Screen
• Completed and signed application
• Evidence of a valid source of payment
• Additional medical and financial information as may be requested.

The Admissions Committee will review the documents submitted, and if possible, will arrange to interview the candidate. The Committee will then make a determination as to whether the candidate is approved for admission.

ADMISSION CRITERIA
Victoria Home will accept and retain only those residents for whom it determines it can provide adequate and appropriate care. Accordingly, the Home will consider the impact of all prospective admission on its ability to provide appropriate care for the applicant, as well as the Home’s overall population. In determining whether or not to accept an applicant, the Home may consider how the admission will effect the immediate and future case mix within the Facility, what impact the admission will have on the Facility’s financial condition, and what impact the admission will have on its ability to fund the level of care and services it has elected to provide. The Home therefore reserves the right to admit candidates out of sequence.

Services offered by the Home are as follows:
• First Floor – Admits residents who require medically supervised environment.
• Second Floor – Admits residents who are cognitively impaired.
• Third Floor – Admits residents who are higher function but require a secure, supervised environment.

The Home applies the following restrictions on the admission and retention of residents:

• Residents under the age of 16 years old.
• Residents who are prenatal, intrapartum or post partum.
• Residents suffering from communicable disease.
• Residents who display a psychiatric disorder and/or are in need of active psychiatric
  treatment beyond the scope of services at Victoria Home will not be admitted or retained.
• Residents who require the following treatment, therapies or nursing supervision:
• Intravenous Therapy.
• Respirator Care
• Applicants with Ducubitus Level 4 or 5 in PRI section II, Question 16. The Facility reserves
  the right to give priority to the following candidates for admission:
• Candidates who are referred from agencies or hospitals with whom the Home maintains a Transfer Agreement.
• Candidates who have previously been residents at the Facility.
• Private paying candidates if the current Medicaid census exceeds 50%.

RECORD KEEPING
All PRI’s received, regardless of disposition, will be kept in a central file in the Social Worker’s office for a period of 18 months. The PRI cover sheet will indicate the date of referral, the referral name, source of referral, race, color, national origin, sex and disposition of referral.

If an applicant who submits a PRI decides to proceed with the application process, the PRI will be kept in an active application file in the Social Worker’s office while further documentation is being gathered. The PRI will be returned to the central file when a final disposition is reached.

The application may be removed from the active file if the request for placement is withdrawn or, if after a period of thirty (30) days, there is no activity by the candidate or his/her representative or agency towards completing the application process.