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11 <br /> Standard Assurance to Comply with Older America.na Act <br /> Requirements Regarding Client Rights <br /> for <br /> Agencies Providing In-Home Services through the <br /> • Home and Community Care Block Grant for Okkr Adults <br /> As a provider of one or more of the a services fisted steel below, our agency agrees to notify all <br /> Home a rid Community Care Block Grant clients receiving any of the below listed services <br /> provided by this agency of the their rights as a service recipient. Services included In this <br /> assn rant include: <br /> -In-Home Aide • <br /> -Horne Care (home health) <br /> -Housing and Home. Improvement <br /> -Adult Day Care or Ad uJt Day H ea Lth Care <br /> Notification will include. at a minimum, an oral review of the information outlined below as weIJ <br /> as providing each service recipient with a copy of the information in written form. In addition, <br /> providers of in-home services will establish a procedure to document that client rights <br /> information has been discussed with in-home services clients (eg. copy of signed Client Bill <br /> of Rights statement). <br /> Client Rights information to be communicated to service recipients will include, at a minimum, <br /> the right to; <br /> -be fui y Informed, i n advance. about each in-home <br /> service to be provided a rtc any change in service(s) <br /> that may affect the well-being of the participate; <br /> -participate in planning and changing any in-horse servioe <br /> provided unless the client is adjudicated incompetent; <br /> -voice a grievance with respect pe to service that is or fails <br /> to be provided, without di scri r i nation or reprisal as a <br /> result of voicing a grievance; <br /> • -confidentiality of records relating to the individual; <br /> have property treated with respect; and <br /> be fully informed both orally and in 'writing, in advance <br /> of receiving an in-home service, of the individual's rights and obligations. <br /> Client R ig h ill be distributed to, and discussed with, each 'new client receiving one or more <br /> of the above listed se Ices prior to the on-set of service. For all existing clients, the above <br /> information will be provided no later than the next regularly scheduled service reassessment. <br /> Agency Name . r i o.t i-- T --_1 r-___.L•__--- <br /> Name of Agency Administrator: irVICALI ers MAI <br /> ----- ---_-TY_iLl.L 1. <br /> Signature: All. 40L,fr � ifiktiaDate: _ ./ 6 --- <br /> (Please return this f.., to your Area Agency on Aging and r lei n copy for your files.) <br />