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Standard Assurance to Comply with Dlder Americans Act <br />Requirements Regarding Client Rights <br />for. <br />Agencies Providing In-Home Services through the <br />Home and Community Care Block Grant for Older Adults <br />9 <br />As a provider of one or more of the services listed below, our <br />agency agrees to notify all Home and Community Care Block Grant ' <br />clients receiving any of the below -listed services provided by <br />this agency of the their rights as a service recipient. Services <br />included in this assurance include: <br />-In-Home Aide <br />-home Care (home health <br />-Housing and Home Improvement <br />• '-Adult Day Care or Adult Day Health Gare <br />Notification will include, at a minimum, an oral review of the <br />information-outlined below as well as providing each service <br />recipient with a copy of the information in written forr-~. In <br />addition, providers of in-home services will establish a procedure <br />to document that client rights information has been discussed with <br />in-home services clients (e.q. copy of signed Client Bill of <br />Rights statement). <br />Client Rights information to be communicated to service recipients <br />will include, at a minimum, the right to: <br />-be fully informed, in advance, about each in-home <br />. service to be provided and any change in service(s) <br />that may affect the well-being of the participant; <br />-participate in planning and changing any in-home service <br />provided unless the client is adjud3.cated incompetent; <br />-voice a grievance with respect to service that is or fails <br />to be provided, without discrimination or reprisal as a <br />result of voicing a grievance;- <br />-confidentiality of records relating to t~~e 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 <br />and obligations. <br />Client Rights will be distributed to, and discussed with, each new <br />client receiving one or more of the above listed services prior to <br />the on-set of service. For all existing clients, the above <br />information will be provided no later than the next regularly <br />scheduled service reassessment. <br />Agency Name: ervices <br />Name of Agency Admini trator: Martin Whitt <br />~ ' <br />Signature: ~_ ~ ~ ,~~ ~~~~ ,_, Date: .5 0 <br />(Please return the this form to your Area Agency on Aging a:zd <br />retain a copy for your files.) <br />