2020-462-E Aging-Triangle Area Agency on Aging Community Home Care Block Grant

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.In-Home Aide.Home Care (home health).Housing and Home Improvement.Adult Day Care or Adult Day Health Care Agency Name: Name of Agency Administrator: Signature:  be fully informed both orally and in writing, in advance of receiving an in- home service, of the individual’s rights and obligations. As a provider of one or more of the services listed below, our agency agrees to notify all Home and Community Care Block Grant clients receiving any of the below listed services provided by this agency of their rights as a service recipient. Services in this assurance include: Notification will include, at a minimum, an oral review of the information outlined below as well as providing each service recipient with a copy of the information in written form. In addition, providers of in-home services will establish a procedure to document that client rights information has been discussed with in-home services clients (e.g. copy of signed Client Bill of Rights statement). Clients Rights information to be communicated to service recipients will include, at a minimum, the right to:  be fully informed, in advance, about each in-home service to be provided and any change and any change in service(s) that may affect the wellbeing of the participant;  participate in planning and changing any in-home service provided unless the client is adjudicated incompetent;  voice a grievance with respect to service that is or fails to be provided, without discrimination or reprisal as a result of voicing a grievance;  confidentiality of records relating to the individual;  have property treated with respect; and Standard Assurance To Comply with Older Americans Act Requirements Regarding Clients Rights For Agencies Providing In-Home Services through the Home and Community Care Block Grant for Older Adults Client Rights will be distributed to, and discussed with, each new client receiving one or more of the above listed services prior to the onset of service. For all existing clients, the above information will be provided no later than the next regularly scheduled service reassessment. Orange County (Please return this form to your Area Agency on Aging and retain a copy for your files.) CLIENT/PATIENT RIGHTS 1. You have the right to be fully informed of all your rights and responsibilities as a client/patient of the program. 2. You have the right to appropriate and professional care relating to your needs. 3. You have the right to be fully informed in advance about the care to be provided by the program. 4. You have the right to be fully informed in advance of any changes in the care that you may be receiving and to give informed consent to the provision of the amended care. 5. You have the right to participate in determining the care that you will receive and in altering the nature of the care as your needs change. 6. You have the right to voice your grievances with respect to care that is provided and to expect that there will be no reprisal for the grievance expressed. 7. You have the right to expect that the information you share with the agency will be respected and held in strict confidence, to be shared only with your written consent and as it relates to the obtaining of other needed community services. 8. You have the right to expect the preservation of your privacy and respect for your property. 9. You have the right to receive a timely response to your request for service. 10. You shall be admitted for service only if the agency has the ability to p rovide safe and professional care at the level of intensity needed. 11. You have the right to be informed of agency policies, changes, and costs for services. 12. If you are denied service solely on you inability to pay, you have the right to be referred elsewhere. 13. You have the right to honest, accurate information regarding the industry, agency and of the program in particular. 14. You have the right to be fully informed about other services provided by this agency. DocuSign Envelope ID: 876C92A1-FFCC-4CCE-9133-469A78CE1DCA 7/24/2020