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n <br /> Standard Assurance To Comply with Older Americans Act <br /> Requirements Regarding Clients Rights <br /> For <br /> Agencies Providing In-Home Services through the <br /> Home and Community Care Block Grant for Older Adults <br /> As a pmvider of one or more of Me services listed below, our agency agrees to notify all Home <br /> and Community Care Block Grad clients receiving any of the belmv listed services provided by <br /> this agency of their rights as a service regipient Services 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 Heath Care <br /> Notification will include, at a minimum, an oral review of Me information Outlined below as well <br /> as providing each service recipient with a copy Of the information in written farm. In addition, <br /> providers of in-home services will establish a procedure to document Mat client rights <br /> infomation has been discussed with in-home services clients(e.g. copy of signed Client Bill of <br /> Rights statemem). <br /> Clients Rights information to be communicated to service recipients will include, st a minimum, <br /> Me tight to <br /> • be fully inormed, in advance, about each In-home service to be provided and any <br /> change and any change in sewice(s) that may affect Me wallbeing of the participant; <br /> • participam in planning and changing any in-home service provided unless Me client is <br /> adjudicated incompetent; <br /> • voice a grievance win respect to service that is or fails o be provided,without <br /> discrimination or reprisal as a result of voicing a grievance; <br /> • confidentiality of records relating to Me individual; <br /> • have property treated with respect; and <br /> • be fully informed both malty and in writing, in advance of receiving an in home <br /> service, of Me individual's nights and obligations. <br /> Chem Rights will be dismbuted to, and discussed with, each new client receiving one or more of <br /> the above listed services prior to Me onset of service. For all existing clients,Me above <br /> information will be provided no later than the next regularly scheduled service reassessment. <br /> Agency Home: 2aj rn +=1L:p{.n^Qg a <br /> Name of Agency AdminisbaloF fMaill C'[ACSm <br /> Signature Axessai Data 0-01Jdg. <br /> (Please return t s f o your Area Agency on Aging and retain a copy far your flea.) <br />