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3tanuara Hssurance i o Vumpiy witn vruer iAmencans F+ct <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 />FY16 <br />As a provider of one or more of the services listed below, our agency agrees to notify <br />all Home and Community Care Block Grant clients receiving any of the below listed services provided by <br />this agency of their rights as a service recipient. Services in this assurance nclude: <br />In -Home Aide <br />Home Care (home health) <br />Housing and Home Improvement <br />Adult Day Care or Adult Day Health Care <br />Notification will include, at a minimum, an oral review of the information outlined below <br />below as well as providing each services 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 information has been <br />discussed with in -home services clients (e.g. copy of signed Client Bill of Rights statement). <br />Clients Rights information to be communicated to service recipients will include, at a <br />minimum, the right to: <br />be fully informed, in advance, about each in -home service to be provided <br />and any change in service(s) that may affect the wellbeing of the <br />participant; <br />participate in planning and changing any in -home service provided unless <br />the client is adjudicated incompetent; <br />voice a grievance with respect to service that is or fails to be provided, <br />without discrimination or reprisal as a 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 of receiving an <br />in -home service, of the individual's rights and obligations. <br />Client Rights will be distributed to, and discussed with, each new client receiving one or <br />more of the above listed services prior to the onset of service. For all existing clients, the above information <br />will be provided no later than the next regularly scheduled service reassessment. <br />Agency Name: Cabarrus County Planning & Development <br />Name of Agency Administrator: K elly 5ifford <br />Signature: Date: <br />(Please return this form to your Area Agency on Aging and retain a copy for your files.) <br />Attachment number 1 <br />F -3 Page 85 <br />