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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 provider of one or more of the services listed below, our agency agrees to notify all Home <br />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 include: <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 as well <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 (e.g. copy of signed Client Bill of <br />Rights statement). <br />Clients Rights information to be communicated to service recipients will include, at a minimum, <br />the right to: <br />• be fully informed, in advance, about each in -home service to be provided and any <br />change and any change in service(s) that may affect the wellbeing of the participant; <br />• participate in planning and changing any in -home service provided unless the client <br />is adjudicated incompetent; <br />• voice a grievance with respect to service that is or fails to be provided, without <br />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 in -home <br />service, of the individual's rights and obligations. <br />Client Rights will be distributed to, and discussed with, each new client receiving one or more of <br />the above listed services prior to the onset 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: <br />Name of Agency Administrator: <br />Signature: <br />Date: <br />(Please return this form to your Area Agency on Aging and retain a copy for your files.) <br />Attachment number 3 <br />F -3 Page 102 <br />