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BILL OF RIGHTS STATEMENT (As Our Client You Have the Right to Exercise Your Rights, and/or to Designate a Representative to Exercise them for you) Rights of the patient. The patient has the right to: (1) Have his or her property and person treated with respect; (2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; (3) Make complaints to our Agency regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of our Agency; (4) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. (5) Receive all services outlined in the plan of care. (6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with regulations. (An OASIS privacy notice to all patients for whom the OASIS data is collected will be provided) (7) Be advised of: (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally funded or federal aid program known to the Agency, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally funded or federal aid program known to the Agency, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided when they occur. Our Agency must advise the patient and representative (if any), of these changes as soon as possible,  in advance of the next home health visit. (8) Receive proper written notice, in advance of a specific service being furnished, if our Agency believes that the service may be non covered care;  or in advance of our Agency reducing or terminating on going care. (9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. (If applicable we will provide the Accreditation Body phone number also) . 10) Be advised of the names, addresses, and telephone numbers of the following Federally funded and state funded entities that serve the area where the patient resides: (i) Agency on Aging, (ii) Center for Independent Living, (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. (11) Be free from any discrimination or reprisal for exercising his or her rights or for voicing grievances to our Agency or an outside entity. (12) Be informed of the right to access auxiliary aids and language services, and how to access these services, free of charge. Transfer and discharge: The patient and representative (if any), have a right to be informed of the HHA’s policies for transfer and discharge. The HHA may only transfer or discharge the patient from our Agency if: (1) The transfer or discharge is necessary for the patient’s welfare because our Agency and the physician who is responsible for the home health plan of care agree that our Agency can no longer meet the patient’s needs, based on the patient’s acuity. Our Agency must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA’s capabilities; (2) The patient or payer will no longer pay for the services provided by our Agency; (3) The transfer or discharge is appropriate because the physician who is responsible for the home health plan of care and our Agency agree that the measurable outcomes and goals set forth in the plan of care have been achieved, and our Agency and the physician who is responsible for the home health plan of care agree that the patient no longer needs the HHA’s services; (4) The patient refuses services, or elects to be transferred or discharged; (5) Our Agency determines, under a policy set by our Agency for the purpose of addressing discharge for cause that the patient’s (or other persons in the patient’s home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of our Agency to operate effectively is seriously impaired. Our Agency must do the following before it discharges a patient  for cause: (i) Advise the patient, represent for the home health plan of care, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from our Agency (if any) that a discharge for cause is being considered; (ii) Make efforts to resolve the problem(s) presented by the patient’s behavior, the behavior of other persons in the patient’s home, or situation; (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; (6) The patient dies; or (7) Our Agency ceases to operate. Investigation of complaints. Our HHA must:  (i) Investigate complaints made by a patient, the patient’s representative (if any), and the patient’s caregivers and family,including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; and (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of our Agency. (ii) Document both the existence of the complaint and the resolution of the complaint; and (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. (2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to our Agency and other appropriate authorities in accordance with state law. (Contact information for our Agency administrator, including the name, business address, and business phone number will be provided in order to receive complaints) Accessibility. Information must be provided to patients in plain language and in a manner that is accessible and timely to:  (1) Persons with disabilities, including accessible Web sites and the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act. (2) Persons with limited English proficiency through the provision of language services at no cost to the individual, including oral interpretation and written translations. (Service Agreement, signed by the patient, or legal representative, acknowledges that he/she received the Notice of the Bill of Rights) Patient Name: __________________________________________________________________ Nombre del Paciente sample