Client Orientation Packet

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Welcome Letter

Client Name:*

First Name Middle Name Last Name

Thank You for letting DISCOVERING KINDNESS IN HOME SERVICES LLC provide your services. It is our commitment to provide the best home health care and we look forward to working with you/your family.

We look forward to providing the quality of care for the services you are requesting to your satisfaction and expectations and will, at times, request your feedback in effort to evaluate processes, improve positive outcomes, and/or change or add new services, programs or resources.

During this meeting you will be given a packet containing information that will assist you in making your service run smoothly and to communicate any feedback concerning your services.

In addition to your Client Handbook, the following forms will be completed electronically . . .

Client Orientation Checklist
Client Visit Interview
Individual Care Plan(s)
Client Release of Information
Physical Body Record
Client Privacy/Concerns/Grievances
Client Rights & Responsibilities & Acknowledgement

By signing below, I (we) acknowledge that I (we) have received the orientation and have had the opportunity to ask questions and fully understand the contents of the information.

Care Plan Is . . .

New

Updated

Provider?

Service Provided?

Start of Services

Client Signature:*

Date*

Print Name of Representative:

Relationship to Client:

Representative Signature:

Other Individual(s) Present:

Supervisor Name:*

Date*

Clent Rights & Responsibilities

Client Name:*

First Name Middle Name Last Name

CLIENT RIGHTS & RESPONSIBILITY

Client Rights:

Home care CLIENTs and their caregivers have a right to mutual respect and dignity.
DISCOVERING KINDNESS IN HOME SERVICES LLC Agency personnel are prohibited from accepting personal gifts and borrowing from CLIENTs/their families/caregivers.
DISCOVERING KINDNESS IN HOME SERVICES LLC Agency does not conduct research activities and projects.

As a CLIENT of DISCOVERING KINDNESS IN HOME SERVICES LLC Agency you have the right to:

Be informed of your rights at the time of admission and before the initiation of care, and on an ongoing basis as necessary.
Receive information in writing and in a manner that you understand from the Agency and from others outside the organization.
Access to legal entities for appropriate representation, self-help support services and advocacy support services to assure that communication, information and services are transmitted in a manner that is clear and understandable with respect and dignity of the client.
Access to their records to view, modify and request copies of the contents. The request can be made using the Client Request form.
Expect confidentiality of all information related to your care, within applicable laws and regulations.
Be informed of your rights under state law to formulate advance directives.
Be treated with consideration, respect and full recognition of your dignity and individuality by trained professional staff.
Have your cultural, psychosocial, spiritual and personal values, beliefs and preferences respected.
Pastoral and other spiritual services.
Have relationships with home care personnel that are based on honesty and ethical standards of conduct.
Be involved in decisions about your care, treatment and/or services.
Have your family, as appropriate and as allowed by law, with your permission or the permission of your surrogate decision maker, be involved in your care, treatment and/or service decisions.
Exercise your rights, or your legally responsible representative may exercise your rights if you have been judged incompetent.
Be involved in resolving dilemmas about your care, treatment and/or services.
Have your person and property treated with respect, privacy, including visual and auditory privacy, and security.
Be informed of the procedures to follow to voice concerns regarding care or lack of respect for property and/or to your person without being subject to discrimination or reprisal.
Be informed and when appropriate, have your family informed with your permission, about the outcomes of care, treatment and/or services, based on the current body of knowledge, along with any barriers to outcome achievement.
Be informed by the Director of Professional Services, his/her designee or the staff member responsible for your care, treatment and/or services of the unanticipated outcomes of your care, treatment and/or services, based on the current body of knowledge.
Be informed in advance of the extent to which payment may be expected from Medicare, Medicaid or other third part payer and any costs for which you may be responsible.
Be informed by knowledgeable personnel about your medical condition, to the extent known and be given an opportunity to participate in designing a care plan that addresses your needs and preferences and updating it as your condition changes.
Have your reports of pain believed and assessed appropriately and comprehensively.
Receive information about pain and pain relief measures.
Receive care from a concerned team of healthcare professionals committed to pain prevention and management and who respond quickly and appropriately to reports of pain.
Effective pain management supported by individuals qualified to manage.
Be informed, and have your family informed when appropriate, of your role in managing pain, along with the potential limitations and side effects of pain treatments, based on the current body of knowledge.
Be advised of any change in the pain of care before the change is made.
Be advised in advance of the name(s) and disciplines of staff member(s) primarily responsible for your care, treatment, and/or services.
Be informed about the nature and purpose of any technical procedure that will be performed as well as who will perform the procedure.
Be informed of any financial benefit when referred to another organization.
Refuse care, treatment and/or services within the confines of the law after being fully informed, and to be told the consequences of your action. When you are not legally responsible, the surrogate decision maker, as allowed by applicable law, has the right to refuse care, treatment and/or services on your behalf.
Access, request amendments to, and receive an accounting of disclosures regarding your personal health information, as permitted under applicable law.
Be informed within a reasonable amount of time of anticipated termination of service or transfer to another organization.

Report any complaints or grievances with respect to care that is provided (without interference, coercion, discrimination or reprisal) to the Supervisor at (877) 507-0779. If not resolved, or at any point during the formal complaint process, we will make available resources and assistance that may help advocate on your behalf. Complaints may be confidentially reported to the Department of Health Services Licensing and Certification Division Hotline at (860) 509-7444 for which help in reporting and resolution is available. Client Responsibilities

As a CLIENT, you have the responsibility to:
Remain under a physician’s care while receiving DISCOVERING KINDNESS IN HOME SERVICES LLC Agency services.
Provide DISCOVERING KINDNESS IN HOME SERVICES LLC Agency with a complete and accurate health history in order to plan and carry out care.
Inform Agency staff about any changes in your health status, condition or treatment.
Provide DISCOVERING KINDNESS IN HOME SERVICES LLC Agency with all requested insurance and financial information/records.
Sign or have your legal representative sign the required consents and releases for insurance billing.
Allow DISCOVERING KINDNESS IN HOME SERVICES LLC Agency to act on your behalf in filling appeals of denied payment of service by third-party payers and to cooperate to the fullest extent possible in such appeals.
Notify DISCOVERING KINDNESS IN HOME SERVICES LLC Agency of any changes in treatment made by the physician.
Participate in your plan of care including, if appropriate, a pain management plan.
Ask your nurse/therapist what to expect regarding pain and pain management.
Discuss pain relief options with your nurse/therapist.
Provide your nurse/therapist with as comprehensive information as possible about your pain and any concerns you may have about pain medications and/or management.
Be available to DISCOVERING KINDNESS IN HOME SERVICES LLC Agency staff for home visits at reasonable times.
Notify DISCOVERING KINDNESS IN HOME SERVICES LLC Agency if you are going to be unavailable for a visit.
Treat DISCOVERING KINDNESS IN HOME SERVICES LLC Agency personnel with respect and dignity without discrimination as to color, religion, sex or national or ethnic origin.
Accept the consequences for any refusal of treatment or choice of noncompliance.
Provide DISCOVERING KINDNESS IN HOME SERVICES LLC Agency personnel with a safe home environment in which your care can be provided.
Cooperate with your physician, DISCOVERING KINDNESS IN HOME SERVICES LLC Agency staff and other caregivers.
Inform the Agency if you are unable to understand or follow the Agency’s written instructions.
Make a family member or substitute available who will assume a primary caregiver role when Agency staff are not in your home.

By signing below, I acknowledge that I have read, been informed and understand my rights and responsibilities.

Client Signature:*

Date*

Client Release or Information

Client Name:*

First Name Middle Name Last Name

RELEASE OF INFORMTION

By signing this authorization, you are giving DISCOVERING KINDNESS IN HOME SERVICES LLC permission to release all or part of your information provided, which includes health information. Failure to provide this authorization may result in limited service by DISCOVERING KINDNESS IN HOME SERVICES LLC. This release includes access to a continuum of service(s) available through DISCOVERING KINDNESS IN HOME SERVICES LLC and/or its providers.

PARTS A, B & C TO BE COMPLETED BY CLIENT OR PERSONAL REPRESENTATIVE

I authorize the release of my information to the following person or agency for the purpose(s) stated in Part A. My information will remain available to the person or agency indicated in accordance with the expiration event or date in Part B.

PART A – Release of Information

I understand that my information may contain protected health information. Release my information to the following person or agency:

Any person or agency necessary to meet my service needs.

Only the persons or entities identified:

Specific Person . . .

Check one of the following:

Release all my information for treatment.

Release only the following information:

Specific information to be released:

PART B – Purpose of Release

option

General: To assist in assessing, arranging, and meeting individual service needs.

Specific

Describe specific information:

Expiration:

Upon Yearly Assessment

Upon a Specific Date

Specific Date:
MM slash DD slash YYYY

PART C – Signature

Client/Representative Signature:

Date
MM slash DD slash YYYY

option
Check if you are signing for the client and describe your authority to act for the client.

Describe Authority to Act on Client Behalf:

Witness/Supervisor Printed Name:

Witness/Supervisor Signature:

Notice to Client:

Once the authorization to release your information is granted, DISCOVERING KINDNESS IN HOME SERVICES LLC is not responsible for any redisclosure of the information by the recipient.

You can withdraw permission you have given DISCOVERING KINDNESS IN HOME SERVICES LLC to use or disclose health information that identifies you, unless DISCOVERING KINDNESS IN HOME SERVICES LLC has already taken action based on your permission. You must withdraw your permission in writing.

Physical Body Record
Client Name:*
First Name Middle Name Last Name
As per the assessment visit, the following conditions was/were observed.

Client Grievances
Client Name:*
First Name Middle Name Last Name
COMPLAINTS/GRIEVANCES/UNRESOLVED COMPLAINTS
Complaints
If you are concerned that the Agency has violated your privacy rights, or you disagree with a decision the Agency made about access to your records, you may contact the office at (877) 507-0779. You may also send a written complaint to the Connecticut Department of Public Health. The Discovering Kindness In Home Services LLC Agency office staff can provide you with the appropriate address upon request. Under no circumstances will you be retaliated against for filing a complaint.

Contact Information

The Agency is required by law to protect the privacy of your information, provide this Notice about our information practices, and follow the information practices that are described in this Notice. If you have any questions or complaints, please contact:

Arline A, Corporate Compliance Officer

Discovering Kindness In Home Services LLC, Agency, 30 Hazel Terrace, Suite 14, Woodbridge, CT,

(877) 507-0779.

All DISCOVERING KINDNESS IN HOME SERVICES LLC staff members are responsible for “On-the-Spot” resolution of client problems, where possible, and for notifying the Credentialing and Compliance Director of complaints expressed to them. Administration retains final responsibility for the resolution of all client complaints.

A record of the complaint, investigation, follow-up action and response to the client will be documented using the Incident Report Form and a copy will be retained in the client file, employee file and the original in the Client Incident File. This form is to be initiated by the person receiving the complaint.

You may report a complaint or grievance at any time without reprisal or disruption of services. Any staff member may receive a complaint or grievance about services or care that is or is not furnished or about the lack of respect for the consumer's person or property by anyone furnishing services on behalf of the agency. Complaints and Grievances Procedure:

Client or client representative reports a complaint/grievance to any staff member or via Incident/Complaint form included in this packet.

Staff member receives complaint/grievance and report it to the Corporate Compliance officer.

Complaints are investigated within 5 business days of receipt of the complaint and the investigation is documented within 30 calendar of receipt.

Unresolved complaints will be forwarded to Administration for further resolution.

Notify the client of actions taken or that the problem has been resolved.

Document the action taken and resolution on the Incident/Complaint Report.

Complaints may also be directed to:
Facility Licensing and Investigations Section
Connecticut Department of Public Health
410 Capitol Ave., MS# 12 HSR, Hartford, CT 06134-0308
Phone: (860) 509-7400 Fax: (860) 730-8390 Email: dph.fliscomplaint@ct.gov

The Connecticut Department of Public Health also maintains the Medicare Home Health Hotline to receive complaints specifically about home health services. The toll-free number is: (800) 828-9769.
Date
MM slash DD slash YYYY

Signature*

HCA.0001488

Client Orientation Packet

Welcome Letter

Client Visit Interview

Clent Rights & Responsibilities

CLIENT RIGHTS & RESPONSIBILITY

Companion Care Plan

Homemaker Care Plan

Personal Care Assistant Care Plan

Recovery Aide Care Plan

Community Support Program Care Plan

Client Release or Information

RELEASE OF INFORMTION

PART A – Release of Information

PART B – Purpose of Release

PART C – Signature

Physical Body Record

Client Grievances

COMPLAINTS/GRIEVANCES/UNRESOLVED COMPLAINTS

Client Orientation Packet

Welcome Letter

Client Visit Interview

Clent Rights & Responsibilities

CLIENT RIGHTS & RESPONSIBILITY

Companion Care Plan

Homemaker Care Plan

Personal Care Assistant Care Plan

Recovery Aide Care Plan

Community Support Program Care Plan

Client Release or Information

RELEASE OF INFORMTION

PART A – Release of Information

PART B – Purpose of Release

PART C – Signature

Physical Body Record

Client Grievances

COMPLAINTS/GRIEVANCES/UNRESOLVED COMPLAINTS

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