A. Resident’s Rights
1. A Provider shall have a written policy on resident’s civil rights and the practices of the Provider shall assure:
a. no resident of a facility shall be deprived of civil or legal rights, benefits, or privileges guaranteed by law or the Constitution of the United States solely by reason of status as a resident of a facility;
b. a resident is not denied admission, segregated, or otherwise subjected to discrimination on the basis of race, sex, handicap, creed, national background, or ancestry;
c. a religious organization may limit admissions to its own adherents;
d. residents shall live within the least restrictive environment possible in order to retain their individuality and personal freedom.
2. In addition to the basic rights enjoyed by other adults, the Provider’s written policy on rights shall assure that residents have the right to:
a. be treated as individuals and with dignity, be assured choice and privacy and the opportunity to act autonomously, take risks to enhance independence, and share responsibility for decisions;
b. participate, and have family participate, if desired, in the planning of activities and services;
c. receive or refuse care and services that are adequate, appropriate, and in compliance with conditions of residency, relevant federal and state laws and rules and regulations;
d. receive upon admission and during his or her stay a written statement of the services provided by the facility and the charges for these services;
e. be free from mental, emotional, and physical abuse and neglect and
assured that no chemical restraints will be used;
f. have records and other information about the resident kept confidential
and released only with a resident’s expressed written consent;
g. have a service animal for medical reasons;
h. receive a timely response to a request, from the Director and/or staff;
i. have visitors of their choice without restrictions, as long as the rights of
others are not infringed upon;
j. have access to private telephone communication;
k. send and receive mail promptly and unopened;
l. furnish their own rooms and use and maintain personal clothing and
possessions as space permits;
m. manage his or her personal funds unless such authority has been delegated to another. If the authority to manage personal funds has been delegated to
the Provider, the resident has the right to examine the account during business hours;
n. be notified in writing by the Provider when the Facility’s license status is suspended, revoked, or limited, and to be informed of the basis of the
Licensing Agency’s action. The resident’s representative must also be notified;
o. have the freedom to participate by choice inaccessible community activities and in social, political, medical, and religious activities and to have
freedom to refuse such participation;
p. arrange for third-party services at their own expense, that is not available through the facility as long as the resident remains in compliance with the
conditions of residency;
q. share a room with a spouse or other consenting resident of the facility;
r. be encouraged and assisted to exercise rights as a citizen; to voice grievances and suggest changes in policies and services to either staff or
outside representatives without fear of restraint, interference, coercion, discrimination, or reprisal;
s. be given written notice of not less than thirty (30) days prior to discharge from the facility, except in life-threatening emergencies and when the
the resident is a danger to him/her self or to others;
t. remain in the current facility, foregoing a recommended transfer to obtain additional services if a mutually agreed upon risk agreement is signed by
the resident, the responsible representative (if any), and the Provider so long as it does not place the facility in conflict with these or other laws or
u. remain in their room/living unit unless a change in room/unit is related to resident preference or to transfer conditions stipulated in their contract
that relate to the need for higher levels of service;
v. be fully informed of all resident rights and all rules governing resident conduct and responsibilities;
w. consult freely with counsel of their choice; and,
x. live in a physical environment that ensures their physical and emotional security and well-being.
3. Each resident shall be fully informed of these rights and of all rules and regulations governing residents’ conduct and responsibilities, as evidenced by
a written acknowledgment, prior to or at the time of admission and when changes occur. Each resident’s file shall contain a copy of the written acknowledgment
which shall be signed and dated by the director/designee, resident, and/or representative.
4. A copy of these rights shall be posted conspicuously in the facility.
B. Resident Association.
The Provider shall provide a formal process and structure by which residents, in representative groups and/or as a whole, are given the opportunity to advise
the Director regarding resident services and life at the facility. Any resident requests, concerns, or suggestions presented through this process will be addressed by the Director within a reasonable time frame, as necessitated by the concern, request, or suggestion.
C. Grievance Procedure.
A Provider shall establish and have written grievance procedures to
include, but not limited to:
1. a formal process to present grievances;
2. a formal appeals process for grievances; and,
3. a process to respond to resident association requests and written grievances in a timely manner.
D. Personal Possessions.
The Provider may, at its discretion, offer to residents the service of safekeeping of valuable possessions. The Provider shall have a written statement of its policy.
1. If the Provider offers such a service, a copy of the written policy and procedures shall be given to a resident at the time of his/her admission.
2. The Provider shall give the resident a receipt listing each item that it is holding in trust for the resident. A copy of the receipt shall be placed in the resident’s record.
E. Resident Funds
1. If a Provider offers the service of safekeeping and/or management of residents’ personal funds, the facility’s admission agreement shall include the resident’s
rights regarding personal funds and list the services offered and charges if any.
2. If a Provider offers the service of safekeeping and if a resident wishes to entrust funds, the Provider:
a. shall obtain written authorization from the resident and/or his/her representative to safekeeping of funds;
b. shall provide each resident with a receipt listing the amount of money The facility is holding in trust for the resident;
c. shall maintain a current balance sheet containing all financial transactions+
to include the signatures of staff and the resident for each transaction; and,
d. shall not accept more than two hundred dollars ($200) of a resident’s money.
3. If a Provider offers the service and if a resident wishes the Provider to assist with
the management of all their funds, the Provider:
a. shall receive written authorization to manage the resident’s funds from the resident and the representative, if applicable;
b. shall only manage a resident’s money when such management is mandated by the resident’s service plan; and,
c. shall keep funds received from the resident for management in an individual account in the name of the resident.
4. Unless otherwise provided by state law, upon the death of a resident, the Provider shall provide the executor or administrator of the resident’s estate or the
a representative of the resident as agreed upon in the admission agreement with a complete accounting of all the resident’s funds and personal property of the
resident being held by the Provider.
F. Emergency and Evacuation Procedures
1. The facility shall have telephone service on a twenty-four-hour daily basis.
2. The Provider shall either post telephone numbers of emergency services, including the fire department, police department, medical services, poison control, and ambulance or else show evidence of an alternate means of immediate access to these services.
3. The Provider shall have a detailed written plan and procedures to meet all potential emergencies and disasters such as fire, severe weather, evacuation of
residences, and missing residents. These emergency and evacuation procedures shall include:
a. evacuation of residents to safe or sheltered areas;
b. means for an ongoing safety program including continuous inspection of the facility for possible hazards, continuous monitoring of safety
equipment, and investigation of all accidents or emergencies;
c. fire control and evacuation plan. In addition, such plan shall be posted in each residential unit in a conspicuous place and kept current;
d. fire drills shall be documented for each shift at least quarterly. The drills may be announced in advance to the residents. The drills shall involve
the participation of the staff in accordance with the emergency plan (resident participation is not required);
e. transportation arrangements for hospitalization or any other services which are appropriate; and,
f. maintenance of a first aid kit for emergencies.
4. The Provider shall train all employees in emergency and evacuation procedures when they begin to work in the facility. The Provider shall review the procedures
with existing staff at least once in each 12 month period.
5. A Provider shall immediately notify DSS and other appropriate agencies of any fire, disaster or another emergency that may present a danger to residents or require
their evacuation from the facility.
G. Critical Incidents
1. A Provider shall have written procedures for the reporting and documentation of unusual incidents and other situations or circumstances affecting the health, safety
, or well-being of a resident or resident. (i.e. death of unnatural causes, injuries, fights or physical confrontations, situations requiring the use of passive physical
restraints, suspected incidents of abuse or neglect).
a. Such procedures shall ensure timely verbal reporting to the Director or designee and a preliminary written report within twenty-four (24) hours of the incident.
b. Copies of all critical incident reports shall be kept as part of the client’s record and a separate copy shall be kept in the administrative file of the provider.
2. Incident/Accident Report. When and if an incident occurs, a detailed report of the incident shall be made. As a minimum, the incident report shall contain the
a. circumstances under which the incident occurred;
b. date and time the incident occurred;
c. where the incident occurred (bathroom, bedroom, street, lawn, etc.);
d. immediate treatment and follow-up care;
e. name and address of witnesses;
f. date and time family or representative was notified;
g. symptoms of pain and injury discussed with the physician; and,
h. signatures of the staff completing the report, resident, and Director.
3. When an incident results in the death of a resident, involves abuse or neglect of a resident or entails any serious threat to the resident’s health, safety or well-being a
a. immediately report verbally to the Administrator and submit a preliminary written report within twenty-four (24) hours of the incident;
b. immediately notify the Department of Health and Hospitals Adult Protection Services or Office of Elderly Affairs in the Office of the Governor, the
Bureau of Licensing, and other appropriate authorities, according to state law, with written notification to the above agencies to follow within
twenty-four hours of the suspected incident;
c. immediately notify the family or representative of the resident, with written notification to follow within twenty-four hours;
d. immediately notify the appropriate law enforcement authority in accordance with state law;
e. provide follow-up written reports to all the above persons and agencies;
f. take appropriate corrective action to prevent future incidents; and,
g. the Provider shall document its compliance with all of the above procedures for each incident, and shall keep such documentation
(including any written reports or notifications) in the resident’s file. A separate copy of all such documentation shall be kept in the provider’s administrative file.
H. Abuse and Neglect.
A Provider shall have comprehensive written procedures concerning
resident abuse and neglect to include provisions for:
1. training and maintaining staff awareness of abuse prevention, current definitions of abuse and neglect, reporting requirements and applicable laws;
2. ensuring that regulations stipulated in §8821.G.3. for reporting critical incidents involving abuse and neglect are followed;
3. ensuring that the Administrator completes an investigation report within ten (10) working days;
4. ensuring that the resident is protected from potential harassment during the investigation;
5. disciplining staff members who abuse or neglect residents; and,
6. protecting residents from abuse inflicted by other residents or third parties, including, but not limited to, criminal prosecution of the offending person and
his/her permanent removal from the facility