Community Services WCCS-71980-66 (2-18) Adult Foster Care Recipient Rights AFC program name: Person s name: DOB: This packet contains information regarding your rights while receiving services and supports from this AFC program, information on restriction of your rights, and information of where you can go if you have questions or need additional information related to your rights. You can ask your case manager or provider to review your rights with you at any time. Initial the boxes below I received the following information upon admission to the Adult Foster Care Program. A copy of my rights under Minnesota Statutes, section 245A.11, Subd. 10. 1. An explanation of what my rights are and that I am free to exercise my rights; and that this AFC program must help me exercise my rights and help protect my rights. Date AFC services were started: Date I received this information: This information was provided to me in a way that I understand. If I needed the information in another format or language, it was given to me in that format or language. If my rights are or will be restricted in any way to protect my health, safety, and well-being, the restriction has been explained to me. I understand the program must document and implement the restriction as required by law to make sure I get my rights back as soon as possible. Are there any restrictions placed on my rights? No Yes (if yes, rights restrictions must be documented in your individual abuse prevention plan. See rights restriction information below.) I want {insert name of my authorized representative/legal representative/family member} to help me exercise my rights. The program has this person s contact information in my record. I understand that I may contact the agencies below if I need help to exercise or protect my rights: Page 1 of 5
Office of Ombudsman for Long-Term Care Your Case Manager or Care Coordinator P.O. Box 64971 St. Paul, MN 55164-0971 Website: www.mnaging.net Phone: 1-800-657-3591 (TDD/TTY, please call 711) or 1-651-431-2555 Name: Phone: Office of Ombudsman for Mental Health and Developmental Disabilities Phone: 651-757-1800 or 1-800-657-3506 Email: ombudsman.mhdd@state.mn.us The Office of Ombudsman for Mental Health and Developmental Disabilities 121 7th Place East Suite 420 Metro Square Building St. Paul, Minnesota 55101-2117 Minnesota Adult Abuse Reporting Center (MAARC) Licensing Complaints Washington County 651 430-6455 Ask for the Licensing Unit inday person or All licensing complaints should immediately be reported to the following county agency: Washington County Adult Protection Intake (651) 430-6484 All suspected vulnerable adult cases of abuse, neglect, or exploitation need to be reported to the Minnesota Adult Abuse Reporting Center: (844) 880-1574 mn.gov/dhs/reportadultabuse By signing this document I am agreeing that I have read and understand the boxes I initialed above. Person: Date: Legal Representative: Date: Page 2 of 5
245A Licensed Adult Foster Care Recipient Rights Program name: This program is licensed under Minnesota Statutes, Chapter 245A. It must help you exercise and protect your rights identified in Minnesota Statutes, section 245A.11, Subd. 10. When receiving services and supports from {program name}, I have the right to: 1. Know the conditions and terms governing the provision of services, including the program s policies and procedures related to service termination. 2. Have my personal, financial, service, health, and medical information kept private, and to be notified if these records have been shared by the license holder; 3. Have access to my records and recorded information that the program has about me as allowed by state and federal law, regulation, or rule 4. Be free from abuse, neglect, maltreatment by the program or its staff. 5. Be treated with courtesy, respect and have my property treated with respect. 6. Be allowed to reasonably observe my cultural and ethnic practices and religion. 7. Be free from bias and harassment regarding my race, gender, age, disability, spirituality, and sexual orientation. 8. Be told about and to use the program's grievance policy and procedures, including knowing how to contact the highest level of authority in the program and how to file a social services appeal under the law. 9. Know the names, addresses and phone numbers of people who can help me, including the ombudsman, and to be given information about how to file a complaint with these offices. 10. Assert my rights on my own or have my rights asserted by my family, authorized representative, or legal representative, without retaliation from the program. 11. Give or not give written informed consent to participate in any research or experimental treatment. 12. Choose my own visitors and time of visits and participate in activities of commercial, religious, political, and community groups without interference if the activities do not infringe on the rights of another resident or household member; 13. Take part in activities that I choose and have my individual schedule that that includes my preferences, supported by the program; 14. Freedom and support to access food at any time; Page 3 of 5
15. Choose my roommate, if I have to share a bedroom. Each roommate must consent in writing to sharing a bedroom with one another. 16. Personal privacy including use of the lock on my bedroom door or unit door. My privacy must be respected by the program, caregivers, household members, and volunteers by knocking on the door of my bedroom or bathroom and seeking consent before entering, except in an emergency; 17. Daily, private access to and use of a telephone for local and long-distance calls made collect or paid for by me. 18. Receive and send uncensored, unopened mail or electronic correspondence or communication. 19. Use of and have free access to common areas in the residence and the freedom to come and go from the residence at will. 20. Privacy for visits with my spouse, family, legal counsel, religious adviser, or others allowed in Minnesota Human Services Rights Act, Minnesota Statutes, section 363A.09, including privacy in my bedroom. 21. Privacy for visits by my spouse if married, and, if we are both residents of the adult foster home, we have the right to share a bedroom and bed; 22. Keep, use, and access my personal clothing and possessions as space permits, unless this right infringes on the health, safety, or rights of another resident or household member, including the right to access my personal possessions at any time; 23. Furnish and decorate my bedroom or living unit; Page 4 of 5
Rights Restrictions Restriction of your rights is allowed only for a specific need if determined necessary to ensure your health, safety, and well-being. Any restriction of your rights must be documented and justified in your Individual Abuse Prevention Plan (IAPP) under section 245A.65, subdivision 2, paragraph (b). If your service is funded under the Elderly Waiver, your case manager or care coordinator must be part of your interdisciplinary team and coordinate your coordinated service and support plan with your IAPP. CAN MY RIGHTS BE RESTRICTED? The only rights your interdisciplinary team may restrict, after documenting the need, include: 1. Your right to choose your own visitors and time of visits; 2. Your right to personal privacy including use of the lock on my bedroom door or unit door; 3. Your right to privacy for visits with your spouse, family, legal counsel, religious adviser, or others allowed by law, including privacy in my bedroom. 4. Your right to have daily, private access to and use of a non-coin-operated telephone for local calls and longdistance calls made collect or paid for by the person; 5. Your right to receive and send mail or electronic correspondence or communication; and not have them opened by anyone else unless I ask; 6. If sharing a bedroom, your right to choose your roommate; 7. Your right to furnish and decorate your bedroom or living unit; 8. Your right to take part in activities that you choose and have an individual schedule that includes your preferences, supported by the program; 9. Your right to freedom and support to access food at any time; 10. Your right to use and have free access to common areas in the residence and the freedom to come and go from the residence at will. WHAT IS THE PROGRAM REQUIRED TO DO IF MY RIGHTS WILL BE RESTRICTED? Before your interdisciplinary team may restrict your rights in any way the following information must be documented: 1. The justification (meaning the reason) for the restriction based on an assessment of what makes you vulnerable to harm or maltreatment if you were allowed to exercise the right without a restriction; 2. The objective measures set as conditions for ending the restriction (meaning the program must clearly identify when everyone will know the restriction is no longer needed and it has to end); 3. A schedule for reviewing the need for the restriction, why the restriction is still needed and how the restriction should change to allow you as much freedom as possible to exercise the right being restricted); and 4. Your signed and dated approval for the restriction from you or your legal representative, if any. You may withdraw your approval of the restriction of your right at any time. If you do withdraw your approval, the right must be immediately and fully restored. Page 5 of 5