Home and Community-based Services - Service Recipient Rights Person name: Program name: This packet contains information regarding your rights while receiving services and supports from this 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. I received the following information within five working days of when I started to receive services and every year after that. 1. A copy of my rights under the law, Minnesota Statutes, section 245D.04. 2. An explanation of what my rights are and that I am free to exercise my rights; and that this program must help me exercise my rights and help protect my rights. Date 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 and 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? Yes (if yes, see rights restriction document) No I understand that I may contact the agencies below if I need help to exercise or protect my rights: Office of the Ombudsman for Mental Health Minnesota Disability Law Center and Developmental Disabilities 430 1st Ave N, Suite 300 121 7th Place E, Suite 420 Minneapolis, MN 55401 Metro Square Building Email: mndlc@mylegalaid.org St. Paul, MN 55101 Website: http://www.mndlc.org/ Phone: (651) 7567-1800 or 1(800) 657-3506 Fax: (651) 797-1950 Website: www.ombudmhdd.state.mn.us I want to help me exercise (name of authorized representative/legal representative/family member) The program has this person s contact information in my record. my rights. By signing this document I am agreeing that I have read and understand the boxes I checked above. Person Date Legal representative Dat Orion ISO 1 of 17
RIGHTS AND RESPONSIBILITIES Orion ISO is licensed under Minnesota Statues, Chapter 245D. Orion ISO must help you exercise and protect your rights identified in Minnesota Statues, section 245D.04. When receiving services and supports from Orion ISO Services, I have the right to: What is a right? Something I am allowed to do or have all of the time. What is a responsibility? Something I agree to do to the best of my ability. Service Related Rights. 1. I HAVE THE RIGHT TO PARTICIPATE IN PLANNING MY SERVICES To participate in the planning and evaluation of the services provided to me. 2. I HAVE THE RIGHT TO SERVICES AND SUPPORTS THAT ARE LISTED IN MY PLAN, AND PROVIDED TO ME IN A WAY THAT RESPECT AND TAKE INTO CONSIDERATION MY PREFERENCES. My team will meet with me to come up with a plan that will help to support me. When they help me with my plan, they should listen to the things that are important to me and let me make choices about my life. Orion ISO 2 of 17
3. I HAVE THE RIGHT TO TERMINATE (STOP) OUR REFUSE SERVICES To go to the boss and explain why I want to stop or refuse services. Remember that people may not agree with me because by doing do I may get sick or harmed. Remember that I could lose my services and not get them back easily. 4. I HAVE THE RIGHT TO KNOW, IN ADVANCE, SERVICE LIMITS. To learn about what services I can and cannot get. To be willing to check out all of my options for services. To try to use the services I have to get the things I need. For the services to have knowledge, skill, and ability to meet my service and support needs. 5. I HAVE THE RIGHT TO KNOW ADMISSSION (START) AND TERMINATION (STOP) TERMS. Admission! Termination! Remember that admission means start and termination means stop. To know the policies, procedures, as related to admission, temporary service suspension, and termination. That you can t be kicked out without explanations being given and understood Need to listen to the reasons why services are being stopped. Need to learn about my appeal rights. I can question what they said or did. Orion ISO 3 of 17
6. IF I CHANGE SERVICES, MY CURRENT SERVICES WILL HELP WITH COORDINATING THE TRANSFER TO ENSURE MY CARE. The team in charge of current services will pass on records and information that I want my next team to have. All of the teams will work together to make sure that I continue to get good services. 7. I HAVE THE RIGHT TO KNOW SERVICES CHARGES. I HAVE THE RIGHT TO KNOW FUNDING SOURCES. To understand this means what the services cost and who pays. To know what I m paying for. I will be told any time there are changes in those charges. 8. I HAVE THE RIGHT TO KNOW, IN ADVANCE WHETHER SERVICES ARE COVERED BY INSURANCE, GOVERNMENT FUNDING, OR OTHER SOURCES. I will be told of any charges that I or a private party may have to pay. I can get specific information about the charges for services. 9. I HAVE A RIGHT TO TRAINED AND COMPETENT STAFF. To know that staff are trained to help and support me. To have understanding and competent staff. To have professional or licensure staff, as required To have staff meet any additional qualifications that is in my coordinated service and support plan addendum. Orion ISO 4 of 17
Protection Related Rights 1. I HAVE TO THE RIGHT TO HAVE ALL INFORMATION ABOUT ME KEPT PRIVATE. This includes my personal, financial, service, health, and medical information. The program will let me know if they have need to share information about me. My team will only share information that is needed to help support me. I will be explained to me the program polices procedures on sharing my private information with others. In most situations, I have to give my permissions for them to share information. 2. I HAVE A RIGHT TO ACCESS MY PRIVATE RECORDS AND RECORDED INFORMATION ABOUT ME. I am able to read what staff writes or put in my records I know I can access my records and written information about myself as allowed by state and federal law, regulation or rule. I need to remember to return the records after reading them in the same shape that I got them in; I can t tear them up if I don t like what they say. 3. I HAVE A RIGHT TO BE FREE FROM MALTREATMENT. THIS INCLUDES: ABUSE, NEGLECT AND FINANCIAL EXPLOITATION. I need to know that maltreatment means bad treatment. Abuse can be verbal abuse, physical abuse, or sexual abuse Neglect means my basic needs are not being met (clothing, shelter, food, medical care, etc). Financial exploitation can occur when someone takes advantage of my money, property or misuses my funds. Orion ISO 5 of 17
4. I HAVE THE RIGHT TO BE FREE FROM STAFF TRYING TO CONTROL MY BEHAVIOR BY: Physically holding me or using a restraint to keep me from moving Giving me medication I don t want to take or that isn t prescribed for me Putting me in time out, seclusion, mechanical restraints, and other things that are prohibited by the state. Except if and when manual restraint is needed in an emergency to protect from physical harm. 5. I HAVE THE RIGHT TO RECEIVE SERVICES IN A CLEAN AND SAFE ENVIRONMENT. My staff will try to fix things in the house when they are broken. My staff will help me to clean the house. They will clean things that I am not able to clean. 6. I HAVE A RIGHT TO BE TREATED WITH RESPECT. I understand that people should treat me with courtesy and respect. I don t think that they should talk about me without my permission. The services in the service plan should be written in a manner that respects and takes into consideration my preferences. I understand that I should receive respectful treatment of my property. 7. I HAVE THE RIGHT TO HAVE REASONABLE OBSERVANCE OF CULTURAL AND ETHNIC PRACTICES AND RELIGION I have the right to have things from my culture and celebrate it I have the right for the company to attempt to have staff from my ethnic and cultural background. I have a right to go to express my faith, attend church or any religious activates. Orion ISO 6 of 17
I have a right for staff to take me to church or any religious activities. 8. I HAVE THE RIGHT TO BE FREE FROM BIAS AND HARASSMENT REGARDING RACE, GENDER, AGE, DISABILITY, SPIRITUALITY, AND SEXUAL ORIENTATION. I have the right for staff to respect my personal sexual orientation. I have the right for staff to respect my disability and assist me with my needs. I have the right for staff to respect my spiritual preferences and bring me to functions. I have the right for staff to respect my race, gender and age. 9. I HAVE THE RIGHT TO BE INFORMED OF AND USE OTION ISO S GRIEVANCE PROCDURES, INCLUDING HOW TO CONTACT PEOPLE RESPONSIBLE FOR ADDRESSING PROBLEMS AND TO APPEAL I have been given the grievance procedure I can ask for assistance from staff to file a grievance. I can call Quality Assurance at any time for assistance. Phone number: 763-450-7915. 10. I HAVE THE RIGHT TO KNOW THE NAMES, ADDRESSES AND PHONE NUMBERS OF OTHER PEOPLE WHO CAN HELP ME There are people who don t work for ORION ISO who can help me, including advocates, protection workers, and the state s ombudsman. I have been given information about how to file a complaint with these offices. I can ask for assistance from staff to file a grievance. I can call Quality Assurance at any time for assistance. 763-450-7915. 11. I HAVE A RIGHT TO STAND UP FOR MY RIGHTS. Orion ISO 7 of 17
I can join a self-advocacy group. I can learn about my rights from another self-advocate. I can talk to an advocate, professional, friend, or family member. I know I can assert these rights myself and I do not need to be afraid of losing my job, home, services or having anything bad happen to me. 12. I HAVE A RIGHT TO REFUSE TO PARTICIPATE IN AN RESEARCH OR EXPERIMENTAL TREATMENT I have the right to just say no. Ask staff to inform me and define for me all the terms and conditions before I agree. Get good information before making a decision. 18. I HAVE A RIGHT TO ASSOCIATE WITH PEOPLE OF MY CHOICE. I can choose my own friends and spend time with them. Know that staff can t tell me who my friends are or who I can be friends with. Remember that I have to be nice and flexible. I should reschedule if I forgot to go somewhere with someone. 19. I HAVE A RIGHT TO PERSONAL PRIVACY. I should tell people when I want to be alone. Close my door for privacy when I want to be alone. I can tell people to go away if I want to be alone. People should knock on the door before they come in. 20. I HAVE A RIGHT TO PLAN ACTIVITIES. Orion ISO 8 of 17
I have a right to let people know what I want to do. I have right to participate in those chosen activities. I have to save my money so I can afford to do things. I may have to ask people to help make arrangements for tickets and transportation. IF I LIVE IN A HOME WHERE THE PROVIDER I AM RECEVING SERVICES FROM IS THE OWNER, LESSOR, OR TENANT OF THEHOME, I HAVE THESE RIGHTS: 1. I HAVE THE RIGHT TO USE THE PHONE. I have access to a non-coin-operated telephone for local calls and longdistance calls made collect or that I paid for. Remember that sometimes I need to wait until a person is done before I can use the phone. Remember that I may have to share the phone, if necessary. Remember that I need to pay my phone bill. I can have free, daily, private access to and use of the phone 2. I HAVE THE RIGHT TO PRIVATE CORRESPONDENCE AND COMMUNICATION. Give my permission for anyone else to read my mail but me. Receive and send mail and emails and not have them opened by anyone else unless asked. I have the right to have staff help me with my mail. 3. I HAVE THE RIGHT TO HAVE USE OF AND FREE ACESS TO COMMON AREAS IN THE RESIDENCE Orion ISO 9 of 17
I have the right to use the common areas of the house. This includes the kitchen. 4. I HAVE A RIGHT TO PRIVACY WHEN HAVING VISITORS I know I can have privacy during visits with my spouse, next to kin, legal counsel, religious advisor or others allowed in MN Human Services Rights Act, MN Statues, section 363A.09, including my bedroom. Orion ISO 10 of 17
RIGHTS RESTRICTIONS CAN MY RIGHTS BE RESTRICTED? Restriction of your rights is allowed only if determined necessary to ensure your health, safety, and well-being. Any restriction of your rights must be documented in your coordinated service and support plan or coordinated service and support plan addendum. The restriction must be implemented in the least restrictive alternative manner necessary to protect you and provide you support to reduce or eliminate the need for the restriction in the most integrated setting and inclusive manner. WHAT IS THE PROGRAM REQUIRED TO DO IF MY RIGHTS WILL BE RESTRICTED? Before this program may restrict your rights in way this program must document the following information: 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 based on the conditions for ending the restriction to occur semiannually from the date of initial approval, at a minimum, or more frequently if requested by the person, the person's legal representative, if any, and case manager (meaning that at least every six months, more often if you want, the program must review with you and your authorized representative or legal representative and case manager, 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. signed and dated approval for the restriction from you or your legal representative, if any. CAN THE PROGRAM RESTRICT ALL OF MY RIGHTS? The program cannot restrict any right they chose. The only rights the program may restrict, after documenting the need, include: 1. Your right to associate with other persons of your choice; 2. Your right to have personal privacy; and 3. Your right to engage in activities that you choose. RESIDENTIAL SUPPORTS AND SERVICES MUST INCLUDE THESE ADDITIONAL RESTRICTIONs IN THIS LIST 4. Your right to have daily, private access to and use of a non-coin-operated telephone for local calls and long-distance calls made collect or paid for by the person; 5. Your right to receive and send, without interference, uncensored, unopened mail or electronic correspondence or communication; and 6. Your right to have use of and free access to common areas in the residence; and 7. Your right to privacy for visits with the person's spouse, next of kin, legal counsel, religious advisor, or others, in accordance with section 363A.09 of the Human Rights Act, including privacy in the person's bedroom. WHAT IF I DON T GIVE MY APPROVAL? A restriction of your rights may be implemented only after you have given your approval. WHAT IF I WANT TO END MY APPROVAL? 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. Orion ISO 11 of 17
Home and Community-Based Services (HCBS) Rights Restriction Person name: Program name and location: Date of initial implementation of restriction: Restriction of a person's rights is allowed only if determined necessary to ensure the health, safety, and well-being of the person. Any restriction of those rights must be documented in the person's coordinated service and support plan or coordinated service and support plan addendum. The restriction must be implemented in the least restrictive alternative manner necessary to protect the person and provide support to reduce or eliminate the need for the restriction in the most integrated setting and inclusive manner. 1. Identify the protection-related rights to be restricted (check the applicable right): A person's protection-related right to: associate with other persons of the person's choice personal privacy engage in chosen activities For a person residing in a residential site licensed according to chapter 245A, or where the license holder is the owner, lessor, or tenant of the residential service site, the right to: have daily, private access to and use of a non-coin-operated telephone for local calls and long-distance calls made collect or paid for by the person receive and send, without interference, uncensored, unopened mail or electronic correspondence or communication have use of and free access to common areas in the residence privacy for visits with the person's spouse, next of kin, legal counsel, religious advisor, or others, in accordance with section 363A.09 of the Human Rights Act, including privacy in the person's bedroom 2. Identify how the restriction of rights is justified based on an assessment of the person's vulnerability related to exercising the right without restriction (meaning why the restriction is needed and how this was determined): 3. Identify how the right will be restricted (in the least restrictive manner necessary to protect the person and provide support to reduce or eliminate the need for the restriction in the most integrated setting and inclusive manner): 4. Identify the objective measures set as conditions for ending the restriction (meaning how and when everyone will know the person s rights must be restored): Orion ISO 12 of 17
5. Identify the schedule for reviewing the need for the restriction based on the conditions for ending the restriction (it must occur semiannually from the date of initial approval, at a minimum, or more frequently if requested by the person, the person's legal representative, if any, and case manager): Date to be reviewed: Restriction was lessened or lifted: Yes No If no, justify why and whether changes to the person s service outcomes or supports are needed to restore the person s rights (attach dated documentation). Date to be reviewed: Restriction was lessened or lifted: Yes No If no, justify why and whether changes to the person s service outcomes or supports are needed to restore the person s rights (attach dated documentation). Date to be reviewed: Restriction was lessened or lifted: Yes No If no, justify why and whether changes to the person s service outcomes or supports are needed to restore the person s rights (attach dated documentation). Date to be reviewed: Restriction was lessened or lifted: Yes No If no, justify why and whether changes to the person s service outcomes or supports are needed to restore the person s rights (attach dated documentation). Approval of rights restriction: I participated in the discussion of why this restriction of my rights is needed to ensure my health, safety, and well-being. My approval of this restriction of my rights is limited to the restriction as identified in this document. I understand that I may withdraw my approval at any time. If I withdraw my approval I understand that my rights must be immediately and fully restored. Person Date Legal representative Date Case Manager Date Withdrawal of approval of rights restriction: I withdraw my approval for my rights to be restricted. All restrictions must end and my rights must be fully restored immediately Orion ISO 13 of 17