Employee’s Acknowledgement of Client’s Bill of Right

1. To participate in the development and future changes in his/her plan of care.
2. To be treated with respect, consideration, dignity, and full recognition of his or her individuality and right to privacy.
3. To receive care and services that are adequate, appropriate, and in compliance with relevant federal and State laws and rules and regulations.
4. To voice grievances about his or her care and not be subjected to discrimination or reprisal for doing so.
5. To have his or her personal medical records kept confidential and not be disclosed without appropriate written consent.
6. To be free of mental and physical abuse, neglect, and exploitation.
7. To receive a written statement of services provided by the agency and the charges the client is liable for paying.
8. To be informed of the process for acceptance and continuance of service and eligibility determination.
9. То ассept or refuse service.
10. To be informed of the agency's on-call service.
11. To be informed of the supervisory accessibility and availability.
12. To be advised of the agency's procedures for discharge.
13. To receive a reasonable response to his or her requests of the agency.
14. To be notified within 10 days when the agency's license has been revoked, suspended, cancelled, annulled, withdrawn, recalled, or amended.
15. To be advised of the agency's policies regarding patient responsibilities.
16. To be provided a copy of the agency's policies regarding client responsibilities as it relates to safety and care plan compliance.
17. To be advised of the address and telephone number for information, questions, or complaints about services provided by the agency:
A1-Omega Healthcare Services, Inc.
(5870 Faringdon Pl. Ste. 2 Raleigh NC 27609)
18. Division of Health Service Regulation complaints hotline number:
Complaint Intake Unit
Division of Health Service Regulation
2711 Mail Service Center
Raleigh, NC 27699
800-624-3004 (Toll Free), (919) 855-4500 (Out of Town)
19. To be provided a copy of the declaration of home care clients' rights in advance care being furnished.
20. To expect that the agency shall investigate, within 72 hours, complaints made to the agency by a client or the client's family.

1. Client and/or family participate in the development of the Plan of Care and subsequent modifications.
2. Client/family is responsible for assisting in providing a safe, non-abusive environment.
3. Client/family has responsibility to notify A1-Omega Healthcare Services when scheduled visits cannot be kept.
4. Client/family is responsible for supplying accurate and complete information about the client's medical history.
5. Client/family is responsible for his/her actions if the Plan of Care is not observed.
6. Client/family is responsible for notifying A1-Omega Healthcare Services if they do not understand the instructions or if they cannot be followed.
7. Client/family has the responsibility to inform the agency of admission and discharge to any institution that conflict with their care, scheduled or unscheduled.

I understand that any violation of this rights and client's confidentiality will result to disciplinary action up to and including immediate termination of my employment.