CS4-245D

PARR - POLICIES, AUTHORIZATIONS, AND RIGHTS REVIEW (245D)

Name: / Dates: From / to

The following information has been presented to me/my legal representative and a copy has been provided:

1. / DRCC Mission Statement. (included in PARR Policy Packet)
2. / Clients' Rights.
a. Service Recipient’s Rights and Notice of Privacy Practices (signatures required, not included in PARR
Policy Packet)
b. DRCC Grievance Procedure and Rights Restrictions (included in PARR Policy Packet)
c. Additional Policies and Procedures at DRCC are available upon request.
d. I authorize DRCC to acknowledge my presence in the program where I reside. Yes No
3. / DRCC Policies.
a. DRCC's Policy on Maltreatment Vulnerable Adults Policy & Procedures – (included in PARR Policy Packet)
(Maltreatment of Minors Policy to be added by program)
b. DRCC's Program Abuse Prevention Plan for (facility) – (attached)
c. DRCC Emergency procedures – (included in PARR Policy Packet)
d. Emergency Use of Manual Restraints (included in PARR Policy Packet)
e. Admission Policy and Temporary Service Suspension and Service Termination Policies and
Procedures (included in PARR Policy Packet)
4. / Medication Authorization.
DRCC provides medication administration, assistance or training. (see attached form CS15A)
DRCC has no responsibility for administering or monitoring medications.
If the above box is checked, form CS15A does not need to be completed.
5. / I authorize DRCC to act in a medical emergency when the person or the person’s legal representative cannot be reached or is delayed in arriving. Yes No
6. / DRCC staff are authorized to open my mail. Yes No
7. / DRCC is authorized to use my photo and/or video for use and display in promotional materials, both in print and social media posts and videos, without limitation as to duration or frequency of use. This includes DRCC’s Newsletter, Facebook, social media and other promotional material as well as events covered by the media.
Yes No
8. / DRCC provides Progress Reviews at least semi-annually, or as requested by the guardian.
other (specify)
9. / What is the frequency of meetings for the ID Team?
semi-annual annual other (specify)
10. / Residency Agreement. (signatures required) This applies only to people who are living in a licensed setting (community residential facility/foster care) and receiving SLS under the waiver.
This does not apply to people living at the following programs: Hillside, Oneota, Manumit, Endion, Meridian or people receiving services through Fourteenth, Soft Hands, Carlton or IHFS.
11. / Cost of services. / a) Room and Board / $ / /month; b) Program Rate / /
12. / Financial Authorization. (check I, II, or III)
has a checking account has a savings account has a debit card
Assistance needed: Yes No If yes describe .
has cash-on-hand (cannot exceed $100) Can safely carry up to $
Level I - Independent, DRCC staff may or may not have any knowledge of my financial transaction.
Describe any restrictions, limitations, or staff involvement:
Level II - DRCC staff may exercise control over part or all of my funds, but will always give personal
money upon request. Describe any restrictions, limitations, or staff involvement:
Level III - DRCC staff will assume responsibility for budgeting and financial decision making.
Describe any restrictions, limitations, or staff involvement:
13. / DRCC provides a copy of Financial Transactions semi-annually, or as requested by the guardian.
NA
other (specify)
14. / From / to / , I authorize DRCC to communicate verbally,
or in writing, with the following Team members listed:
1 / 5
2 / 6
3 / 7
4 / 8

Enter the corresponding number(s) from above

Invitation to staffing / My progress on my program plans
My financial condition / Any problems/emergencies I may have
Medical problems / Work problems
Signature / Date / Emergency Contact Person:
Name:
Legal Representative / Date / Address:
Case Manager / Date / Phone:

10.15.18