Patient Rights

For Clients Being Seen In The Home Only

The patient has the right to:

Be informed and participate in the Plan of Care.
Be treated with respect, consideration, dignity and full recognition of their individual right to privacy.
To receive care and services that are adequate, appropriate and compliance with relevant Federal and State laws, rules and
regulations.
To voice grievances about their care and not be subjected to discrimination and reprisal for doing so.
To have his or her medical records be confidential and not be disclosed without proper written consent.
To be free from any mental or physical abuse, neglect and/or exploitation.
To receive a written statement of services provided by the agency and the charges the client is liable for paying.
To be informed of the acceptance process and countenance of service and eligibility determination to accept or refuse
services.
To be informed of the agency’s on call services.
To be informed of supervisory accessibility and availability and to be advised of the agency’s procedures for discharge.
To receive a reasonable response to his or her request of the agency.
To be notified within 10 days, when the agency license has been suspended, revoked, canceled, revoked, modified or
dismissed.
To be informed of the agency policies regarding patient responsibilities and provided a copy of these responsibilities upon
request.
To be informed that staff therapist are prohibited from smoking while providing therapy to an individual and while in an
individual’s home.
To be provided a copy of the declaration of home care client’s rights in advance of care being provided.
To expect that the agency shall investigate, within 72 hours, complaints made by a client or the client’s family.
To be informed of the address and telephone number for information, questions or complaints about the services provided by
the agency.

Inquiries should be presented in this order:

Raleigh Therapy Services, Inc/Triangle Dysphagia & Feeding, PLCC
3803B Computer Dr, Ste 200 Raleigh, NC 27609
(919) 791-3582
The Acute Care, Home Care and CLIA Branch with Licensure and Certification of the Division of Health Services Regulation shall be responsible for enforcing state laws with regards to home care agencies. 2712 Mail Service Center
Raleigh, NC 27699
(919) 855-4500

Additional Client Rights And Responsibilities

To be informed in advance about the care and to be furnished, the disciplines that will furnish the care and the proposed visit frequency.
To know the identity and responsibilities of those for coordinating, rendering and supervising the care, including health care providers under contractual relationships.
To a complete explanation of all services provided, initially and on a continuous basis. To health teaching and education in a language or form the patient can reasonably be expected to understand.
To be involved in resolving ethical issues or conflicts about care or service.
To have his/her property and person treated with respect.
To know that his/her family or guardian may exercise the patient’s rights if the patient is considered a minor under state laws.
To refuse treatments and to be informed of the consequences of such actions.

The Patient Has The Responsibility

To cooperate with your physician, medical professionals and the agency in your treatment program.
To notify the agency of changes in your address, health status, medications, physicians and admission to the healthcare facility.
To inform the agency of your inability to keep a scheduled appointment.
To notify the agency when you feel as though your rights are not being respected.
To sign a release refusing any medications, treatments, the recommended plan of care or when refusing recommended home-based services.
To notify the agency if you are no longer homebound or require home-based care, should that be a requirement of your payor source.
To notify the agency if you enroll in an HMO.
To provide a safe home environment in which your care can be given.
To express any concerns regarding the course of treatment or your ability to comply with instructions.

By signing below I acknowledge that I have been presented with and understand these rights and responsibilities. I may request a copy of these policies at any time during the course of my care.

Child's Name *

Signature of Parent/Guardian *

Name of Parent/Guardian *

First Name Last Name

Date