Authorization for Release of Information I hereby consent and authorize the Agency to release and receive information for the purposes of treatment, payment, and health care operations. The exchange of information may occur between, but is not limited to, physicians, third party payers, other health providers, and regulatory and/or accrediting reviewers.

Statement to Permit Payment for Home Health Services I hereby request that payment of authorized adult day program services be made on my behalf to the Agency.

Acknowledgements I have received verbal and written information on the following, and have had the information explained to me:

I certify that I have read and agree with the information on this document and have been provided a copy for my records. I have participated in the formation of my plan of care.

Facility Rules

• No weapons are allowed
• No foul language
• No violence
• All medications are to be kept in the facility medication center.
• All people entering the facility must sign in
• Participants may not leave the facility without permission and staff knowledge
• No smoking in the facility
• No use of restraints

Incident/Occurrence Reporting

 INVOLUNTARY RESTRAINT

1. An Incident/Occurrence Report: Consumer or Employee will be completed on all incidents, as defined in policy, by the staff member involved or the first person to become aware of the incident.
2. The report will be submitted to the Facility Director, who is responsible for immediate investigation of the incident and taking any appropriate action, including instituting appropriate measures to prevent similar future occurrences.
3. The Facility Director will review the Incident/Occurrence Report: Consumer or Employee and will document awareness of the incident, adding it to the incident log.
4. The Facility Director will determine the appropriateness of reporting the occurrence to the CDPHE and will ensure compliance with all reporting requirements of 6 CCR 1011-1, Chapter 2, section 3.2.
   1. Documentation regarding the investigation, including appropriate measures to be instituted, shall be made available to the CDPHE, upon request
   2. A report with the investigation findings shall be available for review by the CDPHE within five (5) working days of occurrence.
   3. The Facility shall ensure that all staff have knowledge of Article 3.1 of Title 26, C.R.S. regarding protective services for at-risk adults, and that all incidents involving neglect, abuse or financial exploitation are reported immediately, through established procedures, to the Facility Administrator or manager.
      • The Facility shall report the incident to the appropriate officials as specified in the statute and, if applicable, to the CDPHE as an occurrence. The facility shall make copies of all such reports available to the department upon request.
      • The Facility shall document that all alleged incidents involving neglect, abuse or health professional misconduct are thoroughly investigated in a timely manner.
5. The Facility will continue to provide the consumer with the care agreed upon in the service agreement during the investigation, unless the consumer or consumer's representative requests discontinuation of services, or if continuation of services would place the consumer or employee at risk.
6. The supervisor will assure all applicable federal/state reports/forms are completed, e.g., OSHA 300 Log, as needed.
7. The Incident/Occurrence binder will be maintained with the incident reports and the incident log. Quarterly, the log will be reviewed, and any trends identified will be documented on the quarterly audit performance plan.

Emergency Procedure

1. The facility will develop an emergency plan that supports the facility
   1. During an emergency that requires the facility to evacuate the building
   2. During a consumer of staff member medical emergency
   3. If the Facility has an intruder that intends to cause harm
2. The facility will conduct a fire drill annually
3. The facility will conduct an emergency drill annually
4. Exit evacuation plans are posted in each room
5. A first aid kit is in the facility
6. In the event of a medical accident, the facility personal will follow the posted protocol
7. Staff will be trained to be alert for potential hazards to include but not limited to:
   1. Wet spots in the floor
   2. Consumer equipment (wheelchairs, walkers, oxygen etc.)
   3. Items that could cause a fall.

Consumer Admission

Only consumers whose needs can be met by the Adult Day Services Center within its certification category and population served shall be admitted to the Center.

1. Adult Day Care Centers are classified as follows
   1. Basic Adult Day Services (ADS) is a community-based entity.
   2. Specialized Adult Day Services (SADS) designated when the Center has 2/3 of the consumer population have the following conditions.
   • Consumers must have a confirmed diagnosis of Alzheimer’s and related disorders, multiple sclerosis, brain injury, chronic mental illness. Post stroke consumers who require extensive rehabilitative therapies.
2. For Medicaid consumers, the case manager must forward the most recent copy of the Participants ULTC-100.2 to the Facility as documentation of diagnosis that supports the consumers need for SADS.
3. Admission Documentation
   1. Diagnosis verification either with the ULTC-100.2 or for other consumers the diagnosis and recommended specialized services are documented in the care plan and verified by the consumers physician. Documentation must be verified at the time of admission and with any significant change in condition.
   2. Documentation of interview information prior to admission to determine the consumers level of function and activities and nutrition requirements and development of the consumer care plan.
   3. Documentation that the consumer and/or other responsible party was provided with written information about his/her rights under the state law regarding advanced directives. (The Facility utilizes the MOST form)
   4. Documentation of whether the consumer has executed any advanced directives or declarations.
4. Consumer records contain:
   1. Name, address, sex, and age of each consumer
   2. Documentation concerning advanced directives.
   3. Name, address, and telephone number of responsible parties
   4. Name, address and telephone number and fax of primary physician
   5. Documentation of supervision and monitoring of the services provided.
   6. Documentation of orientation to the facility and the policies and procedures for the consumer and responsible party
   7. Name, address and phone number of the case manager and single-entry point agency (if applicable)
   8. Signed service agreement.
      • Agreed upon days and times of service and payment.
      • Start of service date.
   9. Individualized care plan