Agree Disagree. Use of first name only: ........ Agree Disagree Use of full name: .................
Agree Disagree. I acknowledge that any breach of this agreement may result in the removal of my information for the NDSLIC distribution lists. Agree Disagree
Agree Disagree. INDIVIDUAL RIGHTS AND RESPONSIBILITIES I have received a written copy of the RHC Client / Resident Rights and Responsibilities (attached). I understand if I have any questions or concerns I can contact an RHC Supervisor, the Habilitation Plan Administrator, the Case Manager Resource Nurse, or the Patient Care Coordinator. INITIAL PHYSICIAN ORDERS FOR LIFE-SUSTAINING TREATMENT (POLST) Does the resident have a POLST / advance directive? If interested in obtaining a POLST or to get more information on advance directives, contact the resident’s medical provider. Yes INITIAL No ADVOCACY INFORMATION If you have concerns about abuse or neglect reporting, or have concerns related to resident’s rights, there are advocacy agencies not affiliated with the RHC you can contact for assistance. These include: Disability Rights Washington, DD Ombudsman, Nursing Home Ombudsman program, or Complaint Resolution Unit (CRU) Hotline. CRU Number: 0-000-000-0000 To file a grievance, see the attached Grievance Policy. INITIAL SIGNATURE DATE RELATIONSHIP Parent Guardian Relative (relationship): Superintendent / Custodial Guardian Disclaimer: Services at this RHC are based on the resident’s assessed needs and if you request services outside the interdisciplinary team determination, you are responsible for payment, transportation, and setup for that service. If you feel the resident needs a service not provided by the facility, contact the Habilitation Plan Administrator, Case Manager Resource Nurse, or Patient Care Coordinator so they can facilitate a team meeting to discuss the recommendation.
Agree Disagree. Use of full name: .................
Agree Disagree. For your added security, the front and back doors have a 4-digit code exclusive to your group’s stay. Only management and guests will have access during your time with us. The code will be provided to you at the time of check-in.
Agree Disagree. If disagreement, what is disposition of purported out-of-class work?
Agree Disagree. RESIDENT’S NAME DDA NUMBER RESIDENCE BIRTHDATE
Agree Disagree. Recording: ......................
Agree Disagree. The Newcomer Family never fully opened up to me.
Agree Disagree. The Newcomer Family was open to sharing information immediately. The Newcomer Family does not appear to be reluctant to request my assistance. The Newcomer Family is learning to become more self- sufficient. The Newcomer family and I (the CN) handle our language challenges adequately.
