This Is the Quality Inside Every Manual

To establish and protect the fundamental rights of all individuals receiving services from the Agency, and to ensure every client, guardian, and legally authorized representative is informed of these rights in a manner they understand, consistent with 42 CFR §441.301(c)(4) and applicable state HCBS regulations.

The Agency affirms that every client has the right to be treated with dignity and respect, free from abuse, neglect, exploitation, coercion, and retaliation. Rights are provided in writing, reviewed verbally at intake, and re-reviewed at least annually. No service, admission, or continued care shall ever be conditioned on a waiver of any client right.

1. At intake, the Intake Coordinator provides each client (and guardian or legally authorized representative, where applicable) a written copy of the Client Rights & Responsibilities statement in the client's primary language or preferred communication format.
2. The Intake Coordinator verbally reviews each right, confirms understanding using the teach-back method, and obtains the client's (or representative's) signature on the Client Rights Acknowledgment Form (Form CR-01).
3. The signed acknowledgment is filed in the client record within 24 hours and retained for the duration required by state record-retention rules.
4. Client rights are re-reviewed and re-acknowledged at least annually, upon any significant change in the service plan, and upon client or guardian request.
5. All staff receive training on client rights during orientation and annually thereafter; training completion is documented on the Staff Training Log (Form HR-07).
6. Any alleged violation of client rights is reported immediately to the Administrator and processed under Policy 4.3 (Grievance & Complaint Procedures) and Policy 4.5 (Abuse, Neglect & Exploitation Reporting), including any state-mandated reporting timelines.

• 42 CFR §441.301(c)(4) – HCBS Settings Rule: Person-Centered Service Plan
• 42 CFR §483.10 – Resident Rights (as applicable)
• State Medicaid Provider Agreement – Client Rights Provisions
• State HCBS Waiver Program Manual – Participant Protections

To ensure all medications are administered, self-administered with assistance, stored, and documented safely and accurately, in full compliance with the state Nurse Practice Act, delegation rules, and the applicable HCBS waiver medication administration requirements.

Medications shall only be administered by staff who are licensed, certified, or properly trained and delegated in accordance with state law. Every administration, refusal, or medication error is documented in real time on the Medication Administration Record (MAR). The Agency maintains a zero-tolerance standard for undocumented administration.

1. Prior to administering any medication, staff verify the Six Rights: right client, right medication, right dose, right route, right time, and right documentation.
2. Each administration is recorded on the MAR (Form MM-01) immediately after administration — never before — including date, time, dose, route, and the administering staff member's initials and signature.
3. Medication refusals are documented on the MAR with a refusal code, the prescriber is notified per the service plan, and the refusal is recorded in the client's progress notes within the same shift.
4. Medication errors (wrong dose, missed dose, wrong client, wrong route) are reported to the supervising nurse and Administrator immediately, documented on the Medication Error Report (Form MM-04), and reviewed under the Quality Improvement Plan within 5 business days.
5. All medications are stored in locked storage; refrigerated medications are kept in a dedicated, locked, temperature-monitored container with twice-daily temperature logs (Form MM-06).
6. Controlled substances are double-locked, counted at every shift change by two staff members, and reconciled on the Controlled Substance Count Sheet (Form MM-07). Discrepancies are reported to the Administrator immediately and to state authorities as required.

• State Nurse Practice Act – Delegation of Medication Administration
• State HCBS Waiver Program Manual – Medication Administration Standards
• 42 CFR §441.302 – State Assurances: Health & Welfare
• DEA Controlled Substance Storage & Recordkeeping Requirements