Statement of Recipients Rights and Responsibilities

RocVale Children's Home A Division of Milestone, Inc. 4450 N. Rockton Avenue Rockford, IL 61103

PLACEMENT AGREEMENT

PARTIES: RocVale Children's Home and

Parent/Guardian/Individual (when individual is own guardian) Name: DOB: Date of Admission:

(Individual) I, agree to the following: Parent/Guardian/Individual listed above I. I will make Milestone, Inc. payee of the individual's social security income and/or child support, if the individual does not currently receive social security benefits, I will apply for this benefit at my local Social Security office. I understand this becomes effective on the date the individual is placed. I understand this money will be used to partially fund room and board costs for the above named individual. I understand further that the remaining cost of care will be funded through the Illinois Department of Human Services. In the case of DCFS guardianship, DCFS agrees per license with the agency to pay all agreed-upon costs of care for the above-mentioned individual. By signing this Placement Agreement, I, the parent, guardian, or individual hereby acknowledge that Milestone, Inc. becomes the payee of Supplemental Security Income, and other unearned income, and agree to immediately make arrangements to facilitate this change. I understand that a small portion of the Supplemental Security Income paid to Milestone, Inc. will become part of the individual's restricted account and will be used for allowances and personal expenditures not related to cost of care. II. I understand that I, as Parent/Guardian of the Individual, shall have fiscal responsibility for all Medical and dental treatment incurred by the individual during his/her residency at RocVale Children's Home. This includes any costs incurred by the individual that are not covered by insurance or DHS Public Aid Medical Card. III. I understand that, in case of any emergency involving the health of the above named individual, the Emergency Medical Consent and the policy contained therein shall be followed. Further, I understand that every effort will be made to notify the Parent/Guardian of any serious illness or accident but agree that such notification may be delayed during the time that care is being secured for the individual. IV. I understand that written consent by the Parent/Guardian must be obtained for travel out of the state of Illinois or as indicated on the Activities Consent. V. I understand that, when discharge/change in placement is contemplated, each party will endeavor to give the other sufficient time to make adequate arrangements.

VI. I understand that, although the staff and agents of RocVale Children's Home will endeavor to the best of their ability to protect the individual from harm or injury inflicted by other individuals of the agency, such protection cannot be guaranteed in absolute. If such 1 harm or injury is inflicted upon the individual, I understand that staff and agents of RocVale Children's Home will treat such injuries and will report them to the Parent/Guardian in a timely fashion.

VII. I understand that RocVale Children's Home will provide all services with informed consent. Therefore, the individual and the Parent/Guardian shall be informed of the following: his/her Rights and Responsibilities, including those outlined in the Illinois Mental Health and Developmental Disability Code; An explanation of the individual's condition; The nature of the care, treatment, or medications which the individual will receive; The potential benefits,

risks, and side effects of proposed interventions, treatment, or medications; The problems related to care and the likelihood of success; Any significant alternative medications, treatments, or interventions; The clinical staff responsible for care of the individual and the staff member's professional status; The rules and regulations of the program; The cost of all services rendered and limitations on duration of services; The grievance procedure; level of supervision to be provided; and services available to the individual. IV. I understand that the Parent/Guardian or the Individual has the right to refuse treatment unless such refusal would be a barrier to lifesaving treatment. V. I agree to participate to the best of my ability in the treatment planning for this individual. VI. I agree to inform RocVale Children's Home if I change addresses or phone numbers, especially if moving from the State of Illinois. I agree to do this within 24 hours of such changes. I understand that, should I move from the State of Illinois, my child may need to be moved to residential placement in my new state of residency. VII. I understand and agree that only those individuals listed on the "Visitation Approval List" may be allowed contact with the individual and that any changes to this list are to be made in writing as the changes become effective.

VIII. I understand that, at the age of 18, the individual will become his or her own legal guardian. I agree to assist in any way possible in securing or completing the process for adult guardianship, should it be necessary to ensure the individual's interests are protected.

IX. I understand that RocVale Children's Home is licensed to serve individuals through the age of 21 so long as they are receiving full time educational services. I understand further that, although RocVale personnel will assist in the search for an appropriate adult residence for the individual, it is primarily the responsibility of the parent/guardian to investigate and secure such placement. I also understand that the guardian of the individual has the right to refuse any adult placement options which may be presented, but that, should the individual reach the point of violating our licensing agreement by maintaining the individual beyond the age of 21, the guardian of the individual may be asked to provide placement for the individual.

2 STATEMENT OF RECIPIENTS RIGHTS AND RESPONSIBILITIES RocVale Children's Home ensures that the rights of the individual's served will be respected.

The agency follows guidelines set forth in: Department of Human Services, Rights of Individuals Mental Health and Developmental Disabilities Confidentiality Act Mental Health and Developmental Disabilities Code 89 Ill. Adm. Code, DCFS, part 384 Code of Ethics for Welfare Professional (DCFS) Milestone, Inc. Code of Conduct of Professional/Leadership Staff

RECIPIENT RIGHTS:

1. The right to reasonable access to care, regardless of race, religion, gender, sexual orientation, ethnicity, handicapping condition, age, national origin, or financial standing. 2. The right to personal dignity. 2.1 Recipients shall have the right to privacy in an appropriate area. 2.2 Recipients are entitled to wear their own clothing which must be age and season appropriate, clean, in good repair and available daily. Recipient's clothing which is marked must be marked inconspicuously. Recipients will be provided with sufficient and readily available closet and drawer space. Recipients will be trained and encouraged to choose personal clothing. 2.3 All recipients are entitled to receive and make telephone calls to and from relatives and friends. Toll calls require specific permission of the on duty staff. The recipient will be expected to call collect or pay for the telephone call. 2.4 Recipients have the right to communicate by mail, telephone or visits without obstruction or censorship by the staff. Communication by these means may be reasonably restricted, but only to protect the recipient or others from harm, harassment, or intimidation. 2.5 All recipients are entitled to participate in agency activities and have access to recreational activities. 2.6 All recipients are entitled to go off campus for the purpose of his/her personal enrichment (i.e., trip to hair stylist, shopping for clothing necessities, dental visits, etc.). 2.7 It is the recipient's right to have three meals a day. No food shall be used or denied as punishment. 2.8 If rights are restricted, the person who is responsible for the recipient's services must inform the recipient and the parent/guardian (if the recipient is under age eighteen.) In addition, the service provider must tell all persons or agencies that the recipient requests to be informed about the restriction. Justification for any restriction of individual rights shall be documented in the individual's clinical record. 3. The right to care that is considerate and respects the personal value and belief systems of the individuals served.

3 Rights and Responsibilities Continued,

3.1 Recipients maintain all their legal and civil rights while receiving services. 3.2 Recipients shall have the right to vote. Staff will assist where necessary in getting recipients registered and assure their transportation and access to the polling place. 3.3 All recipients shall have their spiritual needs met and shall have access to the church, synagogue or Sunday School of their choice. 3.4 Recipients have the right to receive, possess, and use personal property unless it is determined that certain items are harmful to them or others. When recipients stop receiving services from the agency, all lawful property must be returned to them. 3.5 Recipients may use their money as they choose, unless they are prohibited from doing so under court guardianship order. 3.6 Recipients have the right to deposit their money at a bank or place it for safekeeping with the service provider. If the service provider deposits the money, any interest earned belongs to the recipient. Neither RocVale Children's Home nor any of its employees may receive directly any funds on behalf of the recipient, including Social Security, pension, annuity, or trust fund payments, without the recipient's informed consent. 3.7 Recipients must be paid for work they are asked to perform which benefits the service provider. However, they may be required to do personal housekeeping chores without being paid. 3.8 Restraints may only be used to protect a recipient from harming himself or others, or as part of a medical/surgical procedure, and only under the supervision of a properly qualified professional. 3.9 The use of seclusion shall not be permitted. 4. The right to be informed of the agency's rules and regulations concerning their conduct. 5. The right to informed participation in decisions regarding care and services. 5.1 Recipients have the right to participate in any team meetings that concern them. 6. The families of recipients served have the right to participate in treatment planning, as well as the right of the recipient, if over twelve years old, to participate in such planning. 6.1 The recipient has the right to continue to receive services unless the recipient voluntarily withdraws or meets the criteria for discharge from the service(s). Recipients have the right to terminate services at any time. 7. The right to individualized treatment. 7.1 All recipients have the right to adequate and humane care, services in the least restrictive environment, and an individual service plan. 7.2 All recipients have the right of freedom from abuse and neglect. If a recipient believes someone has treated him or her badly, the recipient should tell someone he or she trusts so that the problem can be resolved. Any abuse/neglect observed by staff of RocVale Children's

4 Rights and Responsibilities Continued,

Home shall be reported to the Department of Children and Family Services, Inspector General of the Department of Mental Health and Developmental Disabilities, the Department of Public Health or the Department of State Police for investigation. 7.3 All recipients have the right to participate in the development of an individualized service plan and have a clear understanding of the plan. Informed consent will be obtained from the individual and/or parent/guardian for aspects of care. The individual and/or parent/guardian have the right to refuse treatment or withdraw consent. 7.4 A periodic review of the treatment plan must be done. 7.5 An adequate number of competent, qualified, and experienced professional clinical staff must be available to supervise and carry out the treatment plan. 7.6 The recipient or other authorized persons have the right to look at the clinical record and other information about the individual. A clinical staff person must be available during any review of clinical records to explain information in the record. All recipients/parents/guardians have the right to refuse this interpretation with the understanding that such refusals will be documented in the clinical file. Recipients or other authorized persons may obtain copies of the clinical file and other documents with the "Request to Inspect and/or Copy Clinical Record" form. 8. The right to participate in the consideration of ethical issues that arise in the provision of care and services including: 8.1 Resolving conflicts and the right to express grievances in writing to the President/CEO of the agency. Some decisions by the agency (denial, reduction, suspension, termination of services) may be appealed to the Department of Mental Health and Developmental Disabilities. 8.2 Withholding resuscitative services. 8.3 Forgoing or withdrawing life-sustaining treatment, and 8.4 Participation in investigational studies or clinical trials. 9. The right to personal privacy and confidentiality of information. 9.1 Information concerning the recipient and the services he or she received is confidential and may be shared with someone else only if allowed by the Illinois Mental Health and Developmental Disabilities Confidentiality Act. 10. The recipient or the parent/guardian has the right to refuse services, including medication. When services are refused, they will not be given, unless there is a medical or other emergency, or if a judge orders it. 11. Except in an emergency, no medical or dental services will be provided without the informed consent of the individual and/or parent/guardian. The recipient has the right to purchase and use the services of private physicians and other professionals of their choice. The choice will be documented in the service plan. 12. The individual and/or parent/guardian have the right to know if the service provider is not meeting quality standards and to look at written survey reports describing the

5 quality of the services. Rights and Responsibilities Continued,

13. If the recipient is not capable of understanding treatment, procedure or programming, and is not able to communicate his or her wishes regarding care, legal guardians can be court appointed to act on the recipient's behalf. 14. The agency has the responsibility to inform individuals served and their families of their rights in a language that they understand. 15. Individuals may not be suspended or terminated from services or have services reduced for filing a grievance or for exercising any of their rights. 16. The agency's Human Rights Committee and the Behavior Treatment Committee annually review the Policies and Procedures, as well as review any grievance, as needed. 17. The recipient or his or her parent/guardian has the right to report any infringements of his or her rights to the Human Rights Committee at the RocVale Children's Home 815-654-3050.

Department of Mental Health Milestone staff will provide assistance & Developmental Disabilities with contacting these agencies. 1-800-843-6154

Department of Children & Family Services Guardianship & Advocacy, Inc.200 S. Wyman St., Suite 201 Legal Advocacy Service Rockford, IL 61101 4302 N. Main Street 815-987-7640 Rockford, IL 61103 815-987-7657 Equip for Equality 1-866-274-8023 P.O. Box 276 Springfield, IL 62705 1-800-758-0464 217-544-0464

RECIPIENT RESPONSIBILITIES:

1. Provide accurate information regarding primary diagnosis, medications, treatment, hospitalizations, past illnesses, or other information related to the recipient's health or ability to function, including any bicultural or special communication needs. 2. Ask questions if the proposed course of treatment or recommendations are not understood. 3. Respect other's property and that of the agency. 4. Participate in their care by following mutually agreed upon service plans. 5. Cooperate and assist in making discharge plans in a responsible and timely manner. 6. Follow the applicable rules and regulations affecting care and conduct. 7. Inform the appropriate authority if you believe your rights have been violated. 8. Maintain the confidentiality of others. 9. Report grievances to the appropriate authority.

6 PARENT/GUARDIAN RIGHTS AND RESPONSIBILITIES ACKNOWLEDGEMENT

I understand that I have the right to request at any time that these Rights and Responsibilities be explained to me further and/or to have specific Rights and Responsibilities clarified further if I should have questions regarding them.

I THE UNDERSIGNED HAVE READ THE FOREGOING AND UNDERSTAND AND JOINTLY AND SEVERALLY AGREE TO THE TERMS AND CONDITIONS THEREIN, INCLUDING, BUT NOT LIMITED TO, THE PARTS RELATING SPECIFICALLY TO FINANCIAL RESPONSIBILITY AND INDIVIDUALS’ RIGHTS.

______Parent/Guardian Signature Date

______Witness Signature Date

RECIPIENT’S RIGHTS AND RESPONSIBILITIES ACKNOWLEDGEMENT

I, ______, hereby state that I have received a copy of RocVale Children’s Home’s Recipient Rights and Responsibilities. I have had these Rights and Responsibilities explained to me in a language and in terms that I am able to understand. I recognize that, should my Rights be violated, I have the right to file a formal grievance.

______Recipient Signature Date

THIS AGREEMENT WAS READ AND EXPLAINED TO THE ABOVE SIGNED INDIVIDUAL BY:

______, ______, ______Name Relationship Date

______Signature

7 SS.3RV Rev. 12/09