Admission Services Agreement

I hereby consent and authorize BetterLives, its agents and associates to provide services to me in my home or place of residence and community as per program policy. A representative of BetterLives has explained to me the services to be provided and my plan of care (including disciplines, proposed frequency of visits and anticipated outcomes) and my involvement with the plan of care. I understand that the plan, if care may change and if so, the changes will be discussed with me. I further understand that after I or my family receive instructions to assist me in the program, that my care is my responsibility in the absence of the agency staff in my place of residence and that, it is my responsibility to notify my physician or other care providers of any significant events relating to my health.

I certify that the information given by me to BetterLives is correct to the best of my knowledge. I understand that payment of authorized benefits be made in my behalf and will be billed to:

Medicare

Bill directly to me

Other

Other is required.
My Insurance Company is is required.

I understand and agree to pay deductibles, co-payments and any amounts due after payments of benefits on my behalf or any and all third party payers.

I hereby consent to and authorize the agency to disclose and release information contained in my clinical record to the health care providers involved in my care, third party payers, utilization review, and other professional standards review organizations, regulatory review entities and any other companies that may/will help me to meet my health care needs.

Acknowledgement of Information

- Release of Liability and organization's complaint process and state's toll-free hotline

- Emergency planning related to a disruption of services.

• Infection control

I have reviewed an explanation and written information regarding advanced directives. I understand that BetterLives does not discriminate or whether or not I have an advance directive.

I DO I DO NOT have an advanced directive.  I WILL NOT provide a copy to the agency.


I have received a copy and an explanation of the member Rights and Responsibilities.

THIS ADMISSION AGREEMENT is applicable only to this admission to BetterLives. I understand what I have received and what was explained to me and agree to the terms and conditions stated above. Also, I understand either party may terminate this agreement at any time.

Member Representatives is required.
Please provide a valid date.
Agency Representative is required.
Please provide a valid date .
Financial Guarantor is required.
Please provide a valid date .
Agency Representative is required.
Please provide a valid date .
Member Name is required.
Please provide a valid date .
Case Number is required.

Consumer Notice

TO (Service Recipient Name) is required.

Thank you for your trust in allowing us to provide services in your home. Before we begin services, we wanted you to know the following about our operations:

1. All of our caretakers are supervised daily by reporting to our office before and after they provide your services.
2. We assign duties to the caretaker based on the services you need (or as directed by your payer).
3. We require the following of each caretaker we hire. If they do not meet these requirements, we have policies on discipline or firing to follow:
   a. Must pass a criminal background check
   b. Must receive positive references from the majority of individuals they’ve given us to contact.
   c. Must have appropriate credentials, licensure or certification (if required) and adequate training to provide services to you.
4. We provide each of our caretakers with the following:
   a. Identification as one of our caretakers.
   b. Materials or equipment they need to provide your services (i.e., cleaning supplies)
   c. Payroll, taxes, social security, workers' compensation insurance; unemployment compensation payments, and overtime pay for hours worked in excess of 40 hours a week. This assures that you have no liability for the taxes of our caretakers (as you would if youhired them directly).

We would appreciate your signature below signifying that you have been advised of our company's policies. Again, thank you for your confidence and should you have any issues during the course of your services, please call:

(Name of Caretaker's Supervisor) at the following phone number

Name of Service Recipient is required.
Please provide a valid date .

CONSENT FOR TREATMENT

Each person who has chosen BetterLives to provide supports and services, the person's legal representative, or a health care agent named in accordance with a valid health care power of attorney has the right to consent to or refuse any treatment offered by BetterLives

"Treatment" means the process of providing for the physical, emotional, psychological and social needs of a person through services, including routine medical care.

"Service" means an activity or interaction intended to benefit another, with or on behalf of, an individual who is in need of assistance, care, habilitation, intervention, rehabilitation, or treatment.

Consent may be withdrawn at any time by the person who gave the consent. If treatment is refused or deemed inappropriate, the BetterLives Qualified Professional/Program Manager shall determine whether treatment in some other modality is possible. If all appropriate treatment modalities are refused, the person supported may be discharged.

By my signature I give consent for BetterLives to provide treatment to is required.
Person Supported is required.
Please provide a valid date .
Legal Representative Person is required.
Please provide a valid date .
BETTERLIVES Representative is required.
Please provide a valid date .

* This consent will be renewed annually in conjunction with the person's Individual Support Plan review.

ACKNOWLEDMENT OF RECEIPT OF TITLE VI INFORMATION

As required by the Division of Intellectual Disabilities Services, I have beenprovided a copy of the Title VI of the Civil Rights Act "Discrimination is Prohibited" form and a copy of the brochure, "Equal Opportunity is the Lawin Tennessee" and " Discrimination is Prohibited" from the Department of Finance and Administration.

This information includes contact numbers for the DIDO Title VI Compliance Director and the U.S. Department of Human Services Regional Manager, Office of Title VI Compliance, if I feel an act of discrimination has occurred.

Person Supported is required.
Please provide a valid date .
Legally Responsible Person is required.
Please provide a valid date .
BetterLives LLC Representative is required.
Please provide a valid date .

Background Information

Name is required.
Please provide a valid birthdate.
Please select an option.
Height is required.
Weight is required.
Race or Ethnicity is required.
Eye Color is required.
Hair Color is required.
Primary Language is required.
Blood Type is required.
Marital Status is required.
Current Address is required.
Medicaid Number is required.
State ID number is required.
Please select an option.

Consent for Referral

Signature

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As the applicant or conservator/guardian for the applicant, I give consent to the admission and care offered within the requested program.

Program Interest

Program(s) Requested
(Circle each requested program) 		Residential
24 hour daily support towards independent living 		Supported Employment
Program devoted to finding competitive employment 		Day Services
Monday–Friday community based service from 9–3
Personal Assistance
Daily supports in the current home
Respite/Recreation
Saturday program offering recreation opportunities
Asperger's Support
Monthly activity/support group for individuals with Asperger's diagnosis
Contacts Name Phone E-mail
Parent/Guardian/Conservator
Primary Care Physician
Psychiatrist
Neurologist
Physician Specialty
ISC
Behavior Analyst
Therapist Specialty
Therapist Specialty
Please enter a valid reason for referral (describe current situation).
Please enter a valid physical health diagnoses: list any medical diagnoses or physical health problems (visual impairment, arthritis paralysis, etc.).
Please enter a valid describe current home situation: housemates? level of independence? individuals within his/her circle that are important to him/her?.
Please enter a valid day activities (describe the person's daily life routine.).

Medicaid Waiver

Medical Information

Please enter a valid physical health diagnoses: list any medical diagnoses or physical health problems (visual impairment, arthritis. paralysis etc.).
Please enter a valid communicate: how does s/he communicate when s/he is hurting or injured?.
Please enter a valid medication: list all medications, specific schedule, and purpose(s). include prescribed, over the counter medications, and supplements. can s/he give his/her own medications? how does s/he take medications? does s/he know what medications are prescribed and for what purpose?.
Please enter a valid treatments: list all current medical treatments, specific schedule, and for what purpose(s) (i.e . c-pap machine, nebulizer, etc.).
Please enter a valid sleep pattern: (describe sleep in terms of a 24-hour day).
Please enter a valid weight: have there been changes in weight over the past year? (describe).
Please enter a valid medication/ food: allergies: does the person have allergies to food or medications? if so, list the food or medication and the reaction. betterlives llc 141 n. martinwood road, ste. 104-13, knoxville, tn 37931 is the person on a special diet? (regular, diced, or pureed).
Please enter a valid current assistive devices: (wheelchair, walker, etc.).

Psychiatric Information

Please enter a valid current mental health diagnoses (clinical and personality disorders).
Please enter a valid intellectual disability diagnosis (include dates of assessment, iq, and adaptive scores).
Please enter a valid history of inpatient psychiatric treatment (include admission date, reason, length of stay, and outcome).

Behavior Information

Please enter a valid employment: does s/he have a job or want to pursue future emplovment?.
Please enter a valid evacuation: can the individual self- evacuate in case of emergency? what supports are needed?.
Please enter a valid self-care: describe self-care abilities. (showering, toileting, dressing, laundry, etc.).
Please enter a valid chores: describe household maintenance abilities. (dishes, vacuuming, cleaning bathroom, etc.).
Please enter a valid food preparation: describe food preparation abilities. (cutting, microwave use, etc.).
Please enter a valid fears/concerns: is s/he afraid of anything? does s/ he not want to be around certain people or things?.
Please enter a valid safety: are there concerns about his/her safety awareness?.
Please enter a valid transportation: does s/he drive, use public transportation?.
Please enter a valid sensory: does s/he have any sensory integration issues? does s/he have sensory preferences/activities?.
Please enter a valid routines: does s/ he engage in any routine/ ritualistic behaviors? if so describe..
Please enter a valid recreation / leisure: what does s/he like to do for fun? what are his/her hobbies and interests? what activities does s/he enjoy but have limited access?.
Please enter a valid law enforcement: is there a history of law enforcement involvement or legal charges? if so describe..

Maladaptive Behaviors: Behavior

Please enter a valid physical aggression: (hitting, spitting, kicking, etc.) self-injury (head-banging, picking, etc.).
Please enter a valid property destruction: (punching walls, breaking items, etc.).
Please enter a valid elopement (running away from home or family, etc.).
Please enter a valid sexually inappropriate behavior (inappropriate touching, etc.).

DOCUMENT ATTACHMENTS (all referrals)

Please provide the following documents for review with this application.

Please upload a file.
Please upload a file.
Please upload a file.
Please upload a file.
Please upload a file.
Please upload a file.
Please upload a file.

If we chose to admit this individual, we will need the original or a copy of the following documents.

Please upload a file.
Please upload a file.
Please upload a file.
Please upload a file.
Please upload a file.

BetterLives LLC Pre-Planning and Consent Forms for ISP Meetings

Title VI confirmation

-- BetterLives LLC Person Served Grievance Procedure

-- Photo/Video Release

-- Seizure Protocol (Write N/A if no seizure diagnosis)

-- Updated Contact List

-- ISP Meeting Note

-- Release to Contact Employer

-- Emergency Data Form updated

-- Volunteer/Intern Consent

Grievance Procedure

Individual Name is required.

Individual Signature

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Date is required.
Instructions:
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Representative Signature

Clear Signature

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Instructions:
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Relationship to Individual is required.

BetterLives LLC Person Served Grievance Procedure

This procedure is established to safeguard the personal and legal rights of the person supported and provide a process of review for any complaints the person served or representative has with the agency's service delivery. Retaliation against anyone filing a complaint to BetterLives LLC or DI DD will not be tolerated. Decisions arising from local, state, or federal laws will not be handled under this procedure.

   1. Complaints must be filed within thirty days of an act or event with which a person served or representative is dissatisfied. A complaint may be filed with the Executive Director/ Compliant Resolution Coordinator.
   2. The Executive Director/ Compliant Resolution Coordinator will be responsible for securing all facts pertinent to the issues. They will also hear and evaluate evidence and construct a record to permit a prompt and equitable decision for mutual resolution.
   3. The aggrieved person may formally or informally present the complaint to the Executive Director/ Compliant Resolution Coordinator who will review the matter promptly and impartially and respond within seven (7) working days, with final resolution being achieved within thirty (30) days.
   4. If the person is not satisfied with the answer he/she receives from the Executive Director/ Compliant Resolution Coordinator, a complaint can be filed at any time through the DIDD Division of Customer Focused Services, DIDD Regional Office, the DIDD Central Office, or at TennCare.

      Telephone numbers are:
      East Tennessee: 1.888.310.4613
      Middle Tennessee: 1.800.535.9725
      TennCare DLTC: 1.877.224.0219
        DIDD Division of Customer Focused Services
        Dr. Michael Mailahan, CFS Coordinator & Rule 31 Mediator 1.865.588.0508 ext. 236
        Chaneth Quemore, CFS Coordinator 1.865.588.0508 ext. 228

RECEIPT OF GREIVANCE PROCEDURE

My signature below indicates that I have received a copy of the BetterLives LLC Grievance Procedure and that I understand how to file a grievance.

Individual Name is required.

Individual Signature

Clear Signature

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Date is required.
Instructions:
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Representative Signature

Clear Signature

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Date is required.
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Relationship to Individual is required.

Photo / Video Release

I, give BetterLives LLC permission to photograph or video

I authorize BetterLives LLC Co. and BetterLives LLC's community partners to use and publish those photographs or videos in print or electronically.

I agree that BetterLives LLC and/or community partners may use such photographs for any lawful purpose, including but not limited to staff training, visual supports, publicity, marketing, social media and web content.

Individual Name is required.

Individual Signature

Clear Signature

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Date is required.
Instructions:
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Representative Signature

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Relationship to Individual is required.

Updated Contact List

Person Supported is required.

Parent / Conservator / Guardian

Name(s) is required.
Address is required.
Phone Numbers is required.
Please provide a valid email.

ISC

Name(s) is required.
Address is required.
Phone Numbers is required.
Please provide a valid email .

Natural Supports

Name(s) is required.
Address is required.
Phone Numbers is required.
Email is required.

Therapy Provider

Name(s) is required.
Agency is required.
Address is required.
Phone Numbers is required.
Please provide a valid email .

Therapy Provider

Name(s) is required.
Agency is required.
Address is required.
Phone Numbers is required.
Please provide a valid email .

Individual Support Planning Meeting Notes

Person Supported is required.
Please provide a valid date .
Please select an option.
Please enter a valid topics discussed.
(1) Followup Needed is required.
Person Responsible is required.
Due by is required.
(2) Followup Needed is required.
Person Responsible is required.
Due by is required.
(3) Followup Needed is required.
Person Responsible is required.
Due by is required.
(4) Followup Needed is required.
Person Responsible is required.
Due by is required.
(5) Followup Needed is required.
Person Responsible is required.
Due by is required.
Please select an option.
Print is required.

Signature / Title

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Print is required.

Signature / Title

Clear Signature

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Date is required.
Instructions:
• Use your mouse or finger to sign
• Sign clearly within the box
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Print is required.

Signature / Title

Clear Signature

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Date is required.
Instructions:
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• Sign clearly within the box
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Print is required.

Signature / Title

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Date is required.
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Release to Contact Employer

, give BetterLives LLC Supported Employment Staff, permission to communicate with employers on my behalf during my job search for some or all of the following reasons:

Contact or speak with employers on my behalf regarding employment

Complete and submit applications

Attend interviews with job seeker

Participate in training

Speak with employers about my disability, if deemed necessary

Disclaimer We at BetterLives LLC will not do or say anything that we feel will negatively impact the chances of obtaining employment. We will not disclose any information that you do not wish to be shared.

Please enter a valid i do not want the following information to be disclosed during employment search and maintained by anyone other than myself.
Individual Name is required.

Individual Signature

Clear Signature

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Date is required.
Instructions:
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Representative Signature

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Rights, Eligibility, Planning, Grievances and Appeals Information

Department of Intellectual and Developmental Disabilities (DIDD) Website: www.tennessee.gov/ didd. This website has the entire Medicaid Waiver Operations Manual and other information about DIDD for your reference. The information below was taken from this website:

Rights Applicable to All People with Disabilities: People with intellectual and developmental disabilities have the same rights as other people unless their rights have been limited by court order or law. Individuals do not give up their rights when they accept services from DIDD or other state programs. There are basic human and civil rights that are protected by the constitution and state and federal laws. Many of the laws take the form of protecting people from discrimination. The Americans with Disabilities Act is an example of such a law. People with intellectual and developmental disabilities should be treated fairly and equally when service are being developed and provided.

Individual Rights: DIDD persons served shall be entitled to the following rights without limitation:

1) To be treated with respect and dignity as a human being
2) To have the same legal right and responsibilities as any other person unless otherwise limited by law
3) To receive services regardless of gender, race, creed, marital status, national origin, disability or age
4) To be free from abuse, neglect and exploitation
S) To receive appropriate quality services and supports in accordance with the Individual Support Plan (ISP)
6) To receive services and supports in the most integrated and least restrictive setting that is appropriate based on the Person's particular needs
7) To have access to DIDD rules, policies and procedures pertaining to services and supports
8) To have access to personal records and to have services, supports and personal records explained so they are easily understood
9) To have personal records maintained confidentially
10) To own and have control over personal property, including personal funds
11) To have access to information and records pertaining to expenditures of funds for services provided
12) To have choices and make decisions
13) To have privacy
14) To receive mail that has not been opened by provider staff or others
15) To be able to associate, publicly or privately, with friends, family and others
16) To have intimate relationships with other people of their own choosing
17) To practice the religion or faith of one's choosing
18) To be free from inappropriate use of physical or chemical restraint
19) To have access to transportation and environments used by the general public
20)To be fairly compensated for employment
21)To seek resolution of rights violations or quality of care issues without retaliation
■ The Right to Have a Provider of Your Choice and to have Grievances Addressed: The individual has the right to choose from a list of available providers of services. If the individual is not satisfied with the services provided by an agency, they should try to resolve the concern with the agency. Each agency that provides services through the DIDO program has a policy for addressing grievances of the individual. You should be provided with a copy of their Grievance Policy. At any time, the individual can ask their Independent Support Coordinator (ISC) for assistance in resolving the concern. If the ISC cannot help, the person or family can file a complaint. A complaint can be filed at any time through the DIDO Division of Customer Foc:;used Services, DIDD Regional Office, the DIDD Central Office, or at Tenncare. Telephone numbers are: East Tennessee-1-888-310-4613, Middle Tennessee-1-800- 535-9725, Tenncare DLTC- 1-877-224-0219.

DIDO Division of Customer Focused Services
Dr. Michael Mailahn, CFS Coordinator & Rule 31 Mediator 1-865-588-0508 EXT.236
Chaneth Quemore, CFS Coordinator 1-865-588-0508 Ext. 228
Medicaid Waiver Appeals: If a person has a complaint about services through the Statewide Wavier, Managed Care Organization, Behavioral Health Organization, or pharmacy, an appeal can be filed. This can be done if services are denied, delayed, changed organization some way or some event impacts the quality, timeliness, or availability of the service. When this happens, the state will send a letter outlining the right to appeal, how to appeal and how long the person has to begin the appeal. The ISC can assist you with an appeal if this is desired. Questions about an appeal can be directed to the ISC or to the Bureau of TennCare Solutions Unit at 1-800-878-3192.

Concerns Related to Abuse, Neglect or Mistreatment: Report to East - 1-800-579- 0023, Middle - 1-888-633-1313, West - 1-888-632-4479. Title VI of the Civil Rights Act of 1964: Title VI of the Civil Rights Act of 1964 prohibits discrimination in programs that utilize federal funds. Medicaid waivers are an example of programs that are partially funded with federal dollars. The Department of Intellectual and Developmental Disabilities (DIDO), as well as providers who sign provider agreements with DIDD, must comply with Title VI requirements. DIDO and DIDO providers must not exclude persons, deny benefits to or otherwise discriminate against applicant for services or persons served based on race, color or national origin in the admission to or participation in any of its

Programs and Activities. Prohibited Practices: Prohibited practices include but are not limited to the following:
1) Denying any service, opportunity or other benefit for which an applicant or person served is otherwise qualified
2) Providing any applicant or person served with any service or other benefit which is different or is provided in a different manner from that which is provided to others in the same program
3) Subjecting any person served to segregated or separate treatment in any manner related to their receipt of any service
4) Restricting any person served in any way in the enjoyment of services, facilities or any other advantage, privilege or benefit provided to others in the same program
5) Adopting methods of administration that would limit participation or subject any group of applicants or persons served to discrimination
6) Addressing an applicant or person served in a manner that denotes inferiority because of race, color or national origin
7) Subjecting any applicant or person served to racial or ethnic harassment, to a hostile racial or ethnic environment or to a disproportionate burden of environmental health risks

Title VI Complaints: A Title VI complaint may be filed by a person served, a person's family member, a person's legal representative or an agency or service center case manager or other entity acting on the person's behalf. The person served or other entity filing the complaint does not have to be the victim of discrimination. Title VI complaints may be submitted in writing to the Local (provider) Title VI Coordinator, the DIDD Regional Office Title VI Coordinator or the DIDD Central Office Title VI Coordinator at the Office of Civil Rights, Department of Intellectual and Developmental Disabilities located in Atlanta at 404-562-7881. A person filing a Title VI complaint has the right to file the complaint with the federal Office of Civil Rights at any time. Complaints with the Department of Intellectual and Developmental Disabilities or the Department of Human Services must be filed no later than 180 calendar days after the alleged discriminatory event.
Complaints may be filed by letter or by completing the Title VI Complaint Form.

Responsibilities: Along with rights, there are certain responsibilities and requirements that persons served and their families must understand. State and federal Medicaid rules state:
1) A physical examination must be conducted every 1 to 3 years as required
2) A form must be completed each year to document the need for continuing waiver services
3) Financial information must be provided each year for annual redetermination of the Medicaid financial eligibility
4) The person served and family are required to allow state and federal staff to visit them at home, talk with them and their staff, and review their personal records for the purpose of assessing the quality of services being delivered and the persons served safely in the community
5) The person served/family will be visited in the home several times a year by the ISC to ensure that the ISP is being implemented
6) The person served/legal representative will be asked to participate in the selection of the Circle of Support members and will be invited to and encouraged to participate in the ISP planning meetings. Additionally, DIDD requires that a uniform assessment be completed at least every two years for all DIDD persons served.
Items 4, 5 and 6 above apply to state funded persons served also.

The ISP and the Planning Process: The Individual Support Plan (ISP) is person-centered in that it provides an individualized, comprehensive description of a person served, as well as guidance for achieving outcomes which are important to that person in achieving a good quality of life and integration in the community. The ISP is “owned” by the person served and his or her family. The person served and supporter are expected to participate in the planning process to the greatest extent that they are able. The person served may participate in planning on their own or with the support of a "Circle of Support."
The Circle of Support (COS) is a group of individuals who assist the person served share information and make important decisions. The COS is person-centered and person-driven. The COS makeup is determined by the person served. The individual and/or their legal representative decide who is invited to be a member. The individual or their legal representative is the individual with final decision-making authority in the COS regarding whom to include (such as family members, friends, professionals, or others). DIDD staff (including ISC staff) and provider staff may be asked by the person served to participate as members or may be required for planning meetings to explain programs or services. Staff who attend to speak to topic areas but not as support are not considered COS members.
Decisions made by the COS may relate to medical choices, residential planning, daily routines, personal goals, staffing, employment, and other major issues or goals. The responsible parties, natural supports, provider agency representatives, and ISC staff should assure that the person served and/or their legal representative fully understand the importance and requirements for participation. No one is required to be a COS member to support or influence the decisions or selection of services.

RECEIPT OF INFORMATION
My signature below indicates that I have received a copy of the above information and that it has been reviewed with me.

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Section I. BETTERLIVES DUTY AS A COVERED ENTITY UNDER THE PRIVACY RULE.

A. BETTERLIVES is required by Federal Law to maintain the privacy of your PHI. We are also required to provide notice to individuals of the possible uses and/or disclosures of their PHI.

B. BETTERLIVES is also required to provide notice of our legal duties and privacy practices with respect to PHI and to abide by the terms of the Privacy Notice.

C. Changes to this Notice. BETTERLIVES reserves the right to change this notice. We reserve the right to make the revisions effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our vocational centers/administrative unit. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, you may request a copy of the current notice at any time.

D. Complaints. If you believe your privacy rights have been violated, you may file a complaint with BETTERLIVES. All complaints must be in writing to your QP/PM or the Privacy Office of BETTERLIVES at the appropriate address indicated on the first page of this Privacy Notice.

YOU WILL NOT BE PENALIZED NOR IN ANY WAY RETALIATED AGAINST, FOR FILING A COMPLAINT.

Section II. NOTICE OF PHI USES AND DISCLOSURES.

The following categories describe different ways that we may use and disclose PHI.

A. Uses and disclosures to carry out Treatment, Payment and Health Care Operations.

BETTERLIVES will use PHI as we carry out treatment, payment and healthcare operations.

1. Treatment. PHI will be used to provide you with medical treatment. “Treatment” is the provision, coordination, and management of health care and related services. It includes, but is not limited to, consultations and referrals between one or more of your providers. We may disclose medical information about you to direct support staff, nurses, technicians, doctors, providers of support services, and other personnel involved in your treatment.

2. Payment. PHI will be used and disclosed to obtain payment for the medical care that you receive from BETTERLIVES in our healthcare facilities. However, disclosure of such information will be limited to those state and federal programs to which you are involved, such as your health insurers. 'Payment' includes, but is not limited to, actions to determine your eligibility for MEDICAID benefits, billing, and to process payment for treatment or services received from BETTERLIVES. For example, BETTERLIVES may disclose PHI for verification of payment eligibility or to receive payment for our services by governmental services. BETTERLIVES will not disclose your PHI to any private third-party payors nor health or benefit plans without your consent.

3. Health Care Operations. Where permitted by state and federal laws, BETTERLIVES may use and disclose your PHI to operate our business. “Health care operations” refer to activities that allow us to improve the quality of care and evaluate the performance of our staff involved in care and treatment, conduct or an audit to further their skills as healthcare providers, and for service quality improvement or behavioral programs. Health care operations also include: business management and general administrative activities; business planning and development; customer service; resolution of complaints; grievances; legal services; audits and compliance programs; business management, and general administrative activities. We may share relevant medical information with other BETTERLIVES providers or agents. For instance, information may be shared to review the quality and appropriateness of the care provided or to develop better ways to provide our services. We may use your information for case management, activities to provide higher quality care, coordinate services, or study healthcare services that our clients receive by working with the state agencies who may assist in the study information and services over time.

B. Other uses and disclosures that do not require your authorization.
1. Subject to certain requirements, BETTERLIVES may use or disclose PHI about you in certain limited situations

without your prior authorization. These situations include:

a. Public Health. BETTERLIVES may use or disclose your PHI for public health activity purposes to a public health authority where permitted under state and federal law. For example, PHI may be disclosed when necessary for the reporting of adverse events, medical device defects or problems, or biological product deviations, or to track FDA-regulated products, to enable product recalls, or to conduct post-marketing surveillance. BETTERLIVES may also disclose your PHI, if authorized by state or federal law, if you have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

b. Required by Law. BETTERLIVES may disclose your PHI when required to do so by law, for example, when such disclosure is required by state or federal law or other judicial or administrative proceeding.

c. Law Enforcement. In accordance with state and federal law, BETTERLIVES may disclose PHI about you for law-enforcement purposes. For example, BETTERLIVES may disclose PHI about you as necessary to comply with laws that require reporting of certain types of wounds or other physical injuries.

d. Abuse or neglect. Where authorized by state and federal law, BETTERLIVES may report information about abuse, neglect or domestic violence to public authorities or other appropriate government authorities that are authorized by law to receive such reports. BETTERLIVES will often inform you of the disclosure unless doing so could cause a risk of harm.

e. Public health oversight activities. Where authorized under state and federal law, BETTERLIVES may disclose PHI about your for healthcare oversight activities. For example, BETTERLIVES may disclose PHI to a health oversight agency for such activities as audits, investigations (civil, administrative, or criminal), inspections, licensure, or other activities necessary for appropriate healthcare oversight.

f. Judicial or administrative proceedings. In certain limited situations, we may use or disclose PHI in response to a valid judicial or administrative orders. orders of the court. and in response to a subpoena, discovery request, or other lawful process.

g. Medical research. Under certain circumstances, we may disclose PHI about you for medical research.

h. Coroners, Funeral Directors, and Organ Donation. Where permitted under state and federal law, BETTERLIVES may disclose PHI about you to a coroner or medical examiner for the purpose of identifying you should you die, identifying the cause of death, or performing other activities authorized by law. BETTERLIVES may also disclose protected health information to a funeral director, as authorized by state and federal law, in order to permit the funeral director to carry out his or her duties. PHI may also be used and disclosed for cadaveric organ. eye, or tissue donation purposes.

i. Workers' compensation. BETTERLIVES may disclose your PHI as necessary to comply with state workers' compensation laws or other similar programs established by law.

j. Serious threat to health or safety. BETTERLIVES may disclose PHI. consistent with applicable law and standards of ethical conduct, if necessary to prevent or lessen a serious threat to health and safety. For example, the BETTERLIVES professional responsible for your care may disclose PHI about you to prevent or lessen a serious and imminent threat to the health or safety of a person or the public in general.

k. Specialized governmental functions. When the appropriate conditions apply, and where required under state and federal law, we may disclose PHI about you if it relates to military and veterans' activities, national security and intelligence activities. and protective services for the President

l. Inmates. We may, consistent with applicable law, use or disclose PHI about you as it relates to correctional institutions and law enforcement custodial situations Involving you. For example, we may disclose such information if necessary for the provision of healthcare to you in a correctional institution.

m. Uses and Disclosures for Involvement in Your Care and Notification Purposes. In certain circumstances, and consistent with state and federal law, we may release PHI about you to your next of Kin, family member(s) with a legitimate role in your care, or any other person authorized by you to receive your PHI, so long as the professional responsible for your care at BETTERLIVES has not determined that such release of information would be harmful to your physical or mental well-being or that the intended recipient of the information lacks a legitimate need for it. You will have the right to object to these types of disclosures.

n. Emergency. As permitted by federal and state law, BETTERLIVES may disclose your PHI in emergency treatment circumstances involving you.

C. Uses and disclosures that require your written authorization. Except for the general categories of uses and disclosures of PHI for Treatment, Payment and Health Care Operations and other special situations described above, we must obtain your written authorization. For example, except in limited situations, a separate authorization will be obtained before BETTERLIVES will use or disclose your psychotherapy notes. Psychotherapy notes are separately filed notes about your conversations with your mental health professional during a counseling session. They do not include summary information about your mental health treatment.

You may cancel an authorization whenever you choose as long as your withdrawal is in writing. If you cancel your authorization, we will no longer use or disclose PHI about you for the reasons indicated in the authorization. You understand that we are unable to take back any disclosures we have already made prior to your cancellation.

Section III. NOTICE OF YOUR INDIVIDUAL RIGHTS.

A. You have the right to Request Restrictions on the Uses & Disclosures of your PHI. You may request BETTERLIVES restrict your PHI to carry out treatment, payment or health care operations or to restrict uses and disclosures for other reasons. You can request restrictions for family members, relatives, friends or other persons identified by you who are involved in your care or payment for your care. Under federal law, we are not required to agree with your request. However, even if we agree with your requested restrictions, in certain situations your restrictions may not be followed, including emergency treatment, disclosures to the Secretary of the Department of Health and Human Services, and the uses and disclosures described in Section II, B above.
  1. Your request must be in writing.
  2. Please direct such requests to the QP/PM/PM and/or the Privacy Officer.

B. You have the right to Inspect and obtain a Copy of your PHI in designated record sets. With some exceptions, you have the right to inspect and copy your PHI contained in a 'designated record set' as long as BETTERLIVES maintains your information.
  1. A 'designated record set' includes your medical record, billing records, payment, billing and adjudication documents, records of case management contact with you, and other records used to make decisions about your benefits.
  2. There are certain situations in which we are not required to comply with your request. Under these situations, we will respond to your request accordingly; we may not grant your request and will describe any rights you may have to request a review of our denial.
  3. Your request must be in writing and made to the QP/PM/PM and/or the Privacy Officer.
  4. We may charge a reasonable, cost-based fee, for the costs of copying, mailing and/or other supplies associated with your request.

C. You have the right to have your PHI amended. You have the right to request that we make amendments to clinical, billing, and other records used to make decisions about you. Your request must be in writing and must explain your reason(s) for the amendment. The request must be made to the QP/PM/PM and/or Privacy Officer. We may deny your request if it is not in writing, does not include a reason to support the request, or you ask us to amend information that:
  1. Was not created by us (unless you prove the creator of the information is no longer available to amend the record);
  2. Is not part of your designated recordset;
  3. Is not part of the information which you would be permitted to inspect and copy; or
  4. We believe is accurate and complete.
If we deny your request, we will put in writing the reasons for the denial and describe your rights to give us a written statement disagreeing with the denial.

D. You have the right to receive an Accounting of PHI Disclosures made by BETTERLIVES. At your request BETTERLIVES will provide you with an accounting of disclosures during the six-year period prior to the date of your request. Your written accounting request should be made to the QP/PM/PM and/or the Privacy Officer. However, such accounting will exclude limited PHI disclosures made:
  1. For your treatment;
  2. For billing and collection of payment for your treatment;
  3. For our healthcare operations;
  4. Made to or requested by you, or that you authorized;
  5. Occurring as a byproduct of permitted uses and disclosures;
  6. Made to individuals involved in your care, when the use and/or disclosure relates to certain specialized government functions or correctional situations (such as disclosure to correctional institutions and in other law enforcement custodial situations (please see Section II, B above); and
  7. As part of a limited set of permissible disclosures for national security which would identify you.
If you request more than one accounting within a 12-month period, BETTERLIVES will charge a reasonable cost-based fee for each additional request.

E. You have the right to request a Paper Copy of this notice. You have the right to request that we provide you with a paper copy of this notice. We will provide a paper copy upon request. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy. You can obtain a paper copy of the notice by contacting the QP/PM/PM or the Privacy Officer.


ACKNOWLEDGMENT OF THE BETTERLIVES NOTICE OF PRIVACY PRACTICES

BETTERLIVES's commitment to you is to handle your health information with discretion and protect your legal rights. If you have any questions regarding our privacy policies or procedures, please contact your QP/PM/PM at the following address and phone number:
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INSTRUCTION FOR PERSON SUPPORTED, PARENT, LEGAL REPRESENTATIVE, PERSONAL REPRESENTATIVES:
  1. Enter your name, signature, and today’s date in the spaces below. Return this page to your QP/PM.
  2. If you prefer not to sign this page we will note that and continue to ensure the privacy of your health information.
  3. Please keep the prior pages of this Privacy Notice as your copy. If you would like a copy of this signature page, one will be provided.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES:

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Community Living HANDBOOK

The people we support desire to live in a place of their own. They desire to select their home and select with whom they live. The people we support can and do live in our communities but often must be afforded needed supports to live successfully.

Our staff continually provides needed supports to both the person supported and the family as both deals with “day to day issues” of living apart.

BetterLives believes in the people we support ability to make good decisions given the people have good information and needed information about what is available. It is expected that the person supported must receive needed information about what is available, what is expected and what the person supported must do to live in the home of their choice.

We believe in treating the person supported with dignity and respect and are committed to the “whole” person. Staff will assist where the person supported lives and have the right to choose their own house, their doctor, case manager, family involvement, their job of choice and their “unique lifestyle”.

BetterLives staff will assist you in the development of your independent living skills. You will participate and learn different types of cleaning skills, laundry skills, cooking skills, money skills, menu planning and many more.

This handbook is your guide to the Community Living program. We hope your experience in the Community Living program helps you to be the best that you can be.

Introduction


Our Mission: BetterLives provides services that enable adults with intellectual and developmental disabilities to lead purposeful lives.

Our Mission: BetterLives: The model of excellence for adults with intellectual and developmental disabilities.

Our Mission: BetterLives-improving the lives of adults with intellectual and developmental disabilities.

It is the goal of the Community Living program to help you reach your highest level of independence. BetterLives staff are there to assist and support you whenever you may need them, but you are the main decision maker. BetterLives strives to provide a clean and safe living environment that will meet your needs and expectations.

BetterLives policy does not discriminate against people. BetterLives treats everyone fairly, regardless of race, age, religion, color, sex, national origin, veteran, or military status, disability, sexual orientation, or gender identity or expression.
BetterLives's Residential Sites
BetterLives is a not-for-profit organization. Our agency provides residential services in Tennessee. Residential services includes: Supported Living.

In the Community Living you will rent or own your own home and receive up to twenty-four (24) supports from the staff at BetterLives.

Eligibility for Services
  1. Be at least 18 years old.
  2. Have a documented disability that qualifies you to receive services.
  3. Be willing to complete all evaluations (medical and psychological) as required.
  4. You must be willing to care for your personal needs with some or no assistance. Additional assistance will be provided as identified in your ISP (Individual Support Plan/ Individual Service Plan).
  5. You must not be harmful to yourself or others.
  6. You must follow all rules of conduct for the home in which you live. (HUD requires that all group homes have rules posted in each home).
  7. You must attend a day program, or work unless you receive In-Homeservices.
  8. Be willing to help decide what your goals will be and try to reach your goals.
  9. In addition to the above, you must meet any/all other eligibility standards as required.

Termination of Services
You may be terminated from services if:

  1. You or your conservator request termination of services.
  2. You lose your funding for services, if applicable.
  3. You repeatedly break house rules.
  4. You become a danger to yourself or to others.
  5. When a determination is made that BetterLives cannot meet your needs as requested by you, your family, conservator or your Circle of Support.

Service Fees
You may receive funding from the state in which you live to cover all or most of the cost of your residential services at BetterLives. Your funding will determine what services they are willing to pay for. For example, some people are funded for day services at a vocational work site. Others are funded for personal assistance or community based day services. You may be funded to live in a home of yours and receive supported living services. Funding determines what services you receive based on your need. BetterLives cannot provide any service that is not funded.
Who Are The BetterLives Staff Members?
The BetterLives staff members who will work with you while you are at BetterLives are the:
▶  Directors and Coordinators of all services.
▶  Community Living Manager
▶  Direct Support Professional
▶  Case Manager

Your Case Manager helps you find out what you want to learn and are able to do, and then helps you develop a service plan to reach these goals.

Direct Support Professional will teach you new skills and ways to get along with your housemates. This person will work with you most of the time.

BetterLives staff will strive to meet your identified needs. Staff will work with you to identify your needs and to continually assess those needs. If we are unable to meet your needs, we will assist with referrals to other services.

Staff Training:
All BetterLives Staff receive on the job training throughout the year. Staff is trained in First Aid, CPR, communication skills and all guidelines required by the state of Tennessee. Staff is also trained to protect your health and safety, to treat you with kindness and respect and to meet your individual needs. Please tell someone if you ever feel you were treated unkindly.

Getting Started In a Residential Program
Before you come to our agency, staff will gather information from you and/or your conservator to qualify you for services. We will schedule an appointment with you and your family to give you information about our services and provide a tour through our Community Living homes. If it is determined that we can provide you a service, you and your staff will decide how BetterLives can best evaluate your needs.

▶  You will spend the first month getting to know the home, your housemates and your staff.
▶  You will spend time with your staff learning safety. You will learn things like: how to leave the home and where to go in case of an emergency, where the exits of the home are, where first aid kits are located and what you should do in case there is a fire in your home.
▶  You will spend time learning about your rights and responsibilities as an person in the residential home.
▶  You will learn about the weekly and evening schedules in the home and be given the opportunity to join in choosing weekend activities as well as selecting your meals for the home, transportation to and from work and your scheduled activities, values including taking pride in yourself, your appearance and how to assist in keeping your home clean.

Once you settle into your home you will meet with Community Living staff.
Staff will:
▶  Find out what you like and want to do both at the home and in the community.
▶  Watch how you take care of yourself and how you get along with others.
▶  Help you set your goals and teach you how to work toward reaching and obtaining your goals.
▶  Help you find out what you do well and where you need assistance.
▶  You will be provided an opportunity to have a key to your home, please inform your Community Living manager and one will be provided to you.

Then What?
A meeting will be held with you and other people you choose who are interested in your residential success. Other people involved in helping you be successful should attend so they can learn how to support your efforts. Those individuals may include:
▶  Your parents, other family members or conservator
▶  Your agency and/or State Case Manager
▶  Your Community Living Manager, Coordinator, and Director
▶  Your Direct Support Staff
▶  A friend

Your Service Plan
You and this team of people will have things to do, and your staff will have things to do. All of this will be written down and you and your staff will review your plan often to make sure everybody is doing what is expected. Should someone not be following the plan, a meeting (Circle of Support) will be called to talk about concerns.

Your plan will identify how often you will meet with your team to review your progress. In addition, you will meet with your agency Case Manager regularly to:
▶  Talking about progress and feeling safe at home.
▶  Discussing ways to improve.
▶  Setting new goals.
▶  Addressing questions or concerns.
▶  Making necessary changes to one's plan.

A team will support your needs and desires to become and remain successful. You are the most important team member and you are responsible to contribute to your success. For example, you may prefer not to clean your bedroom, but it is important to understand that BetterLives expects you to share in the upkeep of your home. All other team members are just as responsible to complete their tasks for your success. If you are unable or unsure how to clean your bedroom, inform your staff and they will assist you.

PROCEDURES FOR ON-SITE SERVICES

Your Schedule:
Supported employment services are provided based on your employer’s schedule. Community Living services provide in-home services for scheduling community activities and volunteer work.

Hours of Operation:
Community Living staff are available twenty-four (24) hours a day, seven (7) days a week.
365 days a year.

Transportation:
BetterLives provides transportation at residential sites. You are expected to follow safety rules while being transported in BetterLives vehicles or staff’s vehicles.

Bad Weather:
Transportation will not be provided if roads are covered with snow or ice. The Community Living Manager will explain the bad weather schedule.

Your Money:
BetterLives provides payee services for individuals and offers administrative help with this process. You will have a money folder that is locked in the home. This money will be used for all community activities and or special events. Receipts will be obtained / kept for all money spent.

Injuries and Treatment:
If you hurt yourself, no matter how minor, tell your staff right away. Never wait. Your staff may have you seek medical attention.

Medications:
BetterLives staff must be aware of any and all medications that you are taking. BetterLives must have a copy of the medication order from your doctor for the medications that you take. This is to include any and all “over the counter” medications also. It is required that you go to the doctor for an annual physical. Your doctor should send a copy of this report or any other medical reports to BetterLives. You may also need to update your immunizations (shots that keep you from getting sick).

Disaster Training and Drills:
All people will be trained on what to do in the event of a fire, natural disaster and other emergency drills. This will be specific to the home in which you live. Fire drills will be conducted monthly and will occur at different times of the day or night each month. All drills should be taken seriously and treated as if it is a real disaster. These drills train you on what to do in a real disaster. Red exit signs in each group home mark doors in each area of the home and evacuation routes are posted in each area. Your staff is trained in fire drills and knows what to do in a real disaster. If you do not understand what to do during a drill, please ask staff to help you. Your safety is your staff’s main priority and they will be happy to help you.

Fire Drill:
During a fire drill you will hear a loud alarm and may see the alarm lights flashing, if applicable to the home. In a fire drill you should:
    1. Use the nearest exit to leave the building.
    2. Walk slowly and calmly outside with the staff.
    3. Stay with your housemates and staff. Listen to the direction of the staff.
    4. Do not go back into the home.
    5. Staff will tell you “all clear” when it is safe to go back inside the home.

Bomb Threat:
A Bomb threat is like a fire drill because you go outside. Your staff will inform you when you are having a bomb threat drill, and give you instructions. In a bomb threat drill you should:
    1. Use the nearest exit to leave the home.
    2. Walk slowly and calmly outside with staff and housemates.
    3. Stay with your group; listen to the direction of staff.
    4. Do not go back into the home.
    5. Staff will tell you “all clear” when it is safe to go back inside your home.

Violent/ Threatening Situation:
All staff is trained to respond to potentially violent or violent situations. When this occurs:

▶  You will keep all civil/legal rights as given you by state and federal law. No employee of BetterLives can take away these rights just because you get services from BetterLives.
▶  You cannot be denied services because of your race, religion, sex, ethnic origin, age, disability or ability to pay.
▶  You have the right to state a concern or problem to:
    • Any BetterLives staff person
    • The State Licensure Board
    • Any outside representatives like your advocate or Independent Support Coordinator (if you have one)
    • Anyone else you choose.
▶  No BetterLives staff person will try to stop you from stating your problem. Staff will not harass or threaten you or punish you from stating a concern.
▶  Staff will address every problem you share.
▶  You also have the right to hire a lawyer to present your concerns to BetterLives.
▶  You have the right to receive services free from neglect or any form of abuse.
▶  You have the right to receive services timely. Any service you receive will be explained to you.
▶  You have the right to help develop your goals.
▶  Staff will talk to you about any suggested changes to your plan before any changes are made.
▶  You have the right to refuse participation in:
    • Community activities
    • Cultural activities
    • Educational activities
    • Recreational activities
▶  Your right to refuse to participate in activities may be changed or limited if:
    • Changes are necessary because of your mental or physical condition.

Needed Copies of Documents

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CONSENT TO RECEIVE PROFESSIONAL SUPPORT SERVICES

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As my own legally responsible person, I consent / do not consent (check one) to receive Professional Support Services through the provision of nursing related services and/or any other service defined as professional support services (PT, OT, SLP, etc.) by BetterLives, LLC. I understand that for the purpose of treatment, RHA staff will be sharing information with and obtaining information from physicians, hospitals and any other medical service provider involved in the provision of medical services to me.

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to receive Professional Support Services through the provision of nursing related services and/or any other service defined as professional support services (Nursing, PT, OT, SLP, etc.) by BetterLives TN, LLC. I understand that for the purpose of treatment, BetterLives staff will be sharing information with and obtaining information from physicians, hospitals and any other medical service provider involved in the provision of medical services to the individual named above.

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