381-230 — Client Rights, Admission Disclosures and Informed Consent

1.Policy Objective

1. Policy Objective

Harbor Home Healthcare LLC (“Harbor”) shall establish, implement, and maintain written procedures that protect and promote each client’s rights before admission, during service delivery, and at discharge or termination of services. Harbor shall ensure that each client or client designee receives required rights information, admission disclosures, complaint procedures, advance directive information, and informed consent materials in a manner reasonably understandable to the client or designee. (; )

Harbor provides non-skilled home care services, including personal care and respite services. Harbor shall not represent its services as skilled nursing, therapy, medical social work, or pharmaceutical services unless separately licensed, authorized, and staffed to provide such services. This policy applies to Harbor’s non-skilled home care operations and shall be interpreted consistently with Harbor’s licensed scope of services.

Requirements

1.1 Harbor shall maintain written policies and procedures regarding the rights of clients. ()
1.2 Harbor shall review client rights with the client or client designee upon admission and document the review in the client record. (; .7)
1.3 Harbor shall assure each client the rights required by , including privacy, confidentiality, freedom from abuse, participation in care planning, trained personnel, grievance rights, payment information, fee-change notices, advance directive information, and termination notice.
1.4 Before care is initiated, Harbor shall inform the client or client designee orally and in writing of the required service, billing, cancellation, reduction, and refund information required by .
1.5 Harbor shall obtain informed consent and required acknowledgments before services begin, unless an urgent circumstance requires documentation as soon as reasonably possible after service initiation. (.3; .2)
1.6 Harbor shall provide advance directive information before the start of services. (.9; .4)
1.7 Harbor shall provide complaint procedure information at admission, including the Harbor contact person, State Ombudsman contact information, and OLC Complaint Unit contact information. ()
1.8 Harbor shall maintain documentation supporting compliance with this policy in the client record and controlled policy manual. (; )

Definitions

Client Rights means the protections and rights guaranteed to individuals receiving services from Harbor under .
Client Designee means an individual identified by the client or legally authorized to receive information or act on behalf of the client, as applicable.
Representative means an individual legally authorized to act on behalf of the client, including an authorized representative, agent, guardian, or other legally recognized decision-maker, as applicable.
Admission Disclosures means oral and written information provided before care begins regarding the nature and frequency of services, purpose of services, fees, billing, payment, cancellation or reduction of services, and refund policies. ()
Informed Consent means the documented acknowledgment by the client or representative that Harbor explained the proposed non-skilled services, client rights, responsibilities, disclosures, and applicable service agreement terms, and that the client or representative agrees to proceed.
Advance Directive Information means information provided to the client before the start of services regarding advance directives, including Durable Do Not Resuscitate Orders, as applicable. (.4; .9)

Implementation Guidance

A1 Harbor may combine client rights acknowledgments, admission disclosures, service agreements, informed consent forms, advance directive notices, and complaint procedure acknowledgments into one admission package, provided each required element remains clearly identifiable.
A1.1 If Harbor uses an online admission package, the electronic version must preserve all required rights, disclosures, acknowledgments, signatures, timestamps, and final PDF copies in the client record.
A1.2 Harbor should avoid using vague acknowledgments such as “client received paperwork.” The record should identify the specific forms reviewed and signed.

2.Scope & Application

2. Scope & Application

This policy applies to the Governing Body, Administrator, intake/admissions personnel, supervisors, coordinators, personal care aides, respite staff, contractors, and any other personnel involved in client admission, service coordination, service delivery, complaints, discharge, or termination of Harbor services. (; )

Requirements

2.1 Personnel involved in admissions shall follow Harbor procedures for client rights review, admission disclosures, informed consent, advance directive information, complaint procedure distribution, and required acknowledgments. ( Ref: 5)
2.2 Personnel shall protect and support client rights during all phases of service delivery. ()
2.3 Personnel shall immediately escalate suspected client rights violations, abuse, neglect, exploitation, privacy breaches, serious complaints, or service termination concerns to the Administrator or designee. (.9; ; Ref: 5.6)
2.4 This policy applies to Harbor’s non-skilled home care services, including personal care and respite. It does not authorize Harbor personnel to provide skilled nursing, therapy, medical social work, or pharmaceutical services outside Harbor’s licensed scope.
2.5 When a payer, program, managed care organization, or service authorization imposes stricter admission, consent, notice, or documentation requirements, Harbor shall follow the stricter applicable requirement.

Implementation Guidance

A2 Harbor may communicate rights verbally and in writing when necessary to support understanding. Translation, large print, caregiver explanation, or representative review may be used when appropriate.
A2.1 If a client refuses to sign an acknowledgment, Harbor should document the refusal, the information provided, the date, the staff member involved, and any witness or representative present.

3.Regulatory Basis

3. Regulatory Basis

This policy directly implements , Client Rights, of the Virginia Regulations for the Licensure of Home Care Organizations. It also supports related requirements for written policies and procedures, complaint handling, and client record documentation. (; ; )

Requirements

3.1 Harbor shall establish and implement written policies and procedures regarding client rights. ()
3.2 Harbor shall review client rights with the client or client designee upon admission and document the review in the client record. (; .7)
3.3 Harbor shall ensure written procedures address each required client right listed in .
3.4 Harbor shall provide required oral and written admission disclosures before care is initiated. ()
3.5 Harbor shall maintain complaint handling procedures and provide required complaint contacts at admission. ()
3.6 Harbor shall maintain an accurate and complete client record for each client receiving services. ()

Implementation Guidance

A3 Section 8 serves as the regulatory traceability index for this policy and should be reviewed whenever this policy is revised.
A3.1 This policy should be read together with Harbor’s complaint handling, client record, admission/discharge/termination, financial procedures, mandated reporting, and advance directive policies.

4.Roles & Responsibilities

4. Roles & Responsibilities

4.1 Governing Body

4.1.1 The Governing Body shall approve this policy and oversee Harbor’s compliance with client rights, admission disclosure, and informed consent requirements. (; )
4.1.2 The Governing Body shall ensure this policy is reviewed at least annually and that recommended changes are submitted for approval as necessary. ()

4.2 Administrator

4.2.1 The Administrator shall implement systems to ensure client rights are reviewed, required disclosures are provided, informed consent is obtained, and acknowledgments are stored in the client record.
4.2.2 The Administrator shall ensure personnel receive training regarding client rights, complaint procedures, confidentiality, mandated reporting, service limitations, and escalation of rights concerns.
4.2.3 The Administrator shall ensure Harbor’s admission package includes required oral and written disclosures before care begins. ()
4.2.4 The Administrator shall ensure complaint procedure contact information is current and available to clients or designees at admission. ()
4.2.5 The Administrator shall ensure records of rights review, disclosures, consent, and notices are maintained in accordance with Harbor’s client record policy. ()

4.3 Intake/Admissions Personnel

4.3.1 Intake or admissions personnel shall provide and explain the client rights notice, admission disclosures, service agreement, consent forms, advance directive information, and complaint procedures before services begin.
4.3.2 Intake or admissions personnel shall obtain signatures, initials, electronic acknowledgments, or documented refusal when required.
4.3.3 Intake or admissions personnel shall ensure the client or designee receives a copy of signed admission documents, either in paper or electronic form.
4.3.4 Intake or admissions personnel shall identify and escalate questions about payment, scope of service, consent, representative authority, or client refusal before services begin when possible.

4.4 Supervisors and Coordinators

4.4.1 Supervisors and coordinators shall monitor service delivery for consistency with the client’s rights, service agreement, and plan of care or service.
4.4.2 Supervisors and coordinators shall respond promptly to client concerns involving privacy, dignity, service reliability, aide conduct, refusal of services, changes in schedule, or possible termination of services.
4.4.3 Supervisors and coordinators shall document service changes, client concerns, complaints, and rights-related issues in the appropriate client record or complaint record.

4.5 Personnel

4.5.1 Personnel shall treat each client with courtesy, consideration, respect, and privacy. (.1)
4.5.2 Personnel shall protect client confidentiality and shall not disclose medical, service, financial, or personal information except as authorized by law, policy, or client consent. (.2; )
4.5.3 Personnel shall not abuse, neglect, exploit, intimidate, retaliate against, or mistreat a client. (.3)
4.5.4 Personnel shall report suspected abuse, neglect, exploitation, rights violations, serious complaints, or unsafe conditions immediately according to Harbor policy.

Implementation Guidance

A4 One individual may fulfill multiple operational roles in a small agency, provided each responsibility is completed and documented.
A4.1 Harbor should maintain a current admission checklist showing which staff role is responsible for each required disclosure, form, acknowledgment, and client-record upload.

5.Procedures

5. Procedures

Harbor shall follow the procedures below to ensure that client rights, admission disclosures, informed consent, advance directive information, complaint procedures, fee information, service notices, and required documentation are provided, explained, and maintained in accordance with . These procedures apply before admission, during service delivery, and when services are reduced, cancelled, discharged, or terminated.

5.1 Admission Review of Client Rights

5.1.1 Harbor shall review client rights with the client or client designee upon admission to Harbor. ()
5.1.2 The review shall occur before or during admission and before routine services begin whenever practical.
5.1.3 The client rights review shall be documented in the client record. (; .7)
5.1.4 Harbor shall provide the client or designee a copy of the client rights notice in paper or electronic form.
5.1.5 If the client has a representative or designee, Harbor shall document the name, relationship, authority or role, and contact information, as applicable.
5.1.6 If the client or designee does not understand the rights information, Harbor shall provide additional explanation in a manner reasonably understandable to the client or designee.
5.1.7 If the client or designee refuses to sign the acknowledgment, Harbor shall document the refusal, the date, the staff member involved, the rights information provided, and any witness or representative present.

5.2 Required Client Rights

Harbor’s written procedures shall assure that each client is provided the following rights:

5.2.1 The right to be treated with courtesy, consideration, and respect, and to be assured the right of privacy. (.1)
5.2.2 The right to confidential treatment of medical and financial records as provided by law. (.2)
5.2.3 The right to be free from mental abuse, physical abuse, neglect, and property exploitation. (.3)
5.2.4 The right to participate in planning the client’s home care, including the right to refuse services. (.4)
5.2.5 The right to be served by individuals who are properly trained and competent to perform their duties. (.5)
5.2.6 The right to voice grievances and complaints related to Harbor services without fear of reprisal. (.6)
5.2.7 The right to be advised, before care is initiated, of the extent to which payment for Harbor services may be expected from federal or state programs and the extent to which payment may be required from the client. (.7)
5.2.8 The right to be advised orally and in writing of changes in fees for services that are the client’s responsibility as soon as possible, but no later than 30 calendar days from the date Harbor became aware of the change. (.8)
5.2.9 The right to receive advance directive information before the start of services. (.9)
5.2.10 The right to receive at least five days’ written notice when Harbor determines to terminate services. (.10)

5.3 Required Admission Disclosures Before Care Begins

Before care is initiated, Harbor shall inform the client or client designee orally and in writing of the following:

5.3.1 The nature and frequency of services to be delivered. (.1)
5.3.2 The purpose of the service. (.1)
5.3.3 Any anticipated effects, limitations, or service-related considerations, as applicable. For Harbor’s non-skilled services, this disclosure shall not represent personal care or respite as skilled medical treatment. (.2)
5.3.4 A schedule of fees and charges for services. (.3)
5.3.5 The method of billing and payment for services. (.4)
5.3.6 Services to be billed to third-party payers, when applicable. (.4.a)
5.3.7 The extent to which payment may be expected from third-party payers known to Harbor. (.4.b)
5.3.8 Charges for services that will not be covered by third-party payers. (.4.c)
5.3.9 Charges that the client may have to pay. (.5)
5.3.10 Notice requirements for cancellation or reduction in services by Harbor and by the client. (.6)
5.3.11 Harbor’s refund policies. (.7)

5.4 Informed Consent and Service Agreement

5.4.1 Harbor shall obtain informed consent before initiating services when consent is required. (.3)
5.4.2 The consent process shall include explanation of Harbor’s non-skilled services, the client’s rights, client responsibilities, service limitations, fees and billing terms, cancellation or reduction requirements, refund policies, complaint procedures, and applicable plan of care or service process.
5.4.3 The client or representative shall sign and date the applicable service agreement, consent form, rights acknowledgment, and admission disclosure acknowledgment before routine services begin whenever practical.
5.4.4 Harbor shall ensure that the consent and service agreement do not imply that Harbor provides skilled nursing, therapy, medical social work, or pharmaceutical services unless such services are separately authorized and within Harbor’s licensed scope.
5.4.5 If consent is obtained electronically, the electronic record shall include the form version, signer name, date, time, signature or electronic acknowledgment, and final PDF copy or locked record.
5.4.6 If the client refuses services, refuses a disclosure, or refuses to sign an acknowledgment, Harbor shall document the refusal, the information provided, and any follow-up action taken.
5.4.7 Harbor shall provide the client or representative a copy of the signed consent and service agreement in paper or electronic form.

5.5 Advance Directive Information

5.5.1 Harbor shall provide advance directive information before the start of services. (.9)
5.5.2 Harbor’s advance directive information shall include information regarding advance directives and Durable Do Not Resuscitate Orders, as applicable. (.4)
5.5.3 Harbor shall not require a client to execute an advance directive as a condition of receiving Harbor services.
5.5.4 Harbor shall document that advance directive information was provided to the client or designee.
5.5.5 If a client provides an advance directive, Durable Do Not Resuscitate Order, or related document, Harbor shall maintain the document or a copy in the client record as applicable to Harbor’s scope of services.
5.5.6 Harbor personnel shall promptly notify the Administrator or supervisor if a client or representative provides new or updated advance directive information after admission.

5.6 Complaint and Grievance Information

5.6.1 Harbor shall give the client or designee a copy of Harbor’s complaint procedures at the time of admission to service. ()
5.6.2 Harbor shall provide the client or designee with the name, mailing address, and telephone number of Harbor’s complaint contact person. (.1)
5.6.3 Harbor shall provide the client or designee with the name, mailing address, and telephone number of the State Ombudsman. (.2)
5.6.4 Harbor shall provide the client or designee with the name, mailing address, and telephone number of the Complaint Unit of the Office of Licensure and Certification. (.3)
5.6.5 Harbor shall assure clients that complaints and grievances may be voiced without fear of reprisal. (.6)
5.6.6 Complaints shall be logged, acknowledged, investigated, reviewed, resolved, and documented according to Harbor’s Complaint Handling & Grievance Procedures policy. (, D)
5.6.7 Harbor shall notify the complainant of the proposed resolution within 30 days from the date the complaint was received, as required by Harbor’s complaint procedures. (.4)
5.6.8 Rights-related complaints, including allegations of abuse, neglect, exploitation, retaliation, privacy violations, or service refusal concerns, shall be escalated to the Administrator or designee immediately.

5.7 Fee Changes, Billing Changes, and Client Responsibility

5.7.1 Harbor shall advise the client orally and in writing of any change in fees for services that are the client’s responsibility. (.8)
5.7.2 Harbor shall provide fee-change notice as soon as possible, but no later than 30 calendar days from the date Harbor became aware of the change. (.8)
5.7.3 Harbor shall document fee-change notices in the client record or billing record, including the date Harbor became aware of the change, the date notice was provided, the method of notice, and the staff member providing notice.
5.7.4 Harbor shall follow its financial policies for billing methods, correction of billing errors, refund policy, and collection of delinquent accounts. ()
5.7.5 Harbor shall maintain a current fee schedule or payment responsibility disclosure for private-pay services and any other services for which the client may be financially responsible.
5.7.6 If a payer source changes, reduces, denies, or ends coverage, Harbor shall provide available information to the client or designee regarding the effect on services and any known client responsibility.

5.8 Cancellation, Reduction, Discharge, and Termination Notices

5.8.1 Before care is initiated, Harbor shall inform the client orally and in writing of notice requirements for cancellation or reduction in services by Harbor and by the client. (.6)
5.8.2 When Harbor determines to terminate services, Harbor shall provide at least five days’ written notice to the client or designee unless a stricter payer, program, contract, safety, or legal requirement applies. (.10)
5.8.3 Discharge or termination notices shall include the reason for discharge, termination, reduction, or referral, as applicable. (.4.a)
5.8.4 When referral to another organization is made, Harbor shall provide the name, address, telephone number, and contact name at the referral organization, as applicable. (.4.b)
5.8.5 Harbor shall document the referral or notice in the client record. (.4.c)
5.8.6 Harbor shall document the effective date of cancellation, reduction, discharge, or termination and the method used to provide notice to the client or designee.
5.8.7 If services are reduced or terminated due to client request, payer authorization, safety concerns, nonpayment, change in condition, or service need outside Harbor’s scope, Harbor shall document the reason and any follow-up action taken.

5.9 Documentation in the Client Record

5.9.1 Harbor shall maintain documentation of client rights review in the client record. (; .7)
5.9.2 Harbor shall maintain admission disclosures, informed consent, service agreement, advance directive information acknowledgment, complaint procedure acknowledgment, fee-change notices, cancellation or reduction notices, and termination notices as applicable.
5.9.3 Client record entries shall be current, legible, dated, and authenticated by the person making the entry. ()
5.9.4 Client record information shall be safeguarded against loss or unauthorized use and shall remain confidential. ()
5.9.5 Harbor shall maintain client records in accordance with its client record retention policy and applicable regulatory requirements. ()
5.9.6 If Harbor uses electronic records or online admission forms, the system shall preserve the completed document, signature or acknowledgment, date, timestamp, signer identity, and final PDF or locked version.
5.9.7 Harbor shall ensure that documentation is organized so an inspector can verify that rights, disclosures, consent, advance directive information, complaint procedures, payment information, and service notices were completed as required.

Implementation Guidance

A5 Harbor may use one combined admission package if it clearly separates the client rights notice, service agreement, informed consent, advance directive information, complaint procedures, payment disclosures, cancellation/reduction terms, refund policy, and signature acknowledgments.
A5.1 For online forms, Harbor should generate a final signed PDF that mirrors the approved paper packet and stores the completed packet in the client record.
A5.2 The admission checklist should not be marked complete until the required oral review, written disclosures, signatures, and client-record upload are complete.

6.Documentation Requirements

6. Documentation Requirements

Documentation related to this policy shall be maintained in the client record, admission file, complaint log, billing record, or controlled policy manual, as applicable. Harbor shall ensure that required documentation is complete, dated, authenticated, and available for inspection. (; )

Required Documentation

6.1 Client Rights Notice and acknowledgment. (; .7)
6.2 Admission disclosures provided orally and in writing before care begins. ()
6.3 Service Agreement and informed consent documentation. (.3)
6.4 Advance directive information acknowledgment. (.9; .4)
6.5 Complaint procedure acknowledgment and required complaint contact information. ()
6.6 Fee schedule, billing method, payment responsibility, third-party payer information, and refund policy disclosures. (.7-C.8; .3-D.7)
6.7 Cancellation, reduction, discharge, referral, and termination notices, when applicable. (.10; .4)
6.8 Documentation of client refusal to sign, refusal of services, or inability to complete acknowledgment, when applicable.
6.9 Documentation of any rights-related complaint, grievance, investigation, resolution, and notice to complainant, when applicable. ()
6.10 Evidence of annual review and Governing Body approval of this policy. ()

6.1 Forms & Tools

Policy Requirement	Form(s) / Tool(s) Used	Record Location
Client rights review	Client Rights Notice & Acknowledgment	Client record / admission packet
Required oral and written disclosures	Admission Disclosure Checklist	Client record / admission packet
Informed consent	Consent & Service Agreement	Client record / admission packet
Advance directive information	Advance Directive Information Acknowledgment	Client record / admission packet
Complaint procedures	Complaint Procedure Notice	Client record / admission packet
Fee changes	Fee Change Notice	Client record / billing record
Service cancellation or reduction	Cancellation / Reduction Notice	Client record
Discharge or termination	Discharge / Termination Notice	Client record

Implementation Guidance

A6 Harbor may maintain these forms electronically if the system preserves the signed version, date, timestamp, signer identity, and final PDF or locked record.
A6.1 Forms should be organized in the client record so an inspector can easily verify that rights, disclosures, consent, advance directives, complaint procedures, and payment information were provided before or at admission.

8.References & Regulatory Citations

8. References & Regulatory Citations

Regulation	Requirement Summary	How Used in This Policy
	Governing Body responsibility for organization management and oversight.	Supports Governing Body approval and oversight responsibilities in Section 4.
	Written policies and procedures must be approved by the Governing Body and reviewed at least annually.	Supports policy control, annual review, and Governing Body approval requirements.
.3	Administrative and operational policies must include informed consent.	Supports informed consent requirements in Sections 1, 5, and 6.
.4	Administrative and operational policies must include advance directives, including Durable Do Not Resuscitate Orders.	Supports advance directive procedures in Sections 1, 5, and 6.
.5	Administrative and operational policies must include client rights.	Supports the purpose and structure of this policy.
.9	Administrative and operational policies must include mandated reporting of abuse, neglect, and exploitation.	Supports escalation of abuse, neglect, exploitation, and rights concerns.
.11-C.12	Policies must address client records, confidentiality, record retention, and termination of services.	Supports client-record documentation and confidentiality requirements.
	Financial policies must address admission agreements, billing, fee changes, billing errors, refunds, and delinquent accounts.	Supports payment, billing, fee-change, and refund disclosures.
	Admission and discharge or termination policies must include acceptance criteria, plan of care or service, termination criteria, referral process, notice, and documentation.	Supports cancellation, reduction, discharge, referral, and termination procedures.
	Organization must establish and implement written policies and procedures regarding client rights.	Direct basis for this policy.
	Client rights must be reviewed with clients or designees upon admission and documented in the client record.	Supports admission review and documentation procedures.
.1-C.10	Lists required client rights.	Fully incorporated in Section 5.2.
.1-D.7	Requires oral and written admission disclosures before care is initiated.	Fully incorporated in Section 5.3.
	Requires complaint handling procedures, complaint staff responsibilities, admission complaint contact information, and complaint documentation.	Supports complaint and grievance procedures in Sections 1, 5, and 6.
	Requires organized, confidential, accurate, complete, retained client records, including documentation of client rights review.	Supports client-record documentation and confidentiality requirements in Sections 5 and 6.

Controlled Document Statement

Harbor shall maintain this policy as a controlled document within Harbor’s policy manual. Printed copies are uncontrolled unless marked as controlled by the Administrator or Governing Body designee. ()

Implementation Guidance

A8 When Harbor updates any admission form, client rights notice, consent form, complaint procedure, or service agreement, this citation table should be reviewed to confirm the policy and forms still match.
A8.1 The active version of this policy should match the active admission package used with clients.