CONSENT TO RELEASE INFORMATION

I the undersigned, herby consent to the release of information of Support Plan

and communication between Central Care Services.

(Specify information to be disclosed)

I understand that Central Care Services, Inc. and its employees and independent

contractors will not disclose information about me which is not legitimately involved in

the specific issue(s) stated above. The information released must be pertinent to

This consent is effective from Date 10/01/2020 To 10/01/2021.

Policy Any individual who feels that they have discriminated against, threatened, treated unfairly, believe their rights have been violated, or are dissatisfied with services may use the following grievance procedure. Procedure All responses of action(s) taken to resolve the complaint will be documented and a copy provided to the Support Coordinator, the individual or the person filing complaint, and a copy will be placed in the individual’s file. Any individual, who has a grievance with a Central Care Services employee, will first discuss it with that employee. If the grievance is settled to the mutual satisfaction of the individual or the person making the complaint, then the matter will be considered resolved If the individual is not satisfied with the results of the discussion with the Central Care Services employee, he/she must submit the grievance in writing to a Central Care Services supervisor within 48 hours after discussion with the employee.

If the individual is not satisfied with the resolution of the grievance by the supervisor, the individual may appeal to the Director in writing or an alternative format within 48 hours of resolution notice from the supervisor.

If the individual is not satisfied with the resolution of the Director, the individual may appeal the decision by contacting the Advocacy Center for Person with Disabilities, Inc. at 2671 Executive Center Circle West, Suite # 100, Tallahassee, Florida 32301. The Phone number is (850) 488-9071 Toll free 1-800-342-0823.

Individuals, family guardian, and Support Coordinator will be given a copy of Central Care Services Inc. grievance policy along with a copy of the grievance log.

The grievance log will include the name of person making complaint, and the date the complaint was received, and their relationship to individual.

There must also be a clear description of the complaint being made, and the date of final disposition of the complaint.

All individuals and parents/guardians will be asked to sign the grievance policy within 30 days of receipt of service and annually thereafter.

I am a physician, physician’s assistant, or advanced practice registered nurse licensed or authorized to practice in the State of Florida, and a provider of health care services for the above-named client receiving services from the Agency for Persons with Disabilities.

It is my professional opinion, based on my knowledge of his/her health status and physical condition that he/she is:

 

1_ Fully capable of self-administering his/her medications without supervision; or

2_ Requires medication administration assistance; or

3_ Requires medication administration assistance; or

4_ Requires medication administration assistance, with the following exceptions for which the client is fully capable of self-administering without supervision (specify route):

5_ Requires supervision while self-administering his/her medications, with the following exceptions for which the client is fully capable of self-administering without supervision (specify route):

 

 

Health Care Provider’s Signature

APD Form 65G-7.002 A, effective April 2019 Rule 65G-7.002, F.A.C.

Policy

Central Care Services Inc. does not tolerate the abuse, neglect or exploitation of individuals under any circumstances. If an incident should occur the employee will assist the individual as deemed appropriate, and participate in the investigation process. A report will be made to the Agency for Persons with Disabilities program office and the abuse will be called in to the abuse hotline for investigation.

Procedure

Employees will be trained on how to identify abuse, exploitation and neglect, and the proper reporting procedures. Employees will be provided with the phone number of the abuse hotline (1-800-69-ABUSE Employees are expected to have abuse hotline telephone number at all times.

Employees will be trained on the different types of incidents that are reportable. Abuse non accidental action by a caregiver causes, or could reasonable be expected to cause physical or psychological injury or sexual abuse. This also includes encouraging another person to commit such an act. Neglect: failure or omission by a caregiver to provide care, services, supervision or protection necessary to maintain physical and mental health. This include a repeated conduct or a single act of carelessness that caused or could reasonable be expected to cause serious physical or psychological injury, sexual abuse or risk of death.

Exploitation: Anyone who stands in a position of trust of confidence and acts knowingly, by deception or intimidation with the intent to deprive the victim of funds assets of property.

Individuals will be taught the appropriate means of reporting abuse neglect and exploitation.

A. Reporting the incident or suspicion to an employee of CCS, family member in order to stop the situation from occurring.

B. Ensure that all employees are aware that ignoring abuse, neglect and exploitation being committed by others will be treated in the same manner as the person committing the abuse, neglect or exploitation.

C. Employees will report abuse and neglect and exploitation to the Florida Abuse Hotline by calling 1-800-96-ABUSE.

D. An incident report will be completed describing the event that occurred.

NEGLECT

• Dehydration
• Poor or improper hygiene
• Poor grooming (e.g., overgrown fingernails and toenails; uncut, matted, or unclean hair; unshaven facial hair, body crevices caked with dirt)
• Malnourishment/weight loss
• A smell of urine or feces on the person
• Clutter, filth, or bad smell in the home Improper sleeping, cooking, or bathing arrangements
• Infestations (e.g., fleas, lice, roaches, rodents)
• Poor skin condition or skin breakdown (such as rashes, bedsores, or open wounds)
• Lack of necessary adaptive aids such as glasses, hearing aids, leg braces walkers etc. or improper medication management
• Needed medical and dental care (including the administration of prescribed drugs) not provided
• Lack of adequate or appropriate supervision

EXPLOITATION- Taking advantage of individuals with a developmental disability can rob them of their independence and the ability to afford the basic necessities of life, such as food, rent payments and medicine. It's also a crime and should be reported right away to the Florida Abuse Hotline.

PHYSICAL ABUSE- Sometimes abuse of persons with developmental disabilities takes the form of acts that could be thought ofas well-intentioned but unsuccessful attempts by the caregiver to ensure the person's well-being. In other cases, the abuse is deliberate, and is disguised as caregiving. Here are a few examples of that type of abuse:

• Rough physical handling
• Sudden movements of bedding
• Pusing and pulling
• Over medication
• Unnecessary or excessive use of restraints
• Ignoring dietary restrictions
• Toileting abuse (leaving someone on the toilet too long or not taking them to the bathroom when they need to use it)
• Bathing in water that is too hot or too cold

EMOTIONAL ABUSE- Emotional abuse can take the form of threats, insults harassment, and less noticeable forms that are difficult to detect. These can be perpetrated by individuals or by representatives of caregiving systems. Here are some of the most common types of emotional abuse and neglect:

• Exposure to domestic violence
• Insults and harassment
• Denial of conditions necessary for physical and emotional well-being
• Denial of communication
• Denial of right to family life
• Denial of social interaction and inclusion
• Denial of economic stability
• Denial of rights, necessities, privileges, and opportunities
• Denial of ordinary freedoms

IF A CAREGIVER/WORKER/STAFF ABUSES YOU CALL 1-800-96- ABUSE (22873)