Welcome to the Arbor House

Arbor House53 Hall Road

Hannibal, New York 13074

Residents’ Phone Number: 315-564-9906 Staff Phone Number: 315-564-5506Fax Number: 315-564-7567

Revised June 2014Table of Contents

Section 1: Arbor House Overview• Arbor House Overview pg. 5• Philosophy pg. 5• Arbor House Program pg. 6• Program Goals pg. 6• Rights pg. 7• For Your Information pg. 7• AH Program Policy Notice pg. 8• To Get the Most Out of This Program: pg. 8

Section 2: What you need to know• Personal Property pg. 10• What to Bring/Not to Bring to Arbor House pg. 10• Arbor House Residents Rules of Conduct pg. 11-13• Search for Contraband pg. 14• Key Deposit pg. 14• Visitation pg. 15• Residents’ Use of Arbor House Staff Phone pg. 15• Cell Phone and other Electronic Devices pg. 15• Senior Peer pg. 16

Section 3: Structured Program Elements

• Recreational Activities pg. 18

• Structure Program Elements pg. 19• Transportation pg. 20• Daily Schedule/Transportation Runs pg. 21• Program Priorities pg. 22• Meal Preparation pg. 22

Section 4: Reward and Demerit System• Overview of Arbor House Point Systems: pg. 24• Demerit Points pg. 24-27• Reward Points pg. 27-28• Program Levels and Privileges pg. 28• Level Determination pg. 29 • Levels pg. 30-33

Section 5: Passes • Passes pg. 35

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• Residents’ Responsibilities with Passes pg. 36

Section 6: Discharges and Appeal Process • Discharge Types: pg. 38• Corrective Procedures pg. 39• Residents’ Grievance Process pg. 40-42

Section 7: Fire Plan • Fire Plan for Arbor House pg. 44• Fire Escape Plan Diagrams pg. 44-45

Section 8: Health • HIV and Other Blood Borne Pathogens pg. 47• Medications: pg 48• AH Infection Control Precautions pg. 49

Section 9: Residents’ copies

• OASAS Clients’ Rights and Responsibilities pg. 51-53• Notice of Privacy Practices pg. 54-55• Confidentiality Notice pg. 56-58• Resident Admission Contract pg. 59-61• Consent for Release of Information – Residents copy pg. 62• Next of Kin Release of Information pg. 63

• Tobacco Free Policy pg. 64• Patient/Resident Attestation Statement pg. 65

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SECTION 1: ARBOR HOUSE OVERVIEWAN OVERVIEW OF ARBOR HOUSE:

Arbor House is a chemical dependence community residence established in 1987 and certified by the New York State Office of Alcoholism and Substance Abuse Services. It offers 24/7 supervision in a home-like environment. At its maximum capacity it can house 16 adults who are all recovering from the effects of a substance dependence or abuse condition. The staff provide an environment for structured residential living, chemical dependence education groups, supportive counseling services, crisis counseling and intervention services, preemptive crisis management, substance-free recreational and leisure activity planning, vocational and educational planning, and implementation of employee-directed activities.

The community residence is a blend of residents of diverse age, ethnicity, educational achievement, family background, and financial means. The common bond, however, is that all residents have been diagnosed with a substance dependence or abuse condition and are actively engaged in personally meaningful recovery.

Arbor House provides support, assistance, and guidance during this transitional period from active use, through initial treatment, and integration back to a productive lifestyle in the community. The program promotes a total, healthy adjustment to a substance-free lifestyle and encourages continued involvement in appropriate treatment programs, as well as recovery fellowships, following discharge.

PHILOSOPHY:

The Arbor House strives to provide a continuously supervised, controlled, and substance-free environment. It provides recovering persons the necessary transitional time to redirect their lives. It is for those individuals who may require a caring and supportive environment in which to become successful in that transition. It is a supportive and transitional living program and is not to be considered as permanent or long-term housing. The average length of a stay at the Arbor House is approximately six to nine months, depending on the resident’s achievement of mutually agreed upon program goals. The basic tenet of the program is that teamwork is a vital tool and necessary component in the recovery process. A variety of opportunities exist where residents are encouraged to help themselves as well as one another. It is a community atmosphere which stresses individual as well as group responsibilities. All residents are expected to actively participate in maintaining a clean, homelike atmosphere. The program’s philosophy is to provide a substance-free and safe environment in which recovery from addiction can thrive.

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ARBOR HOUSE PROGRAM:

1. Admission to the Arbor House is a privilege extended to those who realize theyhave a substance abuse problem and are sincere in their desire to do somethingabout it. The program is based on self-responsibility and self-help peer groups.We provide an environment conducive to recovery where you can live, learn, andgrow.

2. The length of stay at the Arbor House depends upon how well you are adjusting and achieving your Service Plan goals. While this is an individual program, you

should expect to be at the Arbor House for approximately 6-9 months.This is not a jail, nor is it a flophouse; it is your new home and the otherresidents are your family. We provide the elements essential for self-growth, butonly you can provide the motivation to nourish those elements.

3. There are four levels of program activity, which are described on page 28 in this handbook. Your progression or regression through these levels will be the subject of formal evaluation by the staff and will also involve feedback from other support services, particularly your outpatient program counselor. To advance to the next level you must submit a Level Application a week before your anticipated level increase.

ARBOR HOUSE PROGRAM GOALS:

1. The promotion and maintenance of abstinence from alcohol and other mood-altering drugs and substances except those lawfully prescribed by a physician, physician’s assistant, or nurse practitioner;

2. The improvement of functioning and development of coping skills necessary to enable the resident to be safely, adequately and responsibly treated in the least intensive environment and;

3. The utilization of Comprehensive Service Plans to support the maintenance of recovery and the attainment of self-sufficiency, including, where appropriate, the ability to be functionally employed, and the improvement of the resident’s quality of life.

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RESIDENTS’ RIGHTS:

1. You have the right to expect Arbor House to be an alcohol- and drug-freeEnvironment.

2. You have the right to withdraw from the program at any time. This is a voluntary program.

3. You have the right to expect the confidentiality of your records and treatment atArbor House to meet the standards required by the New York State Office ofAlcoholism and Substance Abuse Services (OASAS).

4. You have the right to be free from physical, sexual, or verbal abuse.

5. You have the rights and privileges granted you as a citizen of the United States.

6. You have the right to expect the staff to carry out their duties in such a way as topreserve your self-respect and individuality.

7. You have the right to send and receive mail without hindrance.

8. You have the right to conduct private telephone conversations as long as you payyour telephone bills.

9. You have the right to have family members, significant others, and friends visityou at the Arbor House during specified visiting hours.

FOR YOUR INFORMATION:

Oswego County Opportunities, Inc. does not accept responsibility for the security of yourpersonal possessions beyond taking reasonable care to insure their security. Large sums of money and valuable items should not be brought to the Arbor House nor should you have them brought to you at a later date.

In accordance with the rules and regulations governing agencies providing alcoholismtreatment or alcoholism residential services, this agency will not divulge any informationregarding your treatment or stay without your specific written permission to do so. Youare encouraged to respect the confidentiality of the other residents by not discussing theircases outside the confines of the Arbor House; in fact, failure to do so will be construedas misconduct and grounds for discharge.

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ARBOR HOUSE PROGRAM POLICY NOTICE:

It is the Arbor House program policy that no person will be denied admission, terminated,or have their services reduced, limited, or otherwise affected negatively, or their statuschanged solely on the basis of their actual, presumed, or alleged HIV related condition orstatus.

TO GET THE MOST OUT OF THIS PROGRAM:Over time we have seen many behaviors or choices that end up with the resident being discharged. If you want to do everything you can to further your recovery we recommend that you follow these recommendations.

• Stay out of any new relationship. A relationship starts long before any physical contact. More residents have left this program without completing due to relationships than for any other reason.

• Avoid spending excessive time anywhere away from the house. This could be the library, on campus, downtown or elsewhere.

• Make your peers your primary sober support system and others including other support group members your secondary support system.

• Think of everything you do here as a beginning of something to be continued for life. That includes what you learn in this program. You may be discharged as Completed Treatment. Never believe your recovery is complete.

• We ask that you do not loan money or anything else to other residents. If you do and it is lost, Arbor House will not repay you for what you have lost

If you chose not to follow the above and this choice negatively impacts your or others’ recovery it will become a treatment issue. We will advise you of the changes we believe you need to make. Choosing not to make these changes will result in discharge.

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SECTION 2: WHAT YOU NEED TO KNOW

PERSONAL PROPERTY: Arbor House will not be responsible for loss or damage to personal property. If circumstances require possession of more than pocket money or items of high value to you, Arbor House may accept money or other items and hold them in safe keeping. A written receipt will be given for anything we accept for safekeeping. What is accepted for safekeeping is at the sole discretion of Arbor House.

WHAT TO BRING TO ARBOR HOUSE:

• Twin size sheet sets• Blankets• Towel and washcloth• Pillow and pillow cases• Laundry basket• Personal hygiene supplies

WHAT NOT TO BRING:

• Any drug, alcohol or nicotine paraphernalia or any items that symbolize drug, alcohol or nicotine

• Anything that is of high financial, sentimental or emotional value. • Weapons of any kind• Motor vehicles• TVs• Stereos• Computer monitors larger than 17 inches• Pets• Furniture• Picture frames that need to be hung on the walls• RED or BLUE Bandana’s or any gang related items. Staff reserves the right to

lock up anything they deem gang related. You will receive it back upon your discharge from the Arbor House.

• Pornography of any sort is not allowed.

Small boom boxes are allowed.Any other item not listed in this handbook requires advance approval, with the understanding that it may not be allowed. Examples: guitar and amp; painting supplies.

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ARBOR HOUSE RESIDENT RULES OF CONDUCT:

Actions resulting in immediate discharge include but not limited to:

1. Possession or use of any alcohol, illegal and non-illegal mood altering substances.

2. Failure to report to a staff person immediately any other resident possessing or using alcohol or illicit drugs or its paraphernalia.

3. Possession of any type of fire arm or weapon on premises.

4. Residents who are physically violent or abusive towards other residents or staff.

5. Sexual contact between residents OR BETWEEN staff persons AND residents; this is against Arbor House rules.

Actions that may result in discharge:

1. Frequenting bars, clubs or social events where the primary focus is thesale/use of alcohol or other illicit drugs may result in discharge.

2. Withholding any prescribed or over the counter medication. It must be turned into staff and your Dr. must provide Arbor House with a stating you are allowed to take that particular medication and the reason for it. Example: You may need Tylenol for headaches but your Dr must provide you with a note stating you can take this medication. Residents are responsible for taking medication

as prescribed at the proper times. Medications must be given to staff and when it is needed, staff will allow you to self medicate.

3. Misconduct, disruptive, illegal or deviant behavior of any kind, within or outsideof the Arbor House, may result in immediate discharge. (This includes physical, verbal or psychological abuse, racial, ethnic, gender or religious disrespect, foul language, including relationships beyond a counselor/client with staff as a current resident or past).

4. Residents using their food stamps for their own personal use.

5. Residents are not permitted to enter another resident’s bedroom withoutinvitation and staff notification.

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6. There is no smoking on Arbor House grounds, in the van or in the presence of staff. . There is to be no tobacco or any type of tobacco paraphernalia. Anyone violating this rule may be discharged.

7 Gambling of any kind is not permitted on Arbor House property. Anyone violating this rule may be discharged.

8. Residents must be in bed by 11 pm on weekdays and midnight on weekends. Excessive noise anytime is not permitted and residents are limited to the downstairs meeting room, or recreation room after this time, with staff permission.

9. Any AH appliances will not be removed from designated areas without prior staff approval. No equipment shall be used with any AH appliances.

10. All TVs/video games must be off between 11 pm – 11 am. Weekend hours are off from midnight -7am,with the exceptions of AH approved holidays. Bedrooms are not to have TVs.

11. Each resident is responsible for maintaining appropriate personalhygiene. Linens are to be laundered at least one time per week along withpersonal laundry. Dirty laundry should be stored in plastic or laundry bags in the bedroom area. After clients start receiving extra monies they will be responsible for purchasing their own laundry detergent.

12. Residents are responsible for appropriate cleanliness and upkeep of their bedrooms. Rooms must be presentable by 9 am on weekdays and 10 am on

weekends. Staff will check bedrooms on a daily basis to ensure their up-keep.

13. Appropriate dress must be worn at all times inside the residence. Shirt, shoes and pants are required at all times. Robes or other appropriate dress must be worn to and from the bathroom areas.

14. Required chores must be completed no later than 9 am daily with theexception of meal and kitchen chores which must be completed afterdesignated meal times. It is the responsibility of the individual resident

to clean up after themselves any time other than meal times. This includes washing the dishes, pots and pans and cleaning the area in which

they have used.

15. All lights and electrical appliances must be turned off when not in use.

16. Passes will be granted only if staff agree that they are meeting program expectations. Residents must inform staff when they are departing and

report to staff upon their return.

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17. Returning back to bed or napping during the day is prohibited. Other than with staff permission, until after dinner. Naps are not permitted in the community areas. Pillows and blankets are not permitted in the community area as well.

18. Residents are not permitted to possess or review pornographic materials at the

residence. Books, posters, magazines, films, etc. must be cleared by primary staff before viewed to determine the appropriateness conducive to recovery.

19. Transportation will be provided only for that which is necessary or agreed upon with staff. All other transportation: passes, home visits, and other leisure time activities, etc., must be secured by individual residents. All residents are required

to wear their seatbelts while in the van. If a resident’s behavior is deemed inappropriate they will be asked to leave the van.

20. Residents are to be present for meals unless they are out of the house. Dinner guests are welcome with proper staff notification and approval. No phone calls are to be made or received after 11 PM, unless its an emergency. Time on the phone is limited to 20 minutes.

21. Kitchen area will be closed after 10 PM. No meals are to be prepared after this hour, with the exception of non-cook snacks.

22. Music with foul language, racist, violent, etc. will not be acceptable. When there is a house activity scheduled everyone must attend and be on time.

23. During any house meeting no one is permitted to leave the meeting unless it is deemed an emergency, this includes getting coffee or answering the phone.

24. There is to be no feet on the furniture or any furnishings. Kitchen chairs must besat in appropriately.

25. There will be no breaking, defacing, destroying or vandalizing any Arbor Houseor any resident’s personal property.

26. Schedules and activities or rules are subject to change based upon individualor facility needs.

27. Staff have the right to search any persons, their belongings and their room, at anytime without resident(s) being present.

28. Residents may not attach anything to any furniture or walls. This could result in requiring the resident to reimburse Arbor House for damages, or the resident could be discharged from the program.

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SEARCH FOR CONTRABAND:

Arbor House reserves the right to search property owned or leased by the program, including individual rooms, without notice. Individuals may be searched for contraband on demand. All individual searches will comply with OASAS regulations (Section 815.10). These regulations are as follows:

Section 815.10 Patient Searches (a) The purpose of patient searches is to ensure a safe and therapeutic environment for all patients. However, patients shall be free from searches except those searches that are authorized pursuant to this section.

(b) Subject to the following requirements, a provider may choose to conduct searches of patients by establishing written policies and procedures which are provided to each patient at admission. Such policies may include the following:

(1) Routine frisk or "pat down" searches of patients at admission or when returning to the service are permitted.

(2) Searches of a patient's room or a patient's belongings may be conducted at any time with reasonable cause.

(3) A provider may conduct a strip search of a patient only if:

(i) reasonable suspicion exists that the patient possesses contraband;

(ii) the provider's director authorizes the search;

(iii) a same-sex-as-the-patient supervisor of the staff member requesting the search is present when the search is conducted; and

(iv) the patient consents to the search.

(c) Under extenuating circumstances and subject to the preceding requirements, a provider may elect to conduct a body cavity search of a patient. Such a search must be conducted only by a member of the provider's medical staff. If the provider does not employ medical staff, the provider must utilize a physician, nurse practitioner, registered physician's assistant, registered nurse, or licensed practical nurse to conduct the search.

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(e) If a patient refuses to consent to a proper request to conduct a search he or she may be discharged in accordance with regulations.

KEY DEPOSIT:

For a key to the client’s room, there is a $5.00 deposit. If a client loses a key there will be a $1.50 charge for a new key to be made. This will not be taken out of the deposit. This will be collected from the resident and he will sign the Key and linen agreement. A copy will be made for the client and a copy of the room key will be given. The money will be returned when the key is returned to the HOUSE MANAGER or their designee. The HOUSE MANAGER will fill out the second half of the sheet, make and give a copy of this form to the resident along with his money. If a client does not retrieve his funds after 30 days from discharge from the program, this money will be used in conjunction with Arbor House petty cash.

VISITATION:

Visitation prior to 4 pm on weekdays and noon on weekends is not permitted without prior staff permission and all visitors must vacate the premises by 7 pm. Visitors are not permitted in the bedroom areas. When children are visiting, direct supervision by the Resident is mandatory and the Resident is responsible for making proper notifications with the staff person on duty that their child is in the building. Visitation for children is limited to the hours of 2 pm-6 pm on Saturdays and Sundays. Visitation by children should be limited to the downstairs meeting room. Each resident’s guest(s) is allowed to visit twice a week, and day and time is limited on the weekend. Visitors CAN BE subject to a personal search of their belongings by staff. At NO TIME will staff require a visitor to be stripped searched. Visitors are not allowed any use/possession of any mood altering substances including but not limited to: tobacco. If they are found to be in possession or under the influence of any mood altering substances, staff holds the right to ask the visitor to leave, ban the visitor from any future visits or calling local authorities.

All visitors need to follow all Arbor House Rules.

RESIDENTS’ USE OF ARBOR HOUSE STAFF PHONE:

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Residents may use the staff telephone for an EMERGENCY situations.

Residents will be billed for all long-distance charges incurred.

CELL PHONE, PERSONAL COMPUTERS AND OTHER ELECTRONIC DEVICES Residents of the Arbor House are permitted to bring and carry a personal cell phone, personal computer and other electronic devices. During the admission process, all equipment must be checked by the resident HOUSE MANAGER or his designee. Please remember the nature of our program and respect the confidentially of other residents and staff. It is understood that no personal device is to be used for any photographing or voice recording of other residents in the program. If it is found that a Resident has misused any of their approved devices, staff holds the right to limit a Resident’s use of that device or prohibit them from using it entirely.

Electronic Devices are also not be used at all during ANY of these activities: Education Group, Meal Times; Outside Meetings; Outpatient Group.

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SENIOR PEER:

Senior Peer is a resident who helps assist with many facet of the Arbor House Program. A resident may apply for the Senior Peer position once they have reached Level II status. They will ask their primary counselor for a job application that will be filled out and interviews will be conducted once the position is open.

Senior Peer is a permanent position for the duration that the resident is at our program. The Senior Peer can be fired from their duties if staff feel his job performance is not up to good standards. A Senior Peer is not a staff member. They are not expected to confront other peers in a negative way if those peers are not doing their duties as expected. Senior Peer is expected to inform staff that is on that they had asked their peer to do their duties with no response.

Pay for the Senior Peer position is 5 reward points a week as long as staff feels he is doing his responsibility adequately.

Duties of Senior Peer:

• Checking chores daily, signing off if they are done according to standards or asking other peers to complete them up to standards.

• Covering chores that are not assigned to anyone, or finding volunteers to cover chores that are not assigned to anyone.

• Minor maintenance around the house with Program Coordinators permission.

• Running/Starting Peer driven groups Monday – Friday as schedule.

• Assist new residents with house tour, chore assignment and answering questions.

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SECTION 3: STRUCTURED PROGRAM ELEMENTS

RECREATIONAL ACTIVITES:

The residence permits a variety of additional recreational activities. This includes television viewing, use of the VCR/DVD, a resident computer, as well as reading, exercise activities and participation in a local area fitness club. Residents are expected to advise on-duty staff when leaving the residence to participate in off residence recreational activities and to notify staff of their anticipated time of return. Noise levels of all recreational activities are to be kept at a level that is non disruptive to other residents as well as non disruptive to staff work activities. Residents are also encouraged to close doors quietly and keep voices to a conversational level at all times. In addition to these recreational activities residents are also afford the opportunities to these monthly assigned activities:

Every first Sunday of the month: Trip to the Mall. Every third Sunday of the month: Bowling

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STRUCTURED PROGRAM ELEMENTS:

Arbor House provides a structured program that all residents are required to participate in. Each activity is one hour in length. This program consists of a combination of groups, classes and mediation that are presented or supervised by Arbor House staff. The content of these structured elements changes over time, as the needs of the residents change.

Community Group Every Wednesday 10 am

Provides an opportunity to enhance interpersonal relationships and communication skills on a feeling level.

Relapse Prevention Every Thursday at 2pm

Introduces basic concepts of relapse/ recovery dynamics. To help residents identify relapse indicators and develop individualized strategies to deal with them.

Volunteer Work at Our Lady Rosary Church

Every Tuesday 10 am - ????

Residents will assist the staff with food pantry requests.

Individual Counseling As schedule Provides supportive counseling, formulation of an Individual Service Plan with ongoing revision

Activities Committee Every Wednesday at 2 pm

Residents join together to make up a list of possible recreational activities. These would include planning family fun days, recovery peer dinner, seasonal parties. This is a peer driven group.

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TRANSPORTATION :

Arbor House maintains a 12-passenger van to transport residents to Arbor House recreational activities, local medical appointments and outpatient treatment, as well as educational, vocational and Support Group meetings or functions. Residents must fill out a transportation request at minimum one week before their expected appointment. A resident must utilize all other modes of transportation before they put in for the request for Arbor House transport. The Substance Abuse Counselors or designee will receive the request and set up the transportation for Arbor House the following week. All resident appointments are to be set up to coincide with the van transportation runs scheduled by the program.

All appointments must be scheduled between the hours of 11:30 am and 3 pm Monday through Friday, unless medical transport or other approved transportation can be arranged with prior primary counselor permission and it does not conflict with any Arbor House scheduled activities.

Arbor House will provide transportation when their is no pubic transportation available within Oswego County or within a 50 mile radius of the home. Transportation may be provided by the program staff IF:

• Public transportation is not available.• The destination is within a 50 mile radius from the Arbor House with the

exception of medical and financial emergencies or related appointments. • You have utilized all other resources to find a ride to your appointment. (ie.

Family, sobriety supports)• You have requested transportation within 3 weeks of the appointment date,

except for what staff deems is an emergency.

Family can provide some transportation upon approval of the Primary Counselor. Request for out of town appointments must be made at least THREE weeks in advance. Emergency Medical or Psychiatric transportation will NOT be provided by STAFF. An ambulance or 911 will be contacted to transport you to the hospital of your choice.

Residents also have available medical transportation provided by Oswego County Opportunities, Inc. Transportation Services for most medically related appointments (which includes outpatient treatment). If the resident is not an Oswego County resident pre-approval might be needed.

Arbor House will not provide transportation money for public transportation.

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DAILY SCHEDULE/TRANSPORTATION RUNS

Day/Time

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

6:45 am

Medication Medication Medication Medication Medication

7:15 am

Breakfast Breakfast Breakfast Breakfast Breakfast

7:45 am

Medication Medication

9:00 am

Chores done/ Rooms Clean

Chores done/ Rooms Clean

Chores done/ Rooms Clean

Chores done/ Rooms Clean

Chores done/ Rooms Clean

10 am Chores done/Rooms clean

Open Volunteer Hours

Community Meeting

Open MENS GROUP

Chores done/Rooms clean

11:00-11:30 am

Van Run/Noon AA

Van Run/Noon AA

Van Run/Noon AA

Van Run/Noon AA

Van Run/Noon AA

NOON Meeting

1 pm Lunch Open Open Open Open Open Lunch

2 pm Peer Group Peer Group Peer Group Relapse Prevention

Peer Group

3:15/5:15pm

Van P/u 5:15

Van P/u 3:15

Van P/u 5:15

Van P/u 5:15

Van P/u 5:15

6:00 PM

Dinner Dinner Dinner Dinner Dinner Dinner Dinner

7:30 pm Sponsor

Meeting

Outside Meeting

Outside Meeting Sponsor

Meeting

Outside Meeting

Outside Meeting

10 pm Kitchen Closed

Kitchen Closed

Kitchen Closed

Kitchen Closed

Kitchen Closed

Kitchen Closed

Kitchen Closed

11 pm Lights Out Lights Out Lights Out Lights Out Lights Out12 pm Lights Out Lights Out

PROGRAM PRIORITIES

Scheduling conflicts do occur. Those activities listed in have the highest priority; #1 below have the highest priority. Those listed in Number 2 have the second highest priority, etc.

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1. All structured program activities. This includes appointments, groups, etc. with Outpatient Services. All residents are to make appointments around structured program activities and to correspond with van runs if not utilizing van runs. 2. Health services including medical, dental, etc. appointments may conflict with #l. In those cases these services take priority. This is allowed only with staff approval in advance3. Recreational and social activities. Residents are to schedule their activities accordingly. Resolve potential conflicts, in sufficient time to avoid problems, by talking with the appropriate staff.

MEAL PREPARATION:

Each resident is encouraged to eat 3 nutritionally balanced meals per day. Monday through Friday breakfast is served family style at 7:15 am. Dinner is also served family style Sunday-Saturday at 6 pm. Lunch is served family style Saturday and Sunday.

Meals are prepared by Arbor House residents. The menus are set up on a 4-week rotating schedule. The program’s staff will be responsible for the procurement of food supplies and the training and directing of food preparation by the residents. A Registered Dietitian will provide menu planning services and educational seminars on healthy meal preparation and nutrition for staff.

Shopping is done on a weekly basis and menus are prepared in advance by the designated “cooking team.” Safe food handling and cooking procedures are discussed with all residents to ensure that safe food preparation and handling procedures are followed at all times. Individuals are required to wear food handling gloves and caps or hairnets when preparing or handling residence food products. Proper food storage procedures utilizing three refrigerators, three large stand-up freezers, and a small dry storage room are supervised by program staff.

SECTION 4: REWARD AND DEMERIT SYSTEM:

OVERVIEW OF ARBOR HOUSE POINT SYSTEMS:

The Arbor House has two different point systems. The systems are called “Demerit Points” and “Reward Points”.

The Demerit Points system is a system in which a resident gets points for negative behavior that is against the rules of the Arbor House. In order to be given certain privileges, a resident must not earn more than a designated number of demerit points. See the “Privileges” section of this handbook to view the demerit point totals that cannot be exceeded for each privilege.

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The Reward Points system is a merit system in which a resident goes above and beyond house expectations and earns “points” for these achievements. When a resident reaches a certain number of points they will be eligible for certain privileges based on their level.

Staff members will write down demerit or reward points on each resident’s point sheet whenever appropriate. Residents will be notified verbally that they have been awarded a Demerit or Reward point and the reason for it. The points will be logged into the appropriate area by the end of the staff member’s shift. You may check with your Primary Counselor regarding your Demerit and Reward points.

The residents’ levels and other privileges are based upon the point system.

DEMERIT POINTS

Demerit Points are accumulated on daily basis.

1. Consequences for Accumulating Points

a. If a resident receives a 30 point demerit they will be issued an Emergency discharge. This occurs when the resident is determined to be a danger to others. The resident will have the right to appeal within 24 hours from another placement.

b. If a resident receives 20 points or more they will be given a Recommendation of Treatment.

c. If a resident earns 15 or more points within 30 day period they will have a Program level drop if not already on Level I.

d. To be able to receive day/weekend passes a client must have no more than 10 Demerit points on their sheet for the week that they are requested pass.2. Ways to reduce accumulated points

a. Every week a resident earns no additional points they will receive a 5 pointdeduction from their point sheet. A sheet will never have negative points.

1 Use of any mood altering substance not prescribed or approved by a qualified medical practitioner or in a way that is inconsistent with recovery, within Arbor House or its vicinity.

30

2 Returning to the Arbor House under the influence of any mood altering substances. 303 Possession of any alcoholic beverages (this includes mouthwash and anything else that

can be swallowed and contains alcohol), “designer drugs”, mood altering substances, medication not prescribed or approved by a qualified medical practitioner (prescribed and over the counter medication are available only through staff).

30

4 Physical abuse or Threat of physical abuse of another person, regardless of 30

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provocation, being a danger to others, including staff. 5 Possession of a weapon, including but not limited to any firearm, blackjack, Billy club,

sap, stiletto, switchblade, army knife, butterfly knife, etc. 30

6 Refusal to submit to any test that screens for alcohol and/or substance usage 307 Theft or willful destruction of individual or Arbor House property. 308 Engaging in sexual activity with other residents, residents of supportive living, or any

staff member. 30

9 Refusal to submit to room search, personal search, pat down, strip search, body cavity search.

30

10 Possession of any mood altering substances paraphernalia including but not limited to: small baggies, containers, pipes, needles etc.

30

11 Failure to treat either other residents or staff with respect and consideration. This includes verbal abuse and any behavior that would make continued residency unsafe for another.

30

12 Engaging in Criminal Behavior that results in your arrest. 3013 Failure to inform staff of another resident’s use of mood altering substances,

possession of any contraband. 20

14 Flagrant disregard of the Arbor House rules and regulations. 2015 Failure to return from pass on time. It is the resident’s responsibility to arrange for

dependable transportation. 20

16 Failure to respect the property of residents, staff or the Arbor House. 2017 Failure to exit the building and meet in the designated location within 2 minutes of the

fire alarm being sounded after the first offense.20

18 Spending Food stamps 2019 Suspicion of use any mood altering substance not prescribed or approved by a

qualified medical practitioner or in a way that is inconsistent with recovery, within Arbor House or its vicinity.

20

20 Testing positive for any mood altering substances. 2021 Failure to comply with a staff member’s direct request. In case of disagreement,

comply with the request than submit a grievance within 24 hours.20

22 Gambling with the intent to win money or any other “prize”, or valuable possession 2023 Smoking E-Cigarettes in or on the property of the Arbor House 2024 Smoking in or around the Arbor House 2025 Behavior once brought to the Residents attention which continues to interfere with

their participation, as a fully integrated group member. This includes failure to abide with any written contract or treatment plan.

20

26 Unauthorized absence from the Arbor House or Out-patient 2027 Repeated violations of the Arbor House rules and regulations. 2028 Frequenting bars, clubs or social events where the primary focus is the

sale/use of alcohol or other illicit drugs will result in discharge. If you need to be 21 to enter, you should not be there.

20

29 Misconduct, disruptive, illegal or deviant behavior of any kind, within or outside of the Arbor House. (This includes physical, verbal or psychological abuse, racial, ethnic,

20

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gender or religious disrespect, foul language and getting arrested).30 Any behavior that is considered not conducive to your recovery or other residents in

the house. 20

31 Failure to arrive on time, actively participate in and remain at: in-house groups, appointments, house sponsored activities in house or anywhere else. This includes failure to reschedule any appointment at least 24 hours in advance

10

32 Entering another bedroom without permission. 1033 Failure to notify staff of leaving or returning from the house. 1034 Possession of, or viewing, X-rated films or videos that are not allowed. 1035

36

Failure to exit the building and meet in the designated location within 2 minutes of the fire alarm being sounded. ______________________________________________________________________Possession of tobacco products, which include but not limited to: cigarettes, cigars, pipe tobacco, chewing or dripping tobacco. Possession of any tobacco paraphernalia including lighters, matches, pipes, rolling papers, etc

10

___

5

37 Failure to contribute to the appearance and daily operation of the facility by doing various assigned chores or by failing to: Complete chore on time, do the work well and as instructed, arrange to have the work done during any absence or help staff when asked.

5

38 Failure to have the bedroom clean and neat including making the bed as instructed before leaving the room. A thorough cleaning once a week. We reserve the right to knock, enter and search at any time.

5

39 Failure to change and launder bed linens and towels once a week. 340 Failure to remove laundry from the machines keeping others from using them. 341 Failure to bathe or shower daily or maintain acceptable personal hygiene including the

use of deodorant products. 3

42 Failure to be dressed in street clothes including shoes or slippers while walking around the house. Failure to be appropriately dressed when entering or exiting the shower.

3

43 Obstructing doors, hallways, stairwells or safety exits. 344 Watching TV outside the designated times. 345 Failure to limit phones to 15 minutes while on the resident’s phone or using cell phone

during non-approved times. 3

46 Attaching anything to bedroom walls, ceiling, doors (both inside and out) or anywhere else.

3

47 Failure to comply with lights out time. 348 Failure to take medication as prescribed. 349 Sleeping or lying down after Morning Meditation until 8 pm. Monday through Friday. 350 Failure to keep your door open while you are occupying your bedroom during non-

sleep hours. 3

51 Playing a radio or other similar equipment loud enough to be heard outside your room. Also playing music that is not recovery conducive, inappropriate language (i.e. cuss words, belittling individuals).

3

52 Playing headphones that can be heard beyond your listening zone. 3

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53 Swearing. 354 Failure to limit eating to the dining rooms. 355 Failure to be at to meals on time. 356 Failure to pick up and clean up after cooking, eating, snacking, etc. Dishes must be

rinsed and placed in dishwasher. Pots and pans must be washed and put away. 3

57 Failure to remain seated for 15 minutes during meal times. 358 Failure to hand in daily schedule. 359 Failure to hand in signed sheets form from appointments. 360 Having your feet on the furniture 3

REWARD POINTS

The Rewards Point system is based upon receiving REWARD POINTS for going above and beyond. Residents will earn reward points for different activities and will be offered several different rewards they can chose from. Points will be tallied at the end of each month by the staff member assigned this task and privileges will be handed out at the first community meeting of the month. You cannot hand in one privilege for a higher level one. If you have more than 10 demerits points for a week you cannot use a reward point certificate.

1. How to earn Reward Points:

ACTION Points Earned

1 Cleaning an area of the home that is not part of an individual chore.(No more than 3 points a week)

1

2 Having a perfect room inspection sheet at the end of the month 53 Having NO DEMERIT points all month. 54 Volunteering hours to the house. (i.e. landscaping, maintenance) 25 Resident of the Month as voted by your peers 106 Senior Peer Position (5 points a week if job is acceptable) 5 2. Privileges that you can receive based on Reward Points:

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Level I Privileges:

1 Sleep-in pass 72 Staff do your chore for a day. 153 Get 5 demerit points deducted (does not apply if a resident receives a 30

point Demerit )15

4 Extra day pass/Sponsor Pass 15

Level II, III and IV Privileges:

1 Extra overnight pass (not to exceed 6 overnights in a month) 202 Any privilege of Level One.

PROGRAM LEVELS AND PRIVILEGES:

Arbor House has four different levels. Each level brings different responsibilities and privileges.

How Resident Attitude and Behavior Impact the Level Earned

A resident’s attitude and behavior over time will determine his levels and privileges.

Advancement depends upon a combination of things. Some of these are clearly measurable. For example, a resident’s point total is either zero or a specific number. Other indicators, not so easily measured, can be even more important to recovery than the easily measured ones.

For example, one peer may not directly threaten another peer but still be threatening. Telling stories that center on the violence done to others by one peer can be threatening to other peers indirectly. The tone of voice, body posture, or the way someone looks at someone else can also be threatening.

By limiting our conditions for advancement to objective or measurable items and ignoring these less easily measurable items, we would not be doing our job. This would make it possible for a resident to complete this program and advance through the levels by keeping a low profile, following all the rules, and doing just enough to get by. “Just getting by” is not what recovery is all about.

To avoid this kind of situation from occurring, advancement to and retention of levels requires work that is measured both objectively and subjectively.

Every resident begins on Level I. All requirements for advancement in Level must be met prior to advancement. Once a level is earned, continued effort is required to keep it.

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Each week a resident’s progress will be assessed and the Level Earned will be posted. A resident on Level IV could drop to Level I. Length of time in the program has no impact on how low the level may drop. Once a level is reached it is kept by continued work.

LEVEL DETERMINATION:

A resident’s level is determined by comparing what the resident has accomplished to the requirements for each level. The resident is then placed on the highest level on which all conditions have been met.

There are two sets of conditions.

1. Objective. This includes anything that is concrete and does not require staff making a judgment to determine, such as:

• Length of time in residence. This is determined by counting the number of full days since admission. The actual day of admission does not count toward time in residence

• Total number of points• All required documentation has been completed (including appropriate discharge

planning)• Resident has been admitted to and continued satisfactorily with an Outpatient

Treatment Provider• Satisfactory progress has been made in meeting the goals specified in the

Comprehensive Service Plan2. The second area examined depends on staff judgment. Your Substance Abuse

Counselor is responsible for this area and any staff member may provide additional input.

The set of behaviors and or attitudes that are examined are listed for each Level under “Earning and Keeping Levels”. All residents are expected to be actively working toward earning Level IV status. Any resident not working toward individual growth will be discharged.

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Approval of the Treatment TeamAdvancement in Level requires the approval of the treatment team. Each member of the treatment team looks at the same behaviors and attitudes of each resident, while using their own individual professional perspectives. The types of behaviors and attitudes each member of the treatment team looks for are similar for each resident while somewhat different based upon their areas of responsibility.

LEVELS:

Level I: Responsibilities While on Level I

During this period, you are in an adjustment phase. You are “learning the ropes” of group living in a sober environment. You should be constantly working towards progressing to Level II within 30 days of your arrival. Level I runs 30 days from the day of admission.

• Attend a minimum of one support group meeting everyday. Night meetings must be attended.

• Submit weekly support activities journal to staff. • Complete your Initial Service plan, Discharge plan, evaluation and

Comprehensive Service Plan. • Participate in all activities sponsored by Arbor House. • Begin working on a telephone support network (have 10 telephone numbers

by day 30.) • Begin volunteer work, GED Classes or ABE Classes. • Having no more than 19 Demerit points on your sheet on your last day of

Level I. • Have one person you consider your main Recovery Peer that you contact at

least 3 times a week. (Cannot be family, significant other or best friend)• Submitting a Level II application one week prior to your anticipated level

advancement.

Observable by Substance Abuse counselor• Is honest at all times

• Treats both peers and staff with courtesy and respect

• Minimal or no isolation

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• Works well with at least three peers

• No use of intimidation or threat either direct or implied

• No relationship is interfering with resident progress

Privileges During Level I:• Two 6-hour day passes permitted per month; must be in context with your

treatment plan.

• Three 2 hour Support Group Passes each month. These passes can not be used in conjunction with other passes. Support Group Passes can only be used on Wednesday and Sunday Evenings.** Your support group member must come to the house and verify your intentions.

If you do not meet any of the tasks or follow any/all of the rules, Level II status may not be granted.

Level II: Earning and Keeping Level II Requires Everything from Level I. Level II is for minimum of 60 days.

Responsibilities While on Level II• Maintaining weekly contact with Recovery Peer. • Add more support network numbers each week. • Attend 5 support group meetings each week. • A Demerit Point Total of 10 or less• More than 30 days at the residence. • Arbor House Comprehensive Service Plans Completed• Admitted to an approved Outpatient Treatment Provider• Submit a Level III application one week before your anticipated level

advancement.

Observable by Substance Abuse counselor• Is honest at all times

• Treats both peers and staff with courtesy and respect

• Minimal or no isolation

• Works well with at peers

• No use of intimidation or threat either direct or implied

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• No relationship is interfering with resident progress

Privileges During Level II:• Three 6-hour day passes permitted per month; must be in context with your

treatment plan. Can not be combined with other passes.• FOUR 2 Hour Support Group Passes each month• Two overnight passes each month. Can not be combined with other passess.

Approval of passes is not automatic and will be approved only if it appears that it is in the best interest of the individual.

Earning Level III Requires Everything from Level I and Level II to be continued AND Level III can not be initiated for at least 60 days from your accepted start date of Level II.

Responsibilities While on Level III

• More than 90 days in residence

• A Demerit Point Total of 5 or less

• Completing your Comprehensive Service Plan review with your Substance Abuse Counselor.

• Submit a Level IV application one week before your anticipated level advancement.

Observable by Substance Abuse Counselor• Growth since admission is obvious. Obvious means that specific changes in

attitudes and behaviors can be identified.

• Acts as a role model in all clinical settings

• Defenses do not block progress

• Accepts feedback and makes positive changes in response

• Focus is on self and individual change needed to continue personal growth

• Understands need for and is supportive to others. Focuses on self and growth in recovery now includes an understanding, with appropriate supporting

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behaviors, that it is only through being there for and giving to others that recovery can continue

Privileges During Level III:

1. FIVE 8-hour day passes permitted per month; must be in context with your treatment plan.

2. SIX 4-hour Support Group Passes each month. Your support group member must come to the house and verify your intentions.

3. May apply for THREE overnight passes each month. Combining passes on this level can be discussed with your Primary Counselor

Earning Level IV Requires Everything from Level I, II and III . This level can be maintained for the rest of your stay at the Arbor House.

Responsibilities While on Level IV• Discharge plan must be nearing completion and your plan for leaving the

Arbor House are beginning to take shape.

• More than 180 days in residence

• A Demerit Point Total of 3 or less

• Outpatient Treatment is Continuing

Observable by Substance Abuse Counselor• Shows continued growth

• Fully engaged in program

• Is a role model EVERYWHERE and ALL OF THE TIME

• Outside activities further recovery without detracting from program responsibilities

Privileges of Level IV:• SEVEN eight hour day passes permitted per month; must be in context with

your treatment plan. • SEVEN overnight passes each month.

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• UNLIMITED 2 hour Support Group Passes each month with Primary Counselor approval.

SECTION 5: PASSES

PASSES: A pass is an approved absence from the facility. A pass request is to be submitted whenever you will be out of the residence without an outside appointment. A pass is NOT a vacation from working on recovery. .There are no other passes than the ones listed below.Types of Passes

• Day PassA Day Pass starts at the time approved by the Substance Abuse Counselor for Saturday or Sunday only and ends at midnight Saturday and 6 pm Sunday.

• Emergency PassAn Emergency Pass depends on individual situations and is granted by your Primary Counselor or Program Coordinator. You must show verification of your whereabouts during an emergency, this includes date and time of departure from the Arbor House and return date and time. If you are bound by a LEGAL AUTHORITY to be at the Arbor House, it is YOUR responsible to get approval from him or her BEFORE submitting an Emergency Pass.

• Legal PassA Legal Pass starts at the time of your DEPARTURE from the Arbor House until the time you LEAVE the courtroom and your business is finished. A legal pass IS NOT a “free pass” to visit with friends or family. IF you live a distance away from the Arbor House, you will be REQUIRED to use any and all passes you gained during that particular month while outside of the Arbor House until the time you RETURN. Before any Legal Pass is approved we must verify from the Legal Agency involved that your appearance is required, the date and time of your departure and your return date and time. It is your responsibility to notify Arbor House staff in a timely fashion about any court dates or issues involving legal authorities. Arbor House does NOT pay for or provide transportation to or from legal appointments.

• Medical PassA Medical Pass must be submitted for any medical procedure that may require an absence from the residence of more than 8 hours. Dates and times must be provided to your Primary Counselor before any Medical Pass is approved. Staff must verify directly from the Medical Provider that the procedure is scheduled and any other details that might be needed to verify time length that is needed.

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• Support Group PassThis pass is for spending time with those in your recovery support group. These passes are reserved for spiritual outings and/or support group meetings.

• Overnight Pass An Overnight Pass is only considered one night. An overnight pass can be taken during these times only:

Leave FRIDAY at 4pm, Return SATURDAY 4pm OR

Leave SATURDAY at 4pm, Return SUNDAY 4pm

RESIDENT’S RESPONSIBILITES ASSOICATED WITH PASSES:

If you have over 10 demerit points for that week, you will not receive any type of pass.

A pass is approved based upon a Resident’s level status. If the level changes so that the Resident no longer qualifies for the pass, the pass is CANCELLED. This does not apply to Emergency, Medical, or Legal Passes.

• Plan for your pass and have enough money for the pass. Arbor House will not advance money for a pass.

• Return from pass on time. The only staff members that may approve the extension of a pass is the Program Coordinator. The Coordinator will not be contacted after work hours to approve an extension. PLAN AHEAD!!

• Notify staff on duty of a decision not to use an approved pass.

• Arrange for transportation. Arbor House will not provide any transportation to or from your destination.

• Get required medications from the staff upon leaving and RETURN any unused medications upon arrival back.

• Make written arrangements to have chores done.

• Notify staff immediately upon return. Returning to the residence ENDS the pass.

• MOST IMPORTANT!! A Pass request MUST be given to your Primary Counselor NO LATER than Tuesday evening at 5 PM.

SECTION 6: DISCHARGES AND APPEAL PROCESS:

DISCHARGE TYPES:

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There are five types of discharges from the Arbor House. Which of them will apply toyou depends on your participation, or lack thereof, in the program.

Note: If you answer to a LEGAL AUTHORITY, ie, Probation, Parole or Drug Court, THEY WILL BE notified upon your discharge.

1. PROGRAM COMPLETION: When you and the staff agree you havecompleted your program at the Arbor House and you are ready to assume independent living, you will be discharged and issued a formal Program Completion Certificate. You will be entitled to return to the Arbor House on a regular basis as an honored guest.

2. VOLUNTARY DISCHARGE: You may at any time during your stay, inwriting, voluntarily request discharge from the Arbor House. Such request will not berefused. Depending on your reasons for leaving and your progress in the program, the staff may grant you a Program Completion. An individual leaving “voluntarily” in an attempt to avoid another type of discharge will not work. For example, a resident with 27 Demerit points who is about to get an additional 3 Demerit points, and says that he is leaving, will not receive a more favorable discharge.

3. DISCIPLINARY/EMERGENCY DISCHARGE: The Program Coordinator and/or House Manager may, at their digression, discharge you for any of the reasons listed below. If you are being asked to leave the program, staff will notify the Coordinator or House Manager for approval.• Returning to the use of alcohol or other drugs in or away from the Arbor House.• Engaging in physical/verbal abuse of other residents or staff.• Repeated violations of the Arbor House rules and regulations.• Flagrant disregard of the suggestions/advice of staff.• Flagrant disregard of the Arbor House rules and regulations.

4. THERAPEUTIC DISCHARGE: The Arbor House is not therapeutic in nature, and staff may decide, after careful consideration, that we are unable to provide the necessary treatment you need. Staff will evaluate each individuals needs and will work closely with you to help facilitate treatment at another agency better equipped to meet your needs.

5. SLP DISCHARGE: When you and the staff agree you are ready for a lessStructured environment, you may be transitioned to our Supportive Living Program.

We will not keep any resident against their will. Any resident is free to leave at any time. The Discharge Type will reflect the circumstances of discharge.

CORRECTIVE PROCEDURES:

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Arbor House has four types of corrective procedures.

1. DISCIPLINARY DISCHARGE: A disciplinary discharge is given in the case of gross misconduct, criminal actions or severe negligence. Examples of disciplinary discharge can include: not returning back to residence, not informing staff of your whereabouts, and disrespecting the rules of the Arbor House. You can be given a discharge even if there has not been any type of prior warning. You will be given the opportunity to APPEAL your discharge however, STAFF reserves the right to ask you to leave the building and APPEAL the decision from another location.

2. EMERGENCY DISCHARGE: An Emergency Discharge is given when the staff feel your behavior(s) is placing yourself or others in immediate harms way. This can include having drug(s) or alcohol at the premises, paraphernalia at the premises, or threatening behavior. You will be asked to leave the premises immediately. You can be given a discharge even if there has not been any type of prior warning.

3. DEMERIT POINTS: Demerit points are given when a resident portrays negative behavior that is against the rules of the Arbor House. See below for further explanation.

4. RECOMMENDATION OF TREATMENT: Is a form in which a resident has committed a behavior that is serious enough in nature that can lead to a disciplinary discharge. The treatment team will meet at the next treatment team meeting on every Wednesday at 1 pm and the decision of treatment will be given after the meeting. Some options that the counselors have is placing you on contract, changing your treatment plan, denying any privileges or a combination of these.

RESIDENTS’ GRIEVANCE PROCESS:

DEMERIT POINTS: When you are given a demerit point, you can submit in writing a letter stating what lead up to the situation that caused you to receive demerit point(s) and why you feel this is not right. This letter shall be given to the Program Coordinator or

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their designee receiving the request for a final decision within 24 hours. You will be notified of the final decision within 72 hours of receiving the appeal.

DISCHARGE: When you are presented with a Emergency/Disciplinary Discharge, it is up to the counselor on duty when you must vacate the premises. It can range from immediately up to 24 hours. You can submit your appeal from another residence. To fulfill the appeal process you must submit in writing very specific reason(s) why you should be allowed to continue your participation in the program. You must include specific steps you will take in order to ensure that these types of behaviors do not occur again. Please be advised that the written appeal does not mean that the appeal will be granted. You have 24 hours from the time you are notified of your discharge to appeal. This written appeal must be given to your Primary Counselor. The treatment team will meet within 72 hours of receiving your appeal and will inform you within the 72 hour period the decision and treatment recommendations.

RECOMMENDATION OF TREATMENT: Depending on the outcome of the recommendations you can respond in two ways. If you are presented with a Disciplinary Discharge please follow the discharge grievance process. If your treatment plan is changed or you are placed on contract you have 24 hours to respond to the Program Coordinator. Please write a letter about the reasons that led up to the recommendations, why you feel course is treatment is not right and solutions to the issue. The treatment team will respond within 72 hours about the decision and treatment recommendations.

OTHER GRIEVANCES/CONCERNS: If you feel that your rights, privacy or any behavior deemed harmful to you have been violated there are steps that need to be followed. Upon request you can get a copy of this policy regarding grievances and a list of contact people.

1. Evaluate if it is a grievance or a program suggestion. A program suggestion is something that is already established and you would like to be changed for the betterment of the program. A grievance is when you feel you were not treated with dignity, respect and/or your rights have been violated. Program suggestions can be talked over with your Primary Counselor, during Community Meeting, or with the Program Coordinator.

2. Take the time think about the situation that occurred. If you decided that this is a grievance we encourage you to speak with the staff that you felt had violated you in some way. Sometimes this could just be miscommunication.

3. If the above process has not worked, then talk to your primary counselor. 4. If the issue is still not resolved please speak to the Program Coordinator. 5. If you continue to feel that it is not resolved please contact the Sr. Division

Director of the Residential Program. 6. The last step is to call OASAS.

Rights and Responsibilities for Filing Complaints

A. On the Agency level, you have the right to:

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1. File a complaint about Arbor House or any OCO program or service at any time, without fear of retribution

2. Receive professional, respectful treatment at all times during the complaint process

3. Request and receive a written response to your complaint4. Request and receive a copy of OCO’s consumer feedback policy and

procedures5. Take a complaint to a higher level within the Agency if you have already

attempted to address the matter at lower levels but the issue has not been resolved to the best of OCO’s ability or to the client’s satisfaction

6. Take your complaint to organizations that regulate the program involved; in the case of Arbor House, that is OASAS

B. On the State level, you have the right to:1. File a complaint about our services, without retribution.2. Question a policy, voice a concern or submit a grievance with our program

to the Office of Alcoholism and Substance Abuse3. Receive a timely response and/or resolution

C. When filing complaints, clients are expected to:1. Make complaints in good faith2. Attempt to resolve their complaints at the lowest possible point or level of

service before taking them to higher levels3. Respect the confidentiality of other consumers and OCO staff4. Be respectful in their speech - no profanity, no yelling or angry outbursts.5. Speak up about concerns when they occur. Holding back information

about abuse, misconduct, fraud, violations of program rules, illegal or unauthorized activities to use in retaliation against other clients or Arbor House staff will not be tolerated.

D. Oswego County Opportunities is expected to:1. Inform clients of their rights to file complaints and the procedures OCO

will follow to resolve complaints2. Have zero tolerance for retaliation or retribution against clients who file

complaints3. Protect the confidentiality of OCO personnel or clients named in a

complaint investigation.4. Cooperate fully with the authorities conducting any external investigations

into OCO employees, board members, volunteers, or program operations.

Complaint Procedure

Revised: 3/1336

If you have questions and/or concern(s) about the treatment services you receive at Arbor House or with The Office of Alcoholism and Substance Abuse (the Office), or feel your rights have been violated, follow these steps:

A. Talk with your counselor. Most problems can and should be handled by your counselor.

B. If matters are not resolved by your counselor, talk to the Arbor House Manager Sean Collins and or Program Coordinator: Gerette Nicotra , 315-564-5506

C. If the matter is not resolved, contact the Residential Services Department Director: Patrick Waite, 315-598-4717

D. If the matter is not resolved, speak to your medical provider. E. If the matter is not resolved, contact the Corporate Compliance Office at Oswego

County Opportunities: 1-800-359-1171 or 315-598-4717 ext 1092. The Corporate Compliance Officer, Betsy Copps, reports directly to the Executive Director and to the Board of Directors.

F. If you still need help, call the OASAS Client Advocacy Unit at 1-800-553-5790.

Arbor House Responsibilities for Treatment Plan Compliance

A. Arbor House will provide copies of all policies and procedures governing patient compliance in the resident handbook upon admission to the program

B. Additional policies and procedures applicable to individual patients as determined by their treatment plans will be provided in writing within 3 days of notification of the additional policies and procedures.

C. Arbor House will not impose any treatment intervention or action that will delay or deny any clinical, medical or other required services vital to the health or recovery of any patient.

D. Patient non-compliance will be addressed individually through an incremental system that begins with a warning, followed by incremental interventions incorporated into treatment plans that are designed to assist patients in responding positively to treatment. These will be specific, time-limited, and documented in the patient’s record.

Patient Responsibilities for Compliance with Treatment Plan

A. All patients are expected to follow the policies and procedures governing patient compliance, which are provided upon admission to the program.

B. All patients are expected to agree to specific expectations for behavior and the consequences for non-compliance, including termination of treatment

SECTION 7: FIRE PLANS

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FIRE PLAN FOR ARBOR HOUSE:

All occupants of Arbor House , staff and visitors upon activation of the fire alarm system, will take the following actions:

1. Ensure that anyone in your immediate vicinity is awake and capable of responding to the alarm.

2. Leave the building by the nearest exit based on your location at the time ofactivation of the alarm system. Must exit immediately.

3. After leaving the building, all occupants will move immediately to the front of thebuilding and assemble in the grassy area surrounding the mailbox and remainthere until further instructions are received by staff.

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SECTION 8: HEALTH:

BLOOD-BORNE PATHOGENS: Hepatitis B and HIV

This section explains Arbor House policy and procedures for dealing with blood-borne pathogens. It is the Arbor House program policy that no person will be denied admission, terminated, or have their services reduced, limited, or otherwise affected negatively, or their status changed solely on the basis of their actual, presumed, or alleged HIV-related condition or status.

Hepatitis B

Hepatitis B is a virus that causes the liver to become inflamed. Most people fight off theinfection themselves. However, approximately 5 -10 percent of those who areinfected with the virus will become carriers and an estimated 5 -10 percent of thosepeople will progress to chronic liver disease, cirrhosis, and possibly liver cancer.Hepatitis B Virus (HBV) is transmitted through infected blood and other body fluids.

HIV

“HIV” stands for Human Immunodeficiency Virus - the virus that causesAcquired Immunodeficiency Syndrome (AIDS). If you’ve been diagnosed as being infected with HIV, you’re “HIV-positive”; your blood test shows the presence of type 1(HIV-1), the most common type in the US and Europe -- or type 2 (HIV-2) virus. Bothtypes can cause the chronic illness AIDS.

AIDS makes the immune system increasingly less effective against infection, so the body is less able to ward off disease. HIV infection is considered to have progressed to AIDS after the infected person develops one or more of the following:

• An “opportunistic” infection or tumor (one that might not have developed if HIV had not been present)

• A “helper” T-cell blood count of less than 200. “Helper” T-cells help infection-fighting antibodies to form in the blood. HIV weakens and kills these cells. A healthy “helper” T-cell count is 600 - 1, 000.

Although HIV has been transmitted between members in a household setting, this type oftransmission is very rare. These transmissions are believed to have resulted from contactbetween skin or mucous membranes and infected blood.

To prevent exposure to blood-borne pathogens, Arbor House infection control precautions must be followed.

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OVER-THE-COUNTER AND PRESCRIPTION MEDICATIONS:

Those who have been treated for chemical dependency are often concerned about issues of recovery and the use of medications. As a chemically dependent person your tendency will be to turn to chemical relief for uncomfortable feelings and aches and pains. You also may want to take more than the prescribed amount of any given medication. Look for “non-chemical” solutions for the aches and discomfort of everyday living.

If you are experiencing mild discomfort, and are in need of “over-the-counterMedications, you will need WRITTEN approval from your Doctor in order to take the over the counter medication. Over the Counter Medications will be locked in the Medication room and will be available for you from the staff on duty. You will be required to sign that you have taken the medication.

It is Arbor House’s policy to store all medications in a locked medicine cabinet. Please hand in all medications to staff upon receiving any medication.

If you think you need to talk to a doctor, be honest regarding the use of medications. Befrank about your substance abuse with any physician or dentist as it is most helpful to thedoctor and yourself. If you have to go to the hospital, the doctor must be aware of the addiction process.

If in doubt, consult a physician who has demonstrated experience in the treatment ofsubstance abuse.

Arbor House has mandatory medication times as follows: Monday through Friday: AM: 6:45 am – 7 amNoon: 11:45 am – 12 pm PM: 5:45 pm – 6 pm Bed: 9:30 pm – 9:45 pm

Saturday through Sunday: AM: 7:45 am – 8 am Noon: 11:45 am – 12 pm PM: 5:45 pm – 6 pm Bed: 9:30 pm – 9:45 pm

You will come to staff office and staff will hand you your bottle. You will then take out what is needed and initial in the medication book that you have received the correct medication and correct dose at the correct time.

ARBOR HOUSE INFECTION CONTROL PRECAUTIONS:

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1. Always assume that any blood or other body fluids from all persons in the residence are potentially infectious.

2. Any resident who encounters blood or other body fluids will notify an Arbor House staff member immediately.

3. Spill kits are available in the main office 4. Gloves must be worn during contact with blood or other body fluids such as urine,

feces, or vomit that may contain blood, whether or not it is visible.5. Gloves must be replaced if torn, punctured, or contaminated, or when their ability to

function as a barrier is compromised.6. Gloves must never be reused.7. Cuts, sores, or breaks on a person’s exposed skin must be covered with bandages.8. Hands and other parts of the body must be washed immediately after contact with

blood or other body fluids.9. Surfaces soiled with blood must be disinfected using EPA-registered disinfectants for

HIV and HBV; the surface must be left wet with the disinfectant for 30 seconds for HIV-1 and 10 minutes for HBV.

10. Laundry contaminated with blood or other potentially infectious materials must be handled as little as possible. The laundry must be washed in hot water and dried completely in clothes dryer immediately after becoming soiled.

11. Residents are not allowed to share razors or toothbrushes.

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SECTION 9: RESIDENTS’ COPIES

OASAS Client Rights and ResponsibilitiesThe Office of Alcoholism and Substance Abuse General Information Line: 1-800-553-5790OASAS Commissioner- Arlene Gonzalez-Sanchez General Information Line: 1-518-473-3460

Arbor House Client Rights and Responsibilities

All chemical dependency treatment programs licensed by OASAS are required to operate in accordance with Mental Hygiene Law and Regulations, as well as other applicable state and federal laws.

As such, patients in OASAS licensed programs are entitled to certain rights, and likewise, must fulfill certain responsibilities.

You have the right to question a policy, voice a concern or submit a grievance with our program or the Office of Alcoholism and Substance Abuse, receive a timely response and/or resolution, to not suffer adverse consequences or retaliation as a result and to communicate with the provider’s director, medical director, board of directors, and/or other responsible staff and the Commissioner.

What You Can Do

If you have questions and/or concern(s) about the treatment services you receive at your program or with The Office of Alcoholism and Substance Abuse (The Office) or feel your rights have been violated, follow these steps:

1. Talk with your counselor. Most problems can and should be handled by your counselor.

2. If matters are not resolved by your counselor, talk with his or her supervisor: Sean Collins/Gerette Nicotra 315-564-5506

3. If that doesn’t work, talk with the program doctor or director: Patrick Waite 315-598-4717

4. If you still need help, call the OASAS Client Advocacy Unit at 1-800-553-5790.

Rights

You Have The Right To:

• To receive services that are responsive to individual needs in accord with an individualized treatment plan, which the patient helps develop and periodically update.

• To receive services from provider staff who are competent, respectful of patient dignity and personal integrity, and in sufficient numbers to deliver needed services consistent with regulatory requirements.

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• To receive services in a therapeutic environment that is safe, sanitary and free from the presence of alcohol or other drugs of abuse.

• To know the name, position, and function of any person providing treatment to the patient, and to communicate with the provider director, medical director, board of directors, other responsible staff or the Commissioner.

• To receive information concerning treatment, such as diagnosis, conditions or prognosis in understandable terms, and to receive services requiring a medical order only after such order is executed by an appropriate medical personal.

• To receive information about provider services available on site or through referral, and how to access such services.

• To receive a prompt and reasonable response for provider services, or a stated future time to receive such services in accordance with a individuals treatment plan.

• To know the standards that apply to his or her conduct, to receive timely warnings or conduct that could lead to discharge and to receive incremental interventions for non-compliance with treatment plans.

• To receive in writing the reasons of a recommendation of discharge and information of appeal procedures.

• To voice a grievance, file a complaint, or recommend a change in procedure or service to provider staff and/or the Office, free from intimidation, reprisal or threat.

• To examine, obtain a receipt, and receive an explanation of provider bills, charges and payments, regardless of payment source.

• To receive a copy of the patients records for a reasonable fee. • To be free from physical, verbal or mental abuse. • To be treated by provider staff who are free from alcohol or drug abuse. • To be free from any staff or patient coercion, undue influence, intimate relationships, and

person financial transactions. • To be free from performing labor or personal service solely for provider or staff benefit, that

are not consistent with treatment goals, and to receive compensation for any labor or employment service in accord with applicable state and federal laws.

• To practice religion in a reasonable manner not inconsistent with treatment plans or goals and/or have access to spiritual counseling if available.

• To communicate with outside persons in accord with the individualized treatment plan. • To freely communicate with the Office, public officials, clergy and attorneys. • To receive visitors at reasonable times in relative privacy in accord with the individualized

treatment plan. • To be free from restraint or seclusion. • To have a reasonable degree of privacy in living quarters and a reasonable amount of safe

personal storage space. • To retain ownership of personal belonging, that are not contrary to treatment goals. • To have a balanced and nutritious diet. • Participants referred to a faith based provider have the right to be given a referral to a non

faith based provider.

Responsibilities

Participants in a chemical dependence service presumes a patient’s continuing desire to change lifestyle habits and requires each patient to act responsibly and cooperatively with

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provider staff, in accord with an individual treatment plan and reasonable provider procedures. Therefore, each patient is expected to:

• To work toward the goal of abstinence from drug, alcohol and tobacco use. • Treat staff and other patients with courtesy and respect. • Respect other patient’s right to confidentiality. • Participate in developing and following a treatment plan. • To become involved in productive activities according to ability. • Pay for services on a timely basis according to financial means. • To participate in individual counseling and/or group and/or family counseling sessions as

applicable. • To inform medical staff if receiving outside medical services. • To address all personal issues adversely affecting treatment• To act responsibly and observe all provider rules, regulations and policies.

Consequences for patient non-compliance.

• Provider policies and procedures to address patient non-compliance shall be designed to support a patient’s positive response to treatment. Such polices and procedures must specify stands and expectations for patient behavior, and any consequences of non-compliance, including behavior which may result in treatment termination.

• Providers shall address patient no-compliance with timely and appropriate incremental interventions designed to assist patient sin responding positively to treatment. Such incremental interventions shall be incorporated in the patients treatment plan, be time-limited, an be documented in the patient’s record.

• No treatment intervention or action can include delay or denial of any clinical, medical, or other required service vital to the health or recovery of the patient.

• Provider shall first warn patients of any behavior that could result in a recommendation of discharge with continued non-compliance, and must document such warning(s) in the patient record.

Directions: Keep this signed document in Clinical Chart. Give Copy to Client.

Clients Name: _______________________ Case Number: _______________

I acknowledge that I have received a copy of the Client Bill of Rights and Responsibilities:

Signature: ___________________________________ Date: _______________

Witness: ____________________________________ Date: _______________

**Resident Copy

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NOTICE OF PRIVACY PRACTICES RESIDENT’S COPY

THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

How Your Information is DisclosedWe use information about you for your care, for administrative purposes, and to evaluate the quality of care that you receive. Your records may be shared by paper mail, electronic mail, fax or other methods. We may use or disclose identifiable information about you without your authorization in limited situations, but beyond those situations, we will ask for your written authorization before using or disclosing any identifiable information about you.

When We May Use or Disclose Information without Your Authorization We may use or disclose your information, as required by law and limited to the relevant requirements of the law, in the following situations without your authorization or opportunity to object:

• Program Oversight - to an oversight agency for activities authorized by law, such as audits, investigations and inspections.

• Abuse and Neglect - to an appropriate authority to report child abuse or neglect, elder abuse or neglect and/or abuse or neglect of the disabled.

• Food and Drug Administration - as required by the Food and Drug Administration to track products.

• Legal Proceedings - in the course of legal proceedings when ordered by an appropriate, legally issued subpoena.

• Compliance - to the Department of Health and Human Services to investigate our compliance.

• Law Enforcement Purposes - to prevent a crime and/or to prevent serious harm to oneself or others.

Written AuthorizationOther uses and disclosures of your information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization, at any time, in writing.Our Legal DutyWe required by law to:

• Protect the privacy of your information• Provide this notice about our information practices• Follow the information practices that are described in this notice

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• Seek your acknowledgment of receipt of this notice.• Provide notice of any significant changes in our privacy policies and post the changes.

Your Rights (per NYS OASAS Regulations)In most cases, you have the right to:• Look at or get a copy of information about you (normal photocopying fees will be charged).• Receive a list of certain types of disclosures of your information that we made.• If you believe that information in your record is incorrect, you have the right to request that

we correct the existing information.• Request a restriction of your information. You may request that information not be disclosed

to family members or friends who may be involved in your care. Your request must state the specific restriction requested and to whom you want the restriction to apply. We are not required to agree to a restriction that you may request, but if we do then we must behave accordingly.

• Request to receive confidential communications. You may receive information from us by alternative means or at an alternative location. We will accommodate reasonable requests.

• Request amendments. You may request an amendment of information about you. If we deny your request for amendment, you have the right to file a statement of disagreement with us, and your record will note the disputed information.

• Obtain an Accounting of Access and Amendments to your information. You may receive an accounting of certain disclosure that we may have made. This right applies to disclosures for purpose other than treatment, payment or operations.• Obtain a paper copy of this notice from us.

You can also request a copy of our notice at any time. For more information about our privacy practices, contact the persons listed below.

Complaints: If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact the site manager or the person listed below.

If you have any questions or complaints, please contact:Privacy Officer: Human Resources Manager

239 Oneida StreetFulton, New York 13069

(315) 598 –4705……………………………………………………………………………………………Acknowledgment of receipt of Notice of Privacy Practices:

Please sign your name, print your name and date this acknowledgment form. Then detach the form from the notice along the dotted line and return your signed acknowledgment to the person assisting you or to the address above.

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Signature: _________________________________________________

Printed Name: _________________________________________________

Date: _________________________________________________

State of New YorkOFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES

CONFIDENTIALITY NOTICE

THIS NOTICE DESCRIBES HOW MEDICAL AND DRUG AND ALCOHOL RELATED INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

General Information

Information about your treatment and care, including payment for care, is protected by two federal laws: The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”)* and the Confidentiality Law**. Under these laws the program may not say to a person outside of the program that you attend the program, nor may the program disclose any information identifying you as an alcohol or drug abuser, or disclose any other protected information except as permitted by the federal laws referenced below.

The program must obtain your written consent before it can disclose information about you for payment purposes. For example, the program must obtain your written consent before it can disclose information to your health insurer in order to be paid for services. Generally, you must also sign a written consent before the program can share information for treatment purposes or for health care operations. However, federal law permits the program to disclose information in the following circumstances without your written permission:

1. To program staff for the purposes of providing treatment and maintaining the clinicalrecord;2. Pursuant to an agreement with a business associate (e.g. Clinical laboratories, pharmacy,record storage services, billing services);3. For research, audit or evaluations (e.g. State licensing review, accreditation, program datareporting as required by the State and/or Federal government);4. To report a crime committed on the program’s premises or against program personnel;5. To medical personnel in a medical/psychiatric emergency ;6. To appropriate authorities to report suspected child abuse or neglect;7. To report certain infectious illnesses as required by state law;8. As allowed by a court order.

Before the program can use or disclose any information about your health in a manner which is not described above, it must first obtain your specific written consent allowing it to make the disclosure. Any such written consent may be revoked by you in writing. (NOTE: Revoking a consent to disclose information to a court, probation department, parole office, etc. may violate an agreement that you have with that organization. Such a violation may result in legal consequences for you.)

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* 42 U.S.C. § 130d et. seq., 45 C.F.R. Parts 160 & 164** 42 U.S.C. § 290dd-2, 42 C.F.R. Part 2

Oswego County Opportunities, Inc.Chemical Dependence Program

53 Hall Road, Hannibal, New York 13074Tel. #: 315/564-5506, Fax. #: 315/564-7567

RESIDENT ADMISSION CONTRACT

I, the undersigned, am entering the Oswego County Opportunities, Inc., Residential Division, Chemical Dependence Program on a voluntary basis and agree to the following terms and conditions as long as I am a resident of the program:

A. Oswego County Opportunities, Inc. Shall provide:

1. Lodging in the: xx Community Residence _____ Supportive Living Program

2. Board, including three meals daily and between meal snacks at the Community Residence. Monthly food allowances while a resident in the Supportive Living Program.

3. All linens, bedding, and towels.

4. Laundry facilities.

5. The current prevailing monthly Personal Needs Allowance (PNA), as set by the New York State Department of Social Services and the Social Security Administration for Congregate Care Level II Community Residences. The Department of Social Services from the resident’s home county may impose by law a forty-five day waiting period for the Personal Needs Allowance. Resident will receive their PNA within 2 weeks after notification that Oswego County Opportunities, Inc has received their PNA.

6. Twenty-four hour staffing at the community residence and twenty-four hour on call staff in conjunction with staff visits for the Supportive Living Program.

7. Assistance in obtaining access to medical, dental, chemical dependence, mental health services, and any other needed services from the community.

8. Arbor House will provide transportation for medical or legal appointments when there is no pubic transportation available within Oswego County or within a 50 mile radius of the program.

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9. A structured program of continued services designed to help residents make the transition to abstinent living.

10. A constant focus on the development and improvement of the sober-living skills necessary for recovery and abstinent living.

B. For as long as I am a resident and member of the Residential Division, Chemical Dependence Program, I agree to and understand that I am responsible for the following:

1. Payment of the required monthly room and board fee established by the Social Security Administration for Congregate Care Level II Community Residences.

2. Turn over entire allotment of Food Stamps each month for grocery expenses while at the Community Residence. Community Residence residents are not to use any food stamps after entering the program. This includes any previous amount. This amount will remain on your card for when after you leave. Arbor House staff hold the right to change your pin number regarding your food stamps while you are a resident of the program. Supportive Living Program residents keep their Food Stamps.

3. Develop and work a Comprehensive Service Plan.

4. Participate in household chores, meetings, meal preparation, and social activities.

5. Remain abstinent from the use of alcohol and all other drugs, not prescribed by my physician or health center medical staff.

6. Refrain from sexual relationships with other residents or any staff member.

7. Treat both peers and staff with respect, consideration, and understanding.

8. Refrain from using foul or obscene language and verbal abuse of both peers and staff.

9. Keep bedroom clean and neat, with a thorough cleaning at least once per week.

10. Launder clothes at least once per week.

11. Bathe or shower daily and maintain acceptable personal hygiene.

12. Reimbursement of any damages to the residence.

13. Abide by all program rules and follow all proper staff requests and directions.

14. Any and all legal matters which may arise as a result of my own behavior or conduct. I understand that Oswego County Opportunities, Inc., nor it’s employees, will intervene

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nor protect me in legal actions arising from my illegal conduct or such other conduct which might necessitate legal action(s) against me.

15. Any and all financial responsibilities.

16. Submit to breath, oral or urine test upon request.

17. Participate in the preparation of my Service Plan and Discharge Plan

18. Actively participate in all aspects of the program as required for my recovery.

19. Submit to searches of my personal belongings or my persons upon request, and including searches without my verbal permission. Searches are to include but not limited to: room searches, pat down searches, strip searches and body cavity searches performed by a medical physician.

C. For as long as I am a resident and member of the Residential Division, Chemical Dependence Program, I agree to and understand the Resident Fee Schedule (Addendum A) attached, established by the Social Security Administration for Congregate Care Level II Community Residences.

D. Termination of Contract:

I agree to and understand that this Resident Admission Contract may be terminated by either myself or the Chemical Dependence Program Staff for reasons including, but not limited to the following causes:

1. Program Completion - I have accomplished the goals and objectives which were identified in my Comprehensive Service Plan and/or have received the maximum benefit from the Chemical Dependence Program.

2. Voluntary Discharge - My admission was voluntary and I am free to discharge myself at any time.

3. Therapeutic Discharge - I have agreed and been referred to other appropriate treatment which cannot be provided by the Chemical Dependence Program.

4. Incarceration Discharge - I have been removed from the program and incarcerated in a correctional facility by the criminal justice system or other legal process.

5. Disciplinary Discharge - I have been asked by staff to leave the program because my behavior poses a danger to myself or others, is disruptive to the program, and/or fails to comply with the reasonably applied written behavioral standards of the Chemical Dependence Program.____________________________________________ __________________

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Signature of Resident Date

____________________________________________ __________________Signature of Staff Witnessing Date

CONSENT FOR RELEASE OF INFORMATION CONCERNINGALCOHOLISM/DRUG ABUSE PATIENT – Resident Copy

REVOKED ON___________ Staff sig___________

RELEASE WITH PATIENT'S CONSENT

I, the undersigned, have read the above and authorize the staff of the disclosing/releasing facility named to disclose/release such information as herein contained. I understand that this consent may be withdrawn by me in writing at any time except to the extent that action has been taken in reliance upon it. This consent shall expire six (6) months from its signing, unless a different time period, event or condition is specified below, in which case such time period, event or condition shall apply. I also understand that any disclosure/release is bound by Title 42 of the Code of Federal Regulations governing the confidentiality of alcohol and drug abuse patient records, as well as the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) 45 C.F.R. Pts. 160 &164; and that redisclosure of this information to a party other than the one designated above is forbidden without additional written authorization on my part. I understand that generally the program may not condition my treatment on whether I sign a consent form, but that in certain limited circumstances I may be denied treatment if I do not sign a consent form. I have received a copy of this form, as recognized by my signature below. Time period, event or condition replacing period specified above: Shall expire one (1) month after my discharge from this facility._____________________________________ _____________Signature of Patient Date:

_______________________________________________________

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PATIENT'S LAST NAME FIRST M.I. :      CASE NO.      

INSTRUCTIONS: GIVE A COPY OF THE FORM TO THE PATIENT! Prepare one (1) copy for the Patient's Case Record. If this form is sent to another agency with a request for information, prepare an additional copy for the Patient's Case Record.

EXTENT OR NATURE OF INFORMATION TO BE DISCLOSED/RELEASED

PURPOSE OR NEED FOR DISCLOSURE/RELEASE Please check which box needed:

Coordination of treatment Eligibility for benefits/services Assist with legal concerns

Coordination of referrals Collateral contacts Contact referral source

Emergency notices Other Specify:      

NAME OR TITLE OF PERSON OR ORGANIZATION DISCLOSING/RELEASING INFORMATION Between: Arbor House

NAME OR TITLE OF PERSON OR ORGANIZATION TO WHICH THE DISCLOSURE/RELEASE IS TO BE MADE And:      

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Printed name of Patient

Any information released through this form will be accompanied by the form prohibition on Redisclosure of Information Concerning Alcoholism/Drug Abuse Patient (TRS-1)

CONSENT FOR RELEASE OF INFORMATION CONCERNINGALCOHOLISM/DRUG ABUSE PATIENT – Resident Copy

REVOKED ON__________Staff sig__________

I, the undersigned, authorize the staff of this facility to say that I am present or not at this facility and provide informationabout my general condition to those persons listed below who are personally interested in my whereabouts and progress.I agree to have my next of kin as listed below notified in case of injury, illness or other emergency.

Name Of Next of Kin:       Telephone Number:      Address:      

NAME(S) OF INTERESTED PERSONS RELATIONSHIP                                            

I understand that this consent may be withdrawn by me, in writing, except to the extent authorized information has been disclosed in reliance upon it. In any event, this consent shall expire one (1) month after my discharge from this facility. I also understand that any disclosure made on my behalf by this facility is bound by Title 42 of the Code of Federal Regulations governing the confidentiality of alcohol and drug abuse records as well as the Health Insurance Portabilityand Accountability Act of 1996 (“HIPAA”)

__________________________________________ __________________Signature of Patient /Guardian when needed Date:

_     ______________________________________________________Printed name of Patient

Any information released through this form will be accompanied by the form prohibition on Redisclosure of Information Concerning Alcoholism/Drug Abuse Patient (TRS-1)

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PATIENT'S LAST NAME FIRST M.I. :      CASE NO.      FACILITY: Arbor House

INSTRUCTIONS: INSTRUCTIONS: GIVE A COPY OF THE FORM TO THE PATIENT! Prepare one (1) copy for the Patient's Case Record

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Oswego County Opportunities, Inc.Chemical Dependence Program

Tobacco-Free Policy

To comply with strict licensing regulation and provide a healthy environment at the Arbor House, as of July 1, 2008 the use of tobacco products is prohibited at all times. This tobacco-free policy applies to all persons who are at the community residence and supportive apartments including staff, residents, and visitors. In addition, all program staff is prohibited from using tobacco products during work hours which includes no evidence of tobacco use. Evidence of tobacco use is considered to be smelling of tobacco and visibly carrying tobacco products or paraphernalia.

The Arbor House will provide services to assist residents who desire to stop the use of tobacco products and such services will be documented and included in the resident’s Comprehensive Service Plan. Employee assistance programs will be made available to staff who desire to stop smoking.

Signs will inform all persons who enter the Arbor House that tobacco use is prohibited. The signs will clearly convey the message that smoking and the use of tobacco products is not allowed anywhere in the Arbor House, on the Arbor House grounds or in the supportive apartments by any person at any time. The resident handbook, program policy, and program brochure will specify that the program maintains a tobacco-free environment.

The Program Coordinator will be informed of any and all incidents of the use of tobacco products at the Arbor House. Violations of the tobacco-free policy will be addressed as follows:

1. If a resident violates this policy and uses tobacco products while in the program, it will be considered in the context of his Comprehensive Service Plan. The program will respond in a manner consistent with the policy regarding the possession and/or use of drugs or alcohol.

2. If a staff member violates this policy and uses tobacco products at the Arbor House or during work hours they will be subject to the same agency disciplinary procedures used for violating any other work performance policy.

3. A visitor to the Arbor House who violates this policy will be asked to leave and reminded not to smoke or use tobacco products on future visits.

I have read and understand the above information and acknowledge that this program is tobacco-free. My signature below indicates my intent to follow the rules regarding tobacco and smoking at the Arbor House and Supportive Living Program.

______________________________________________Print Name

______________________________________________ ________________Signature Date

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Resident Attestation Statement

Rules/Regulations, Client Rights and Voluntary Basis

• I have been provided with a copy of the Patient/Resident Handbook which contains Program Rules and Regulations, Patient Rights and Responsibilities and a summary of the Federal Confidentiality Regulations/Rights under HIPAA, OASAS Clients Rights and Responsibilities, Consent for Release of Information, and Tobacco Free Policy. I have been given the opportunity to discuss these documents and to have my questions answered. By signing this form, I am indicating that I understand these rules, rights and regulations.

I also understand that all treatment services are provided on a voluntary basis and that I have the right to discharge myself from treatment at any time. If I have been mandated to treatment, there may be consequences for leaving treatment prematurely, but my participation remains a voluntary choice. I further understand that if I leave the Arbor House, I am required to take all of my belongings. My belongings will not be stored and ONLY the person I have listed as my Emergency contact will be permitted to pick up my things should I leave unexpectedly. Should no one be available to pick up my belongings, I further understand that Arbor House reserves the right to throw them away after 10 days.

_______________________________________ ___________________Patient/Resident Signature Date

(This page to be placed in the patient/client case record)

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**Residents copy

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