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DCHV (rev. 6/16/2021) Page 1 DOMICILIARY RESIDENTIAL REHABILITATION TREATMENT PROGRAM ADMISSION TREATMENT AGREEMENT Welcome to the Domiciliary Rehabilitation Treatment Program! This treatment agreement outlines your consent to participate in treatment in this setting and your responsibilities as a participant in this program. Please read it carefully and ask for clarification from staff if you have any questions or to provide input to the program. Please write in your initials next to each item to indicate your review and agreement. SAFETY COVID-19 Precautions (Initial each item below) ______ I agree to practice social distancing by maintaining at least 6 feet (2 meters) from others when possible, wear a mask when outside my room, and frequent, appropriate hand hygiene (e.g., washing with soap/water for 20 seconds). ______ I agree to adhere to restrictions that may be put in place to prevent the spread of infection. Examples of restrictions are below, frequently being updated, and at discretion of staff: Discontinuation of social passes and visits by family/friends Limited passes for only essential needs, which will be approved by staff Limited reporting to outside employment, which will be approved by staff Limited or cessation of access to dining hall, canteen, store, etc. Limited or cessation of access to group areas like gyms, group rooms, etc. Limited approval or areas for food/package delivery ______ I agree to present to my medical team if I am experiencing symptoms of upper respiratory infection, including cough, sore throat, runny nose, shortness of breath, wheezing, fever, etc. ______ I understand that a medical provider will require a swab to test for infection and will determine if I am a Person Under Investigation (PUI). A PUI is someone who is having concerning symptoms, someone who has been exposed to a source of infection, or someone for whom we are waiting test results to return. If I am determined to be a PUI, I agree to comply with the following parameters until the test results return. To ensure my safety and safety of other residents and staff: I may be asked to move to an area of isolation and be restricted to my room. I will be required to wear a mask or other protective equipment when interacting with others. If I am determined to be positive for an infection, my medical team will make plans for my care in collaboration with the hospital and infection control. I may be required to move areas or units. ______ I understand that staff recommendations for infection control will be based on guidelines informed by public health and infectious disease experts and may be subject to change at any time to maintain safety of all residents and staff on the unit. I understand that staff will provide the rationale for any recommendations to the best of their ability and that recommendations will attempt to be as least restrictive as possible while reducing risk of transmission of infection. Thus, I agree to adhere to additional staff recommendations that may not have been specified above. DCHV (rev. 6/16/2021) Page 2 Substance Use (Initial each item below) ______I understand that substance use is not compatible with treatment at places other Veterans at risk, and may result in my immediate discharge from the program. I agree not to use or bring to the program illicit or non-prescribed drugs and alcohol. ______I understand that I must give Domiciliary staff accurate information about my recent substance use to ensure my health during my first days at the Domiciliary. I understand that using within 3 days before admission won’t necessarily prevent my admission, but if I test positive on my initial drug or alcohol screen and have not told staff about the substance use that caused this, I am subject to discharge for undermining my own safety and treatment. ______I understand that, as part of my treatment, I am expected to disclose information with staff and peers about my substance use. This information is necessary to ensure the safety and sobriety of all program participants and will lead to improved treatment outcomes. This may include information about any substance use I engage in while in the program and may include disclosure of results of drug screens and breathalyzer tests, as well as history of use and current use, with staff and fellow program residents. I understand that I may revoke this form at any time during my stay in the program, however I understand that doing so may lead to my discharge from the program. ______I agree to follow the Domiciliary Self-Medication Policy and will not use or have non-VA medications or herbal supplements during my stay (e.g., non-VA prescribed vitamins, protein powder, etc.). ______I understand that Alcometer/Breathalyzer tests and observed urine analysis drug screens (UAs) are part of residential treatment and I agree to provide urine for drug screens and take breathalyzer tests as requested by staff – and I may ask staff to test any member of the Community I suspect of using drugs or alcohol. I understand that refusal to be tested may result in my discharge from the program. ______I understand that a Repair Council process is further described in the program manual. This process is often used if it is discovered that I have returned to substance use or have tested positive for an unapproved substance while in the program. I will review this process and inform my treatment team if I have further questions. Contraband (Initial each item below) ______I agree to a search of my belongings (which may include vehicles) for safety concerns and contraband. Searches occur at admission, upon returning back to the unit, or at any point during treatment at the Domiciliary. If I refuse, I understand that I may be denied admission or be discharged. ______ I understand that the following items are contraband: Alcohol & alcohol based products (e.g. hand sanitizer, alcohol based mouthwash, cologne/perfume, etc.) Energy drinks. Explosive materials/flammables e.g. fireworks, gunpowder, ammunition, butane, propane, and lighter fluid and model glue. All medications other than those prescribed at the VA including over the counter medications, herbal supplements, protein powders and protein supplements, and marijuana/cannabinoid or CBD substances. Illegal Drugs or Drug Paraphernalia. Scissors and knives of any length, including pocketknives, cane swords, and machetes. DCHV (rev. 6/16/2021) Page 3 Mace, pepper spray, etc. Weapons or Firearms (includes all items that could be used as a weapon, any item that projects including rifles, shotguns, pistols, BB guns, CO2 guns, pellet guns, slings, slingshots, blowguns, starter pistols, etc.) Other weapons, including: Mace, taser, martial arts equipment, throwing stars, nun-chucks, brass knuckles, tear agent, spears. Work Tools such as hammers, saws, crow bars, rope, etc. Incense, candles, air fresheners, aerosols, or anything else that can be burned. Clothing with representations of weapons or violence, including military fatigues (may be triggering). Pornography of any type. Vapes and electronic cigarettes of any kind and chew tobacco. Inhalants including compressed air, aerosol products and canned dusters. Other items determined clinically unsafe or items that can be potentially used in a manner threatening to self or others. ______ I agree to not bring any weapons or contraband to the program and will not store weapons or contraband in my room, vehicle or on grounds during the course of my stay in the program. ______I understand that upon arrival, my personal possessions will be searched and items not allowed will be returned to my home. Staff will help me store property that could potentially be used as a weapon (such as a pocketknife, tools) and will return it to me upon discharge. Possession of a weapon or contraband may result in my immediate discharge from the program and may require involvement of the VA Police. Dangerous Behavior (Initial each item below) ______I understand that I have the right to dignity, respect, and safety. Physical violence, verbal abuse, threats of violence, intimidation, harassment, hazing, etc. are not compatible with treatment at the Domiciliary, places other Veterans at risk, and will be grounds for my immediate discharge from the program. ______I agree to refrain from making culturally insensitive statements about race, sex, religion, sexual orientation, gender identity, age, language, national origin, political affiliation, disability, branch of service, etc. that could impact the emotional or physical safety of others during my stay. ______I understand that sexual harassment or harassment based on sex, gender identity, sexual orientation, or pregnancy status are all prohibited. Sexual harassment can be committed by anyone to anyone, regardless of sex, gender or sexual orientation. Sexual harassment includes: Unwanted sexual advances Threats or intimidation in order to obtain sex Physically touching someone without permission, sexual assault, or blocking someone’s movements Leering, making sexual gestures, or displaying sexually suggestive objects, pictures, videos, cartoons or posters. Making or using derogatory comments, slurs, or jokes Excessive compliments and compliments that may be of a sexual nature. Sexual comments including graphic comments about an individual’s body, sexually degrading words used to describe an individual, or suggestive or obscene letters, notes or invitations. DCHV (rev. 6/16/2021) Page 4 Safety Procedures (Initial each item below) ______Regular fire and earthquake drills are conducted at the Domiciliary and I am required to participate in these drills and to know the safety rules listed in the program manual. I will receive a safety orientation of the unit to make me aware of safety features on the premises. ______I understand that while I am an inpatient at the Domiciliary, there are some restrictions on when I can leave the hospital grounds. I agree to abide by these restrictions and to keep staff informed as to my whereabouts by signing in and out when leaving the program building. I understand that I am required to know and follow these guidelines as outlined in the program manual. ______I understand that the Domiciliary secures its doors and I will complete an orientation to the environment. I will defer to staff to open its doors to visitors (including former patients who have discharged from the program) and complete visitation procedures. ______I understand that there are security cameras in some public areas of the building. ______I understand that there may be service dogs on the unit and I agree to inform program staff if I have any allergies or other concern about being around animals. I understand that emotional support or companion animals are not considered service animals and are not permitted. I understand that seclusions and restraints are not used at the Domiciliary. ______I understand that I am responsible for all monies and items I bring with me. I will be given a key to a private drawer with a lock in my room, where I am to keep medications and valuables when I am not using them. I understand that the care of my belongings, such as clothes, jewelry, money, eye glasses, hearing aids, dentures and other personal items is always a problem in a hospital. Articles are occasionally lost, misplaced, or broken. I am strongly encouraged to have my valuables kept with family or friends. I release the VA Palo Alto Health Care system from any responsibility for these items. If I fail to take my belongings (including bikes) when I discharge, they will be maintained for 30 days after which they will be considered donated to the hospital. ______I understand that the Domiciliary is a mixed gender program and that only women are guaranteed rooms with locks. Patients are not permitted in each other’s rooms regardless of gender. I understand that staff may enter a patient’s room at any time in cases of emergency or welfare checks, including nightly security rounds. Staff also conduct regularly scheduled and random contraband searches of patient rooms. TREATMENT COVID-19 Precautions (Initial each item below) ______ I understand that in-person contact for assessment and treatment will be provided to me on an as- needed basis, and that staff will interact with me by telephone or telehealth whenever possible to reduce risk of transmission of infection. If interacting with staff in person, I agree to practice physical distancing when possible to receive effective care, and I understand that some interventions require closer physical presence (e.g., medical examinations, receiving medications, exchanging items). DCHV (rev. 6/16/2021) Page 5 ______ I understand and agree to receive assessment and treatment in a way to minimize risk of spread of infection, including through telephone or telehealth using my personal device (e.g., laptop, tablet, phone). If I do not have a compatible personal device, I understand that I can check out a VA-issued device (e.g., tablet) to be used temporarily during my admission and to be returned to program staff. I understand that I will be oriented to the use of telehealth technology early in my stay in the program. ______ I agree to participate in assessment and treatment by telehealth with appropriate telepresence, which means that I will participate from a relatively quiet and private location free from distractions, be dressed appropriately, turn on my video and audio in order to be seen and heard, and practice telehealth etiquette to the best of my ability (e.g., judicious use of the mute button and chat box features; not record sessions; not talk over others). ______ I understand that due to various limitations and ease of user interface of various VA and non-VA telehealth platforms, I am agreeing to participate in treatment through VA Veteran Video Connect, Zoom, Skype, FaceTime, etc. I understand that staff will use VA or HIPAA-compliant enterprise accounts whenever possible, and I will be informed of the platform that will be used in advance verbally and/or by email. I understand that staff will take all possible measures to ensure patient privacy and confidentiality, but these telehealth platforms may have inherent security vulnerabilities outside of staff control. I understand that staff will never use any public-facing platforms to communicate with me (e.g., TikTok, Twitch, Facebook Live, etc.). Treatment Planning (Initial each item below) ______Upon admission, I will receive a comprehensive assessment by interdisciplinary providers which will be used to inform an individualized treatment plan. ______I will be assigned a licensed therapist/clinician and a case manager who will work with me to develop a treatment plan that takes into account my particular needs, barriers to treatment, and objectives. My treatment team will update my treatment plan as appropriate, based upon my input, feedback from peers and staff, and my progression through the program. ______Treatment at the Domiciliary occurs in small group, large group, and individual settings. In order to benefit from treatment in this setting, I understand that I need to be able to provide and receive feedback in groups. I understand that treatment may require a certain amount of self-disclosure (e.g. my income when learning to budget). Staff may disclose important, need-to-know information to the residential community that may impact them (e.g., safety, unplanned discharges). ______I understand that if I have a problem or emergency (ex. family emergency other change in circumstances), which requires a change in my agreed-upon treatment, I am expected to renegotiate with staff or the Domiciliary Community ahead of time – before treatment assignments are due, before an appointment, before taking passes or discharging, or before stopping a medication. ______I understand that this process can be stressful. I recognize that staff are available to me 24hrs a day, 7 days a week, if I need support to cope with my distress. Participation (Initial each item below) ______I agree to participate in and attend all scheduled groups and activities and to adhere to all aspects of my individual treatment plan, including but not limited to prescribed medications, dietary restrictions, DCHV (rev. 6/16/2021) Page 6 volunteer activities, exercise and recreation programs, daily community clean-up, and, when approved (date TBD, dependent on local public health guidelines), planned passes with peers on the weekend. ______I understand that all program and nursing staff must regularly confer with one another to ensure I receive the safest and highest quality of treatment possible. ______I will be familiar with the policies and procedures stated in the program manual. ______I am responsible for keeping agreements I make with staff and peers related to my treatment, for following treatment recommendations, taking medications as prescribed, keeping appointments, attending appointments and classes on time, following wake-up times and preapproved pass plans (eligibility for passes TBD, dependent on local public health guidelines). ______I agree to accept responsibility for my behavior. I understand that treatment involves being open to receiving coaching from staff and peers. I agree to maintain my willingness to change so that I can live a more effective life. I understand that if I am consistently unwilling to accept coaching or feedback, I may be recommended for alternative treatment on an outpatient basis. ______I agree to participate effectively in groups and refrain from engaging in treatment-interfering behaviors (i.e., verbal and/or nonverbal behavior that detracts from my and others’ benefit from treatment). If I demonstrate a pattern of treatment-interfering behaviors, I may be asked to leave in-person group sessions, and can be electronically removed from group sessions via video. Treatment team members will alert my therapist/case manager, and I may be recommended for alternative treatment on an outpatient basis. ______I understand that there is a separate Trauma Recovery Program at the Palo Alto VA and Domiciliary staff will assist me with a referral if I am assessed as clinically appropriate. I understand that applying to the If I have a safety concern or become aware of an issue related to the safety of another Veteran, the program, or a staff member, I agree to immediately notify a staff member 24hrs/7days a week. ______I am encouraged to have my family, and other social supports, participate remotely in my treatment. Visitors, when allowed on grounds (TBD, dependent on local public health guidelines), must not be under the influence of substances or alcohol. In order to maintain a safe treatment environment, all belongings brought by visitors will be searched before being allowed on the unit. ______ Children visiting the program (TBD, dependent on local public health guidelines), must be within view of a supervising parent or responsible adult who came with the child at all times. Visiting hours, when permitted are listed in the program manual. ______I understand that residents are restricted from pursuing intimate relationships with any peers in the program during the course of their stay to avoid dual relationships (peer and partner) and to maintain their focus on their treatment. If residents decide to pursue an intimate relationship, they are expected to disclose it to the therapeutic community and remain open to feedback regarding any perceived problems or concerns. I agree to hold confidential the names of the program participants and may not communicate with anyone outside of the Domiciliary Community (family, friends, legal representatives, etc.) about anyone else in the Program. ______I understand that I may not take pictures or audio recordings of other Veterans, staff, or the physical environment without expressed verbal consent. This includes not sharing pictures, audio recordings, or any personal information regarding other residents or staff on social media websites (ex: Twitter, Facebook, Instagram, etc.). To do so undermines that person’s privacy and treatment, and I will be subject to discharge. I understand that I may not research, acquire or share information from the internet or social media that another Veteran has not chosen to share themselves. To do so undermines that person’s privacy and treatment. A resident who undermines someone else’s privacy in this way is subject to discharge. ______I have the right to phone calls and mail while I am staying at the Domiciliary. Public phones are available in the building and I may ask staff to use a phone in an office if I have a special need for privacy. ______If I have a problem or concern with procedures, rules, another Veteran, or a staff member in the