Patient Rights/Responsibilities

Section I. Welcome to the Immediate Homecare and Hospice Family!

Thank you for allowing us the privilege to provide you with home health services. We offer personal and individual quality home care based on the specific care needed. We offer high level care and warm, friendly smiles. We have proudly been serving the Philadelphia and surrounding counties since 1995. Ou organization is Medicare certified and we are proud to be accredited by the Joint Commission for home health and hospice services!

There is a nurse available 24 hours a day who is prepared to assist  you. However, remember Immediate HomeCare and Hospice is not an emergency facility. Therefore, if an emergency should arise please call 911 or your appropriate county emergency number. If you have any comments, suggestions or complaints, please contact us. Any concerns will be addressed promptly. A satisfactory resolution will be sought or implemented.

Immediate HomeCare also wants you to know that you may be contacted after discharge by our well care team to check on how you are doing. If you wish to not be contacted please let us know and we will remove you from our call list.

Once a patient of Immediate HomeCare and Hospice, we will try to keep you as a forever client in your times of need! Please remember to always request that you want Immediate Homecare and Hospice for your home health and hospice needs. Also, access to the information in this booklet is your right./ Share it only if you choose to do so.

Welcome to the Immediate HomeCare and Hospice Family,

Your Care Team

 

PLAN OF CARE

We involve you, you caregiver, your representative (if any), key professionals and other staff members in developing your individualized plan of care and identifying your specific measurable outcome and goals. Your plan of care is based upon identified problems, needs, physician orders for medications care, treatments and services, time frames your environment and your personal goals whenever possible. The plan of care is designed to increase your ability to care for yourself and may include the following interventions: nursing care, personal care, medication management, rehabilitation therapy, pain management psychosocial needs and discharge planning.

The plan is reviewed and updated as needed, based on your changing needs. We encourage your participation and will provide necessary medical information to assist you. We will notify you, your representative (if any), your caregiver, and all physicians involved in your plan of care of any revisions to the plan of care due to change in health status.

On admission, you and an agency clinician will create a list of your current medications (including any over the counter medications, herbal remedies and vitamins). We will compare this list to the medications ordered by your physician. Our staff will continue to compare the list to the medications that are ordered, administered or dispensed to you while under our care. This will be done to identify any changes omissions, duplications, contraindications, unclear information, potential drug interactions, and ineffectiveness of and noncompliance with drug therapy.

You have the right to refuse any medication or treatment procedure; however. Such refusal may require us to obtain written statement releasing the agency from all responsibility resulting from such action. Should this happen, we would encourage you to discuss the matter with your physician for advice and guidance.

If you are an original Medicare (fee for service) beneficiary and your plan of care changes, including a decrease of  home health visits or a discontinuation of services during your episode of care, you or your authorized representative will be issues and asked to sign and date a HOME HEALTH CHANGE OF CARE NOTICE (HHCCN).

We fully recognize your right to dignity and individuality, including privacy in your treatment and in the care of your personal needs. We will notify you if an additional individual needs to be present for your visit for reasons of safety, education or supervision.

We do not participate in any experimental research connected with patient care except under the direction of your physician and with your written consent.

There must be a willing, able and available caregiver to be responsible for your care between agency visits. This person can be you, a family member, a friend or a paid caregiver.

 

MEDICAL RECORDS

Your medical record is maintained by our staff to document physician orders, assignments, progress notes and treatments. Your records are kept strictly confidential by our staff and are protected against loss, destruction, tampering and unauthorized use. Our Notice of Privacy Practices describes how your protected health information be used by us or disclosed to others, as well as how you may have access to this information.

DISCHARGE, TRANSFER AND REFERRAL POLICY

We may only discharge or transfer you from the agency if:

• It is necessary for your welfare, and your physician who is responsible for your home health plan of care and our agency agree that we can no longer meet your needs based on your acuity level. We must arrange a safe and appropriate transfer to another care provider when your needs exceed our agency’s capabilities
• You or your payer will no longer pay for the home health services
• Your physician who is responsible for your home health services
• Your physician who is responsible for your home health plan of care our agency agrees that the measurable outcomes and goals of your plan of care have been achieved and you no longer need home health services.
• You refuse services or elect to be transferred or discharged
• Our agency closes;
• Our agency determines, based on our policy that your behavior or the behavior of other persons in your home is disruptive, abusive or uncooperative to the extent that delivery of your care or the ability of our agency to effectively operate is seriously impaired. Prior to discharging for cause, our agency, must:

∙Advise you, your representative, if any, you physician(s) issuing orders for your home health plan of care, your primary care practitioner or any other health care professional who will be providing care and services to you after discharge from our agency that a discharge for cause is being considered;

∙Make efforts to resolve the problem(s) presented by your behavior or the behavior of other persons in your home or situation;

∙Provide you and your representative, if any, with contact formation for other agencies or providers who may be able to provide your care; and

∙Document in your medical record the problem(s) and efforts made to resolve the problem(s).

• Your Death occurs while you are receiving home health services.

Discharge Planning will begin when you are admitted to the agency based on the finding of the comprehensive assessment performed at admission. You and/or your representative will receive education and training to facilitate a timely discharge. Any revisions related to plans for your discharge will be communicated to you, your representative, your caregiver, all physicians issuing orders for our agency plan of care, your primary care practitioner and any other health care professionals who will be providing care and services to you after discharge from our agency.

You will be given advance notice of your discharge or transfer to another agency in accordance with applicable state regulations, except in the case of an emergency. All discharges or transfers will be documented in your medical record. When a discharge occurs, an assessment will be done. You will receive an updated list of your current medications along with any instructions needed for ongoing care or treatment. We will coordinate referrals to available community resources as needed.

Following your discharge or transfer, we will send a discharge or transfer summary within the timeframes specified by federal regulations to your primary care practitioner or other health professional who will be providing care and services to you after discharge or transfers from our agency. The summary may include, but will not be limited to, a list of your current medications and information necessary for your continued care, including pain management.

If you elected to transfer from another agency and were under an established plan of care, Medicare requires us to coordinate the transfer. The initial home health agency will no longer receive Medicare payment on your behalf and will no longer provide you with Medicare covered services after the date of your elected transfer to our agency.

You or your authorized representative will receive and be asked to sign and date a Notice of Medicare Non-Coverage (NOMNC) at least two days before your covered Medicare services will end. If you or your authorized representatives are not available, we will make contact by phone, and then mail the notice. If you do not agree that your covered services should end, you must contact the Quality Improvements Organization (QIO) at the phone number listed on the form no later than noon of the day before your services are to end and ask for an immediate appeal.

 

NOTICE OF NONDISCRIMINATION/FILING A GRIEVANCE

Immediate HomeCare and Hospice complies with applicable federal and civil rights laws and the Pennsylvania Human Relations Act and does not discriminate, exclude or treat people differently on the basis of social status, political belief, sexual preference, race color, religion, sex, national origin,  age or disability with regard to admission, access to treatment or employment.

Immediate HomeCare and Hospice provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters, written information in other formats (large print, audio, accessible electronic formats, other formats; and free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services contact Bill Peltekis, Administrator, who serves as our Civil Rights Coordinator.

If you believe that Immediate HomeCare and Hospice has failed to provide these services or discriminated in any other way, you may file a grievance in person or by mail, phone, fax or email using the following contact information.  If you need help filing a grievance, our Civil Rights/Section 1557 Coordinator is available to help: Bill Peltekis, 2920 Olga Ave, Bensalem Pa 19020, Phone: 215-638-2223 Fax: 215-638-3439; or email Billpeltekis@immediatehomecareinc.com.

It is the law for Immediate HomeCare and Hospice not to retaliate against anyone who opposes, discrimination files a grievance or participates in the investigation of a grievance.

Grievances must be submitted to Immediate HomeCare and Hospice within 60 days of the date you become aware of the possible discriminatory action, and must state the problem and the solution sought. We will issue a written decision on the grievance based on preponderance of evidence no later than 30 days after it filing, including a notice of your right to pursue further administrative or legal action. You may also file an appeal of our decision in writing to the CEO within 15 days . The CEO will issue a written response within 30 days after its filing.

The availability and use of this grievance procedure does not prevent you from pursuing other legal or administrative remedies.

You may also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights by using any of the following methods:

• Submit electronically through the Office for Civil Rights Complaint Portal, available https://ocrportal.hhs.gov/ocr/portal/lobby.jsf.
• Write to Centralized Case Management Operations, U.S. Dpeartment of Heath and Human Services, 200 Independence Ave, SW Room 509F, HHH Building, Washington, D.C. 20201. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index/html.
• Call 1-800-368-1019 (toll free) or 1-800-537-7697 (TDD).

PROBLEM SOLVING PROCEDURE

We are committed to ensuring that your rights are protected. If you feel that our staff has failed to follow our policies or has in any way denied you your rights, please follow these steps without fear or discrimination or reprisal:

1. Notify the Clinical Manager by Phone 215-638-2223, Monday through Friday from 8:00am to 5:00pm. You may also submit your complaint in writing to 2920 Olga Ave Bensalem Pa 19020. Most problems can be solved at this level.
2. Notify the Administrator Bill Peltekis, by phone at 215-638-2223 or in writing to 2920 Olga Ave Bensalem Pa 19020.
3. You may also contact the state’s home health care hotline 1-800-254-5164 (toll free). The hotline receives com plaints or questions about local home health agencies regarding the implementation of advance directive requirements. Voicemail if available 24 hours a day, seven days a week. Leave a message with your name, telephone number (including area code), the name of the agency and the nature of your compliant and your call will be returned within normal business hours, Monday through Friday 8:00am – 4:30pm. During off-hours and non-business days your call will be returned by the next business day. You may submit your complaint in writing to Pennsylvania Department of Health and Welfare Building, 8^th floor west, 625 Forster Street, Harrisburg, Pa 17120.
4. You may also contact the Joint Commission’s Office of Quality and Patient Safety to report any concerns or register complaints about a joint Commission accredited health organization by calling 1-800-994-6610, emailing patientsafetyreport@jointcommission.org or writing the joint Commission, Office of Quality and Patient Safety, One Renaissance Boulevard, Overbrook Terrace, IL 60181/.

 

SECTION III. PATIENT RIGHTS AND RESPONSIBILITIES

As a homecare provider, we have an obligation to protect and promote the exercise of your homecare rights. We must provide these rights and responsibilities to you and/or your legal representative in a way you can understand. Written rights must be provided during the initial evaluation visit before care begins. A verbal explanation of these rights may be provided at the same time or within a specified time frame and ongoing as needed.

YOUR RIGHTS

RESPECT AND CONSIDERATION-YOU HAVE A RIGHT TO:
●Be fully informed or your rights and responsibilities, and to exercise your rights as a homecare patient. You may select a representative who may also exercise these rights for you. In the event that you are declared to lack a legal capacity to make health care decisions, your legal representative may exercise your rights.

• Have a relationship with our staff that is based on honesty and esthetical standards of conduct to have ethical issues addressed.
• Be free from mistreatment, neglect, verbal, mental, sexual and physical abuse, including injuries of an unknown source and misappropriation of your property (exploitation). Agency staff who identify, notice or recognize these incidence or circumstances must report their findings immediately to the home health agency and other appropriate authorities in accordance with state law.
• Have your property and person treated with respect and consideration; recognition of your individuality and dignity; and to have cultural psychosocial, spiritual and personal values, beliefs and preferences respected. You will not be discriminated against based on social status, political belief, sexual preference, race, color religion, national origin, age sex or disability. If you feel that you have been the victim of discrimination, you have the right to file a grievance without retaliation for doing so. Our staff is prohibited from accepting gifts or borrowing from you.
• Receive information in plain language to ensure accurate communication, in a manner that is accessible, timely and free of charge to:

∙Persons with disabilities. This includes access to website, auxiliary aids, and services in accordance with state and federal law regulations.

∙Persons with limited English proficiency. This includes access to interpreters and written translation.

∙Persons may choose their own interpreter.

 

FILING A GRIEVANCE- YOU HAVE THE RIGHT TO:

• Receive the name, business address, and phone number for the agency Administrator in order to lodge complaints.
• Lodge complaints and have your complaints as well as your families or your representative’s complaints heard, investigated and if possible resolved. .

∙Complaints may include, but are not limited to:

∙Treatment of care that is (or fails to be) provided

∙Treatment or care that in inconsistent or inappropriate

∙Lack of respect for your property and/or person by anyone who is providing services on behalf  of our agency or; or

∙Mistreatment, neglect or verbal, mental, sexual and physical abuse., including injuries of unknown source  and or/misappropriation of your property (exploitation) by anyone providing services on behalf of the agency .

• Receive information on our complaint resolution process, and know about the results of complaint investigations. We must document both the existence and the resolution of the complaint. We must also take action to prevent further potential violations, including retaliation, while the complaint is being investigated.
• Voice grievances/complaints regarding treatment or care , or recommend changes in policy, staff or care/service to us or an outside entity without fear of coercion, discrimination, restraint, interference, reprisal, or an unreasonable interruption in care, treatment or services for doing so.
• Be advised when you are accepted for treatment or care, of the availability of the state’s toll free homecare hotline number, its purpose and hours of operation. The hotline receives complaints or questions about local home care agencies and is also used to lodge complaints concerning the implementation of the advance directive requirements. Be informed how to contact The Joint Commission to ask questions, report grievances or voice complaints.

Our complaint resolution process, the state hotline number and contact information for the Joint Commission are provided in our Problem Solving Procedure.

 

DECISION MAKING-YOU HAVE THE RIGHT TO

• Choose your health care providers, including your attending physician, and communicate with those providers.
• Participate in, consent to or refuse care in advance of and during treatmentand be fully informed about your care/service, where appropriate, including:

∙The completion of all assessments;

∙The care, treatments and services to be provided, based on the comprehensive assessment;

∙Establishing and revising your plan of care;

∙The disciplines that will provide the care, including the name(s) and responsibilities of staff  members who are providing and responsible for your care;

∙The frequency of visits;

Expected outcomes of care, including patient-identified goals and anticipated risks and benefits;

∙Any factors that could impact treatment effectiveness; and

∙Any changes in the care provided.

• Receive all services outlined in your plan of care.
• Consent to or refuse care in advance of and during treatment without fear of reprisal or discrimination and after being informed of the consequences for doing so.
• Receive proper written notice, in advance of a specific service being furnished, if the agency believes that the service may be non-covered care; or in advance of reducing or terminating ongoing care in accordance with federal laws and regulations.
• Be informed of our transfer and discharge policies.
• Have family involved in decision making as appropriate concerning your care, treatment and services, when approved by you or your representative (if any) and when allowed by law.
• Participate or refuse to participate in research, investigational or experimental studies or clinical trials. Your access to care, treatment and services will not be affected if you refuse or discontinue participation research.
• Formulate advance directives and receive written information about the agency’s policies and procedures on advance directives, including a description of applicable state law before care is provided. You will be informed if we cannot implement an advance directive based on the execution of conscience.
• Have your wishes concerning end of life decisions addressed to have health care providers comply with your advance directives in accordance with state laws. You have the right to receive care without conditions or discrimination based on the execution of advance directives.

PRIVACY AND SECURITY – YOU HAVE THE RIGHT TO:

• Personal privacy and security during home care visits. Our visiting staff will wear proper identification so you can identify them.
• Confidentiality of written, verbal and electronic protected health information including your medical records, information about your health, social and financial circumstances or about what takes place in your home.
• Refuse filming or recording or revoke consent for filming and recording of care, treatment and services for purposes other than identification, diagnosis and treatment.
• Access request changes to and receive an accounting of disclosures regarding your own protected health information as permitted by law.
• Request us to release information written about you only as required by law or with your written authorization and to be advised of our policies and procedures regarding access and/or disclosure of clinical records. Our Notice for Privacy Practices describes your rights in detail.

FINANCIAL INFORMATION-YOU HAVE THE RIGHT TO 

• Be advised orally and in writing before health care is initiated of:

∙The extent to which payment may be expected from Medicare, Medicaid, any other federally funded or aided program or any other third-party sources to us;

∙Charges for services that may not be covered by known payers; and

∙Charges that you might have to pay.

• Be advised orally and in writing of any changes in payment, charges and your payment liability when they occur, and to be advised of these changes as soon as possible, in advance of the next home health visit in accordance with federal patient notice laws and regulations.
• Have access to all bills, upon request, for the services you have received regardless of whether the bills are paid by you or another party.

QUALITY OF CARE-YOU HAVE THE RIGHT TO:

• Receive high quality, appropriate care without discrimination, in accordance with physician orders.
• Pain assessment and to receive effective pain management and symptom control. You also have the right to receive education about your role and your family’s role in managing pain when appropriate, as well as potential limitations and side effects of pain treatments.
• Be admitted only if we can provide the care you need. A qualified staff member will assess your needs. IF you require care or services that we do not have the resources to provide, we will inform you and refer you to alternative services, if available, or we will admit you, but only after explaining our care/service limitations and the lack of suitable alternative.
• Receive emergency instructions and be told what to do in case of an emergency.
• Be advised of the names, addresses and telephone numbers of the following federal- and state-funded entities that serve the area where you reside; Are on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center and the Quality Improvement Organization.

YOUR RESPONSIBILITIES

YOU HAVE THE RESPONSIBILITY TO:

• Provide complete and accurate information to the best of your knowledge about your present complaints and past illness(s), hospitalizations, medications, allergies and other matters relating to your health.
• Remain under a doctor’s care while receiving skilled agency services
• Notify of us of perceived risks or unexpected changes in your condition (e.g., hospitalization, changes in plan of care, symptoms to be reported, pain, homebound status or change of physician).
• Follow the plan of care and instructions and accept responsibility for the outcomes if you do not follow the care, treatment or service plan.
• As questions when you do not understand about your care, treatment and service or other instruction about what you are expected to do. If you have concerns about your care or cannot comply with the plan, let us know.
• Report and discuss pain, pain relief options and your questions, worries and concerns about pain medication with staff or appropriate medical personnel.
• Tell us if your visit schedule needs to be changed due to medical appointment, family emergencies, etc.
• Tell us if your Medicare or other insurance coverage changes or if you decide to enroll in a Medicare or private HMO (Health Maintenance Organization) or hospice.
• Promptly meet your financial obligations and responsibilities agreed upon with the agency.
• Follow the organization’s rules and regulations.
• Tell us if you have an advance directive or If you change your advance directive.
• Tell us of any problems or dissatisfaction with the services provided.
• Provide a safe and cooperative environment for care to be provided (such as keeping pets confined, putting away weapons or not smoking during your care).
• Show respect and consideration for agency staff and equipment,
• Carry out mutually agreed responsibilities.

 

Home Health Agency

Outcome and Assessment of Information Set (OASIS)

STATEMENT OF PATIENT PRIVACY RIGHTS (Medicare/Medicaid)

As a home health patient, you have the privacy rights listed below.

• You have the right to know why we ask you questions.

We are required by law to collect health information to make sure:

1. You get quality health care, and
2. Payment for Medicare and Medicaid patients is correct.

• You have the right to have your personal health care information kept confidential.

1. You may be asked to tell us information about yourself so that we will know which home health services will be best for you. We keep anything we learn about you confidential. This means, only those who are legally authorized to know, or who have a medical need to know, will see your personal health information.

• You have the right to refuse to answer questions

1. We may need your help in collecting your health information
2. If you choose not to answer, we will fill in the information best we can.

You do not have to answer every question to get services.

• You have the right to look at your personal health information

1. We know how important it is that the information we collect about you is correct.
2. If you think we made a mistake, ask us to correct it
3. If you are not satisfied with our response, you can ask the Centers for Medicare & Medicaid Services, the federal Medicare and Medicaid agency, to correct your information.

 

You can ask the Centers for Medicare & Medicaid Services to see, review, copy or correct your personal health information which that Federal agency maintains in its HHA OASIS System of records.

As a Home health patient, there are a few things that you need to know about our collection of your personal health information.

• Federal and State governments oversee home health care to be sure that we furnish quality home health care services, and that you, in particular, get quality home health care services.
• We need to ask you questions because we are required by law to collect health information to make sure that you get quality health care services.
• We will make your information anonymous. That way, the Centers for Medicare and Medicaid Services, the federal agency that oversees this home health agency, cannot know that the information is about you.

We will keep anything we learn about you confidential.

This is a Medicare & Medicaid approved notice

PRIVACY ACT STATEMENT-HEALTH CARE RECORDS

THIS STATEMENT GIVES YOU ADVICE REQUIRED BY LAW (the Privacy Act of 1974).

This statement is not a consent form. It will not be used to release or to use your health care information.

1. AUTHORITY FOR COLLECTION OF YOUR INFORMATION, INCLUDING YOUR SOCIAL SECURITY NUMBER, AND WHETHER OR NOT YOU ARE REQUIRED TO PROVIDE INFORMATION FOR THIS ASSESSMENT. Sections 1102(s), 1154,1861(o),1861(z),1863, 1864, 1865,1866, 1871, 1891(b) of the Social Security Act.

Medicare and Medicaid participating home health agencies must do a compete assessment that accurately reflects your current health and includes information that can be used to show your progress toward your health goals. The home health agency must use the “outcome and Assessment Information Set” (OASIS) when evaluating your health. To do this, the agency must get information from every patient. This information is used by the Centers for Medicare and Medicaid Services (CMS, the federal Medicare and Medicaid agency) to be sure that the home health agency meets quality standards and gives appropriate health care to its patients. You have the right to refuse to provide information for the assessment to the home health agency. If your information is included in an assessment, it is protected under the Federal Privacy Act of 1974 and the “Home Health Agency Outcome and Assessment Information Set” (HHA OASIS) System of records. You have the right to see, copy, review, and request correction of your information in the HHA OASIS System of Records.

2. PRINCIPAL PURPOSES FOR WHICH YOUR INFORMATION IS INTENDED TO BE USED

The information collected will be entered into the Home Health Agency Outcome and Assessment Information Set (HHA OASIS) System No. 09-70-9002. Your health care information in the HHA OASIS System of Records will be used for the following purposes:

∙Support litigation involving the Centers for Medicare and Medicaid Services;

∙Support regulatory, reimbursement, and policy functions performed within the Centers for      Medicare and Medicaid Services or by a contractor or consultant;

∙Study the effectiveness and quality of care provided by those home health agencies.

∙Survey and certification of Medicare and Medicaid home health agencies;

∙Provide for development, validation, and refinement of a Medicare prospective payment system.

∙Enable regulators to provide home health agencies with data for their internal quality   improvement activities.

∙Support research, evaluation, or epidemiological projects related to the prevention of disease or disability ,or the restoration or maintenance of health, and for health care payment related           projects; and

∙Support constituent requests made to a Congressional representative.

3. ROUTINE USES

These “routine uses” specify the circumstances when the Centers for Medicare and Medicaid Services may release your information from the HHA OASIS System of Records without your consent. Each prospective recipient must agree in writing to ensure the continuing confidentiality and security of your information. Disclosures of the information may be to:

∙The Federal Department of Justice for litigation involving the Centers for Medicare and Medicaid services;

∙Contractors or consultants working for the Centers for Medicare and Medicaid Services to assist in the performance of a service related to this system of records and who need to access these  records to perform the activity.;

∙An agency of a state government working for purposes of determining, evaluating, and/or assessing cost, effectiveness, and/or quality of health care services provided in the state; for   developing and operating Medicaid reimbursement systems; or for the administration of     Federal/State home health agency programs within the state;

∙Another Federal or State agency to contribute to the accuracy of the Centers for Medicare and Medicaid Services’ health insurance operations(payment, treatment and coverage) and/or to support State agencies in the evaluations and monitoring of care provided by HHA’s;

∙Quality Improvement organizations, to perform Title XI or Title XVIII functions relating to assessing and improving home health quality of care;

∙An individual or organization for a research, evaluation, or epidemiological project related to the prevention of disease or disability, the restoration or maintenance of health, or payment         related projects;

∙A congressional office in response to a constituent inquiry made at the written request of the constituent about whom the record is maintained.

4. EFFECT ON YOU, IF YOU DO NOT PROVIDE THE INFORMATION

The home health agency needs the information obtained contained in the Outcome and Assessment Information Set in order to give you quality of care. It is important that the information be correct. Incorrect information could result in payment errors. Incorrect information also could make it hard to be sure that the agency is giving you quality services. If you choose not to provide information, there is no federal requirement for the home health agency to refuse you services. NOTE: This statement may be included in the admission packet for all new home health agency admissions. Home health agencies may request you or your representative to sign this statement to document that this statement was given to you. Your signature is not required. If you or representative sign the statement, the signature merely indicated that you received this statement. You or your representative must be supplied with a copy of this statement.

Contact Information
If you want to ask the Center for Medicare and Medicaid Services to see, review, copy or correct your personal health information that the Federal agency maintains in its HHA oasis System of Records:

Call 1-800-Medicare; toll free for assistance in contacting the HHA OASIS System Manager;

TTY for hearing and speech impaired: 1-877-486-2048

NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION

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

Our agency is required by law to maintain the privacy of protected health information, to provide you adequate notice of your rights and our legal duties and privacy practices with respect to protected health information and to notify affected individuals following a security breach on unsecured protected health information. [45 CFR 164.520]  We will use or disclose protected health information in a manner that is consistent with this notice.

The agency maintains a record (paper/electronic) file of the information we receive and collect about you and of the care we provide to you. This record includes physicians’ orders, assessments, medication lists, clinical progress notes and billing information.

As required by law, the agency maintains policies and procedures about our work practices, including how we create, receive, access, transmit, maintain and protect the confidentiality of all health information in our workforce and contracted business associates and/or subcontractors; security of the agency building and electronic files; and how we educate staff on privacy patient information.

As our patient, information about you must be used and disclosed to other parties for purposes of treatment, payment and health care operations.

Treatment: Providing, coordinating or managing health care and related services, consultation between care providers relating to a patient or referral of a patient for health care from one provider to another. For example, we meet on a regular basis how to coordinate care for patients and to schedule visits.

Payment: Billing and collecting for services provided, determining plan eligibility and coverage, utilization review (UR), precertification, medical necessity review. For example, occasionally the insurance company requests a copy of the medical record be sent to them for a coverage review prior to paying the bill.

Health Care Operations: General agency administrative and business functions, quality assurance/improvement activities; medical review, auditing functions; developing clinical guidelines; determine the competence or qualifications of health care professionals; evaluating agency performance; conducting training programs with students or new employees; licensing, survey, certification, accreditation and credentialing activities; internal auditing; and certain fundraising activities and with your authorization, marketing activities.  For example, our agency periodically holds clinical record review meetings where the consulting professional of our record review will audit clinical records for meeting professional standards and utilization review.

The following uses and disclosures do not require your consent, and include, but are not limited to, a release of information containing financial records/and or medical records, including information concerning communicable diseases such as Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS), drug/alcohol abuse, psychiatric diagnosis and treatment records and/or laboratory test results, medical history, treatment progress and/or any other related information as permitted by state law to:

1. Your insurance company, self-funded or third party health plan, Medicare, Medicaid or any other entity that may be responsible for paying or processing any portion of your bill for services;
2. Any person or entity affiliated with or representing us for purposes of administration, billing and quality and risk management;
3. Any hospital, nursing home or other health care facility to which you may be admitted;
4. Any assisted living or personal care facility of which you are a resident;
5. Any physician providing your care;
6. Licensing and accrediting bodies; including the information contained in the OASIS data set to the state agency acting as a representative of the Medicare/Medicaid program;
7. Contact you to raise funds for the Agency; you will be given the right to opt out of receiving such communications;
8. Any business associate or institutionally related foundation for the purpose of raising funds for the agency (information may include: demographics- name, address, contact information, age, gender, date of birth, dates of health care provided, department of services, treating physician, outcome information and health insurance status). You will be given the right to opt out;
9. Refill reminders for drugs, biological and/or drug delivery systems that have already been prescribed to you;
10. Marketing communications promoting health products, services and information if the communication is made face to face with you or only financial gain consists of a promotional gift of nominal value provided by the agency; and
11. Other health care providers to initiate treatment.

We are permitted to use or disclose information about you without consent or authorization in the following circumstances.

                ∙In emergency treatment situations, if we attempt to obtain consent as soon as practicable after treatment;

∙Where substantial barriers to communicating with you exist and we determine that the consent is clearly inferred from the circumstances.;

∙Where the use or disclosure of medical information about you is required by federal, state or local law;

∙To provide information to state or public health authorities, as required by law: to prevent or control disease, injury or disability, report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify persons of recalls of products they may be using; notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and notify the appropriate government authority if we believe the person has been the victim of abuse, neglect or domestic violence (if you agree or when required or authorized by law);

∙Health care oversight activities such as audits, investigations, inspections, and licensure by a government health care oversight agency as authorized by law to monitor the health care system, government programs and compliance with civil rights laws;

∙To business associates regulated under HIPAA that work on our behalf under a contract that requires appropriate safeguards of protected health information;

∙Certain judicial administrative proceedings in response to court or administrative order, a subpoena discovery request or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order from the Court protecting the information requested;

∙Certain law enforcement purposes such as helping to determine whether a crime has occurred, to alert law enforcement to a crime on our premises or of your death if we suspect it resulted from criminal conduct, identify or locate a suspect, fugitive, material witness or missing person, or to comply with a court order or subpoena and other law enforcement purposes;

∙To coroners, medical examiners and funeral directors, in certain circumstances, for example to identify a deceased person, determine the cause of death or to assist in carrying out their duties;

∙For cadaveric organ, eye or tissue donation purposes to communicate to organizations involved in procuring, banking or transplanting organs and tissues (e.g. if you are an organ donor);

∙For certain research purposes under very select circumstances. We may use your health information for research, before we disclose any of your health information for such research purposes, the project will be subject to an extensive approval process. We will usually request your written authorization before granting access to your individually identifiable health information;

∙To avert a serious threat to health and safety: To prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public, such as when a person admits to participation in a violent crime or serious harm to a victim or is an escaped convict. Any disclosure, however, would only be to someone able to help prevent the threat;

∙For specialized government functions, including military and veterans’ activities, national security and intelligence activities, protective services for the President, foreign heads of state and others, medical suitability determinations, correctional institution and custodial situations; and

∙For workers; compensation purposes: Workers’ compensation or similar programs provide benefits for work-related injuries or illness.

We are permitted to use or disclose protected health information about you provided you are informed in advance and given the opportunity to individually agree to, prohibit, opt out or restrict the disclosure in the following circumstances.

∙Use of a directory (includes name, location, and condition, described in general terms of individuals by our agency.

∙Share information to a public or private entity authorized by law or by its charter to assist in disaster relief efforts for purposes of notifying your family, personal representatives or certain others of your location or general condition;

∙Provide proof of immunization to a school that is required by state or other law to have such proof with agreement to disclose by parent guardian or other person acting in loco parentis if record is of an unemancipated minor; and

∙Provide a family member, relative, friend or other identified person, prior to, or after your death , the information relevant to such person’s involvements in your care  or payment for care; to notify a family member, relative friend or other identified person of your location, general condition or death.

Other uses and disclosures not covered in this notice will be made only with your authorization. Authorization may be revoked, in writing, at any time, except in limited situations for the following disclosures:

∙Marketing of Products or services or treatment alternatives that may be of benefit to you when we receive direct payment from a third party for making such communications;

∙Psychotherapy notes under most circumstances, if applicable; and

∙Any sale of protected health information resulting in financial gain by the agency unless an exception is met.

YOUR RIGHTS – You have the right, subject to certain conditions to:

• Request restrictions on uses and disclosures of your protected health information for treatment payment or health care operations. However we are not required to agree to any requested restriction. Restrictions to which we will agree will be documented. Agreements for further restrictions may, however be terminated under applicable circumstances (e.g. emergency treatment).

We must agree to your request to restrict disclosure of protected health information about you to a health plan if: 1) The disclosure is for the process of carrying out payment or health care operations and is not otherwise required by law; and 2) the protected health information pertains solely to a healthcare item or service for which you or someone on your behalf paid the covered entity in full. (164.522 Rights to request privacy protection for protected health information).

• Confidential communication of protected health insurance. We will arrange for you to receive protected health information by reasonable alternative means or alternative locations. Your request must be in writing. We do not require an explanation for the request as a condition of providing communications on a confidential basis and will attempt to honor reasonable requests for confidential communications.

If you request your protected health information to be transmitted directly to another person designated by you, your written request must be signed and clearly identify the designated person and where the copy of protected health information is to be sent.

• Inspect and obtain copies of protected health information that is maintained in a designated record set, except for psychotherapy notes, information complied in reasonable anticipation of, or for use in, a civil criminal or administrative action or proceeding, or protected health information that may not be disclosed under the Clinical Laboratory Improvements Amendments of 1988 [42 UCS 263a AND 45 CFR 1493 (A)(2)].

If the requested protected health information is maintained electronically and you request an electronic copy, we will provide access in an electronic format you request, if readily producible, or if not, in a readable electronic form and format mutually agreed upon.

If we deny access to protected health information you will receive a timely, written denial in plain language that explains the basis for the denial. Your review rights and an explanation of how to exercise those rights. If we do not maintain the medical record, we will tell you where to request the protected health information.

• Request to amend protected health information for as long as the protected health information is maintained In the designated record set. A request to amend your record must be in writing and must include a reason to support the requested amendment. We will act upon on your request within 60 days of receipt of the request. We may extend action by up to 30 days, If we provide you with a written explanation of the reasons for the delay and the date by which we will complete action on the request.

We may deny the request for amendment if the information contained in the record was not created by us, unless you provide a reasonable basis for believing the originator of the information is no longer available to act on the requested amendment; is not part of the designated medical record set; would not be available for inspection under applicable laws and regulations; or the record Is accurate and complete. If we deny your request for amendment, you will receive a timely, written denial in plain language that explains the basis for the denial, your rights to submit a statement disagreeing with the denial and an explanation on how to submit that statement.

• Receive an accounting of disclosures of protected health information made by our Agency for up to six years prior to the date on which the accounting is requested for any reason other than treatment, payment or health operations and other applicable exceptions. The written accounting includes the date of each disclosure , the name/address (if known) of the entity or person who received the protected health information , a brief description of the information disclosed and a brief statement of the purpose of the disclosure or a copy of the written request, However we may extend the time period for providing the accounting by 30 days if we provide you with a written statement of the reasons for the delay and the date by which you will receive the information. We will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee.
• Receive notification of any breach in the acquisition, access, use or disclosure of unsecured protected health information by the agency, its business associates and/or subcontractors.
• Obtain a paper copy of this notice, even if you had agreed to receive this notice electronically, from us upon request.

COMPLAINTS- If you believe that your privacy rights have been violated, you may complain to the Agency or to the Secretary of U.S. Department of Health and Human Services. There will be no retaliation against you for filing a complaint. The complaint should be filed in writing, and should state the specific incident(s) in terms of subject, date and other relevant matters. A complaint to the secretary must be filed in writing within 180 days of violation of applicable requirements. [45 CFR 160.306] For further information regarding filing a complaint contact: Denise Tosto, Compliance Officer, Immediate Homecare and Hospice 2920 Olga Avenue, Bensalem, Pa 19020; Phone: (215)638-2223.

EFFECTIVE DATE– This notice if effective August 23, 2018. We are required to abide by the terms of the notice currently in effect, but we reserve the right to change these terms as necessary for all protected health information that we maintain. If we change the terms of this notice (while you are receiving service), we will promptly revise and distribute a revised notice to you as soon as possible by mail, email (if you have agreed to electronic notice, hand delivery or by posting on our website.

If you require further information about matters covered by this notice please contact, Denise Tosto, Compliance Officer, Immediate Homecare and Hospice 2920 Olga Ave, Bensalem Pa 19020, Phone: (215) 638-2223.

Admission Consent
Patient Name: ___________________________________
Patient Id_______________
PATIENT RIGHTS AND RESPONSIBILITIES.; I acknowledge verbal explanation and writer receipt of my rights and responsibilities as a patient ( including OASIS rights, agency administrator’s name and contact information, agency discharge , transfer and referral policy and how to contact local resource(s) and I understand them. The state home health hotline number, its purpose and hours of operating have been provided and explained to me. I acknowledge that I have chosen this agency to provide home health care. No employee of this agency has solicited or coerced my decision in selecting a home health agency.
CONSENT FOR TREATMENT: I hereby give my permission for authorized personnel of your agency to perform all necessary assessments, procedures and treatments as prescribed by my physician for the delivery of home health care. I understand that the agency will supervise services provided. I may refuse treatment for terminate services at any time, and the agency may terminate their services to me as explained in my orientation. I agree and consent to the home care plan and payment as outlined in this admission booklet. I understand that this is the initial plan of care. I will be notified by the agency in advance each time there is a change made to my plan of care. The initial service(s) and visit frequencies are as follows:
SN:__________ HHA:________ MSW:______ PT:_______ OT:________ST:_______OTHER:___________
RELEASE OF INFORMATION; I acknowledge receipt of the Notice of Privacy Practices and was given an opportunity to ask questions and voice concerns. I understand that the agency may use or disclose protected health information (PHI) about me to carry out treatment, payment or health care operations. The agency may release information to or receive information from insurance companies, health plans, Medicare, Medicaid or any other person or entity that may be responsible for paying or processing for payment any portion of my bill for hospital, nursing home or other health care facility to which I may be/have been admitted; any assisted living or personal care facility of which I am a resident; any physician providing my care; family members and other caregivers who are part of my plan of care; licensing and accrediting bodies, other health care providers in order to initiate treatment.
I agree that the agency share my PHI with emergency officials or to hers involved in my care to assist in disaster relief efforts □ Yes □ No
AUTHORIZATION FOR PAYMENT: I certify that the information given by me in applying for payment under Title VXIII of the Social Security Act is correct. I consent to the release of all records required to act on this request. I request that payment of authorized benefits from Medicare, Medicaid or other responsible payer may be made in my behalf to Immediate HomeCare and Hospice. If I have Medicare Part A benefits, I understand that Medicare payments will be accepted as payment in full and I have no financial liability , unless I have been notified in writing that I that service(s) will not be covered by Medicare and wish to receive the care or service. I understand that while I am under the agency’s plan of care, the agency will coordinate all medically necessary therapy services and medical supplies for me.