As a patient, you have the right to be informed of your rights. Celebrity Home Health Care must protect and promote the exercise of these rights.

1. Notice of Rights
   1. Celebrity Home Health Care must provide you a written notice of your rights in advance of furnishing care to you or during the initial evaluation visit before the initiation of treatment.
   2. Celebrity Home Health Care must maintain documentation showing that it has complied with the requirements of this section.
2. Exercise of Rights and Respect for Property and Person
   1. You have the right to exercise your rights as a patient of Celebrity Home Health Care.
   2. Your family or guardian may exercise your rights when you have been judged incompetently.
   3. You have the right to have you properly treated with respect.
   4. You have the right to voice grievances regarding treatment or care that is (or fails to be) furnished, or regarding the lack of respect for property by anyone who is furnishing services on behalf of Celebrity Home Health Care and you will not be subject to discrimination or reprisal for doing so.
   5. Celebrity Home Health Care must investigate complaints made by you, your family or guardian regarding the lack of respect for your property by anyone furnishing services on behalf of Celebrity Home Health Care. Celebrity Home Health Care must document both the existence of the complaint and the resolution of the complaint.
3. Right to be Informed and to Participate in Planning Care and Treatment
   1. You have the right to be informed, in advance, about the care to be furnished, the plan of care, expected outcomes, barriers to treatment, and any changes in the care to be furnished:
      1. Celebrity Home Health Care must advise you in advance of the disciplines that will furnish your care, and the frequency of visits proposed to be furnished
      2. Celebrity Home Health Care must advise you in advance of any change in the plan of care before the change is made.
   2. You have the right to participate in the planning of care. Celebrity Home Health Care must advise you in advance of the right to participate in planning the care or treatment, and in planning changes in the care or treatment.
4. Confidentiality of Medical records
   1. You have the right to confidentiality of the clinical records maintained by Celebrity Home Health Care. Celebrity Home Health Care must advise 1 you of its policies and procedures regarding disclosure of clinical records.
5. Patient Liability for Payment
   1. You have the right to be advised before care is initiated, of the extent to which payment for Celebrity Home Health Care services may be expected from Medicare or other sources; and the extent to which payment may be required from you. Before the care is initiated, Celebrity Home Health Care must inform you orally and in writing of:
      1. The extent to which payment may be expected from Medicare, Medicaid, or any other federally funded or aided program known to Celebrity Home Health Care;
      2. The charges for services that will not be covered by Medicare; &
      3. The charges that you may have to pay
   2. You have the right to be advised orally and in writing pf any changes in the information provided in accordance with paragraph 1) of this section when they occur. Celebrity Home Health Care must advise you of these charges orally and in writing as soon as possible, but no later than 30 calendar days from the date that Celebrity Home Health Care becomes aware of a change.
6. Home Health Hotline

   You have the right to be advised of the availability of the toll-free HHA hotliner in the State. When Celebrity Home Health Care accepts you for treatment or care, Celebrity Home Health Care must advise you in writing of the home health hotline established by the State, the hours of its operation, and that the purpose of the hotline is to receive complaints or questions about local HHAs.

7. Advance Directives

   You have the right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives.

As a patient, you have the responsibility to:

• Remain under the doctor’s care while receiving services from Celebrity Home Health Care.
• Provide Celebrity Home Health Care with complete and accurate health and OASIS information.
• Sign the required consent prior to care being given or received.
• Treat Celebrity Home Health Care personnel with respect and consideration.
• Notify Celebrity Home Health Care when you cannot keep appointments.
• Comply with the Plan of Treatment while under the care of Celebrity Home Health Care and understand that non-compliance may result in discharge from Celebrity Home Health Care.
• Participate in the planning of care
• Provide Celebrity Home Health Care with a copy of the Advance Directives if applicable.
• Provide the evaluating staA with Outcome and Assessment Information Set (OASIS) as mandated by Medicare and allow Celebrity Home Health Care to transmit OASIS data to Centers for Medicare and Medicaid Services.

Consent to Treatment

I hereby give permission for all examinations and treatments as may be prescribed by my attending physician and rendered by nurses, physical therapists, speech pathologists, occupational therapists, home health aides and social workers of Celebrity Home Health Care. I understand that my care is directed and monitored by my attending physician and that Celebrity Home Healthcare is not liable for any act of omission when following the instructions of the said physician, who is neither an employee nor an agent of the agency. I agree to fully cooperate with my physician’s order (with the fullest possible extent) to achieve the best possible result for my medical care.

Rights and Responsibilities

I acknowledge that I have been informed about my rights orally and in writing by thid agency. I acknowledge receipt of a copy of my rights as a client of the agency as stated in Part 484-Conditions of Participation: Home Health Care Agencies of the Code of Federal Regulations and all rules and regulations to make decisions concerning medical care, including the right to accept or reuse medical or surgical treatment and the right to formulate and to issue advance directives to be followed should I become incapacitated.

Consent for Computerized Charting

I hereby give permission to Celebrity Home Health Care to use computerized charting in my clinical condition. I have been informed that Celebrity Home Healthcare is bound to patient’s confidentiality at all times and given the copy of documentation governing the use of computerized charting.

Advance Directives

This is to acknowledge that I have been informed of my rights as a patient as stated in Part 484-Conditions of Participation: Home Health Care Agencies of the Code of Federal Regulations and all rules and regulations to make decisions concerning medical care, including the right to accept or reuse medical or surgical treatment and the right to formulate and to issue advance directives to be followed should I become incapacitated. I understand that it is the policy of Celebrity Home Health 3 Care to respect individual choice and to avoid discrimination based on whether I have an “advance directive” or not:

Participation in Planning Care and Treatment

I have received an explanation and was furnished a copy of the disciplines that will be involved in my care and their proposed frequency of visits. I understand that I have the right to participate in planning my care or treatment and in planning changes in my care or treatment.

Consent for Pain Management

I acknowledge that I have been informed and given a copy of documentation about nursing functions and my rights about pain management by this agency: I understand that I have the right to ask the healthcare provider about pain management and to participate in the discussions and decisions.

Authorization for the Release of Medical Records / Assignment of Medicare Benefits / Patient Confidentiality

I certify that the information given to me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize the release of the records required to act on this request. I hereby request that payment of authorized Medicare benefits be made for and in my behalf. I have received an explanation and written information regarding Celebrity Home Health Care’s policies and procedures regarding disclosure of confidential information to third parties in order to safeguard and prevent inappropriate and / or unauthorized disclosure of my record or any other related information. Authorization ids hereby given to disclosure all or any part of my medical records, including treatment of mental illness, drug abuse or alcoholism, or any information pertaining to my medical care in a facility, to anyone who is or may be obligated to pay for my care. The release is subject to revocation by the undersigned at any time, except to the extent that action has been taken in reliance hereon, and if not earlier revoked, it shall terminate six months after the completion of treatment rendered by personnel of the agency. I am fully aware that I am authorizing this agency to collect, encode and transmit my record or any other related information. I fully understand the purpose of the collection concerning CMS’s mandated regulation on OASIS via modem or secure broadband connection to the centralized OASIS system.

I agree to authorize Celebrity Home Health Care to collect related information from any healthcare facilities that would assist Celebrity Home Health Care in the provision of my health care services. This authorization expired on _____/_____/_______

Consent to Photograph

I hereby authorize Celebrity Home Health Care to photograph or permit other persons to photograph me while under the care of Celebrity Home Health Care. I agree that Celebrity Home Health Care and the attending physician may use and permit other persons to use the negatives or prints prepared from such photographs for such purposes and in such manner as either may deem appropriate in providing the health care services.

Patient Liability for Payment/Assignment of Benefits

I fully understand that Medicare, Medicaid, and any other federally funded or aided program or any insurance known to the agency, shall cover only the services that are ordered by my physician. The agency shall provide ONLY these services. Services rendered that are not included in the Plan of Treatment coordinated with my physician will not be covered by my insurance. It is this agency’s responsibility to inform me in advance about the care and charges that are not covered which I may have to pay. I have the FULL RIGHT TO REFUSE such services. I further understand that services provided to me by the agency will be billed to:

Privacy Rights

I fully understand that I was notified and furnished a copy of my PRIVACY RIGHTS regarding mandated CMS regulation on OASIS and NOTICE OF PRIVACY PRACTICES Mandated by HIPM upon admission to this agency. I have been provided an opportunity to review the above stated documents and I understand that all information pertaining to me is kept confidential and secure and will not be disclosed except for the legitimate purposes allowed by the Federal Privacy Act.

Complaints/Grievances/Home Health Hotline

I was advised of the availability of the toll-free HHA hotline in the State. I acknowledge receipt of a copy of the home health hotline established by the State, the hours of its operation, and I understand that the purpose of the hotline is to receive complaints or questions about local home health agencies.

Admission Document Checklist

I hereby acknowledge that I have received the following document upon admission to Celebrity Home Health Care:

Advance Directive Brochure, Consent to Treatment, Arbitration Agreement, Emergency Phone Numbers and Instructions, HHA Assignment Sheet (if applicable), Drug Regimen, Drug Classification, Medicare Secondary Payer 5 Questionnaire, Frequency of Proposed Visits, Celebrity Home Health Care Welcome Packet (Welcome Note, Celebrity Home Health Care/Medicare/CA DPHI JCAHPOI hotline numbers; Privacy Act statement; Notice of Privacy Practices; Notice About Privacy; Statement of Patient Privacy Rights; Patient Rights; Policy of computerized Documentation, interactions; Infection instruction sheet; Fall Prevention Program)

I hereby acknowledge receipt and explanation of the above items.

This Consent to Treatment is applicable only to admission to the agency. I understand what I have read and what has been explained to me and agree to the terms and conditions stated above. In addition, I understand that either party may terminate this agreement at any time. I understand and agree that any of my representatives signed below and additional authorized representative/s listed below may have access to my medical records and my protected health information.

Please, list names of individuals that can be contacted regarding your health information:

HOME CARE PATIENTS have a right to be notified in writing of their rights during the initial evaluation visit before initiation of care and to exercise those rights. THE PATIENT’S FAMILY OR GUARDIAN may exercise the patient’s rights when the patient is incapacitated. Home care providers have an obligation to protect and promote the patient’s rights, including the following:

PATIENTS HAVE A RIGHT TO DIGNITY AND RESPECT

Home care patients and their formal caregivers have a right to not be discriminated against based on race, color, religion, national origin, age, biological sex, sexual preference, or handicap. Furthermore, patients and caregivers have a right to mutual respect and dignity, including respect for property. Agency sta􀆯 are prohibited from accepting personal gifts and borrowing money or items from patients.

Said Patients also have the right…:

• To be advised of the telephone number and hours of operation of the state’s Home Health Agency Hotline, that receives complaints or questions about local home care agencies. The hours are 24 hours a day, seven (7) days a week and the telephone number (+1) 213-596- 2606. The hotline also receives complaints about advance directives.
• To refuse to participate in investigational, experimental, research, or clinical trials.
• To be informed of rights under state law to make decisions concerning medical care, including the right to accept or refuse treatment and the right to formulate advance directives.
• To be informed of policies and procedures for implementing advance directives, including any limitations if the Agency cannot implement and advance directive based on conscience.
• To receive care without condition on, or discrimination based on, the execution of advanced directives.
• To have access upon request to all bills for service the patient has received, regardless of whether the bills are paid out-of-pocket or by another party.
• To be admitted by the agency only if it has the resources needed to provide the care safely and at the required level of intensity, as determined by a professional assessment. The Agency with less-thanoptimal resources may nevertheless admit the patience of the agency’s limitations and the lack of suitable alternative arrangements.
• To effective pain management.
• Voice concerns related to care, treatment, or services and patient safety issues: Please call Agency Director of Clinical Services. We also encourage you to contact ACHC at:
  • TOLL FREE: 855-937-2242; L919OCAL: 919-785-1214; FAX: 919-785-3011.
  • EMAIL: customerservice@achc.org
• Be informed of his/her rights.
• Exercise rights at any time.
• Have his / her property and person treated with respect.
• Be free from neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and / or misappropriation of patient property by anyone furnishing services on behalf of the agency.
• Make complaints to the Agency regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the agency
• Voice and report grievances or complaints regarding treatment or care that are (or fail to be) delivered, the lack of respect for property and/or person, or the violation of any rights to the Agency, ACHC, and state of California local agencies.
• Receive all services in the Plan of Care.
• Have a confidential patient record and access to or release of patient information and records in accordance with Health Insurance Portability and Accountability Act (HIPPA) law and regulation.
• Be advised of the extent to which payment for services may be expected from Medicare, Medicaid, or any other federally funded or federal aid program known to the agency.
• Be advised of the charges for services that may not be covered by Medicare, Medicaid, or any other federally funded or federal aid program known to the agency.
• Be advised of the charges the individual may have to pay before care is initiated.
• Be advised of any changes in the information provided with respect to payment and charges, if they occur. The patient and representative (if any) are advised of these changes as soon as possible, in advance of the next home visit.
• 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 the Agency reducing or terminating on-going care. Agency will also comply with the federal requirements.
• Be advised of the names, addresses, and telephone numbers of the following federally funded and state-funded entities that serve the area where the patient resides:



Agency on Aging	(+1) 213-482-7252
Center for Independent Living	(+1) 818-988-9525
Protection and Advocacy Agency	(+1) 866-311-8595
Aging and Disability Resource Center	(+1) 213-738-2600
Quality Improvement Organization	(+1) 877-588-1123

• Be free from any discrimination or reprisal for exercising his/her rights or for voicing grievances to the Agency or an outside entity.
• Be informed of the right to access auxiliary aids and language services and how to access these services.
• Participate in, be informed about and consent or refuse care in advance of and during treatment, where appropriate, with respect to:
  • Completion of all assessments.
  • The care to be furnished based on the comprehensive assessment.
  • Establishing and revising the plan of care.
  • The disciplines that will furnish the 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.
  • Any changes in the care to be furnished.
• To be informed of the Patient’s Rights in a language and manner the individual understands. The agency must protect and promote the exercise of these rights. The agency will provide verbal notice of the Patient’s Rights and Responsibilities in the individual’s primary or preferred language and in a manner the individual understands, free of charge, with the use of a competent interpreter, if necessary, no later than the completion of the second visit from a skilled professional.
• The following information during the initial evaluation visit, in advance of furnishing care to the patient:
  • Written notice of the Patient’s Rights and Responsibilities, and Agency’s Transfer and Discharge Policies. Written notice will be understandable to persona who have limited English proficiency and accessible to individuals with disabilities.
  • Contact information for the Agency Administrator, include the Administrator’s name, business address and business phone number to receive complaints.
  • An OASIS privacy notice to all patients for whom the OASIS data is collected.
• Receive written notice of the patient’s rights and responsibilities and the Agency’s Discharge Policies to a patient-selected representative within four (4) business days of the initial evaluation visit.
• If a patient has been adjudged to lack legal capacity to make health care decisions under state law by a court of proper jurisdiction, the rights of the patient may be exercised by the person appointed by the state court to act on the patient’s behalf.
• If a state court has not judged a patient to lack legal capacity to make health care decisions under state law by a court of proper jurisdiction, the patient’s representative may exercise the patient’s rights.
• If a patient has been adjudged to lack legal capacity to make health decisions under state law by a court of proper jurisdiction, the patient may exercise his/her rights to the extent allowed by court order.
• To have complaints investigated, The Agency will investigate complaints made by a patient, the patient’s representative (if any) and the patient’s caregivers and family, including, but not limited to, the following topics:
  • Treatment or care that is (or fails to be) finished inconsistently, or is furnished inappropriately.
  • Mistreatment, neglect or verbal, mental, sexual, and physical abuse: including injuries of unknown source and/or misappropriation of patient’s property by anyone furnishing services on behalf of the agency.
  • Document both the existence of the complaint and the resolution of the complaint.
  • Take action to prevent further potential violations, including retaliation, while the complaint is being investigated.
• To know that any agency sta􀆯 (whether employed directly or under arrangement) in the course of providing services to patient, who identified, notices, or recognizes incidences or circumstances or mistreatment, neglect, verbal, mental, sexual and/or physical abuse: including injuries of unknown source or misappropriation of patient property, must report these findings immediately to the Agency and other appropriate authorities in accordance with state law.
• To be informed of:
  • Visit schedule and frequency.
  • Patient medication schedule / instructions.
  • Treatments to be administered by Agency staff.
  • Other pertinent instructions related to care.

  • Name of Clinical Manager

    ; and Contact Information:

• Have the patient’s or legal representative’s sign confirming that he/she has received a copy of the notice of rights and responsibilities.
• To be able to identify visiting personnel through agency generated photo identification.

AGENCY TRANSFER CRITERIA:

A patient will be discharged from Agency based on Agency Discharge Criteria Policy:

• Transfer is necessary for the patient’s welfare because the agency and the physician who is responsible for the home health plan of care agree that the agency can no longer meet the patient’s needs, based on the patient’s acuity. The agency will arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the agency’s capabilities.
• The patient or representative payer will no longer pay for the services provided by the agency.
• The transfer is appropriate because the physician who is responsible for the home health plan of care and the agency agree that measurable outcomes and goals set forth in the plan of care have been achieved. Both the agency and physician responsible for the home health plan of care agree the patient no longer needs the Agency’s services.
• The patient refuse services or elects to be transferred.
• Agency ceases operation.
• Patient/Family requires transfer.
• The patient has moved out of service area.

AGENCY DISCHARGE CRITERIA:

• Discharge is necessary for the patient’s welfare because the agency and the physician who is responsible for the home health plan of care agree that the agency can no longer meet the patient’s needs, based on the patient’s acuity. The agency will arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the agency’s capabilities.
• The patient or representative payer will no longer pay for the services provided by the agency.
• The discharge is appropriate because the physician who is responsible for the home health plan of care and the agency agree that measurable outcomes and goals set forth in the plan of care have been achieved. Both the agency and physician responsible for the home health plan of care agree the patient no longer needs the Agency’s services.
• The patient refuse services or elects to be transferred.
• Agency ceases operation.
• Patient/Family requires discharge.
• The patient’s (or other people in the patient’s house) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the agency to operate e􀆯ectively is seriously impaired. The Agency will do the following before it discharges a patient for cause:
  • Advise the patient, representative (if any), the physician’s issuing orders for the home health plan of care and the patient’s primary care practitioner, or other health care professional who will be responsible for providing care and services to the patient after discharge from the Agency (if any) that a discharge for cause is being considered.
  • Make e􀆯orts to resolve the problem(s) presented by the patient’s behavior, the behavior of other people in the patient’s home or situation.
  • Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care.
  • Document the problem(s) and e􀆯orts made to resolve the problem(s) and enter this documentation into its clinical record.
• The patient has moved out of service area.
• Services can no longer be provided safely and/or e􀆯ectively in the patient’s place of residence (patient’s physician will be consulted for alternative follow-up care and/or referral).
• Physician order discharge of patient from service.
• Patient dies.

PATIENT RESPONSIBILITY:

Patients have the responsibility to:

• Notify the Agency of any perceived risks in your care or unexpected changes in your condition; e.g. Hospitalization, changes in the plan of care, symptoms to be reported, etc.
• Notify the Agency if the visit schedule needs to be changed.
• Notify the Agency the existence of, and any changes made to, advance directives.
• Notify the Agency of any problems of dissatisfaction with the services provided.
• Provides a safe environment for care.
• Follow instructions and express any concerns you have about your ability to follow and comply with proposed plan or course of treatment. The Agency will make every e􀆯ort to adapt the plan to your specific needs and limitations. If such changes are not recommended, the Agency will inform you of the consequences of care alternatives.
• Provide accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters related to the patient’s health.
• Know that in the event of an emergency that disrupts Agency’s services to patient, that Agency will make every e􀆯ort to visit or telephone patient. However, if patient has a medical emergency and is not able to contact the Agency, the patient should access the nearest emergency medical facility.
• Ask questions about care or services when you do not understand your care or what you are expected to do.
• Provide feedback about service needs or expectations.
• Follow Agency rules and regulations concerning patient care and conduct.
• Show respect and consideration for Agency’s personnel and property.
• Meet financial commitments agreed upon with the Agency promptly.
• Understand and accept consequences for the outcomes.

I acknowledge that I have received a copy of the notification of Rights / Responsibilities and Transfer / Discharge Criteria.

Patient Name:

(To be completed by all patients transferring from other agencies)

Not applicable

Verify reason(s) for this request is:

I am making the request of my own free will and have not been coerced, solicited, or pressured to do so by any employee of CELEBRITY HOME HEALTH CARE.

• How to handle complaints / grievances
• Infection control training
• Cultural diversity
• Communication Barriers
• Ethics training
• Workplace (OSHA), patient safety and components
• Methods for coping with work related issues of grief, loss and change, and Patient Right and Responsibilities
• Compliance program
• Pain and symptom management
• To exercise one’s rights as a patient of the hospice
• Receive information about the services covered under the Medicare hospice benefit
• Receive information about the scope of services that the hospice will provide and specific limitations on those services
• Be fully informed in advance about care/service to be provided, including the disciplines that furnish care and the frequency of visits as well as any modifications to the plan of care
• Be informed in advance, both orally and in writing, of care being provided; of the charges, including payment of care/service expected from third parties, and any charges for which the patient will be responsible
• Participate in the development and periodic revision of the plan of care
• Be free from mistreatment, neglect or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property
• Voice grievances/complaints regarding treatment or care that is (or fails to be) furnished and lack of respect of property by anyone who is furnishing care/service on behalf of the hospice
• Have grievances/complaints regarding treatment of care that (or fails to be) furnished or lack of respect of property investigated
• Confidentiality and privacy of all information contained in the patient record and of Protected Health Information
• Be advised on agency’s policies and procedures regarding the disclosure of clinical records
• Refuse care or treatment after the consequences of refusing care or treatment are fully presented
• Be informed of patient rights under state law to formulate Advance Directives
• Receive eAective pain management and symptom control for conditions related to terminal illness(es)
• Have one property and person treated with respect, consideration, and recognition of patient dignity and individuality
• Be able to identify visiting personnel members through agency generated photo identification
• Recommended changes on policies and procedures, personnel, or care/service
• Not be subject to discrimination or reprisal for the exercising of one’s rights
• Choose a health provider, including an attending physician
• Receive appropriate care without discrimination in accordance with physician orders
• Be informed of any financial benefits when referred to a hospice
• Be fully informed of one’s responsibilities
• Be informed of anticipated outcomes of care and of any barriers in outcome achievement

In order to prevent falls and injuries at home, we have outlined for you some important precautions / measures to follow:

• DO NOT attempt to climb up/downstairs without assistance and/or without holding on to rails.
• If you have poor vision, please make sure you have adequate light in the house. DO NOT attempt to walk in the dark.
• If you are taking hypnotics or sleeping pills and feel drowsy, do not attempt to do activities unassisted. If you live alone, DO NOT do any activities until your drowsiness wears oA.
• Make sure rooms that you spend a lot of time are uncluttered and furniture is out of your way of walking.
• Remove loose carpets / loose rugs, sharp objects, glasses from hallways and pathways.
• Please use devices such as cane, walker, or wheelchair to move around.
• Keep most of the items that you need often within easy reach such as MEDICATIONS, TELEPHONE, and PERSONAL ITEMS.
• If you are walking and suddenly you feel very weak and unable to go any further, stay calm and slowly lower yourself onto the floor until you feel stronger, or call for help.
• (IHSS/PCG) IF THE PATIENT IS CONFUSED OR DISORIENTED, DO NOT LEAVE THE PATIENT UNATTENDED, IF THEY ARE UP AND ABOUT.

I understand that an Advance Directive includes:

• A living will.
• Durable Power of Attorney.
• Any other written document executed by the patient, signed and dated that expresses the patient’s health care treatment decisions.

I understand that additional information is included in my home health folder.

I understand that the agency will honor all of my Advance Directives:

I have reviewed and understood my Bill of Right/Responsibilities as described above and have been given written information concerning advance directives and my rights and responsibilities.

CONSENT FOR COMPUTERIZED CLINICAL DOCUMENTATION

Computerized Documentation becomes a [art of the permanent medical record and is always used with discretion and with the concern for the privacy of the patient.

The undersigned does hereby authorized CELEBRITY HOME HEALTH CARE to use computerized documentation and agrees to allow this agency to use these records as part of my medical chart.

CONSENT TO PHOTOGRAPH – HOME HEALTH

I hereby consent to CELEBRITY HOME HEALTH CARE, taking photographs during my home care services. The photographs will be used for internal purposes, such as quality reviews, education, and to supplement written documentation about my medical condition. The photographs may be used to assist the payor of my services with coverage / payment decisions.

The undersigned does hereby authorized CELEBRITY HOME HEALTH CARE to take photographs and agrees to allow this agency to use these records as part of my medical chart.

CONSENT FOR CAHPS – PATIENT SATISFACTION SURVEY

CELEBRITY HOME HEALTH CARE participates in CAHPS patient satisfaction surveys. This is an optional survey for patients to participate in. The survey consists of 15 questions that are conducted by telephone and/or through a mailed survey to help us improve our services. All patients have the right to choose to participate in this survey.

I HEREBY CONSENT TO BE INCLUDED IN THE CAHPS PATIENT SURVEY.
I HEREBY DECLINE TO BE EXCLUDED IN THE CAHPS PATIENT SURVEY.

NOTICE OF MEDICARE NON-COVERAGE

Your provider and/or health plan determined that Medicare probably won’t pay for your services after the above date. You may have to pay for any services you get after this date.

Your right to appeal this decision

• You have the right to appeal against the decision to end Medicare coverage of your services. This means you’ll get an independent medical review right away. Your services will continue during the appeal,
• If you choose to appeal, the independent medical reviewer will ask for your opinion. You don’t have to prepare anything in writing, but you have the right to do so. The reviewer also will look at your medical records and/or other relevant information.
• If the independent reviewer agrees that Medicare coverage for your services should end, neither Medicare nor your plan will pay for these services after the above date.
• If you stop services by the above date, you’ll avoid financial liability.

How to ask for an immediate appeal

• Ask for the appeal as soon as possible. You must ask for a timely appeal no later than noon on the day before the above date.
• Make your request to your Quality Improvement Organization (QIO). A QIO is the independent reviewer authorized by Medicare
• If you miss the deadline to ask for an immediate appeal, you may still have appeal rights.
• Call your QIO at Livanta, BFCC-QIO program, toll fee at (+1) 877-5881123 to appeal, or if you have questions.

What happens next

• The QIO will let you know its decision as soon as possible, generally no later than two days after the eAective date above. If you’re in a Medicare health plan, the QIO generally will let you know its decision by the eAective date above
• Call your QIO at Livanta, BFCC-QIO program, toll fee at (+1) 877-5881123 to learn more.

If you miss the deadline to request an immediate appeal, you may have other appeal rights:

• If you have original Medicare: call the QIO listed on Page 1
• If you belong to a Medicare health plan: call your plan at the number given below

Plan Contact information:

HMSA Akamai Advantage

Attention: Appeals Coordinator

P.O. Box 1958, Honolulu, HI 96805-1958

Call M-F, 08:00 to 18:00; (+1) 808-948-5090, toll fee (+1) 800-462-2085

TTY: 711

Fax: (+1) 808-944-7546

You have the right to get your information in an accessible format, like large print, Braile, or audio. You also have the right to file a complaint if you feel you’ve been discriminated against. Visit Medicare.gov/about-us/accessibilitynondiscrimination-notice, or call (+1) 800-MEDICARE (1-800-633-4227) for more information. TTY users can call (+1) 877-486-2048.

As a patient, CELEBRITY HOME HEALTH CARE you and your representative are entitled to be informed orally and in writing the following rights & responsibilities prior to the initiation of care during the initial evaluation visit.

PATIENT BILL OF RIGHTS

As a patient, you have the right to:

1. Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to completion of all assessments, the care to be furnished, based on the comprehensive assessment, establishing and revising the plan of care, the disciplines that will furnish the care, the frequency of visits, expected outcomes of care, including patient identified goals, and anticipated risks and benefits, any factors that could impact treatment eAectiveness, and any changes in the care to be furnished.
2. Receive any services outlined in the Plan of Care.
3. Be cared for by qualified, competent and trained personnel.
4. Have full access to the care record maintained by CELEBRITY HOME HEALTH CARE.
5. Receive complete information about his/her health and recommended treatments, as developed jointly with CELEBRITY HOME HEALTH CARE.
6. Be treated with courtesy, dignity and respect.
7. Be spoken to or communicated with in a manner or language they can understand.
8. Speak freely without fear.
9. Be free from involuntary confinement and from physical or chemical restraints.
10. Be free from any actions that would be interpreted as being abusive: E.G. intimidation, physical including injuries or unknown source. Neglect / sexual / verbal / mental / emotional / material or financial abuse / misappropriation of property.
11. Report all instances of potential abuse, neglect exploitation, involving any employee of CELEBRITY HOME HEALTH CARE to the Elder Abuse Hotline (Los Angeles County: (+1) 877-477-3646)
12. Be dealt with in a manner that recognizes their individuality and is sensitive to and responds to their needs and preferences, including preferences based on ethnic, spiritual, linguistic familial, and cultural factors.
13. Receive services and be dealt with without regard to race, color, age, biological sex, sexual orientation, creed, religion, disability, and familial / cultural factors.
14. Express complaints verbally or in writing about services of care that is or is not furnished or about the lack of respect for your personal or property by anyone who is furnishing services on behalf of the agency Armine Khacharian; CEO Phone#: 818-536-7369
15. Be informed of the right to access auxiliary aids and language services and how to access these services.
16. Receive a written notice from the licensure and certification section CALIFORNIA department of health and ACHC when/if it appears that licensing regulations are being violated by the provider. All inquiries should be forwarded to the following address: 225 E. Broadway, Suite 111C, Glendale, CA, 91205.
17. Be informed of the cost of services and procedures for notifying them of any increase in the cost of services.
18. Be informed of the laws, regulations, and policies of the agency including:
    1. Code of Ethics
    2. Unstable Health Conditions
    3. Withdrawal / Termination of Services
    4. Others as required / tested
19. Be provided with the name, certification, and staA position of person(s) supplying, staAing, or supervising the care and services you receive.
20. Be informed of where ownership lies for any equipment/supplies provided in the provision of services.
21. Have their property treated with respect.
22. Participate in the development of a plan for their care & receive and explanation of any services proposed, changes in service, and alternative services that may be available.
23. Receive written information on the care plan, including the names of care aide(s) & supervisor assigned and the agency’s phone number, and after hour/on call minutes.
24. Provide input on which care aide they want and request a change of care aide, if desired.
25. Be briefed on any procedure/treatment before it is carried out in order that they can give informed consent.
26. Receive regular nursing supervision of the care aide, if medically related personal care is needed.
27. Expect that CELEBRITY HOME HEALTH CARE will only release information with written authorization and/or as a requirement of law.
28. Be given written documentation on CELEBRITY HOME HEALTH CARE Advance Directives Policy.
29. Receive notice of any changes in their service prior to the changes taking place.
30. Be informed within a reasonable amount of time of CELEBRITY HOME HEALTH CARE plans to terminate the care or service and/or their intention to transfer their care to another home health agency.

PATIENT BILL OF RIGHTS & PATIENT RESPONSIBILITIES

1. Provide complete information about matter relating to their health and abilities when it could influence the care they are being given.
2. Know their medical history and have details on any medications being taken.
3. Accept the consequences of their own decisions.
4. Report unexpected changes in their condition such as having suAered a mild stroke.
5. Request information about anything that they do not understand.
6. Contact CELEBRITY HOME HEALTH CARE with any concern or problems regarding services.
7. Follow service plans and/or express any concerns about the service plan.
8. Accept the consequences, if the service plan is not followed.
9. Follow the terms and conditions of the service agreement.
10. Notify CELEBRITY HOME HEALTH CARE in advance of any changes to the work schedule.
11. Inform CELEBRITY HOME HEALTH CARE of any existence of and any changes to the work schedule.
12. Report any potential risks that might exist to the CELEBRITY HOME HEALTH CARE staA such as the possibility that a client/family member might have a contagious illness or condition.
13. Be considerate of property belonging to CELEBRITY HOME HEALTH CARE and our home health staA.
14. Ensure that CELEBRITY HOME HEALTH CARE staA are from any actions that could be interpreted as being abusive such as intimidation, physical, sexual, verbal, mental, emotional, material, or financial abuse.
15. Respect the dignity and privacy of the staA.
16. Avoid asking CELEBRITY HOME HEALTH CARE staA the agency to act outside the law in the delivery of service.
17. Notify CELEBRITY HOME HEALTH CARE of any changes being made to their contact information such as address or phone number.
18. Advice CELEBRITY HOME HEALTH CARE of any changes being made to their health care professionals (e.g. physician, physiotherapist, occupational therapist, dietician, registered nurse, etc.)
19. Be responsible for payment for charges that are not covered by other parties such as Medicare, Medicaid, & Private Pay.
20. Notify CELEBRITY HOME HEALTH CARE of any changes in insurance coverage for home care services.
21. Pay bills according to agreed up rates and timeframes.
22. Assume financial responsibility for all materials, supply, and equipment required for their care, which are not covered by any other parties.
23. Provide a safe environment for care and services to be delivered.
24. Exercise a reasonable level of discretion and confidentiality regarding service / treatment records that are kept in the home.
25. Give reasonable notice, when possible, if service is going to be cancelled.
26. Keep all weapons in the home away from the work area during visits made by the CELEBRITY HOME HEALTH CARE staA.
27. Secure aggressive or menacing pets before the CELEBRITY HOME HEALTH CARE staA enters the home.
28. Prove a smoke-free environment when CELEBRITY HOME HEALTH CARE staA are present.
29. Review and sign the employee time sheet, upon completion of shift and carry out the defined responsibilities.

CELEBRITY HOME HEALTH CARE is committed to providing the highest quality health care for our patients and their families. We want you to be informed of your rights and responsibilities while undergoing care with CELEBRITY HOME HEALTH CARE.

Kindly review the above patient rights and responsibilities with your family / representative. Should you have any questions and/or concerns, please discuss them with your home health nurse and/or contact your assigned clinical manager at (+1) 818-536-7369.