We at Bowes In Home Care are proud to provide you with your home health services. Our primary concern is to give you appropriate, safe, and quality care — recognizing your individual needs. We will take the time to evaluate you and your family about specific care required to keep you healthy and at home.
Thank you for allowing us to come into your home to provide physician-directed medical care. We look forward to working with you and your family.
From All of the Professionals at Bowes In Home Care
Bowes In Home Care
Patient Rights and Responsibilites
As a home care patient, you have the right to be informed of your rights and responsibilities before the initiation of care/ service. If/when a patient has been judged incompetent, the patient’s family or guardian may exercise these rights as described below. As they relate to:
1. To receive services appropriate to your needs and expect Bowes In Home Care to provide safe, professional care at the level of intensity needed, without unlawful restriction by reason of age, sex, race, creed, color, national origin, religion or disability.
2. To have access to necessary professional services 24 hours a day, 7 days a week.
3. To have your pain management needs recognized and addressed as appropriate.
4. To be informed of services available.
5. To be informed of the ownership and control of Bowes In Home Care.
6. To be told on request if Bowes In Home Care’s liability insurance will cover injuries to employees when they are in your home, and if it will cover theft or property damage that occurs while you are being treated.
1. To be involved in your care planning, including education of the same, from admission to discharge, and to be informed in a reasonable time of anticipated termination and/or transfer of service.
2. To receive reasonable continuity of care.
3. To be informed of your rights and responsibilities in advance concerning care and treatment you will receive, including any changes, the frequency of care/service and by whom (disciplines) services will be provided.
4. To be informed of the nature and purpose of any technical procedure that will be performed, including information about the potential benefits and burdens as well as who will perform the procedure.
5. To receive care/service from staff who are qualified through education and/or experience to carry out the duties for which they are assigned.
6. To be referred to other agencies and/or organizations when appropriate and be informed of any financial benefit to the referring agency.
1. To be treated with consideration, respect, and dignity, including the provision of privacy during care.
2. To have your property treated with respect.
3. To have staff communicate in a language or form you can reasonably be expected to understand and when possible, Bowes In Home Care will assist with or may provide special devices, interpreters, or other aids to facilitate communication.
4. To maintain confidentiality of your clinical records in accordance with legal requirements and to anticipate Bowes In Home Care will release information only with your authorization or as required by law.
5. To be informed of Bowes In Home Care policies and procedures for disclosure of your clinical record.
1. To be informed on the extent to which payment for the home care services may be expected from Medicare, Medicaid or any other payer.
2. To be informed of charges not covered by Medicare and/or responsibility for any payment(s) that you may have to make.
3. To receive this information orally and in writing before care is initiated and within 30 calendar days of the date Bowes In Home Care becomes aware of any changes.
1. To refuse all or part of your care/treatment to the extent permitted by law and to be informed of the expected consequences of said action.
2. To be informed in writing of rights under state law to formulate advance directives.
3. To have Bowes In Home Care comply with Advance Directives as permitted by state law and state requirements.
4. To be informed of Bowes In Home Care’s policies and procedures for implementing advance directives.
5. To receive care whether or not you have an Advance Directive(s) in place, as well as not to be discriminated against whether or not you have executed an Advance Directive(s).
6. To be informed regarding the organization’s policies for withholding of resuscitative services and the withdrawal of life-sustaining treatment, as appropriate.
7. To not participate in research or not receive experimental treatment unless you give documented, voluntary informed consent.
8. To be informed of what to do in an emergency.
9. To participate in consideration of ethical issues that may arise in your care.
1. To voice complaints/grievances about treatment or care that is (or fails to be) furnished, or regarding lack of respect for property without reprisal or discrimination for same, and be informed of the procedure to voice complaints/grievances with Bowes In Home Care. Complaints or questions may be registered with the agency administrator Deb Peric by phone, in person or in writing.
The address and phone are:
Bowes In Home Care
813 Tek Dr
Crystal Lake, IL 60014
To be informed of the State Hotline. The Illinois Department of Public Health also has a State Hotline for complaints or questions about local home care agencies as well as to voice concerns regarding Advance Directives.
The State Hotline number is 1.800.252.4343.
Bowes In Home Care Days of Operation are:
Monday through Friday – 8:30 a.m. to 4:30 p.m.
The Illinois Relay Center can be reached at these phone numbers:
• 800.526.0844 (TTY only)
• 800.526.0857 (Voice only)
• 800.501.0864 (Spanish TTY)
• 800.501.0865 (Spanish voice)
1. To provide complete and accurate information about illness, hospitalization, medications, pain and other matters pertinent to your health — any changes in address, phone or insurance/payment information — and changes made to advanced directives.
2. To inform Bowes In Home Care when you will not be able to keep your home care appointment.
3. To treat the staff with respect and consideration.
4. To participate in and follow your plan of care.
5. To provide a safe environment for care to be given.
6. To cooperate with staff and ask questions if you do not understand instruction or information given to you.
7. To assist Bowes In Home Care with billing and/or payment issues to help with processing third party payment.
8. To inform Bowes In Home Care of any problems (including issues with following the plan of care), dissatisfaction with services or recommendations for improvement.
Home Health Agency
Outcome And Assessment Information Set (OASIS)
As a home health patient, you have the privacy rights listed below. You have the right to know why we need to ask you questions.
We are required by law to collect health information to make sure:
1) You get quality healthcare, and
2) Payment for Medicare and Medicaid patients is correct.
You have the right to have your personal healthcare information kept confidential. 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. We may need your help in collecting your health information. If you choose not to answer, we will fill in the information as 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.
• We know how important it is that the information we collect about you is correct. If you think we made a mistake, ask us to correct it.
• 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 the Federal agency maintains in its HHA OASIS System of Records. See page 14 in this handbook for CONTACT INFORMATION. If you want a more detailed description of your privacy rights, see statement on the following pages.
PRIVACY ACT STATEMENT – Healthcare RECORDS.
As a home health patient, there are a few things that you need to know about our collection of your personal healthcare information.
• Federal and State governments oversee home healthcare to be sure that we furnish quality home healthcare services, and that you, in particular, get quality home healthcare services.
• We need to ask you questions because we are required by law to collect health information to make sure that you get quality healthcare services.
• We will make your information anonymous. That way, the Centers for Medicare & Medicaid Services, the federal agency that oversees this home health agency, cannot know that the information is about you.
We keep anything we learn about you confidential.
This is a Medicare & Medicaid Approved Notice
PRIVACY ACT STATEMENT – Healthcare 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 Healthcare INFORMATION.
I. 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(a), 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 complete 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 & Medicaid Services (CMS, the federal Medicare & Medicaid agency) to be sure that the home health agency meets quality standards and gives appropriate healthcare 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.
II. 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 healthcare information in the HHA OASIS System of Records will be used for the following purposes:
• Support litigation involving the Centers for Medicare & Medicaid Services;
• Support regulatory, reimbursement, and policy functions performed within the Centers for Medicare & 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; Bowes In Home Care | Patient Handbook 13
• 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 healthcare payment related projects; and
• Support constituent requests made to a Congressional representative.
III. ROUTINE USES
These “routine uses” specify the circumstances when the Centers for Medicare & 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:
1. The federal Department of Justice for litigation involving the Centers for Medicare & Medicaid Services;
2. Contractors or consultants working for the Centers for Medicare & 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;
3. An agency of a State government for purposes of determining, evaluating, and/or assessing cost, effectiveness, and/or quality of healthcare services provided in the State; for developing and operating Medicaid reimbursement systems; or for quality of healthcare 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;
4. Another Federal or State agency to contribute to the accuracy of the Centers for Medicare & Medicaid Service’s health insurance operations (Payment, treatment and coverage) and/or to support State agencies in the evaluations and monitoring of care provided by HHAs;
5. Quality Improvement Organizations, to perform Title XI or Title XVIII functions relating to assessing and improving home health agency quality of care;
6. 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;
7. A congressional office in response to a constituent inquir y made at the written request of the constituent about whom the record is maintained.
14 IV. EFFECT ON YOU, IF YOU DO NOT PROVIDE INFORMATION
The home health agency needs the information contained in the Outcome and Assessment Information Set in order to give you quality 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 your representative signs the statement, the signature merely indicates that you received this statement. You or your representative must be supplied with a copy of this statement.
If you want to ask the Centers for Medicare & 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
TTY for the hearing and speech impaired: 1.877.486.2048
STATEMENT OF ILLINOIS LAW ON ADVANCE DIRECTIVES AND DNR ORDERS
You have the right to make decisions about the healthcare you get now and in the future. An advance directive is a written statement you prepare about how you want your medical decisions to be made in the future, if you are no longer able to make them for yourself. A do not resuscitate order (DNR order) is a medical treatment order that says cardiopulmonary resuscitation (CPR) will not be used if your heart and/or breathing stops.
Federal law requires that you be told of your right to make an advance directive when you are admitted to a healthcare facility. Illinois law allows for the following three types of advance directives: (1) healthcare power of attorney; (2) living will; and (3) mental health treatment preference declaration. In addition, you can ask your physician to work with you to prepare a DNR order. You may choose to discuss with your healthcare professional and/or attorney these different types of advance directives as well as a DNR order. After reviewing information regarding advance directives and a DNR order, you may decide to make more than one. For example, you could make a healthcare power of attorney and a living will.
If you have one or more advance directives and/or a DNR order, tell your healthcare professional and provide them with a copy. You may also want to provide a copy to family members, and you should provide a copy to those you appoint to make these decisions for you.
State law provides copies of sample advance directives forms. In addition, copies of these forms and the Illinois Department of Public Health (IDPH) Uniform Do Not Resuscitate (DNR) Advance Directive are available online at www.idph.state.il.us.
HEALTHCARE POWER OF ATTORNEY
The healthcare power of attorney lets you choose someone to make healthcare decisions for you in the future, if you are no longer able to make these decisions for yourself. You are called the “principal” in the power of attorney form and the person you choose to make decisions is called your “agent.” Your agent would make healthcare decisions for you if you were no longer able to makes these decisions for yourself. So long as you are able to make these decisions, you will have the power to do so. You may use a standard healthcare power of attorney form or write your own. You may give your agent specific directions about the healthcare you do or do not want.
The agent you choose cannot be your healthcare professional or other healthcare provider. You should have someone who is not your agent witness your signing of the power of attorney.
The power of your agent to make healthcare decisions on your behalf is broad. Your agent would be required to follow any specific instructions you give regarding care you want provided or withheld. For example, you can say whether you want all life-sustaining treatments provided in all events; whether and when you want life-sustaining treatment ended; instructions regarding refusal of certain types of treatments on religious or other personal grounds; and instructions regarding anatomical gifts and disposal of remains. Unless you include time limits, the healthcare power of attorney will continue in effect from the time it is signed until your death. You can cancel your power of attorney at any time, either by telling someone or by canceling it in writing. You can name a backup agent to act if the first one cannot or will not take action. If you want to change your power of attorney, you must do so in writing.
A living will tells your healthcare professional whether you want death-delaying procedures used if you have a terminal condition and are unable to state your wishes. A living will, unlike a healthcare power of attorney, only applies if you have a terminal condition. A terminal condition means an incurable and irreversible condition such that death is imminent and the application of any death delaying procedures serves only to prolong the dying process.
Even if you sign a living will, food and water cannot be withdrawn if it would be the only cause of death. Also, if you are pregnant and your healthcare professional thinks you could have a live birth, your living will cannot go into effect.
You can use a standard living will form or write your own. You may write specific directions about the death-delaying procedures you do or do not want.
Two people must witness your signing of the living will. Your healthcare professional cannot be a witness. It is your responsibility to tell your healthcare professional if you have a living will if you are able to do so. You can cancel your living will at any time, either by telling someone or by canceling it in writing.
If you have both a healthcare power of attorney and a living will, the agent you name in your power of attorney will make your healthcare decisions unless he or she is unavailable.
MENTAL HEALTH TREATMENT PREFERENCE DECLARATION
A mental health treatment preference declaration lets you say if you want to receive electroconvulsive treatment (ECT) or psychotropic medicine when you have a mental illness and are unable to make these decisions for yourself. It also allows you to say whether you wish to be admitted to a mental health facility for up to 17 days of treatment.
You can write your wishes and/or choose someone to make your mental health decisions for you. In the declaration, you are called the “principal” and the person you choose is called an “attorney-in-fact.” Neither your healthcare professional nor any employee of a healthcare facility in which you reside may be your attorney-in-fact. Your attorney-in-fact must accept the appointment in writing before he or she can start making decisions regarding your mental health treatment. The attorney-in-fact must make decisions consistent with any desires you express in your declaration unless a court orders differently or an emergency threatens your life or health.Your mental health treatment preference declaration expires three years from the date you sign it. Two people must witness you signing the declaration. The following people may not witness your signing of the declaration: your healthcare professional; an employee of a healthcare facility in which you reside; or a family member related by blood, marriage or adoption. You may cancel your declaration in writing prior to its expiration as long as you are not receiving mental health treatment at the time of cancellation. If you are receiving mental health treatment, your declaration will not expire and you may not cancel it until the treatment is successfully completed.
You may also ask your healthcare professional about a do-not-resuscitate order (DNR order). A DNR order is a medical treatment order stating that cardiopulmonary resuscitation (CPR) will not be attempted if your heart and/or breathing stops. The law authorizing the development of the form specifies that an individual (or his or her authorized legal representative) may execute the IDPH Uniform DNR Advance Directive directing that resuscitation efforts shall not be attempted. Therefore, a DNR order completed on the IDPH Uniform DNR Advance Directive contains an advance directive made by an individual (or legal representative), and also contains a physician’s order that requires a physician’s signature.
Before a DNR order may be entered into your medical record, either you or another person (your legal guardian, healthcare power of attorney or surrogate decision maker) must consent to the DNR order. This consent must be witnessed by one person who is 18 years or older. If a DNR order is entered into your medical record, appropriate medical treatment other than CPR will be given to you. A copy of the Illinois Department of Public Health (IDPH) Uniform Do Not Resuscitate (DNR) Advance Directive that may be used by you and your physician and a link to guidance for individuals, healthcare professionals and healthcare providers concerning the IDPH Uniform DNR Advance Directives are available online at www.idph.state.il.us.
WHAT HAPPENS IF YOU DON’T HAVE AN ADVANCE DIRECTIVE?
Under Illinois law, a healthcare “surrogate” may be chosen for you if you cannot make healthcare decisions for yourself and do not have an advance directive. A healthcare surrogate will be one of the following persons (in order of priority): guardian of the person, spouse, any adult child(ren), either parent, any adult brother or sister, any adult grandchild(ren), a close friend, or guardian of the estate.
The surrogate can make all healthcare decisions for you, with certain exceptions. A healthcare surrogate cannot tell your healthcare professional to withdraw or withhold lifesustaining treatment unless you have a “qualifying condition,” which is a terminal condition, permanent unconsciousness, or an incurable or irreversible condition. A “terminal condition” is an incurable or irreversible injury for which there is no reasonable prospect of cure or recovery, death is imminent and life-sustaining treatment will only prolong the dying process. “Permanent unconsciousness” means a condition that, to a high degree of medical certainty, will last permanently, without improvement; there is no thought, purposeful social interaction or sensory awareness present; and providing life-sustaining treatment will only have minimal medical benefit.
An “incurable or irreversible condition” means an illness or injury for which there is no reasonable prospect for cure or recovery, that ultimately will cause the patient’s death, that imposes severe pain or an inhumane burden on the patient, and for which life-sustaining treatment will have minimal medical benefit.
Two doctors must certify that you cannot make decisions and have a qualifying condition in order to withdraw or withhold life-sustaining treatment. If your healthcare surrogate decision maker decides to withdraw or withhold lifesustaining treatment, this decision must be witnessed by a person who is 18 years or older. A healthcare surrogate may consent to a DNR order, however, this consent must be witnessed by one individual 18 years or older.
A healthcare surrogate, other than a court-appointed guardian, cannot consent to certain mental health treatments, including treatment by electroconvulsive therapy (ECT), psychotropic medication or admission to a mental health facility.A healthcare surrogate can petition a court to allow these mental health services.
You should talk with your family, your healthcare professional, your attorney, and any agent or attorney-in-fact that you appoint about your decision to make one or more advance directives or a DNR order. If they know what healthcare you want, they will find it easier to follow your wishes. If you cancel or change an advance directive or a DNR order in the future, remember to tell these same people about the change or cancellation.
No healthcare facility, healthcare professional or insurer can make you execute an advance directive or DNR order as a condition of providing treatment or insurance. It is entirely your decision. If a healthcare facility, healthcare professional or insurer objects to following your advance directive or DNR order then they must tell you or the individual responsible for making your healthcare decisions. They must continue to provide care until you or your decision maker can transfer you to another healthcare provider who will follow your advance directive or DNR order.
Last updated August 2, 2011
IDPH Online Home
Illinois Department of Public Health
535 West Jefferson Street
Springfield, Illinois 62761
Nursing Homes in Illinois
Questions or Comments?
This declaration is made this day__________________
I,______________________ , being of sound mind, willfully and voluntarily make known my desires that my moment of death shall not be artificially postponed. If at any time I should have an incurable and irreversible injury, disease, or illness judged to be a terminal condition by my attending physician who has personally examined me and has determined that my death is imminent except for death delaying procedures, I direct that such procedures which would only prolong the dying process be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication, sustenance, or the performance of any medical procedure deemed necessary by my attending physician to provide me with comfort care. In the absence of my ability to give directions regarding the use of such death delaying procedures, it is my intention that this declaration shall be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal.
City, County and State of Residence_____________________
The declarant is personally known to me and I believe him or her to be of sound mind. I saw the declarant sign the declaration in my presence (or the declarant acknowledged in my presence that he or she had signed the declaration) and I signed the declaration as a witness in the presence of the declarant. I did not sign the declarant’s signature above for or at the direction of the declarant. At the date of this instrument, I am not entitled to any portion of the estate of the declarant according to the laws of intestate succession or, to the best of my knowledge and belief, under any will of declarant or other instrument taking effect at declarant’s death, or directly financially responsible for declarant’s medical care.
(Source: P.A. 85-1209.)
Note. This section was Ill.Rev.Stat., Ch. 110 1/2, Para. 703.
What You Can Do to Prevent Falls
Exercise makes you stronger and feel better. Exercises that improve balance and coordination are the most helpful. Ask your doctor or healthcare provider about the best type of exercise program for you.
(Always tell your home health nurse of any extra “over the counter” medicines you are taking along with your medicines prescribed by your doctor).
• As you get older, the way medicines work in your body can change. Some medicines or combinations of medicines can make you sleepy or dizzy, and can cause you to fall.
You may be wearing the wrong glasses or have a condition like glaucoma or cataracts that limits your vision. Poor vision can increase your chances of falling.
About half of all falls happen at home. To make your home safer:
• Keep emergency numbers in large print near each phone
• Put a phone near the floor in case you fall and cannot get back up
• Think about wearing an alarm device that will bring help in case you fall and cannot get up
General Home Safety
Infection Control in the Home
Emergency Safety Checklists and Procautions