Patient Handbook

WELCOME
Welcome to Galaxy Home Health and thank you for choosing us as you home care provider.  
Galaxy Home Health LLC provides high quality home health care services to young, elderly and disabled patients to improve their quality of life through clinical excellence, extraordinary service and compassionate care. 
We provide these services without regard to the origin, age, sex, religion, race, sexual orientation, political beliefs, disability, physical diagnosis, creed, or other status of the individual. We protect the lives of all people. We are prepared to adapt to the changing needs of the community and those we serve.
We appreciate the opportunity working with you and your family!
HOME HEALTH ADMISSION PROCESS
What is home health care?
Home health care is a wide range of health care services that can be given in your home for an illness or injury. Home health care helps you get better, regain your independence, and become as self-sufficient as possible.
The following services are provided under a home health care benefit

• Skilled Nursing Services – provided by Registered Nurse (RN) and/or Licensed Practical Nurse (LPN) -Registered nurses and licensed practical nurses provide skilled care services that cannot be performed safely and effectively by nonprofessional personnel. Patients needing may need intermittent care that may require injections, dressing changes, instruction in their disease process or the administration of medication, wound care or infusion therapy (IV medications).
• Certified Nursing Assistant (CNA) - CNA provides personal care such as bathing, dressing, assistance with ambulation, and other activities of daily living.
• Therapy Services-provided by occupational, physical and speech therapists and include a variety of services to promote rehabilitation.
  • Occupational Therapy (OT) - OT helps patients to improve basic motor functions and tasks such as dressing, bathing or eating after an injury or illness. By using rehabilitation techniques and training the patients in the use of special equipment, occupational therapists can help patients achieve greater independence.
  • Physical Therapy (PT) - PT helps patients to improve function and quality of life by implementing techniques that allow patients to regain strength and mobility. PT also provides education and instruction in using mobility equipment, performing safe transfers and home exercise programs.
  • Speech Therapy (ST) - ST helps retrain and treat patient’s speech and language impairments, swallowing and muscle control problems, and cognitive skills. Patients with communication or swallowing disorders, which are commonly the result of traumas such as surgery or stroke, often require speech therapy.
• Medical Social Worker (MSW) - MSW usually becomes a part of care if it becomes necessary to evaluate the social and emotional needs affecting a patient. Social workers also help patients and family members identify and access available community resources.

(Homebound patient is the patient who is confined to home due to illness or injury, and when the patient does leave home, it is infrequent and for a short period of time to receive medical care, attend adult day care program or religious services. Leaving home requires a considerable and taxing effort, as well as assistance of another person or use of an assistive device.)
 
To Qualify for Home Health Care, you need to meet the following requirements:

• You Must Be Under Care of a Physician
• You must need, and a doctor must certify that you need, one or more of the following:
  • Intermittent skilled nursing care (other than drawing blood)
  • Physical therapy, speech-language pathology, or continued occupational therapy services.
  • These services are covered only when the services are specific, safe and an effective treatment for your condition. The amount, frequency and time period of the services needs to be reasonable, and they need to be complex or only qualified therapists can do them safely and effectively. To be eligible, either: 1) your condition must be expected to improve in a reasonable and generally predictable period of time, or 2) you need a skilled therapist to safely and effectively make a maintenance program for your condition, or 3) you need a skilled therapist to safely and effectively do maintenance therapy for your condition. The home health agency caring for you is approved by Medicare (Medicare certified).
• Receiving services under a plan of care established and periodically reviewed by a physician
• You Must be Homebound (Homebound patient is the patient who is confined to home due to illness or injury, and when the patient does leave home, it is infrequent and for a short period of time to receive medical care, attend adult day care program or religious services. Leaving home requires a considerable and taxing effort, as well as assistance of another person or use of an assistive device.)

FACE TO FACE ENCOUNTER 
As part of the certification of patient eligibility for the Medicare home health benefit, a face-to-face encounter with the patient must be performed by the certifying physician himself or herself, a physician that cared for the patient in the acute or post-acute care facility (with privileges who cared for the patient in an acute or post-acute care facility from which the patient was directly admitted to home health) or an allowed non-physician practitioner.
The encounter must occur no more than 90 days prior to the home health start of care date or within 30 days after the start of care.
In situations when a physician orders home health care for the patient based on a new condition that was not evident during a visit within the 90 days prior to start of care, the certifying physician or an allowed non-physician practitioner (NPP) must see the patient again within 30 days after admission. Specifically, if a patient saw the certifying physician or NPP within the 90 days prior to start of care, another encounter would be needed if the patient’s condition had changed to the extent that standards of practice would indicate that the physician or a non-physician practitioner should examine the patient in order to establish an effective treatment plan.
CONSENT FOR TREATMENT
Home care services are provided under consent for treatment. By signing the consent for treatment, patient or patient’s responsible party confirms that he/she has been informed and has participated in developing a plan of care to be carried out by Galaxy Home Health and signs home health care consent willingly and voluntarily. The patient or patient’s responsible party understands that signed consent is valid from the initial visit by the Agency’s staff member and it may be withdrawn at any time with the notice to the Agency. If the patient or patient’s responsible party choses to withdraw the consent, home health care services will be discontinued and no further treatment will be provided. Patient and patient’s responsible party understands that continuation of home health care service is subject to Medicare and Medicaid regulations, as well as Agency’s Policies and Procedures. 
PLAN OF CARE
Your team of home care professionals, in conjunction with your physician and with your participation, will establish a plan of care individualized to your needs. The plan of care will be updated and reviewed based on your status, progress and changing needs. We will also develop home care goals that will be directed to assist you in becoming independent in health and self-care.
HOME VISITS
Visits are scheduled in accordance with the plan of care. The agency’s staff will make every effort to meet patient’s needs, scheduled visits and individual preferences when it comes to scheduling. If home visits schedule is affected by inclement weather conditions, patient related circumstances, emergencies or patient’s change in schedule or declination, we will make every effort to make up the visit, if possible and if the patient allows. We ask you to notify the Agency as soon as possible of any changes in your schedule that require either a cancellation of care or a visit to be rescheduled. We also ask you to notify us of any ER visits, hospitalizations, standing appointments (dialysis, chemotherapy, radiation, wound care, etc.).
FINANCIAL OBLIGATIONS
Home health care services are covered by Medicare Part A and Part B, managed care Medicare plans (United, AARP, Humana, Aetna, etc.), Medicaid, and commercial insurance plans.
Medicare Part A & B reimburses home health care at 100%. There is no patient liability involved as long as the patient meets home health care qualifications. Medicare covers intermittent and short- term home health care services; it DOES NOT cover long term care. 
The Agency will also provide patient with routine medical supplies as well as some of the non-routine supplies (urinary catheters, wound care supplies, ostomy care supplies) during the time you are receiving care from the Agency. Please inform the Agency at the start of care if you are receiving supplies from a different vendor, as only the home health agency can receive Medicare payment.
Medicaid usually covers home health care at 100%. Medicaid covers both acute and long-term care services. There are limitations to the type and extend of services that you may be eligible to receive under Medicaid benefits. The Agency’s representative will inform you of any limitations that may apply to your care. 
Private insurance will cover home health care services as per specific plan coverage. Some plans require pre-authorization from the initiation of care, while other plans require no authorization for the first 60 days of service. Some plans have a cap on the number of visits that can be authorized, while other plans have no limit on the number of visits per year. Depending on the plan, it is possible that the patient may have co-payment and/or deductible for services. The Agency’s representative will notify you of the above prior to admission to home health care. 
When patient’s primary payer is a private insurance, and in the event that patient’s insurance carrier does not accept “assignment of benefits” or any other payments are sent directly to the patient, the patient will hold them in trust for Galaxy Home Health for payment of their financial obligations.  Patient or patient’s responsible party understands that he/she must promptly make payment for services by either a personal check or by endorsing the insurance payment by writing “Pay to the order of Galaxy Home Health, LLC.” and the signature.
Self-Pay: if you chose to receive home health care services as a private arrangement, you will be responsible for all expenses, including home visits, medical supplies and medical equipment that may be necessary for provision of care. You will receive bi-weekly invoice for services rendered with payment due within 15 days of the receipt of the invoice. 
The patient or patient’s responsible party authorizes the Agency to bill patient’s insurance carrier as appropriate for furnished home health care services. Patient or patient’s responsible party also authorizes the insurance carrier to provide Galaxy Home Health with all necessary information pertaining to patient’s insurance benefits, authorization requirements and claims status and submission.
 
PATIENT RIGHTS AND RESPONSIBILITIES
 
The rights of the patient may be exercised by the patient or authorized representative, if any, without fear of retribution or retaliation. The Patient Bill of Rights includes, but is not limited to, the right to:
 

• Have one’s person and property treated with respect.
• Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property;
• Live free from involuntary confinement, and to be free from physical or chemical restraints.
• Express complaints verbally or in writing about services or care that is or is not furnished, or about the lack of respect for the patient’s person or property by anyone who is furnishing services on behalf of the Agency and must not be subject to discrimination or reprisal for doing so.

 
The Agency must investigate complaints made by a patient or the patient’s authorized representative, if any, regarding treatment or care that is (or fails to be) furnished, or regarding the lack of respect for the patient’s property by anyone furnishing services on behalf of the Agency and must document both the existence of the complaint and the resolution of the complaint.
 

• Be free from any discrimination or reprisal for exercising his or her rights or for voicing grievance to the HHA or an outside entity
• Confidentiality of all records, communications, and personal information. The Agency shall advise the patient, in writing, of the agency's policies and procedures regarding disclosure of clinical information and records.
• Participate in, be informed about and consent or refuse care in advance of and during treatment, where appropriate, with respect to:

(i) Completion of all assessments; (ii) The care to be furnished based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished.

• Receive all services outlined in the plan of care.
• Refuse treatment within the confines of the law, to be informed of the consequences of such action and to be involved in experimental research only upon the patient’s voluntary written consent.
• Be informed of the Agency’s policies on advance directives, including:

1. determine the existence of advance directives
2. educate patients and families about advance directives as well as rendering of service/care in the absence or presence of advance directives
3. facilitate advanced directives, as may be appropriate

• Receive a proper written notice, in advance of a specific service being furnished, if HHA believes that the service may be non-covered care, or in advance of the HHA reducing or terminating on –going care.
• Choose a healthcare provider, including an attending physician.
• Receive appropriate care without discrimination in accordance with physician orders.
• Be advised orally and in writing prior to the start of services of the extent to which payment for the Agency services may be expected from Medicare, Medi-Cal, or any other Federally funded or aided program known to the Agency, insurance or other sources; the charges for services that will not be covered by Medicare, Medi-Cal, or any other Federally funded or aided program; and the extent to which payment may be required from the patient.
• Be advised of any changes in billing or payment procedures before implementation, in advance of the next home health visit.

If an agency is implementing a scheduled rate increase to all Patients, the agency shall provide a written notice to each affected patient at least 30 days before implementation.

• Be informed of any financial benefits when referred to a home health agency.
• Be advised of the availability of the state’s toll-free Home Care Agency (HCA) hotline. The patient and/or authorized representative, has the right to use this hotline to lodge complaints regarding the Agency, including care received or not received and/or implementation of the advance directives’ requirements.

 

The Colorado Department of Public Health and Environment

State Hotline (1-800-842-8826)

At any time, the patient may register a complaint about home health agency with the agency’s accrediting organization

ACHC (Accreditation commission for Health Care) 

at 1-855-937-2242 or 919-785-1214

• Be advised of the addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area:

Area Agency on Aging

1001 17th Street, Suite 700

Denver, CO 80202

Phone: 303-455-1000

Fax: 303-480-6790 E-mail: Send DRCOG an e-mail at drcog@drcog.org

Center for Independent Living

Atlantis Community, Inc.

201 South Cherokee Denver, CO 80223 Phone: 303- 733-9324 Fax: 303- 733-6211

www.atlantiscommunity.org

Protection and Advocacy Agency for Colorado

455 Sherman Street, Suite 130 Denver, CO 80203 Phone: 303-722-0300, Toll Free 1.800.288.1376 E-mail: tlcmail@thelegalcenter.org

Aging and Disability Resource Center (ADRC)

1001 17th Street, Suite 700

Denver, CO 80202

Phone: 303-480-6700

Toll Free: 1(866) 959-3017

Quality Improvement Organization

Area 3 - KEPRO

Phone: 844-430-9504

http://www.keproqio.com/

• Be informed, upon request, of the full name, licensure status, staff position and employer of all persons with whom the patient has contact and who is supplying, staffing or supervising care or services. The patient has the right to be served by agency staff that is properly trained and competent to perform their duties.
• Be able to identify visiting personnel members through the agency generated photo identification. 
• Be informed, upon request, of all individuals or other legal entities having ownership or controlling interest in the agency.
• Be informed of the right to access auxiliary aids and language services and how to access these services.
• Be informed of transfer and discharge rights as follows:

1. The transfer or discharge is necessary for the patient's welfare because the HHA and the physician who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities;
2.  The patient or payer will no longer pay for the services provided by the HHA;
3.  The transfer or discharge is appropriate because the physician who is responsible for the home health plan of care and the HHA agree that the measurable outcomes and goals set forth in the plan of care have been achieved, and the HHA and the physician who is responsible for the home health plan of care agree that the patient no longer needs the HHA's services;
4. The patient refuses services, or elects to be transferred or discharged;
5. The HHA determines that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause:

(i)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 HHA (if any) that a discharge for cause is being considered;
 (ii)Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation;  (iii)Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and
 (iv)Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records;

• The patient dies; or
• The HHA ceases to operate.

As a Patient, I also understand I have a responsibility to:
Provide accurate and complete information to Galaxy Home Health regarding my medical history and current condition, medication regimen and any circumstances that may affect provision of care.
Remain under the care of physician at all times and notify Galaxy Home Health of any changes in physician.
Maintain adequate and safe environment for provision of care.
Arrange for supplies and medications that cannot be provided by Galaxy Home Health.
Notify the agency prior to a scheduled visit if you will not be available for a visit or if you wish to discontinue services. 
Treat Agency’s employees with respect, courtesy and consideration.
Acknowledge and accept consequences of any refusal of treatment or non-compliance. 
 
RIGHT TO PAIN MANAGEMENT 
Galaxy Home Health respects and supports your right to appropriate pain assessment and management.
As the patient you can expect:
Proper, respectful, informed and non-discriminatory pain management and care.
Your pain to be managed with collaborative and multidisciplinary efforts.
To have your questions and concerns about pain and pain management addressed as appropriate.
To receive information about pain and pain relief measures as well as communication between you, your responsible party and family/support system and home health care staff regarding your needs related to pain management. 
 
COMPLAINT AND GRIEVANCE PROCEDURE 
The patient or authorized representative has the right to express grievances/complaints/concerns verbally or in writing to management within the Agency (Galaxy Home Health LLC) or to report to the state hotline (303-692-2910 or 1-800-842-8826).
If the patient or authorized representative notifies the Agency after normal business hours of a grievance/complaint/concern, the on-call staff will notify the Administrator and/or Director of Clinical Services no later than the following day, or sooner if the complaint is of an urgent nature. All grievances/complaints/concerns will be documented on the On-Call Log Form.
The Administrator and/or Director of Clinical Services will begin the process of investigation within 48 hours of learning of the grievance/complaint/concern.
Any information that is deemed reportable will be done so to the correct authority.
The Administrator and/or Director of Clinical Services will document the existence, the investigation and the resolution of the complaint. The Administrator and/or Director of Clinical Services shall notify the complainant of the results of the investigation and the Agency’s plan to resolve any issue identified within five (5) business days of receiving the grievance/complaint/concern.
The Administrator and/or Director of Clinical Services will incorporate substantiated findings into the quality management program in order to evaluate and implement systemic changes where needed.
The Administrator and/or Director of Clinical Services will maintain a separate record/log/file detailing all activity regarding complaints received, and the investigation and resolution thereof.  The record shall be maintained for at least a two (2) year period of time and shall be available for audit and inspection purposes.
The designated individual to respond to and takes action to resolve complaints is the Administrator and/or
Director of Clinical Services.
The Agency shall comply with the occurrence reporting requirements set forth in 6 CCR 1011, Chapter  
II, and section 3.2.  (See Chapter 6, Policy 6.6 Incident/Occurrence Reporting.) 
Corrective action is specific and directly related to the complaint.
Patient and family rights are protected.
Complaint resolution is achieved in accordance with established time frames.
At any time, the patient may register complaints about home health care to the Colorado Department of
Public Health and Environment. The patient may call the state Home Health Agency hotline for
complaints/grievances or questions about local home health agencies or implementation of advance 
directives.
 
NOTICE OF INFORMATION AND PRIVACY PRACTICE –HIPPA
THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.    PLEASE READ IT CAREFULLY.
While receiving care from our organization, information regarding your medical history, treatment, and payment for your health care may be originated and/or received by us.  Information which can be used to identify you and which relates to your past, present or future medical condition, receipt of health care or payment for health care (“Protected Information”). 
We are required by law to maintain your privacy and the security of your health information and to provide you with this Notice of Privacy Practices. This Notice describes how your health information may be used and shared, and explains your privacy rights. We are required to follow the terms of this Notice.   We may, however, change our privacy practices and the terms of this Notice in the future, and those changes may affect all health information maintained by the organization. If our privacy practices change, we will prominently provide the revised notice to you in writing. 
 
PERMITTED USES AND SHARING OF YOUR HEALTH INFORMATION: 
Treatment:  We will use and share your health information to ensure you are provided medical treatment and services. For example, we may share your health information with a doctor or hospital that is providing you health care. 
Payment: We will use and share your health information to pay for your medical treatment and services. 
Health Care Operations: We will use and share your health information for organization operations that are authorized by law. For example, we may share your health information with an outside contractor to coordinate your care, resolve disputes, or audit the compliance of our providers with regulations. 
Communications: We may use your health information to communicate with you about health care programs and health care choices. 
Legal Requirements: We will share health information about you when required to do so by federal or state law. 
To Avoid Harm: We may use or share your health information to prevent a serious threat to your health and safety or the health and safety of others such as in abuse, neglect, or domestic violence situations, or for law enforcement purposes. 
Research: Under certain circumstances, we may share your health information for research purposes. 
Public Health: We may share your health information with public health agencies to prevent or control the spread of diseases. 
Health Oversight Activities: We may share your health information with a health oversight agency for activities authorized by law. These activities may include, for example, audits, investigations, and inspections. 
Lawsuits and Disputes: We may share your health information in response to a valid judicial or administrative order. 
Coroners, Medical Examiners, Funeral Directors and Organ Procurement Organizations/Entities: Consistent with applicable law, we may share your health information with a coroner, medical examiner, or funeral director so that they may carry out their duties, or with appropriate personnel for the purpose of facilitating organ, eye or tissue donation and transplantation. 
Workers Compensation: We may share your health information with programs that provide benefits for work-related injuries or illness. 
National Security and Intelligence Activities and Specialized Government Functions: We may share your health information with authorized federal officials for activities related to national security and special investigations or for military and veterans activities. 
Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may share your health information with the correctional institution or law enforcement official for the purposes of health care or safety. 
Marketing and Sale of Health Information: We will not use or disclose your health information for marketing purposes (with limited exceptions), or sell your health information, without your written Authorization. 
Other uses and disclosures not described in this Notice will be made only with your written authorization.
 
YOUR HEALTH INFORMATION RIGHTS: 
Right to See and Get a Copy of Your Health Information: You may see and get a copy of your health information and billing records by making a written request to the Privacy Officer. We can only provide those records that were created for or on behalf of the organization. We need not provide psychotherapy notes or information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding. 
Right to be Notified Following a Breach of Your Unsecured Health Information: We required by law to notify you following a breach of your unsecured health information. This notice will describe the circumstances of what happened and the information that was inappropriately used or disclosed. 
Right to Request that We Correct Your Health Information: If you feel that the health information, we have provided to you is incorrect or incomplete, you may ask us to amend the information by making a written request to the Privacy Officer. In certain cases, we may deny your request to amend your information. 
Right to a List of Disclosures Made of Your Health Information: You have the right to a list of those instances in which we have shared your health information, other than for treatment, payment, and health care operations, or other than when you specifically authorized us to share your information. Your request must be in writing to the Privacy Officer. 
Right to Request that Your Health Information be Communicated in a Confidential Manner: You may request that we contact you in a specific way, for example, home or office phone, or to send mail to a different address. We will consider all reasonable requests, and will agree to your request if you tell us you would be in danger if we did not. 
Right to Request that We Not Use or Share Your Health Information: You have the right to request that we not use or share your health information for treatment, payment, or health care operations. This would include your right to request that we not share your information with persons involved in your care except when specifically authorized by you. Your request must be in writing to the Privacy Officer, and we will consider your request but we are not legally required to agree to it. 
Right to a Copy of the Notice: You may ask us for a paper copy of this Notice at any time and we will provide it to you. 
FOR MORE INFORMATION OR TO REPORT A PROBLEM: 
If you have questions about your privacy rights, would like additional information about something in this Notice, or would like to file a complaint because you believe your privacy rights have been violated, you may contact the Privacy Officer at: 720-484-5770
You may also file a complaint with the Secretary of the United States Department of Health and Human Services at: 
Secretary/U.S. Department of Health and Human Services 
Office of Civil Rights; 200 Independence Avenue, SW 
Washington, DC 20201 
Or by visiting: http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html 
THE ORGANIZATION WILL NOT TAKE AWAY YOUR BENEFITS OR RETALIATE AGAINST YOU IN ANY WAY IF YOU FILE A PRIVACY COMPLAINT. 
Patient or patient’s responsible party understands the organization has the right to revise these information practices and to amend the Notice of Privacy Practices.  In the event the organization revises its information practices, a revised Notice will be prominently provided to the patient or patient’s responsible party in writing and a copy of the current Notice may be obtained at any time from the Privacy Officer.
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(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) 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 
health care 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; A 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;
• 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:

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 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; 
4. another Federal or State agency to contribute to the accuracy of the Centers for Medicare & Medicaid Services' health insurance operations (payment, treatment and coverage) and/or to support State agencies in the evaluations and monitoring of care provided by HHAs; 
5. 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;
6. a congressional office in response to a constituent inquiry made at the written request of the constituent about whom the record is maintained. 
7. 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 sign the statement, the signature merely indicates 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 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 System manager. TTY for the hearing and speech impaired: 1-877-486-2048
Home Health Agency
Outcome and Assessment Information Set (OASIS)
 
STATEMENT OF PATIENT PRIVACY RIGHTS
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:

• you get quality health care, and
• payment for Medicare and Medicaid patients is correct.

 
You have the right to have your personal health care 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.
Home Health Agency
Outcome and Assessment Information Set (OASIS)
NOTICE ABOUT PRIVACY
For Patients Who Do Not Have Medicare or Medicaid Coverage
```````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````
As a home health patient, there are a few things that you need to know about our collection of your personal health care 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 & 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.
 
ADVANCE DIRECTIVE AND HEALTH CARE DECISION
Your right to make medical care decisions includes giving “advance directives” which are written instructions concerning your wishes about your medical treatment. These instructions are used in the event you become unable to make health care decisions for yourself. You must be given information on advance directives by Medicare and Medicaid funded hospitals, nursing homes, HMO’s, hospices, home health care and personal care programs at the time you are admitted as a patient or resident in any of these programs or facilities. You must also be given written information on facility and provider policies concerning advance directives.
Please understand that you are not required to have an advance directive in order to receive care
and treatment or for admission to a facility. You must only be informed about them. Whether or not you have an advance directive, you will receive the medical care and treatment appropriate for you condition and consistent with your consent and health care provider policies. However, if you have prepared and signed an advanced directive make sure; that copies of your advanced directives are included in your medical records. It is your responsibility to provide these copies to your health care providers.
Health care directives protect an individual’s right to make medical decisions and choices about personal care, help family members make decisions if the individual cannot, and help physicians, hospitals, and long-term care facilities by providing guidelines for care. 
In Colorado the following kinds of medical directives are recognized: living will (which applies in cases of terminal illness); the medical durable power of attorney (which allows your named agent to make decisions for you if you become unable to make them) and a CPR Directive (which tells emergency and other personnel not to do resuscitation on you). All of these documents do not take away your right to decide what you want if you are able to do so.
 
LIVING WILL
A Living Will is a written declaration that allows a person to state in advance his or her wishes regarding the use of life-sustaining medical treatment, such as nutrition and hydration, in terminally ill situations when he or she is unable to convey his or her wishes. A Living Will does not go into effect until the individual has been unconscious or comatose for seven days and until two doctors agree in writing that the condition is terminal as defined by Colorado law. 
 
MEDICAL DURABLE POWER OF ATTORNEY
A Medical Durable Power of Attorney (also called Durable Power of Attorney for Health Care) allows an individual to appoint an agent over 18 years of age to make any or all health care decisions in the event the individual becomes mentally unable to make decisions. A Medical Durable Power of Attorney is not limited to terminal illness situations and can enumerate more health care issues than a Living Will. It becomes effective when the individual is unable to make decisions. These decisions can include orders for life-sustaining treatment, nutrition, hydration, and resuscitation.
 
CARDIO PULMANORY RESUSUTATION (CPR) DIRECTIVE
CPR directive allows individuals or their agents to refuse cardiopulmonary resuscitation (CPR) for someone whose breathing or heart has stopped on its own. CPR directive forms are available from your physician or from a hospice, hospital, nursing home or home health agency. Singing this form will not prevent you from receiving other kinds of needed medical care such as treatment for pain, bleeding, broken bones or other comfort care.   
To define and assure the rights of the patients in health care decision –making, it is agency policy that staff will pursue the following in working with the patient:
 

• The Agency will furnish advance directives information to a patient or patient’s authorized representative at the time of the first home visit.
• Agency admission staff will document in the patient’s medical record whether the patient has executed any advance directives. Copies will be requested, and upon receipt, become a permanent part of the patient’s medical record. 
• No individual will be discriminated against or have care conditioned upon whether an advance directive has been executed. 
• Staff will adhere to any advance directive signed by the patient that is consistent with state legal requirements.
• Agency staff is not allowed to act as witnesses to the signature of an advance directive.
• The agency will comply with the patient’s wish to revoke any advanced directive wishes or orders at any time that the patient informs an agency staff member, in writing, that he/she has changed or voided the advance directive.
• The patient or patient’s authorized representative is responsible for notifying agency staff when the patient has completed or changed an advanced directive and for making a copy of  the directive available for the agency.
• If you have questions regarding agency policies concerning advanced directives, please discuss with the agency staff member or contact the agency office at (303)597-0505. 

 
EMERGENCY AND DISASTER PREPAREDNESS
As part of the  admission process,  you will review a personal emergency/disaster plan. It is imperative to have a disaster  plan  in place before an actual disaster occurs. 
 
IN CASE OF EMERGNECY
Call 911 or your local EMS for ambulance, fire or police.
Provide the following information to the responder:

1. Describe the emergency
2. Provide street address or directions

Alert responding unit by:

1. Turning on the house lights
2. Flashing yard/porch lights
3. Sending person to wave to responding unit

 
EMERGENCY PREPARADNESS 
There might be times when we find ourselves in the state of emergency or a natural disaster when we are not able to follow our regular schedule. In this case, emergency response tree will be initiated to assure that patients, who require daily assistance and have conditions that may be life threatening or cause severe adverse effects if left unattended, are attended as appropriate either by the agency staff or emergency management system. Service triage code utilized in case of emergencies will be assigned to each patient on admission. 
If you are involved in a natural disaster, (i.e. hurricane, tornado, flood, earthquake or fire), follow these instructions:

• Shelter in place and if you must leave home call and notify the agency. Provide us with the new

address and phone number where you can be reached.

• If you are going to a shelter, take your home medications, portable oxygen tank and other supplies with you, as may be necessary for your daily needs. If you are instructed to evacuate immediately, gather your supplies and go. Make transportation arrangements with your family, friends, emergency contact or your local government, as appropriate. If you are not mobile, emergency responders will be notified to assist you with evacuation. 

 
Colorado disaster shelter locations will be determined based on type and location of emergency. Set your TV or radio to the emergency broadcast station for announcements. 
 

• Go the nearest hospital outside the disaster area if you need emergency medical care or supplies.
• If your care involves electrical medical equipment, notify your local fire department as soon as you are home, so that they are aware of your needs in case of power or communication failure or special emergency evacuation needs. Be sure that your Public Service company is aware of the electrical medical equipment as well.  Be sure that backup batteries have been provided to you by the company that you obtained the electrical medical equipment from.
• If you have speech or communication needs, and you use a laptop computer or other technology for communication, consider getting a power converter or extra portable battery. 
• If you have a hearing impairment, have a pre-printed copy of key phrase messages handy, such as “I use American Sign Language (ASL), “Please write down instructions/announcements for me.” Consider getting a weather radio with a visual/text display that warns of weather emergencies. 
• If you have a visual impairment, mark your emergency supplies with fluorescent tape, large print, or Braille. You may also place security lights in each room to light paths of travel.
• If you use an assistive device, label your equipment with your name. 
• If you have pets, keep a list of “pet friendly” places (shelters, veterinarians) that could shelter your pets during a disaster. Ask your friends or relatives outside the affected area whether they could shelter your animals. Keep your pet’s essential supplies (leashes, carriers, food, and water) easily accessed. 
• Listen to your local radio station or local news channel for announcements.
• You can also contact  your local Red Cross Emergency  Management for additional information and support at 303-722-7474

 
EMERGENCY SUPPLIES
At a minimum, have the basic supplies listed below. Keep supplies in an easy to carry emergency preparedness kit that you can use at home or take with you in case you must evacuate, i.e. backpack.
 
Water: one gallon per person, per day (3-day supply for evacuation, 2-week supply for home)
Food: nonperishable, easy to prepare items (3day supply for evacuation, 2-week supply for home)
Oxygen: if you are oxygen dependent keep at least 8 hours of oxygen tanks on hand, arrange for a backup unit.
Flashlight
Battery powered or hand crank radio (NOAA Weather Radio, if possible)
Extra batteries
First aid kit
Medications (7day supply) and medical items
Multipurpose tool
Sanitation and personal hygiene items
Copies of personal documents (medication list and pertinent medical information, proof of address,
deed/lease to home, passports, birth certificates, insurance policies)
Cell phone with chargers
Family and emergency contact information
Extra cash
Emergency blanket
Map(s) of the area
Additional supplies that are recommended to keep at home or in your kit based on the types of disasters common to your area:
Whistle Towels
N95 or surgical masks Work gloves
Matches Tools/supplies for securing your home
Rain gear Extra clothing, hat, shoes
HOME SAFETY
* General Information:

• Install proper locks and keep doors locked. Ask visitors to identify themselves before opening the door.
• Open the door only if you know the person, or if you are expecting that person
• Be cautious with sharp objects
• Mark glass doors and windows with decals

* Medication Safety:

• Keep all medications in original containers and label clearly.
• Write medication schedule and take only as prescribed.
• Be aware of side effects of medications

* Poison Prevention:

• Label all poisons.
• Keep all substances in their original containers.
• Do not mix cleaning products, such as chlorine and ammonia.
• Have syrup or IPECAC on hand.
• Store cleaning agents away from foods and medications.
• Know the Poison Control Center number: 1 (800) 222-1222

* Fall Prevention:

• Remove all scatter rugs forever.
• Tack down the edges of all carpets.
• Never leave articles of clothing on the floor.
• Keep boxes out of hallways or stairwells.
• Keep electric cords, telephone cords, newspaper, magazines and other clutter away from walking areas.
• Use handrails that are sturdy and strong.
• Avoid use of extension cords.
• Lift feet when walking
• Wear proper fitting shoes with non-ski soles.
• Do activities and exercises to improve balance and strengthen legs.
• Do not attempt to climb or use ladders.
• Be careful if using tranquilizers.
• Have sufficient lighting throughout house.

* Bathroom:

• Install grab bars or handrails by toilet and tub.
• Place skid-proof floor covers and tub/shower mats in bathroom.
• Install a stable tub/shower seat.

* Kitchen:

• Store commonly used items within easy reach.
• Us a cart to move heavy or awkward objects.
• Avoid the use of floor wax. Use the non-skid type and never walk on wet floors.

* Stairs:

• Install handrails and always use them.
• Place a strip of bright tape on the top and bottom step on each staircase.
• Place non-skid threads on steps.

* Bedroom:

• Use nightlight in hall between bedroom and bathroom.
• Take your time, get up from bed or chair slowly to avoid dizziness.
• Sit on the edge of the bed or in a chair when putting on socks, shoes, or slacks.
• Ensure that side rails are in upright position on hospital beds.

* Living Room:

• Avoid sharp-cornered furniture.
• Utilize proper transfer techniques (ex. Chair to bed or toilet).
• Utilize proper ambulation techniques; use walker, cane or crutch as prescribed.
• Utilize wheelchair safety:
• Install ramps; 12-foot ramp for 1-foot rise.
• Rearrange furniture placement and always lock wheels.

* Fire Safety:

• Make an escape plan; then practice it.
• Keep at least one fire extinguisher; check the charge often.
• Be aware that nylon catches fire.
• Do not every smoke in bed!
• Be very careful with space heaters; do not tip them!
• Make sure your electrical wiring is not frayed and is free of shorts.
• Keep electrical appliances away from water and unplug after use.
• Have smoke detectors properly located; check battery monthly.
• Store flammables properly.
• Turn off oven and stove; clearly mark controls on stove.
• Be cautious around any open flame heater or fireplace.
• Do not use lighted matches or lighters around any suspected natural gas leaks.

* Burn Prevention:

• Always check hot water for temperature; label hot and cold faucets.
• Keep pot handles turned to the back of the stove.
• Keep flammable towels away from the stove.
• Open lids away from you to avoid steam burns.
• Use heating pads with caution:
• Use only on low (unless Doctor/Nurse states otherwise)
• Check area frequently for redness
• Do not apply directly to skin.

* Medical Equipment Safety:

• The company that supplies your medical equipment should instruct you in the safe use of each item.
• If you have question or need assistance with any item, please ask your nurse!

  *Oxygen Safety

• Keep all oxygen equipment away from open flames.
• Do not smoke around oxygen and post DO NOT SMOKE sign in your home.
• Register with your utility company if you have an electronically powered equipment such as a concentrator or a ventilator.
• Change oxygen cannulas every 1-2 weeks. 
• Have a plan for power outages and keep backup supply of oxygen at home. 

HEARING AND SPEECH IMPAIRED
Galaxy Home Health will ensure that qualified persons who are sensory impaired receive effective notice concerning benefits of services or written material concerning waivers of rights or consent to treatment. All aids needed to provide this notice are provided without cost to the person being served. The identification of special needs and disabilities is a part of the referral process. For persons with hearing impairments a qualified sign-language interpreter available.  The following state agency offers the needed services.
Colorado Relay Service:
Relay Colorado Numbers  TTY 7-1-1 or 800-659-2656 
Voice 7-1-1 or 800-659-3656 
VoiceCarry-over 877-659-8260 
HearingCarry-Over 800-659-3656 
Speech-to-Speech 877-659-4279 
Telebraille: 800-659-2656
For Person with Visual Impairments: Our staff will communicate the content of written materials concerning the benefits, services, waivers of rights and consent to treatment forms by reading them out loud.
 
STANDARD PRECAUTIONS AND INFECTION CONTROL
Infection control refers to policies and procedures used to minimize the risk of spreading infections. The purpose of infection control is to reduce the occurrence of infectious diseases. These diseases are usually caused by bacteria or viruses and can be spread by human-to-human contact, animal to human contact, human contact with an infected surface, airborne transmission through tiny droplets of infectious agents suspended in the air, and, finally, by such common vehicles as food or water. 
Signs and symptoms of infection include rise in body temperature above 100 F, tenderness, pain, swelling, redness or drainage around wound(s), catheter site(s), increased tiredness, lethargy or confusion. 
There are simple steps that can be taken to prevent spread of infection.
 
Hand washing:
Hand washing is the most effective  way of preventing disease transmission. Adherence to recommended hand washing practices and/or use of  alcohol-based hand rubs has been shown to terminate  infection outbreaks in health care settings, to reduce  overall infection rates and to reduce transmission  MRSA.  Alcohol-based  hand rubs are effective  for hand hygiene unless your hands are visibly solid, then you should use soap and water. Soap and water are also recommended when taking care of patients with diagnosis of c-diff. 
Wash hands after touching body fluids, after removing gloves and between gloves changes, and between patient contacts. Wash hands with an antimicrobial agent immediately after glove removal. After glove removal and hand washing, ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient’s room to avoid transfer of microorganisms to other patients or environment.
Gloves:
Wear gloves before touching body fluids, mucous membranes and non-intact skin. Change gloves after having contact with infective material that may contain high concentrations of microorganisms (fecal material and wound drainage).
Wear mask and eye protection or face shield:
Protect eyes, nose, and mouth during procedure that cause splashes or spays of body fluids.
Patient Care Equipment:
Handle soiled equipment so as to prevent personal contamination and transfer to other patients. Dedicate the use of non-critical patient care equipment to a single patient. If common equipment is used, clean and disinfect between patients. 
Linen:
Handle linen soiled with body fluids so as to prevent self-contamination and transfer to patients.
Occupation Health and Blood – borne Pathogens:  
Prevent injuries from needle and other sharp devices.
Never recap used needle using both hands.
Place sharps in puncture-proof sharps containers.
Use resuscitation devices as an alternative to mouth-to-mouth resuscitation.
 
STORING MEDICAL SUPPLIES
Store any disposable medical supplies in their original packages (or in other protective, closed plastic packages) in a clean, dry place. If the package becomes wet or soiled, discard it immediately. Wash your hands with soap and water  before touching clean supplies. Take supplies from the box or a package only when they need to be used. Prevent contact of your pets with clean supplies as well.
 
CONTAMINATED WASTE
Items that have been  exposed to blood or body fluids should be handled minimally with bare hands and in such a manner to prevent splash, spray and clothing or environmental contamination. Disposable items such as used sanitary pads, tissues, paper cups, dressings, plastic equipment, urinary catheters, disposable diapers, chux, plastic tubing, etc. should be disposed in a plastic bag. Securely close the bag, then dispose of it in the normal trash in a closed garbage container. Certain contaminated waste generated by your homecare provider may  have to be placed in a “BIO HAZARD” bag or container and transported off site for disposal. Your home care staff will advise you of any materials that must be handled  in this manner. 
 
SHARPS DISPOSAL GUIDELINES
“Sharps” are any device with physical characteristics capable of puncturing, lacerating or otherwise penetrating the skin. Example of sharps include lancets, needles, and syringes. Sharps are considered bio hazardous and must be disposed of properly to protect your family and other personnel from needle stick injuries and/or infections. Do not place needles, syringes or lancets into your trash! Utilize made sharp container as a designate container for disposal of needles, syringes, lancets, etc.
 
DISCHARGE PLANNING
Discharge planning activities are integrated into the plan of care from day one to the day of discharge and are an integral part of each visit, which involves each clinical team member, the patient, the physician and the family. As discharge planning is implemented, you and your family will be prepared for discharge having met the goals of the homecare services. Discharge planning includes all activities on your behalf as you prepare for management of your condition with or without assistance of family, friends or health care providers. 
Patient may also be discharged from home health care services when a patient is no longer eligible for Home Health (e.g., no longer homebound, no skilled need). Discharge may also be caused by patient’s refusal of services or a documented safety threat, abuse threat or persistent non-compliance with the plan of care. 
You will be given a notice of discharge as appropriate. 
GALAXY HOME HEALTH EMERGENCY AND ON-CALL GUIDELINES
When calling Galaxy Home Health office, identify yourself as a home care patient. An administrative manager and a nurse are available twenty-four (24) hours a day, seven (7) days a week.
 

OFFICE HOURS:8-4:30 PM., MONDAY TO FRIDAY

CALL 720-484-5770 TO REACH ON-CALL STAFF AFTER HOURS

If you need care or medical attention and it is not a life-threatening problem, call

Galaxy Home Health

Phone: 720-484-5770

We are available by phone 24/7

For a life or limb threatening medical emergency,

Call 911 or go to the nearest ER

 
AGAIN, THANK YOU FOR WELCOMING US INTO YOUR HOME AND ALLOWING US TO PROVIDE YOU WITH HOME HEALTH CARE SERVICES!
SINCERELY, 
GALAXY HOME HEALTH, LLC STAFF