Medicare Sign Up pack sample

POLICY ON PATIENT TRANSFER It is the Policy of the Agency that no information may be disclosed from the patient’s file without the written consent of the patient or the patient’s guardian. All information received by any employee, contractor, or State Regulatory Agency employee regarding a patient of the Agency is confidential. If the patient transfers to another home health agency, Hospital or any In-patient facility, a copy of his record must be transferred at his request/authorization, if needed for continuing care (the Medication Record must be reconciled/updated before the transfer). In all cases, when the Patient is transferred to a Hospital or In-Patient facility, if the home care episode is not ending, at discretion of the Director of Nursing, Clinical Manager and/or Doctor order, the patient may be Discharge or not from our Agency, the hold period depend only of the episode ending date, if the patient still hospitalized on/or after episode ending date, the patient must be Discharge from Agency, an In-Office Discharge form must be completed by a qualified staff, not OASIS discharge assessment will be completed. When a patient is transferred or referred to any other provider of health care services, the information given may include the Medication Record (reconciled/verified), whether the patient has Advance Directives or does not have Advance Directives. Reasons for patient transfer may include the patient moves outside of the Agency’s geographic service area, the patient requires care not provided by our Agency, or our Agency is not a preferred provider by the patient’s insurance company. A transfer summary is completed and a copy maintained in the patient record and a copy forwarded to the receiving service entity and the patient’s Physician. A transfer summary includes, but is not limited to: Date of transfer, Patient identifying information, Emergency contact, Destination of patient transferred, Date and name of person receiving report, Patient’s physician and phone number, Diagnosis related to the transfer, Significant health history, Transfer orders and instructions (if applicable), a brief description of services provided and ongoing needs that cannot be met, Patient’s Status. Our Home Health Agency, shall in compliance of Federal conditions of participation, collect OASIS Transfer. (If applicable, Medicare recipient only). TRANSFER TO OUR AGENCY: When a patient is transferred to our Agency, we are responsible for collecting all authorizations and information needed, including: Obtain Patient Verbal consent for transfer to our facility (must be signed later), Check to verify episode, and services for previous provider, Obtain verbal authorization from Patient’s physician, Inform Patient/Caregiver of our services. Complete a full sign up assessment. DISCHARGE OF PATIENTS Discharge of Patients policy includes but is not limited to the following: Reasons for patient discharge may include the patient expires, the patient’s condition improves and therefore the patient no longer needs the care provided, the physician discontinues the order for care, inadequate patient’s behavior or the patient declines (the Agency no longer meet the patient’s needs) the care and requests discontinuation of services. When services are to be terminated, the person shall be notified of the date of termination and reason for termination which shall be documented in the clinical record, at least 48 hrs before or the second to last day of service if care is not being provided daily , unless there is imminent danger for the patient (like unexpected emergency care that require transfer to an in-patient facility, unexpected exacerbation of health condition), and then the discharge should be processed as soon as possible. A plan shall be developed or referral made for any continuing care indicated. Planning for the Patient’s discharge from the home care service is an integral part of the Treatment Plan. The professional employee, in coordination with the patient’s physician will closely monitor the patients progress toward the achievement of the therapeutic goals. When services are to be terminated, the patient shall be notified of the date of termination and a letter of discharge will be sent to the patient and his/her physician. The discharge instructions will accompany the letter for the patient to follow. A copy of the discharge summary is maintained in the patient record and a copy is forwarded to the primary physician. The discharge summary includes, but is not limited to: Date of discharge , Patient identifying information , Patient’s physician and phone number , Diagnosis , Reason for discharge , A brief description of care provided , Patient's medical and health status at the time of discharge , Any instructions given to the patient or responsible party . The clinical record should maintain documentation that the physician was notified of the discharge in compliance with coordination of care, (Summary must be faxed/emailed to the patient’s physician), discharge instructions to patients, in Medicare beneficiaries must be included the Medicare Non Coverage information and if applicable the Advanced Beneficiary Notice. If applicable, the OASIS Discharge assessment must be completed by a qualified staff, the summary completed in the form can be faxed to the patient’s physician instead of any other summary form, and is not necessary request doctor signature. page 1 6 The Patient will be notified of transfer and/or discharge reason(s) which may include the following: 1. We can no longer meet the patient’s needs, based on patient’s acuity. We must arrange a safe, appropriate transfer. 2. The patient or payer will no longer pay 3. The physician agrees that the patient no longer needs the Agency’s services : The physician that is responsible for the plan of care and the Agency(HHA) agree that the measurable outcomes and goals in the plan of care have been achieved, and the Agency(HHA) and the physician who is responsible for the home health plan of care agree that the patient no longer needs the services of the Agency(HHA) 4. The patient refuses services, or elects to be transferred or discharge 5. Under our policy, behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient, or the ability of the Agency to operate effectively is seriously impaired. We will: a. Advise the patient, representative. b. Make efforts to resolve the problem(s). c. Provide contact information for other agencies or providers. d. Document the problem(s) and efforts made. Discharge for cause : the patient (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. We will 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. We will make an effort to resolve the problem(s) presented by the patient’s behavior, the behavior of other persons 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; and document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records. 6. The patient dies. 7. The HHA ceases to operate. sample