Calvert Digital Admissions packet

CALVERT HOSPICE A HOSPICE OF THE C

HESAPEAKE AFFILIATE

Calvert Hospice is an affiliate organization of Hospice of the Chesapeake and is a member of the Hospice Alliance. Calvert Hospice is referred to throughout this document as “Hospice.”

Purpose of Hospice: The purpose of hospice is to improve the quality of life for those who have a progressive and life-limiting illness. The primary goal of Hospice is to provide assistance that enables patients to stay at home or in their place of residence and to enhance the comfort of the patient. Short-term inpatient care is available for the control of symptoms and/or brief respite for caregivers.

Choice of Care: Hospice offers a wide range of services designed to enhance the patient's life and to control pain and other symptoms. The patient has a choice about the services and techniques being used by Hospice. The patient may review the plan of care that guides Hospice services and may refuse a particular treatment or service. Hospice does not provide advanced life support, ventilators, or other procedures that artificially prolong life.

Levels of Hospice Care:

The Centers for Medicare and Medicaid Services has defined four kinds, or “levels,” of hospice care. One patient may experience all four levels, perhaps in just a week or ten days of hospice services. Another patient may experience one level of care throughout the duration of his or her hospice care. Each level of care meets specific needs, and every hospice patient is unique.

Every Medicare-certified hospice provider must provide these four levels of care:

• Routine hospice care is the most common level of hospice care. With this type of care, an individual has elected to receive hospice care at their residence, which can include a private residence, assisted living facility or nursing facility.

• General inpatient care is provided for pain control or other acute symptom management that cannot feasibly be provided in any other setting and begins when other efforts to manage symptoms have been ineffective. General Inpatient Care can be provided in a Medicare certified hospital, hospice inpatient facility or nursing facility that has a registered nurse available 24 hours a day to provide direct patient care.

• Continuous home care is care provided for between eight and 24 hours a day to manage pain and other acute medical symptoms. Continuous home care services must be predominantly nursing care, supplemented with caregiver and hospice aide services and are intended to maintain the patient at home during a pain or symptom crisis.

• Respite care is available to provide temporary relief to the patient’s primary caregiver. Respite care can be provided in a hospital, hospice facility or a long-term care facility that has sufficient 24-hour nursing personnel present on all shifts to guarantee that the patient’s needs are met. Respite care is provided for a maximum of five consecutive days.

Interdisciplinary Team: Basic Hospice services may include visits from Physicians, Medical Residents, Medical Interns, Registered Nurses, Social Workers, Chaplain, Volunteers, Home Health Aides or Certified Nursing Assistants. As a teaching institution, Hospice offers clinical internships for students in all professions of the interdisciplinary team. Students and Interns may be included in home visits by Hospice professionals. Other professionals may be called on from time to time to assist in the care of the patient. Need for these services will be reviewed by the Hospice team as the needs change. The patient will be consulted regarding changes.

Care Coordinator: During a patient's participation with Hospice, it is usually the Care Coordinator (a family member,aclosefriend,orsomeonehiredto providethis assistance)whois responsibleforseeing that thephysical needs of the patient are safely met on a day-to-day basis. Sometimes the Care Coordinator role is shared among several individuals. The Care Coordinator assures the patient's safety and well-being in the home, at all times. The Care Coordinator also conveys appropriate information about changes in the patient's condition to members of the Hospice team. This communication helps the Hospice Team anticipate the changing need for services (such as additional help in the home, supplies or medications).

Withdrawal: The patient may withdraw from Hospice at any time Additionally, Hospice may discharge a patient based on the following criteria: patient no longer requires Hospice services as they desire curative care not consistent with Hospice philosophy; patient/family/caregiver are not in agreement with Hospice plan of care and elect to discontinue services; patient is no longer terminal (six months or less), or the medical director and/or attending physician determine the patient is not Hospice appropriate; patient chooses another Hospice program; patient leaves service area of Calvert Hospice; family or care coordinator not providing or arranging appropriate caregiving assistance.

CALVERT HOSPICE

It is the policy of Hospice to provide the following services for patients covered under the Medicare/Medicaid/Champus Benefit.

COVERED SERVICES

o Nursing care

o Medical social services

o Physician services (related to terminal illness)

o Counseling services by Hospice personnel

o Certified Nursing Assistant (CNA) and homemaker services

o Physical therapy, occupational therapy, speech therapy

o Bereavement counseling and follow-up

o Volunteer support services

o Medications related to the terminal diagnosis for palliation of symptoms which are included in the Calvert Hospice formulary

o Durable medical equipment as needed for patient comfort

o Laboratory services necessary for palliative care

o Spiritual care

All services and treatments rendered are by the Plan of Care which is determined by the Interdisciplinary Team. All services must be pre-authorized by the IDT.

SERVICES WHICH REQUIRE PRE-AUTHORIZATION

• Surgery

• Major diagnostic workups

• CT scans/MRI

• Respiratory support (except oxygen and nebulizer treatments)

• Liquid oxygen and oxylite

• Renal Dialysis

• Total Parenteral Nutrition (TPN)

• Radiation therapy

• Chemotherapy

• Transfusion of blood and/or blood components

• Specialized beds

• Gamma knife procedure

Effective date: January 6, 1997

STATEMENT OF PATIENT AND FAMILY RIGHTS AND RESPONSIBILITIES

MISSION STATEMENT

The mission of Calvert Hospice is to care for life during the journey with illness and loss. Our Chesapeake Life Center provides services to anyone in the community grieving a death. Our commitment is to provide high quality, cost effective care regardless of age, race, creed, gender, religion, sexual orientation, diagnosis, or ability to pay, with a goal of improving quality of life through comprehensive palliative and supportive services.

ADMISSION CRITERIA

Admission requirements are:

* An attending physician who agrees to be responsible for the patient's care

* The patient's desire for Hospice care

* The availability of a care coordinator who is responsible for the patient's care twenty-four (24) hours a day If patient has no care coordinator, must work with the team to develop a plan when no longer can safely care for self independently.

* A life expectancy of six months or less

Admission is based upon patient and family need without regard to ability to pay or race, creed, sex, age, national origin, sexual orientation, or handicap.

BILL OF RIGHTS

We believe that it is our obligation to promote and protect your rights, as well as those of each patient under our care, including each of the following:

1. The right to a verbal and written explanation of your rights as a patient and the right to receive information in a manner that you understand.

2. The right to exercise your rights as a patient of this agency and to have your property treated with respect.

3. The right to have your cultural, psychosocial, spiritual, and personal values, beliefs, and preferences respected.

4. Right to be free from physical and or/or mental abuse and neglect.

5. The right to effective pain and symptom management, and the right to receive information about factors that affect palliation and comfort.

6. The right to be informed of the policies concerning the management and disposal of controlled substances.

7. The right to make an advance directive and to receive Hospice's policy respecting the implementation of that right.

8. The right to be fully informed in advance about the care and treatment to be furnished by this agency and any changes in the care and treatment that may affect your wellbeing. As a patient, you may participate in planning and implementing your care. You have the right to be given an explanation of the

likely outcome.

9. The right to refuse any portion of planned treatment without relinquishing other portions of the treatment plan, except where partial treatment is medically contraindicated.

10. The right to be informed of short-term inpatient care options for respite, pain control and management.

11. The right to know, before services are provided, which services, to the best of our knowledge, will be paid by Medicare, Medicaid and other Federal or private insurers and which services are not covered. You also have the right to know the charges of any services for which you will have to pay and to be notified of changes in charges or coverage within 30 working days of this agency becoming aware of such changes.

12. The right to confidentiality in all matters associated with your care including your clinical records. Hospice families can expect that discussion of their cases will be confined to hospice personnel unless the information is deemed a question of safety to patients or others. Clinical records are released with written permission of the patient the medical power of attorney, or when required by law.

13. The patient has the right to access, request amendment to, and receive an accounting of disclosures regarding his or her own health information as permitted under applicable law.

14. The right to voice grievances without discrimination, reprisal or interruption of care and to be informed of the State Home Health Hotline number and the accreditation agency’s hotline number.

15. The patient's family or guardian has the right to exercise the patient's rights when the patient has been judged incompetent.

16 Patient/Caregiver has a responsibility to act reasonably while receiving services, including: participation in their plan of care; to provide all medical and pertinent information impacting patient care; communicating with hospice staff; asking questions; following instructions; accepting consequences when instructions are not followed; following rules and regulations; showing respect and consideration toward staff; meeting financial commitments; and provide for staff safety while in their homes.

17. Responsible for safeguarding the hospice patient’s medications from use by anyone other than the patient. This may include compliance with a plan to obtain a locked box and in counting and witnessing the current count of controlled substances.

COMPLAINTS AND GRIEVANCES

Calvert Hospice encourages the active participation in decision making by the patient and family caregivers. We are committed to excellence in the quality and delivery of services. We encourage you to voice any concerns or complaints to the members of your hospice team so that they can address.

If you find that you need to escalate your concern and/or if you wish to file a formal grievance, please contact the Director of Quality Improvement at 443-837-1518 or qualitycompliance@hospicechesapeake.org and you will receive a return call or email by the next business day. We will explain our formal grievance resolution process of investigation.

You also have the right to contact the following agencies to register a formal complaint:

Maryland Department of Health, Office of Health Care Quality 7120 Samuel Morse Drive, Second Floor

Columbia, MD 21046-3422

Phone number for hospice: 800-492-6005

Online submission form: https://health.maryland.gov/ohcq/Pages/Complaints.aspx

Email: complaints.ohcq@maryland.gov

Calvert Hospice is accredited by CHAP – Community Health Accreditation Partner. You may contact them at 800-656-9656 or complaints@chapinc.org.

For those with Medicare insurance, you may also contact: Livanta’s Medicare Helpline for Maryland at 888-3964646. They only accept requests for their immediate advocacy informal review process through a phone call.

PATIENT SELFDETERMINATION

POLICY

Calvert Hospice will inform patients about their right to make an informed decision regarding their medical care and will protect and promote the exercise of these rights. No patient will be denied care based on the presence or absence of an advanced directive.

The Omnibus Budget Reconciliation Act of 1990 (OBRA-90) includes a requirement for health care providers to assure patients' participation in decisions that affect their care. The law requires that the following information be provided at the time of admission:

1. Hospice's written policy concerning advanced directives.

2. Written information concerning the relevant state law on "living wills", including durable powers of attorney.

3. Inquiry of whether an adult patient has formulated an advance directive and documentation of patient's response.

4. A copy of patient's bill of rights which includes the patient's right to accept or refuse medical treatment and the right to make advance directives.

PROCEDURE

1. On the first visit to a patient, the health care professional (RN or Social Worker) will inquire as to whether or not the patient has an advance directive.

2. The health care professional will also inquire if a living will or durable power of attorney has been executed.

3. If the patient is incapacitated, this information will be obtained from the primary caregiver.

4. The patient's, or primary caregiver's, response will then be documented on the patient/family teaching check list, and a copy will be left in the patient's home teaching book.

5. If patient has made an advance directive, the health care professional will request a copy for our records If this is not possible, the health care professional will document the contents on the admission note.

6. All patients will receive a copy of the Patient's Bill of Rights, an information sheet entitled "Legal Rights ofMarylandersto Decide AboutFutureMedical Treatments" and acopy ofourPatient SelfDetermination Act Policy.

7. For additional information outside the knowledge of the RN and/or Social Worker, the patient will be instructed to contact:

Maryland State Attorney General's Office

200 St. Paul Place

Baltimore, MD 21202 410-576-6300

8. All health care providers will attend an in-service of Advance Directives and patient's rights, and new employees will be in serviced during their orientation.

TOTHE PATIENT AND FAMILY....

As a part of your decision to be cared for by a Hospice Program, you have the right to decide whether you wish to be resuscitated.

In order to ensure that your wishes are carried out even in an emergency, the State of Maryland has developed a system under which you can declare your wishes in case of the need for life-sustaining treatment.

The Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form which is included in this packet includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation and other life-sustaining treatment options in the patient’s medical record.

If you have any questions, please contact your Hospice nurse at 1-410-535-0892.

PATIENT/HOSPICE AGREEMENT

Calvert Hospice hereby agrees to provide the following services to Hospice patients. This agreement is made subsequent to the patient's request for consideration for hospice services, and the completion of Hospice assessments of the patient's needs.

It is agreed that Hospice will:

▪ Accept and incorporate orders of attending physician in the Hospice Plan of Care.

▪ Follow the wishes and desires of the patient in the Hospice Plan of Care.

▪ Coordinate and maintain in writing an individual patient Plan of Care, incorporating the medical, social, emotional, and spiritual needs expressed by the patient, family and attending physician.

▪ Provide in-home nursing care at any time needed by the patient or indicated by the Plan of Care.

▪ Provide counseling, support, and relief to family members as needed or indicated in the Plan of Care.

▪ Provide direct spiritual care counseling or assistance in obtaining such spiritual counseling as needed or indicated in the Plan of Care.

▪ Provide specific treatment as needed for palliation (to include speech, physical therapy, dietary counsel, and occupational therapy) or as needed or indicated in the Plan of Care.

▪ Provide volunteer services for the comfort, company, occasional household duties of the patient and/orfamily as needed or indicated in the Plan of Care.

▪ Provide drugs and biologicals necessary for palliative treatment of the patient's terminal illness as indicated by the Plan of Care.

▪ Determine appropriate location for treatment in the event the patient's condition and Plan of Care requires inpatient care.

The patient and the patient's primary caregiver(s) agree to:

▪ Provide the Hospice team with complete medical history and information necessary for the planning and delivery of appropriate care.

▪ Discuss needs and preferences with the Hospice team members.

▪ Participate in the developing of a Plan of Care.

▪ Report immediately to the Hospice staff any changes in the condition of the patient which will affect the Plan of Care. (Hospice staff may be contacted 24 hours a day.)

▪ Notify Hospice staff immediately of any decision to seek or obtain treatment of services not included in the Hospice Plan of Care.

▪ Follow the policy and procedure of the Hospice in handling and caring for drugs and/or equipment supplied by the Hospice.

I understand that I may choose care other than Hospice at any time Such a choice will relieve Hospice of any responsibility for further provision of care automatically.

Calvert Hospice’s phone lines is answered 24 hours a day, seven days a week. 1-410-535-0892.

YOUR INTERDISCIPLINARY TEAM

Your Hospice interdisciplinary team works closely together with you, your family, and each other to meet the highest possible standards of care for you. Team members are responsible for regular communication and sharing of important information concerning our patients with other team members and with appropriate Hospice staff in order to provide you and your family with well-coordinated and comprehensive treatment Here are the team members available to assist you:

Team Coordinator

Liaison Nurse

Hospice Nurse

Licensed Practical Nurse

A Registered Nurse who is responsible for coordination of patient/family hospice clinical services. Supervises the primary nurses in the care of patients.

A Registered Nurse who coordinates the transition of patient/family from the hospital or nursing home to hospice care Provides outreach and education to nursing staff, physicians, and discharge planners. Informs patients and families about hospice philosophy, goals and services.

A Registered Nurse who is responsible for primary hospice care management. Regular visits are made to patient's home, hospital, or nursing home to carry out care and treatment prescribed by physician. The Registered Nurse supports patient/family through crisis situations.

The LPN makes visits to patients requiring nursing treatments as assigned by registered nurse Assists and supports family through physical and/or emotional crisis situations.

On-Call Nurse

Certified Nursing Asst

A Registered Nurse who provides nursing care during after-hours times, 4:30 pm - 8:00 am, weekdays, weekends and holidays.

A Nursing Assistant who provides personal care services under supervision of the Registered Nurse.

Hospice Volunteer Hospice Volunteer who visits patient and family on a regular basis Provides respite for families. Offers practical help and is available to provide understanding and caring to patient and family.

Social Worker

Social Worker assesses patient and family needs and is available for counseling. Educates about community resources and provides ongoing support Services may be provided in the home, nursing home or office.

Hospice Chaplain Chaplain provides spiritual care for hospice patients and families. Assesses spiritual needs of patients and families who request chaplaincy services and provides spiritual comfort.

Hospice Medical Director

A physician who assumes overall responsibility of medical care of patients in conjunction with patient's own physician and Hospice team. The Medical Director is available for consultations and emergencies when patient's own physician is not available.

Bereavement Counselor

Responsible for bereavement care/counseling for Hospice families. Counselors in the Chesapeake Life Center provide grief support through individual or family counseling for adults and children/teens In addition, various grief support groups and educational events are available to hospice families after the death of their loved one. Hospice families are eligible for up to 10 grief counseling sessions and a variety of support groups at no charge for up to 13 months following death.

Bereavement Volunteer

A volunteer from Chesapeake Life Center will call within the first couple of months after your loss to see how you are doing and to remind you of the availability of bereavement support. In addition, the Chesapeake Life Center sends informational mailings about grief throughout the 13 months following the death Volunteers also assist in Chesapeake Life Center activities.

The Role of Volunteers in Hospice Care

Hello,

We are honored that you have entrusted your care or the care of your loved one with us. We are committed to ensuring the best care and are proud to have a team of dedicated, compassionate, and highly trained people to serve you As a part of your care, we have volunteers who are available to you and can provide the additional support and assistance that you may need during your time with us.

We often hear how our volunteers make a positive difference in our patients and their families’ lives. Our volunteers go through an extensive screening and training process and are skilled to help you in many ways Among many things that they can do for you, they are able to provide companionship, be a supportive presence, offer respite to caregivers, and run errands for you and your family.

Volunteers are assigned to a patient and their family and generally come to your place of residence one time a week for up to four hours per visit Once assigned, we ask that you let your volunteer know how they can best help you. Although our volunteers can do many things in your home, they are not able to administer over the counter or prescription medications Here are some guidelines to help you plan your time when your volunteer is with you in the event that medication needs to be administered.

• If medication is needed by the patient during the caregiver’s absence, the caregiver may pre-pour and place it within the reach of the patient so he/she can take their own medication.

• Volunteers may guide patient’s hand to a cup or remind a patient to take their medication, pour water, or note the time that the medication was taken.

• In the event that a patient cannot take their medication on their own, please have a contingency plan in place that designates a person responsible for administering the medications. You will need to provide the name and contact person to the volunteer

We are privileged that you have chosen us to walk alongside you in your journey and strive to provide you the best care during this time. Because many of our volunteers have been former caregivers, they truly understand what you are experiencing. If you would like the services of a volunteer, please ask your primary nurse or social worker for a referral With their willingness to serve and their compassionate heart, they can be the support and help that you may need to make things a bit better or the load a little lighter for you and your family. We hope that you will invite a volunteer into your home and experience the benefit of having them be a part of your care.

Sincerely,

Christine Wilson Director of Advancement and Volunteer Services

VOLUNTEER GUIDELINES FOR MEDICATION ADMINISTRATION

1. Volunteers are not permitted to administer medication of any kind, (including over the counter) to patients while performing their duties as patient care volunteers.

2. If medication will be needed by the patient during the caregiver’s absence, the caregiver may pre-pour and label medication, place it within the reach of the patient so he/she can self-medicate when necessary. Volunteers may guide patient’s hand to cup, but not pass medication. They may remind the patient that it is time to take medication, pour a cup of water to drink with medication, and note the time that the patient took the medication.

3. In the event that a patient cannot self-medicate, the family will be asked to have a contingency plan specifying who the volunteer can call to administer medications.

a. A letter explaining the role of the volunteer on the interdisciplinary team will be in the admissions packet given to the family It will contain the policy regarding medication administration and include a contingency plan form, which the family can complete and use if necessary The primary nurse will place it in the blue book in the patient’s home The volunteer will keep a copy for her information.

b. The volunteer will also inform the family of this policy during the initial contact.

c. The contingency plan will be noted in the patient’s chart.

4. If people specified in the contingency plan are unavailable when needed, the volunteer will call the triage nurse in the Hospice office during normal working hours and the on-call nurse after hours and note this in the volunteer progress note.

Dear Hospice Patient, Family, and Caregivers,

Welcome to Calvert Hospice. As you learn more about this program and who will be taking care of you, let me introduce you to our Spiritual Care Services For many people, this period of time offers an opportunity to look back over life's memories, and to reflect on the value of a life well lived. We recognize how deeply spiritual these moments can be and we want to provide you with the possibility of enriching your spiritual life.

Therefore, we provide spiritual support to all patients, families, and caregivers who request these services The following Spiritual Care Services are offered:

· Spiritual Counseling and Support that is in keeping with your belief systems and practices.

Referrals to churches, synagogues, and faith communities that are consistent with your preferences.

Assistance with spiritual resources and faith practices which will enhance your spiritual growth.

Discussion and reflection on the cares, concerns, and issues which are most important to you.

· Informational and supportive counseling to assist you in coping with stress, crisis, and spiritual pain.

Your nurse and your social worker will be asking you if you would like to have a visit from the Spiritual Care staff. Please let them know if you would like to make use of these services, or simply call the office and ask to speak with the Chaplain A visit will be scheduled at your convenience.

With care,

The Spiritual Care Staff

ETHICS COMMITTEE

Mission Statement

The mission of the Ethics Committee is to:

1. consider matters of an essentially ethical nature involving patient care and/or Hospice policy or practice which are raised by a patient, family member, Hospice staff member or any person significantly involved with the care or support or welfare of a patient.

2. and, after confidential deliberation, to present its findings and when applicable make recommendations to the person or persons raising and/or presenting the matter or other appropriate persons.

If you would like the Ethics Committee to review an ethical matter, please notify your nurse or social worker by calling Calvert Hospice at 1-410-535-0892.

BASIC HOME SAFETY STANDARDS

I. Electrical Safety

A. Cords should not be placed beneath furniture and rugs or across pathways.

B. Replace frayed cords.

C. Extension cords should not be overloaded. Check rating labeled on cord and appliance.

D. Multiple outlet adapters should not be used on electrical outlets.

E. Light bulbs must be appropriate wattage and shape.

II. Rugs, Runners, and Mats

A. Loose rugs, runners, and mats should be removed or secured to floor with double- sided adhesive or rubber matting.

B. Carpet edges should be tacked down.

C. Torn, worn, frayed carpeting should be repaired, replaced, or removed.

III. Telephone

A. Locate at least one phone where it is accessible in event an accident renders a person unable to stand.

B. Emergency numbers should be posted near the phone.

C. Have one landline (non-portable) phone or a cell phone in case of electric power outage.

IV. Fire Safety

A. Fire regulations recommend one smoke detector on every level of the home.

B. Fire Extinguisher (re-chargeable, multi-type -"C"). One on each floor - the kitchen in particular.

C. Develop evacuation plan to exit the residence in event of fire. Prioritize family members who are dependent, non-ambulatory, or will require assistance.

D. Establish clear pathways to all exits. DO NOT BLOCK EXITS with furniture or boxes.

E. HAVE KEY accessible near deadbolt locked doors.

F. DO NOT LEAVE COOKING unattended for extended periods of time.

G. Chimneys should be inspected annually to avoid dangerous buildup of creosote.

H. Kerosene heaters, wood stoves, fireplaces SHOULD NOT be left unattended while in use.

I. For safety, set up rules related to smoking in your home.

V. Cupboards and Closets

A. Cupboards should be organized so that frequently used items are on lower/easier to reach shelves.

B. A sturdy step stool should be used to reach items on high shelves.

C. Heavy items should be stored flatly on lower levels of closet to avoid falling and injuries.

VI. Bathrooms & Kitchen

A. Wipe up or mop up spills immediately to prevent slipping

B. Store cleaning products separate from food or personal care products

C. Use a non-slip tub or shower mat.

D. Consider investing in safety bars, shower chairs &/or toilet seat risers to increase safety in bathroom.

E. Keep areas well lit & consider a night light for the bathroom

VII Take Extra Precautions to reduce your risk of falls:

A. Turn on the lights when you enter a room. Do not walk in the dark. Use night lights in your bedroom, the bathroom, and hallway leading to the bathroom.

B. Make sure your pathway is clear.

C. Use the handrails on staircases.

D. Sit in chairs that do not move and have arm rests to help when you sit down and stand up.

E. Wear shoes that have firm, flat, non-slip soles. Do not wear shoes that do not have backs on them.

F. Replace the rubber tips on canes and walkers when they are worn.

G. If you feel unsteady, ask for help going to the bathroom or walking around.

H. Put frequently used items in easy-to-reach places.

(Section VII contains recommendations from The Joint Commission “Reduce your risk of falling” pamphlet.)

APPENDIX: ADMISSIONS FORMS AND ADDITIONAL MATERIALS

Hospice of the Chesapeake and Affiliates Hospice of the Chesapeake  Hospice of Charles County Calvert Hospice

Election of Hospice Benefit

Patient Name:

Hospice Philosophy

I acknowledge that I have been given a full explanation and have an understanding of the purpose of hospice care. Hospice care is to relieve pain and other symptoms related to my terminal illness and related conditions and such care will not be directed toward cure. The focus of hospice care is to provide comfort and support to both me and my family/caregivers.

Effects of a Medicare Hospice Election

I understand that by electing hospice care under the Medicare Hospice Benefit, I am acknowledging that I understand the holistic palliative rather than curative nature of hospice care, as it relates to my terminal illness and related conditions. I understand that by electing hospice care under the Medicare Hospice Benefit, I am waiving (giving up) all rights to Medicare payments for services related to my terminal illness and related conditions and I understand that while this election is in force, Medicare will make payments for care related to my terminal illness and related conditions only to the designated hospice and attending physician that I have selected. I understand that services not related to my terminal illness or related conditions will continue to be eligible for coverage by Medicare; however, I also understand that services unrelated to my terminal illness and related conditions are exceptional and unusual and hospice should cover all care related to my terminal illness and related conditions needed under the hospice election.

Hospice Coverage and Right to Request "Patient Notification of Hospice Non-Covered ltems, Services, and Drugs" Medicare Patients Only

I acknowledge that I have been provided with information about my financial responsibility for certain hospice services (drug copayment and inpatient respite care). I understand that I have the right to request at any time, in writing, the "Patient Notification of Hospice NonCovered ltems, Services, and Drugs" addendum that lists the items, services, and drugs that the hospice has determined to be unrelated to my terminal illness and related conditions that would not be covered by the hospice. I acknowledge that I have been provided information regarding the provision of Immediate Advocacy through the Beneficiary and Family-Centered Care Quality Organization (BFCC-QIO) if I disagree with any of the hospice's determinations and I have been provided with the contact information for the BFCC-QIO that services my area: https://livantaqio.com/en or 1-888-396-4646.

Right to choose an attending physician

I understand that I have a right to choose my attending physician to oversee my care. My attending physician will work in collaboration with the hospice agency to provide care related to my terminal illness and related conditions.





I do not wish to choose an Attending Physician.

Physician Full name:

Office Address:

I acknowledge that my choice for an attending physician is: NPI (if known): _

 I acknowledge and understand the above and authorize Medicare hospice coverage to be provided by my elected hospice above to begin on .

(Effective Date of Election)

Note: The effective date of the election, which may be the first day of hospice care or a later date but may be no earlier than the date of the election statement. An individual may not designate an effective date that is retroactive.

Signature of Beneficiary/Representative:

Printed Name and Relationship of Representative:

 Beneficiary is unable to sign. Reason:

Date:

Signature of Witness: Date: (Hospice Representative) Updated Jul 2022

HOSPICE OF THE CHESAPEAKE AND AFFILIATES ADMISSIONCHECKLISTANDCONSENT

 Hospiceof the Chesapeake  Hospiceof Charles County  Calvert Hospice

PatientName: Pt.#:

 Iconsenttoacceptpharmaceuticalservicesprovidedbyhospiceand to the release of my medical information to obtain medications.

 I consent to the medication disposal policy that allows hospice staff to dispose of my medication as outlined in the policy.

Signature of Patient or Legal Representative Signature of Hospice Representative

 I DO NOT consent to the medication disposal policy and accept the responsibility to dispose of the medications in an appropriate manner. Date

I acknowledge receipt of the following documents:

 HospiceInformation

 CoordinationofCare

 FinancialPlan

 RightsandResponsibilities

 Policy for Home Use and Disposal Controlled Substances and Other Prescribed Medications

I have had the opportunity to review such documents and to ask questions and to discuss their contents with a Hospice representative. I understand the scope of services which Hospice provides andmyrightsandresponsibilities. IhaveprovidedtheinformationrequestedunderCoordinationof Care. I have reviewed the information contained in the Financial Plan and have agreed to the terms of the Plan, including assignment of benefits. I acknowledge that CPR is not performed by hospice staff per the Hospice of the Chesapeake policy which I have read.

Consent to Release Information: I authorize the release of medical and financial information to or from health care practitioners, medical personnel, government agencies, accreditation agencies, CRISP, and insurers, if necessary for the coordination and continuity of my care, reimbursement for services and supplies furnished, or for the quality of my care. Such information will not be released for any other purpose or to any other person without my written consent or that of my representative.

I consent to admission to Hospice under terms and conditions set forth herein and in the documents attached.

Signature of Patient or Legal Representative Date

Printed Name of Patient or Legal Representative Date .

Signature of Hospice Representative Date

A parent or legal guardian must sign for patients who are under 18 years of age. 7 22 22 White/Chart Yellow/Family

Hospice of the Chesapeake and Affiliates

 Hospice of the Chesapeake  Hospice of Charles County  Calvert Hospice

Patient Notification of Hospice Non-Covered Items, Services and Drugs

Date of Request: Name of Hospice Agency: hospice elected above

Patient Name

Furnished Date:

The purpose of this addendum is to notify the requesting Medicare beneficiary (or representative), in writing, of those conditions, items, services, and drugs not covered by the hospice benefit because the hospice has determined they are unrelated to your terminal illness and related conditions. If you request this notification within 5 days of a hospice election, the hospice must provide this form within 5 days of your request. If you request this form at any point after the first 5 days of the start date of hospice care, the hospice must provide this form within 3 days of your request.

Diagnoses

Non-covered items, services, and drugs determined by hospice as not related to my terminal illness and related conditions: Items/Services/Drugs Reason for Non-Coverage

Note: The hospice makes the decision as to whether or not conditions, items, services, and drugs are related for each beneficiary. This addendum should be shared with other healthcare providers from which you seek items, services, or drugs, unrelated to your terminal illness and related conditions to assist in making treatment decisions. The hospice should provide its reasons for non-coverage under the hospice benefit in language that you (or your representative) can understand.

Right to Immediate Advocacy

As a Medicare beneficiary you have the right to contact the Medicare Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) to request for immediate advocacy if you (or your representative) disagree with the decision of the hospice agency on items not covered because the hospice has determined they are unrelated to the individual's terminal illness and related conditions. Visit this website to find the BFCC-QIO for your area: https://livantaqio.com/en or call 1-888-396-4646, or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

Signing this notification (or its updates) is only acknowledgement of receipt of this notification and does not constitute your agreement with the hospice's determinations

is unable to sign. Reason:

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

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health condition and related health care services.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.

Treatment:

We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment:

Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations:

We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment, employee review, training of medical students, licensing, fundraising, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment, and inform you about treatment alternatives or other health- related benefits and services that may be of interest to you.

CRISP:

We have chosen to participate in the Chesapeake Regional Information System for our Patients (CRISP), a regional health information exchange serving Maryland and D.C. As permitted by law, your health information will be shared with this exchange in order to provide faster access, better coordination of care and assist providers and public health officials in making more informed decisions. You may “opt-out” and disable access to your health information available through CRISP by calling 1-877-952-7477 or completing and submitting an Opt-Out form to CRISP by mail, fax or through their website at www.crisphealth.org. Public health reporting and Controlled Dangerous

Substances information, as part of the Maryland Prescription Drug Monitoring Program (PDMP), will still be available to providers.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as required by law, public health issues as required by law, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, organ donation, research, criminal activity, military activity and national security, workers’ compensation, inmates, and other required uses and disclosures. Under the law, we must make disclosures to you upon your request. Under the law, we must also disclose your protected health information when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements under Section 164.500.

Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or opportunity to object unless required by law. You may revoke the authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

YOUR RIGHTS

The following are statements of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information (fees may apply) – Under federal law, however, you may not inspect or copy the following records: Psychotherapy notes, information compiled in reasonable anticipation of, or used in, a civil, criminal, or administrative action or proceeding, protected health information restricted by law, information that is related to medical research in which you have agreed to participate, information whose disclosure may result in harm or injury to you or to another person, or information that was obtained under a promise of confidentiality.

You have the right to request a restriction of your protected health information – This means you may ask us not to use or disclose any part of your protected health information and by law we must comply when the protected health information pertains solely to a health care item or service for which the health care provider involved has been paid out of pocket in full. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. By law, you may not request that we restrict the disclosure of your PHI for treatment purposes.

You have the right to request to receive confidential communications – You have the right to request confidential communication from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.

You have the right to request an amendment to your protected health information – If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures – You have the right to receive an accounting of all disclosures except for disclosures: pursuant to an authorization, for purposes of treatment, payment, healthcare operations; required by law, that occurred prior to April 14, 2003, or six years prior to the date of this request.

You have the right to obtain a paper copy of this notice from us even if you have agreed to receive the notice electronically. We reserve the right to change the terms of this notice and we will notify you of such changes on the following appointment. We will also make available copies of our new notice if you wish to obtain one.

COMPLAINTS

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Compliance Officer of your complaint. We will not retaliate against you for filing a complaint.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. We are also required to abide by the terms of the notice currently in effect. If you have any questions in reference to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number.

Please sign the accompanying “Acknowledgment” form. Please note that by signing the Acknowledgment form you are only acknowledging that you have received or been given the opportunity to receive a copy of our Notice of Privacy Practices

Patient Name:

ID #: _____________________

Notice of Privacy Practices Acknowledgment

I understand that under the Health Insurance Portability and Accountability Act (HIPAA), I have certain rights to privacy regarding my protected health information. I acknowledge that I have received or have been given the opportunity to receive a copy of your Notice of Privacy Practices. I also understand that this practice has the right to change its Notice of Privacy Practices and that I may contact the practice at any time to obtain a current copy of the Notice of Privacy Practices.

We participate in the CRISP health information exchange (HIE) to share your medical records with your other health care providers and for other limited reasons. You have rights to limit how your medical information is shared. We encourage you to read our Notice of Privacy Practices and find more information about CRISP medical record sharing policies at www.crisphealth.org.

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Individual refused to sign

Communications barriers prohibited obtaining the acknowledgement

An emergency situation prevented us from obtaining acknowledgement

Other (Please Specify)

*If Patient Representative is signing, legal documentation must be included designating authority to sign or receive information. This form must be maintained for 6 years.

Discrimination Is Against the Law

Hospice of the Chesapeake and its affiliate brands, including Calvert Hospice, comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. Hospice of the Chesapeake does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Hospice of the Chesapeake and affiliates provides:

• free aids and services to people with disabilities to communicate effectively with us, such as: qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, other formats)

• free language services to people whose primary language is not English, such as: qualified interpreters and information written in other languages

If you need these services, contact the Director of Quality and Compliance If you believe that Hospice of the Chesapeake has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Director of Quality and Compliance, Hospice of the Chesapeake, 90 Ritchie Highway, Pasadena, MD 21122, 410-987-2003, qualitycompliance@hospicechesapeake.org. You can file a grievance in person or by mail, phone, or email. If you need help filing a grievance the Director of Quality and Compliance is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

Hospice of the Chesapeake cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-410-9872003.

Hospice of the Chesapeake 遵守適用的聯邦民權法律規定，不因種族、膚色、民族血統、年齡、殘障或性別而歧視任何人。 注意：如果您 使用繁體中文，您可以免費獲得語言援助服務。請致電 1-410-987-2003。

Hospice of the Chesapeake 은(는) 관련 연방 공민권법을 준수하며 인종, 피부색, 출신 국가, 연령, 장애 또는 성별을 이유로 차별하지 않습니다 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다 1-410-987-2003 번으로 전화해 주십시오

Hospice of the Chesapeake tuân thủ luật dân quyền hiện hành của Liên bang và không phân biệt đối xử dựa trên chủng tộc, màu da, nguồn gốc quốc gia, độ tuổi, khuyết tật, hoặc giới tính. CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-410987-2003

Hospice of the Chesapeake respecte les lois fédérales en vigueur relatives aux droits civiques et ne pratique aucune discrimination basée sur la race, la couleur de peau, l'origine nationale, l'âge, le sexe ou un handicap. ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-410-987-2003.

Sumusunod ang Hospice of the Chesapeake sa mga naaangkop na Pederal na batas sa karapatang sibil at hindi nandidiskrimina batay sa lahi, kulay, bansang pinagmulan, edad, kapansanan o kasarian. PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-410-987-2003.

Hospice of the Chesapeake соблюдает применимое федеральное законодательство в области гражданских прав и не допускает дискриминации по признакам расы, цвета кожи, национальной принадлежности, возраста, инвалидности или пола. ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-410-987-2003

Hospice of the Chesapeake የፌደራል ሲቪል

Hospice of the Chesapeake tele ilana ofin ijoba apapo lori eto ara ilu atipe won ko gbodo sojusaju lori oro eya awo, ilu-abinibi, ojo-ori, abarapa tabi okunrin ati obinrin. AKIYESI: Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun yin o. E pe ero ibanisoro yi 1-410-987-2003.

Hospice of the Chesapeake konfòm ak lwa sou dwa sivil Federal ki aplikab yo e li pa fè diskriminasyon sou baz ras, koulè, peyi orijin, laj, enfimite oswa sèks. ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-410-987-2003.

Hospice of the Chesapeake cumpre as leis de direitos civis federais aplicáveis e não exerce discriminação com base na raça, cor, nacionalidade, idade, deficiência ou sexo. ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-410-987-2003.

Hospice of the Chesapeake and Affiliates

Hospice of the Chesapeake Hospice of Charles County

Patient: ID#:

MEDICARE

REVOCATION OF HOSPICECARE

Calvert Hospice

As a Hospice beneficiary, I wish to revoke the election of coverage of Hospice Care for the remainder of the current Benefit Period. I understand that I am forfeiting the right to days of Hospice coverage in the current Benefit Period. Should I choose to re-elect the Hospice Benefit at a later time, I will access the next Benefit Period.

The Benefit Periods

First Benefit Period 90 Days

Second Benefit Period 90 Days

Subsequent Benefit Periods Unlimited 60 Day Periods

This Revocation is effective . I understand that I will not be covered for Hospice Care on the effective date indicated, but will be restored to (whichever applies) regular Medicare, TriCare, or Maryland Medical Assistance program coverage (if still eligible), beginning with the effective date.

REVOCATION OF HOSPICE CARE OTHER INSURANCE

As a Hospice beneficiary, I wish to revoke the election of coverage of Hospice Care. This Revocation is effective (date)

Health Care Decision Making Worksheet

Instructions

Use this worksheet either to indicate current treatment preferences (which will be reflected in Maryland MOLST orders) or to clarify wishes for future situations (which will be applied only when the issues become relevant in the future). Only initial those items for which a decision has been made or is needed. The remaining items can be left blank and may be completed later.

Although the choices on this worksheet represent wishes regarding various life-sustaining treatment options, this is not an order sheet or an advance directive.

For example, preferences about artificially administered fluids and nutrition would be incorporated into current orders if the individual currently has impaired nutrition or fluid/electrolyte balance that cannot be corrected by some other means. On the other hand, if the individual is eating or drinking adequately and related problems are not anticipated in the near future, then orders related to limiting these treatments may not need to be entered on the MOLST form. It may still be appropriate to do so if the individual has definitely decided about these treatments for the future.

Make one choice for cardiopulmonary resuscitation, by initialing the appropriate line. If no choice is made, resuscitation will be attempted by default. Choose one option for each of the other categories, as appropriate and desired, by initialing the appropriate line. Clarify specific care instructions, as needed.

Part A, Main goal(s) of care: Specific treatment preferences should reflect the main goal or goals of care. Part A invites the patient or the patient’s authorized decision maker to identify goals. It allows for the identification of more than one main goal of care. Often, two goals can be pursued at the same time – for example, prolonging life while controlling pain and other distressing symptoms. But if the use of a life-sustaining treatment would be inconsistent with maximum comfort, as sometimes happens, then health care providers ought to know which goal is more important.

If the patient lacks capacity, the main goal(s) of care should be identified from the patient’s perspective, based on the authorized decision maker’s understanding of the patient’s wishes, if known, or the patient’s best interests. The authorized decision maker’s personal beliefs and values should not override those of the patient, even if he or she is an appointed health care agent.

If there are multiple surrogate decision makers of equal authority involved in the preparation of the Health Care Decision Making Worksheet, they may not all agree on a life-sustaining treatment. Or, even if they agree, the attending physician may consider that the identified main goal of care is unrealistic or, if pursued, would result in burdens with little or no benefit for the patient. A health care provider should follow its customary procedures for addressing such conflicts, including, as appropriate, referral to the facility’s patient care advisory (ethics) committee.

Part B, Advance directive and authorized decision maker contact information: The Health Care Decision Making Worksheet is not an advance directive or an order form. If a patient has already completed an advance directive, this worksheet could be attached to it. If the advance directive names a health care agent, contact information for the health care agent should be inserted. If there is no health care agent, contact information for the guardian or surrogate decision maker should be inserted. Even if the patient still has capacity, the contact information for whoever is to serve as health care proxy after loss of capacity should be included.

HEALTH CARE DECISION MAKING WORKSHEET

Patient’s name Date of Birth □ Male □ Female

Part A Fill in briefly, then initial on the line

Part B

Most Important Goal(s) of Care (What does the patient or proxy hope to achieve?

_______

If the patient has a written advance directive check this box □ and attach a copy.

If the patient does not have the capacity to make health care decisions, check this box□. In case the patient lacks or loses capacity, the following individual will make decisions:

Name Phone Number

□ Health Care Proxy, □ Guardian, or □ Surrogate Decision Maker

Meaning and Implications

1 CPR Status: What should be done to try to prevent or manage an actual or impending cardiopulmonary arrest?

_______ Attempt CPR, Comprehensive Cardiopulmonary Resuscitation Efforts

• If cardiac and/or pulmonary arrest occurs, initiate cardiopulmonary resuscitation (CPR).

• CPR should include comprehensive medical efforts to try to restore and/or stabilize heart and lung function and prevent arrest, including any form of artificial ventilation.

_______ No CPR, Option A-1, Intubate, Comprehensive Efforts to Prevent Arrest, Including Intubation

• If cardiac and/or pulmonary arrest occurs, resuscitation should not be attempted (No CPR). Allow death to occur naturally.

• In order to try to prevent cardiopulmonary arrest, use comprehensive efforts to try to stabilize and/or restore heart and lung function, including intubation where indicated.

_______ No CPR, Option A-2, Do Not Intubate, Comprehensive Efforts to Prevent Arrest, No Intubation

• In order to try to prevent cardiopulmonary arrest, make a comprehensive effort to try to stabilize and/or restore heart and lung function, except for intubation. It is acceptable to use CPAP or BiPAP to try to prevent respiratory failure.

• If cardiac and/or pulmonary arrest occurs, do not attempt resuscitation (No CPR). Allow death to occur naturally.

_______ No CPR, Option B, Palliative and Supportive Care, Palliative and Supportive Care Before and After Cardiopulmonary Arrest

• Do not initiate cardiopulmonary resuscitation (No CPR). Allow death to occur naturally.

• Give supportive measures only, including 1) passive oxygen for comfort, 2) efforts to control any external bleeding (i.e., bleeding that is visible to an observer), 3) only medications indicated for symptom relief (e.g., pain management).

• Do not attempt to prevent cardiopulmonary arrest. Do not intubate or use CPAP or BiPAP.

Meaning and Implications

2 Artificial Ventilation: What should be done for respiratory failure where cardiopulmonary arrest is not involved?

2a _______ In case of respiratory failure (the individual cannot breathe adequately unaided), intubation and artificial ventilation may be initiated and continued for as long as breathing needs mechanical assistance, even indefinitely.

2b _______ In case of respiratory failure, intubation and artificial ventilation may be initiated and continued for a limited time (time limit up to ______ days) to see if artificial ventilation is effective in light of a patient’s overall condition and underlying causes of respiratory failure. During that trial period, reassess the situation to determine if continued use of artificial ventilation is warranted or if it should be discontinued.

2c _______ In case of respiratory failure, only CPAP or BiPAP may be used for artificial ventilation, as indicated, and continued for a limited time (time limit up to ______ days), to see if any of these interventions are effective and their continued use is pertinent in light of the patient’s overall condition and underlying causes of respiratory failure. However, do not intubate or place on a ventilator.

2d _______ Do not use artificial ventilation (i.e., no intubation, CPAP or BiPAP) under any circumstances.

3 Blood Transfusion: Should blood transfusions or infusion of blood products be given in case of bleeding?

3a _______ Blood and blood products (plasma, whole blood, and platelets) may be administered if indicated to replace or try to stop blood loss or to treat life-threatening anemia. This does not mandate transfusion for anemia or acute blood loss, regardless of medical indication, but authorizes it if it is medically indicated.

3b _______ Do not give any blood transfusions or blood products.

4 Hospital Transfers: Should hospital transfers occur to assess or treat medical conditions, and under what circumstances?

4a _______ Transfer to the hospital is OK for any situation requiring medical care (i.e., if hospitalization is needed to diagnose, treat, or monitor the individual) that cannot be given outside of a hospital (This does not mandate automatic hospital transfer for any acute illness or change of condition, but only authorizes it if the situation cannot be addressed adequately outside of a hospital).

4b _______ Hospital transfer may be used if necessary for comfort; to relieve distressing medical symptoms that cannot be managed elsewhere. Hospitalization should not be used primarily to try to identify, diagnose, and treat or cure underlying causes of symptoms.

4c _______ Do not transfer to a hospital under any circumstances. Assess, treat, and monitor the patient with options available outside the hospital, as needed and consistent with patient goals.

Meaning and Implications

5 Medical Tests: To what extent should medical tests be performed for diagnosis, treatment, and monitoring?

5a _______Any medical tests that are indicated to diagnose, treat, or monitor a patient may be obtained. This does not mandate medical tests, but authorizes testing if medically indicated.

5b _______ Only perform limited medical tests necessary for symptomatic relief or comfort. Beyond that, it is acceptable to base any needed assessment, diagnosis, treatment, and monitoring on clinical findings instead of on diagnostic testing.

5c _______ Do not do any medical tests. It is acceptable to base assessment, diagnosis, treatment, and monitoring on clinical findings instead of on diagnostic testing.

6 Antibiotics: When should antibiotics be given, and how extensively?

6a _______ Any antibiotics (oral, intravenous or intramuscular injection) that are medically indicated may be used, by any route of administration, to try to treat an infection. This does not mandate antibiotics, but authorizes their use if medically indicated.

6b _______ Oral antibiotics may be used, if medically indicated, on a limited basis and not indefinitely, to treat an infection. Intravenous or intramuscular antibiotics should not be used.

6c _______ Antibiotics should only be used if needed to try to relieve symptoms for comfort, and should only be given orally, and not with the primary goal of trying to cure an infection.

6d _______ Do not give antibiotics. In case of an infection, give only symptomatic treatment, such as medicines for fever or pain relief.

7 Artificially administered fluids and nutrition: Under what circumstances, and to what extent, should artificially administered fluids and nutrition be given?

7a _______ Artificially administered fluids and nutrition may be given, even indefinitely, if indicated, by any available means. This does not mandate giving these interventions regardless of lack of a medical indication. It recognizes that medical treatment may address treatable causes of weight loss and fluid imbalances.

7b _______ Artificially administered fluids and nutrition may be administered, if indicated, as a therapeutic trial for a limited time (time limit: up to ______ days). During that trial period, reassessment will be done to determine if continued use of these interventions is indicated and desired or if it should be discontinued. For example, because underlying causes of weight loss cannot be corrected. Artificially administered fluids and nutrition may also be administered for palliation, if consistent with the patient’s goals and wishes.

7c _______ Artificially administered hydration (intravenous or subcutaneous fluids or PEG tube) may be given, but not artificial nutrition.

7d _______ No artificially administered fluids and nutrition will be give. Offer food and fluids by mouth as desired and tolerated.

8

Kidney Dialysis: Should dialysis be used if the kidneys do not function adequately, and under what circumstances?

8a _______ Dialysis (either hemodialysis or peritoneal) may be given, even indefinitely, for any medical indication related to inadequate kidney function including end-stage kidney disease.

8b _______ Dialysis (either hemodialysis or peritoneal) may be administered, but only for a limited period (time limit: up to ______ days), until prognosis is determined, etc.), to see if dialysis is effective and pertinent in light of the overall situation. This does not mandate giving dialysis regardless of lack of a medical indication, but authorizes its use if medically appropriate.

8c _______ No dialysis of any type or duration should be provided.

9 Other Treatments: Are there any other instructions related to life-sustaining treatments not otherwise covered in Sections 1-8 above?

Maryland Medical Orders for Life-Sustaining Treatment (MOLST)

Patient’s Last Name, First, Middle Initial Date of Birth

This form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation and other life-sustaining treatment options for a specific patient. It is valid in all health care facilities and programs throughout Maryland. This order form shall be kept with other active medical orders in the patient’s medical record. The physician, nurse practitioner (NP), or physician assistant (PA) must accurately and legibly complete the form and then sign and date it. The physician, NP, or PA shall select only 1 choice in Section 1 and only 1 choice in any of the other Sections that apply to this patient. If any of Sections 2-9 do not apply, leave them blank. A copy or the original of every completed MOLST form must be given to the patient or authorized decision maker within 48 hours of completion of the form or sooner if the patient is discharged or transferred.

CERTIFICATION FOR THE BASIS OF THESE ORDERS:

Mark any and all that apply.

I hereby certify that these orders are entered as a result of a discussion with and the informed consent of: the patient; or the patient’s health care agent as named in the patient’s advance directive; or the patient’s guardian of the person as per the authority granted by a court order; or the patient’s surrogate as per the authority granted by the Heath Care Decisions Act; or if the patient is a minor, the patient’s legal guardian or another legally authorized adult. Or, I hereby certify that these orders are based on: instructions in the patient’s advance directive; or other legal authority in accordance with all provisions of the Health Care Decisions Act All supporting documentation must be contained in the patient’s medical records.

________ Mark this line if the patient or authorized decision maker declines to discuss or is unable to make a decision about these treatments The patient’s or authorized decision maker’s participation in the preparation of the MOLST form is always voluntary. If the patient or authorized decision maker has not limited care, except as otherwise provided by law, CPR will be attempted and other treatments will be given.

CPR (RESUSCITATION) STATUS: EMS providers must follow the Maryland Medical Protocols for EMS Providers

_____ Attempt CPR: If cardiac and/or pulmonary arrest occurs, attempt cardiopulmonary resuscitation (CPR). This will include any and all medical efforts that are indicated during arrest, including artificial ventilation and efforts to restore and/or stabilize cardiopulmonary function.

[If the patient or authorized decision maker does not or cannot make any selection regarding CPR status, mark this option. Exceptions: If a valid advance directive declines CPR, CPR is medically ineffective, or there is some other legal basis for not attempting CPR, mark one of the “No CPR” options below.]

No CPR, Option A, Comprehensive Efforts to Prevent Arrest: Prior to arrest, administer all medications needed to stabilize the patient. If cardiac and/or pulmonary arrest occurs, do not attempt resuscitation (No CPR). Allow death to occur naturally.

Option A-1, Intubate: Comprehensive efforts may include intubation and artificial ventilation.

Option A-2, Do Not Intubate (DNI): Comprehensive efforts may include limited ventilatory support by CPAP or BiPAP, but do not intubate.

_______

No CPR, Option B, Palliative and Supportive Care: Prior to arrest, provide passive oxygen for comfort and control any external bleeding. Prior to arrest, provide medications for pain relief as needed, but no other medications. Do not intubate or use CPAP or BiPAP. If cardiac and/or pulmonary arrest occurs, do not attempt resuscitation (No CPR). Allow death to occur naturally.

3

ARTIFICIAL VENTILATION

2a. _______ May use intubation and artificial ventilation indefinitely, if medically indicated.

2b. _______ May use intubation and artificial ventilation as a limited therapeutic trial.

Orders in Sections 2-9 below do not apply to EMS providers and are for situations other than cardiopulmonary arrest. Only complete applicable items in Sections 2 through 8, and only select one choice per applicable Section. 2

Time limit________________________________________________

2c. _______ May use only CPAP or BiPAP for artificial ventilation, as medically indicated.

Time limit______________________________________________________________________

2d. _______ Do not use any artificial ventilation (no intubation, CPAP or BiPAP).

BLOOD TRANSFUSION

3a. May give any blood product (whole blood, packed red blood cells, plasma or platelets) that is medically indicated.

HOSPITAL TRANSFER

3b. Do not give any blood products.

4

4a. _______ Transfer to hospital for any situation requiring hospital-level care.

MEDICAL WORKUP

5

5a. _______ May perform any medical tests indicated to diagnose and/or treat a medical condition.

4b. _______ Transfer to hospital for severe pain or severe symptoms that cannot be controlled otherwise.

4c. _______ Do not transfer to hospital, but treat with options available outside the hospital.

5b. _______ Only perform limited medical tests necessary for symptomatic treatment or comfort.

ANTIBIOTICS

6a. _______ May use antibiotics (oral, intravenous or intramuscular) as medically indicated.

5c. _______ Do not perform any medical tests for diagnosis or treatment. 6

6b. _______ May use oral antibiotics when medically indicated, but do not give intravenous or intramuscular antibiotics.

6c. _______ May use oral antibiotics only when indicated for symptom relief or comfort.

ARTIFICIALLY ADMINISTERED FLUIDS AND NUTRITION

7a. _______ May give artificially administered fluids

6d. _______ Do not treat with antibiotics. 7

7c. _______ May give fluids for artificial hydration and nutrition, even indefinitely, if medically as a therapeutic trial, but do not give indicated. artificially administered nutrition.

7b. _______ May give artificially administered fluids and Time limit_________________ nutrition, if medically indicated, as a trial.

DIALYSIS

8b. _______ May give dialysis for a limited period.

_______ Do not provide artificially administered Time limit__________________________ fluids or nutrition. 8

8a. _______ May give chronic dialysis for end-stage Time limit_________________________ kidney disease if medically indicated.

OTHER ORDERS

_______ Do not provide acute or chronic dialysis.

SIGNATURE OF PHYSICIAN, NURSE PRACTITIONER, OR PHYSICIAN ASSISTANT (Signature and date are required to validate order)

INSTRUCTIONS

Completing the Form: The physician, NP, or PA shall select only 1 choice in Section 1 and only 1 choice in any of the other Sections that apply to this patient. If any of Sections 2-9 do not apply, leave them blank. Use Section 9 to document any other orders related to life-sustaining treatments. The order form is not valid until a physician, NP, or PA signs and dates it. Each page that contains orders must be signed and dated. A copy or the original of every completed MOLST form must be given to a competent patient or authorized decision maker within 48 hours of completion of the form or sooner if the patient is discharged or transferred.

Selecting CPR (Resuscitation) Status: EMS Option A-1 – Intubate, Option A-2 – Do Not Intubate, and Option B include a set of medical interventions. You cannot alter the set of interventions associated with any of these options and cannot override or alter the interventions with orders in Section 9.

No-CPR Option A: Comprehensive Efforts to Prevent Cardiac and/or Respiratory Arrest / DNR if Arrest – No CPR. This choice may be made either with or without intubation as a treatment option. Prior to arrest, all interventions allowed under The Maryland Medical Protocols for EMS Providers. Depending on the choice, intubation may or may not be utilized to try to prevent arrest. Otherwise, CPAP or BiPAP will be the only devices used for ventilatory assistance. In all cases, comfort measures will also be provided. No CPR if arrest occurs.

No-CPR Option B: Supportive Care Prior to Cardiac and/or Respiratory Arrest. DNR if Arrest Occurs – No CPR. Prior to arrest, interventions may include opening the airway by non-invasive means, providing passive oxygen, controlling external bleeding, positioning and other comfort measures, splinting, pain medications by orders obtained from a physician (e.g., by phone or electronically), and transport as appropriate. No CPR if arrest occurs.

The DNR A-1, DNR A-2 (DNI) and DNR B options will be authorized by this original order form, a copy or a fax of this form, or a bracelet or necklace with the DNR emblem. EMS providers or medical personnel who see these orders are to provide care in accordance with these orders and the applicable Maryland Medical Protocols for EMS Providers. Unless a subsequent order relating to resuscitation has been issued or unless the health care provider reasonably believes a DNR order has been revoked, every health care provider, facility, and program shall provide, withhold, or withdraw treatment according to these orders in case of a patient’s impending cardiac or respiratory arrest.

Location of Form: The original or a copy of this form shall accompany patients when transferred or discharged from a facility or program. Health care facilities and programs shall maintain this order form (or a copy of it) with other active medical orders or in a section designated for MOLST and related documents in the patient’s active medical record. At the patient’s home, this form should be kept in a safe and readily available place and retrieved for responding EMS and health care providers before their arrival . The original, a copy, and a faxed MOLST form are all valid orders. There is no expiration date for the MOLST or EMS DNR orders in Maryland.

Reviewing the Form: These medical orders are based on this individual’s current medical condition and wishes. Patients, their authorized decision makers and attending physicians, NPs, or PAs shall review and update, if appropriate, the MOLST orders annually and whenever the patient is transferred between health care facilities or programs, is discharged, has a substantial change in health status, loses capacity to make health care decisions, or changes his or her wishes.

Updating the Form: The MOLST form shall be voided and a new MOLST form prepared when there is a change to any of the orders. If modified, the physician, NP, or PA shall void the old form and complete, sign, and date a new MOLST form.

Voiding the Form: To void this medical order form, the physician, NP, or PA shall draw a diagonal line through the sheet, write “VOID” in large letters across the page, and sign and date below the line. A nurse may take a verbal order from a physician, NP, or PA to void the MOLST order form. Keep the voided order form in the patient’s active or archived medical record.

Revoking the Form’s DNR Order: In an emergency situation involving EMS providers, the DNR order in Section 1 may be revoked at any time by a competent patient’s request for resuscitation made directly to responding EMS providers .

Bracelets and Necklaces: If desired, complete the paper form at the bottom of this page, cut out the bracelet portion below, and place it in a protective cover to wear around the wrist or neck or pinned to clothing. If a metal bracelet or necklace is desired, contact Medic Alert at 1-800-432-5378. Medic Alert requires a copy of this order along with an application to process the request.

How to Obtain This Form: Call 410-706-4367 or go to marylandmolst.org

Use of an EMS DNR bracelet is OPTIONAL and at the discretion of the patient or authorized decision maker. Print legibly, have physician, NP, or PA sign, cut off strip, fold, and insert in bracelet or necklace.

HOME USE AND DISPOSAL OF CONTROLLED SUBSTANCES AND OTHER PRESCRIBED MEDICATIONS

Policy No. 3-005.1

PURPOSE

To ensure the appropriate use and disposal of controlled substances and other prescribed medications, in accordance with applicable state and federal regulations.

POLICY

Hospice of the Chesapeake and Affiliates voluntarily adhere to a controlled drug reporting and disposal process for all prescribed medications.

Note: This policy is applicable to sample medications if utilized.

PROCEDURE

1. Controlled substances and other prescribed medications will be distributed directly to the patient or his/her representative. (See “List of Controlled Substances Available” Addendum 3005.A.) The interdisciplinary group will be responsible for monitoring the amount of drug issued and the length of time between renewals.

2. The Admitting Nurse/Case Manager will provide a copy of the written policies and procedures on the management and disposal of controlled drugs and other prescribed medications to the patient/representative and family. The Admitting Nurse/Case Manager will verbally discuss this policy in a language and manner that they understand to ensure the safe use and disposal of controlled drugs.

3. The Admitting Nurse/Case Manager will obtain written authorization for disposal of prescription medications at the time hospice enrollment begins and document the authorization in the patient’s plan of care. If authorization for disposal is refused, the name of the patient/representative refusing will be documented in the medical record and additional education related to medication safety and disposal will be provided.

4. The Admitting Nurse/Case Manager will outline an informal documentation procedure for the patient and family/caregiver when hospice personnel are not present in the home, when necessary.

5. In cases where hospice personnel are in the home 24 hours a day, a drug count will be made by licensed personnel at the time of shift change.

A. Controlled drugs will be accounted for on a narcotic count record, which will be maintained as a part of the clinical record.

6. When a hospice patient no longer has a need for a prescribed medication, the Case Manager will instruct the patient and family/caregiver regarding proper disposal of the drugs in accordance with federal, state, and local law/regulation. The Case Manager will also provide information on take-back and mail-back programs.

7. The Admitting Nurse/Case Manager will document in the clinical record that the patient and family/caregiver were given the written policy and procedure for managing prescribed medications and discussed the disposal of medications and they took responsibility for proper disposal of all medications.

8. The hospice nurse, social worker, or chaplain attending the death of a hospice patient (not residing in a nursing home, assisted living facility, or GIP setting) will inform the family/caregivers of their responsibility to dispose of all the patient's prescribed medications and will document this instruction in the medical record (assessment or a clinical note).

9. The medications will be collected and disposed of:

i. in the location where hospice services were delivered

ii. according to EPA and FDA guidelines

iii. under the witness of the patient/ patient representative, another hospice employee or a local law enforcement officer

10. The following must be documented in the medical record:

i. The name and quantity of each unused medication

ii. The date of the disposal

iii. Name of individual authorizing the disposal and their relationship to the patient

iv. The name of the witness

11. If the patient/caregiver refuses disposal, hospice employee will urge the representative to dispose of the medication providing verbal instruction. The hospice employee will also document the name of the patient/ patient representative refusing disposal and the name and quantity of the medication not surrendered will be documented in the medical record.

IF YOUR LOVED ONE HAS PASSED AWAY, PLEASE CONTACT OUR 24 HOUR CARE NUMBER 1-877-462-1102

Please note: Hospice of the Chesapeake is now an umbrella care organization that includes our affiliates Calvert Hospice and Hospice of Charles County. You can reach or may hear from team members from any of these organizations. Rest assured all team members can assist you equally.

MEDICATION SAFETY

TAKE ALL MEDICATION EXACTLY AS PRESCRIBED

1.

HOW TO DISPOSE OF MEDICINE

1-2-3

DISPOSE OF MEDICATIONS AT HOME:

Place pills in a sealable container, such as a plastic bag, add warm water to dissolve. Mix with coffee grounds, sawdust, kitty litter, dirt, etc.

KEEP OUT OF REACH OF CHILDREN OR PERSONS WITH IMPAIRED JUDGMENT

Contact your Hospice of the Chesapeake Nurse. They will assist you in disposing of medication you no longer need.

KEEP INVENTORY OF ALL MEDICINE

Controlled substances should be disposed of quickly (see the list on FDA’s website)

STORE ALL MEDICINE IN A COOL, DRY SECURE PLACE MEDICATIONS STORED IN A REFRIGERATOR SHOULD BE LABELED AND AWAY FROM FOOD ITEMS

2.

DISPOSE OF UNNEEDED OR EXPIRED MEDICINE

Find a “take back” site and bring all medications to this site (these can be set up in various places such as state police, sheriff departments and local pharmacies)

Seal the bag and dispose Remove identifying information from empty medicine container.

DO NOT FLUSH

so medications do not pollute our water supply.

Proper disposal of these medications prevents drug abuse, accidental ingestion, or unsafe sharing of prescribed medications.

Hospice of the Chesapeake and Affiliates Wash Your Hands

Keeping hands clean is one of the best ways to prevent the spread of infection and illness.

Handwashing is easy to do and it's one of the most effective ways to prevent the spread of many types of infection and illness in all settings from your home and workplace to child care facilities and hospitals Clean hands can stop germs from spreading from one person to another and throughout an entire community.

Learn more about when and how to wash your hands.

When should you wash your hands?

Before, during, and after preparing food

Before eating food

Before and after caring for someone who is sick

Before and after treating a cut or wound

After using the toilet

After changing diapers or cleaning up a child who has used the toilet

After blowing your nose, coughing, or sneezing

After touching an animal, animal feed, or animal waste

After touching garbage

What is the right way to wash your hands?

Wet your hands with clean, running water (warm or cold), turn off the tap, and apply soap.

Lather your hands by rubbing them together with the soap. Be sure to lather the backs of your hands, between your fingers, and under your nails.

Scrub your hands for at least 20 seconds. Need a timer? Hum the "Happy Birthday" song from beginning to end twice.

Rinse your hands well under clean, running water. Dry your hands using a clean towel or air dry them.

What should you do if you don't have soap and clean, running water?

Washing hands with soap and water is the best way to reduce the number of microbes on them in most situations. If soap and water are not available, use an alcohol-based hand sanitizer that contains at least 60% alcohol. Alcohol-based hand sanitizers can quickly reduce the number of microbes on hands in some situations, but sanitizers do not eliminate all types of germs.

Hand sanitizers may not be as effective when hands are visibly dirty or greasy. How do you

use hand sanitizers?

Apply the product to the palm of one hand (read the label to learn the correct amount). Rub your hands together.

Rub the product over all surfaces of your hands and fingers until your hands are dry.

Why? Read the science behind the recommendations

For more information on handwashing, please visit CDC's Handwashing website You can also call 1-800-CDCINFO or contact CDC-INFO for answers to specific questions.

Coughing & Sneezing

Hand Hygiene etiquette involves practices that prevent the spread of illness and disease. A critical time to practice good hygiene etiquette is when you are sick or when you are caring for a sick family member. Serious respiratory illnesses are spread by:

Coughing or sneezing

Unclean hands

Touching your face after touching contaminated objects

Touching objects after contaminating your hands

To help stop the spread of germs:

Cover your mouth and nose with a tissue when you cough or sneeze. Put your used tissue in a waste basket.

If you don't have a tissue, cough or sneeze into your upper sleeve, not your hands.

Remember to wash your hands after coughing or sneezing:

Wash with soap and water, or Keeping hands clean through improved hand hygiene is one of the most important steps we can take to avoid getting sick and spreading germs to others. Many diseases and conditions are spread by not washing hands with soap and clean, running water. If clean, running water is not accessible, as is common in many parts of the world, use soap and available water. If soap and water are unavailable, use an alcohol-based hand sanitizer that contains at least 60% alcohol to clean hands.

Cough etiquette is especially important for infection control measures when caring for a sick family member. It is important to protect their health and yours!

More information on respiratory hygiene and cough etiquette in healthcare settings may be found on CDC’s seasonal flu pages.

One final practice that helps prevent the spread of respiratory disease is avoiding close contact with people who are sick. If you are ill, you should try to distance yourself from others, so you do not spread your germs. Distancing includes staying home from work or school when possible.

For more information on stopping the spread of germs, please visit CDC’s Good Health Habits for Preventing Seasonal Flu pages.

Please note Hospice of the Chesapeake is now an umbrella care organization that includes our affiliates Calvert Hospice and Hospice of Charles County. You can reach or may hear from team members from any of these organizations. Rest assured all team members can assist you equally.

TEACHING TOOL: THE HOSPICE STARTER KIT

Before the first use of a medication, call Hospice of the Chesapeake at:

1-877-462-1102

24 Hours a Day, 7 Days a Week

Tell the nurse:

• The symptom

• When the patient last received pain or anxiety medication

CONTENT AND PURPOSE OF STARTER KIT:

Morphine Sulfate (Roxanol) liquid is used for pain and shortness of breath.

DO NOT GIVE WITHOUT SPEAKING TO A HOSPICE NURSE FIRST

Lorazepam (Ativan) tabs are used for anxiety, agitation and/or shortness of breath. DO NOT GIVE WITHOUT SPEAKING TO A HOSPICE NURSE FIRST

Haldol (Haloperidol) liquid is used for nausea/vomiting and agitation. DO NOT GIVE WITHOUT SPEAKING TO A HOSPICE NURSE FIRST

Hyoscyamine tablets to be given under the tongue are used for excess oral secretions. DO NOT GIVE WITHOUT SPEAKING TO A HOSPICE NURSE FIRST

Acetaminophen (Tylenol) suppositories are used for fever. DO NOT GIVE WITHOUT SPEAKING TO A HOSPICE NURSE FIRST

Prochlorperazine tablets are used for nausea and vomiting. DO NOT GIVE WITHOUT SPEAKING TO A HOSPICE NURSE FIRST

Bisacodyl suppositories are used for constipation. DO NOT GIVE WITHOUT SPEAKING TO A HOSPICE NURSE FIRST

Be Red Cross Ready

It’s important to prepare for possible disasters and other emergencies. Natural and humancaused disasters can strike suddenly, at any time and anywhere. There are three actions everyone can take that can help make a difference …

Be Red Cross Ready Checklist

❏ I know what emergencies or disasters are most likely to occur in my community

❏ I have a family disaster plan and have practiced it

❏ I have an emergency preparedness kit

❏ At least one member of my household is trained in first aid and CPR/AED

❏ I have taken action to help my community prepare

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

• Water one gallon per person, per day (3-day supply for evacuation, 2-week supply for home)

• Food non-perishable, easy-to-prepare items (3-day supply for evacuation, 2-week supply for home)

• Flashlight

• Battery-powered or hand-crank radio (NOAA Weather Radio, if possible)

• Extra batteries

❐ Meet with your family or household members

❐ Discuss how to prepare and respond to emergencies that are most likely to happen where you live, learn, work and play

❐ Identify responsibilities for each member of your household and plan to work together as a team

❐ If a family member is in the military, plan how you would respond if they were deployed

Learn what disasters or emergencies may occur in your area These events can range from those affecting only you and your family, like a home fire or medical emergency, to those affecting your entire community, like an earthquake or flood

❐ Identify how local authorities will notify you during a disaster and how you will get information, whether through local radio, TV or NOAA Weather Radio stations or channels

• Medications (7-day supply) and medical items

• First aid kit

• 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

Consider the needs of all family members and add supplies to your kit Suggested items to help meet additional needs are:

• Medical supplies (hearing aids with extra batteries, glasses, contact lenses, syringes, cane)

• Baby supplies (bottles, formula, baby food, diapers)

• Games and activities for children

• Pet supplies (collar, leash, ID, food, carrier, bowl)

•

• Two-way radios

Extra set of car keys and house keys

• Manual can opener

Additional supplies to keep at home or in your kit based on the types of disasters common to your area:

• Whistle

• N95 or surgical masks

•

Plan what to do in case you are separated during an emergency

❐ Choose two places to meet:

• Right outside your home in case of a sudden emergency, such as a fire

• Outside your neighborhood, in case you cannot return home or are asked to evacuate

❐ Choose an out-of-area emergency contact person It may be easier to text or call long distance if local phone lines are overloaded or out of service Everyone should have emergency contact information in writing or programmed into their cell phones

Plan what to do if you have to evacuate

❐ Decide where you would go and what route you would take to get there You may choose to go to a hotel/motel, stay with friends or relatives in a safe location or go to an evacuation shelter if necessary

❐ Know the difference between different weather alerts such as watches and warnings and what actions to take in each

❐ Know what actions to take to protect yourself during disasters that may occur in areas where you travel or have moved recently For example, if you travel to a place where earthquakes are common and you are not familiar with them, make sure you know what to do to protect yourself should one occur

❐ When a major disaster occurs, your community can change in an instant Loved ones may be hurt and emergency response is likely to be delayed Make sure that at least one member of your household is trained in first aid and CPR and knows how to use an automated external defibrillator (AED) This training is useful in many emergency situations.

❐ Share what you have learned with your family, household and neighbors and encourage them to be informed.

Emergency Contact Cards for All Household Members

Matches

• Rain gear

• Towels

• Work gloves

• Tools/supplies for securing your home

• Extra clothing, hat and sturdy shoes

• Plastic sheeting

• Duct tape

• Scissors

•

❐ Practice evacuating your home twice a year Drive your planned evacuation route and plot alternate routes on your map in case roads are impassable

Get your cards online at http://www.redcross.org /prepare/ ECCard.pdf

❐ Print one card for each family member.

Household liquid bleach

• Entertainment items

• Blankets or sleeping bags

❐ Plan ahead for your pets. Keep a phone list of pet-friendly hotels/motels and animal shelters that are along your evacuation routes

Let Your Family Know You’re Safe

Tell your loved ones about the American Red Cross Safe and Well Web site available through RedCross org This Internet-based tool should be integrated into your emergency communications plan People within a disaster-affected area can register themselves as “safe and well” and concerned family and friends who know the person ’ s phone number or address can search for messages posted by those who self-register If you don’t have Internet access, call 1-866-GET-INFO to register yourself and your family

❐ Write the contact information for each household member, such as work, school and cell phone numbers.

❐ Fold the card so it fits in your pocket, wallet or purse

❐ Carry the card with you so it is available in the event of a disaster or other emergency

Please note Hospice of the Chesapeake is now an umbrella care organization that includes our affiliates Calvert Hospice and Hospice of Charles County. You can reach or may hear from team members from any of these organizations. Rest assured all team members can assist you equally.

REMINDER

Now that you or your loved one are being cared for by our care team, please call us for all your care needs including:

• if it is an emergency

• if you are out of or running low on medications that we ordered

• if you need supplies or equipment

• general questions about the care we provide to you or visit questions

Our trained team is available and ready to assist you 24-hours per day, 7-days per week including holidays, please call us at:

1-877-462-1102

Please note that reaching out to your care team directly by cellphone, leaving messages or texting will result in significant delays. Calling our care team hotline at the number above will connect you immediately with a support team member who will assist you and get the resources you need quickly.

Patient Specific Emergency Plan

While we make every effort to provide the services needed, I understand that there may be emergency situations that arise when my home care provider may not be able to safely travel to my home or I may need to evacuate. I understand I need to be prepared in this event with an emergency plan

Patient Name: Patient ID# ___________

Date Form Completed: ________________

 Patient resides in a facility with an active emergency preparedness plan

IMPORTANT CONTACTS

CONTACT

Emergency Support: this is the person who will be available to help me in case an emergency prevents my home care provider from coming to my home

Emergency Contact: this is the person to call if my home care provider is unable to contact me.

Out-of-Town Contact: this is the person to contact if there has been a community-wide disaster, and I may need to relocate out of the area.

Name:

Phone:

Name: Phone:

Name:

Address:

NAME/PHONE NUMBER

During a disaster I plan to:

Phone:

 Stay with a relative / friend in the area: (who/where)

 Stay at home

 Stay with a relative/ friend out of the area: (who/where)

 Go to a shelter located at:

In case of hurricane, tornado, high wind events: I can safely relocate to: (basement, inner room away from windows, etc.)

In case of bad weather or flooding: if you can’t get out and others can’t get to you:

 Maintain a 7-day supply of all needed medications

 Maintain a 7-day supply of food

 Other:_

 I have Oxygen or other respiratory devices:

In case of prolonged power outage, I will:

• Change to portable Oxygen tanks

• Contact the Electric company to determine timeframe of outage

• Contact my O2 supplier (or Hospice) if I do not have enough portable Oxygen to last until expected power return

Supplier name / number

• Relocate to somewhere with electrical power if unable to continue to function without power.

• Go to the emergency department if my oxygen runs out (or “if my oxygen is about to run out”)

In case of prolonged power outage, I will:

 I have other electrical medical devices

• Move devices to emergency battery power as possible

• Make sure back up batteries are available and charged.

 My safe evacuation route is: _

 Contact your home health or hospice agency with your new location as soon as possible

 I have equipment I need (Oxygen, IV pump, enteral pump etc.)

In case I need to evacuate my home:

• Use portable equipment or equipment on batteries during transport as needed

 I have wound care or other supplies I need on a regular basis

• Create an emergency supply kit with wound care supplies.

 Other