As a hospice patient, you have the right to be fully informed of your rights and responsibilities before the initiation of service. If/When a patient has been judged incompetent or at the patient’s request, the patient’s legal surrogate decision maker may exercise these rights as described below. Community Hospice will protect and promote your right to exercise these rights; you will not be subjected to discrimination or reprisal for exercising these rights.

Patient Rights

• To know Community Hospice’s mission and care and services provided directly or through contractual arrangement.
• The right to pain management and symptom control for conditions related to your terminal illness.
• To be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse of any kind, including injuries of unknown source, and misappropriation of patient property. Corporal punishment is prohibited.
• To be assured the personnel who provide care are qualified through education and experience to carry out the services for which they are responsible and to choose your attending physician.
• To be advised of what services are to be rendered and by what discipline (e.g. Registered Nurse, Chaplain, Social Worker, etc.) and the names and professional relationship of the staff who will see you.
• To exercise these rights and receive services appropriate to your needs and to expect Community Hospice to provide safe, professional care at the level of intensity needed, without unlawful restriction by reason of age, sex, race, creed, color, national origin, religion, economic status, educational background, ancestry, sexual orientation or marital status, source of payment for care or disability.
• To know the hours of care and service and how to obtain care or service after hours.
• To be informed of ownership and control of Community Hospice.
• To be fully informed by a physician of your medical condition, unless medically contraindicated. This includes information about your illness, the course of treatment and prognosis in terms you can understand.
• To participate in the planning of your medical treatment including pain and symptom management as well as to be involved in resolving dilemmas about your care, treatment and services. This includes the right to refuse treatment and services to the extent permitted by law and to be informed of the expected consequences of such refusal.
• To allow your family and other individuals to be involved in care, treatment and service decisions to the extent you desire and as allowed by law.
• To receive reasonable continuity of care, to know in advance the time and location of visits, and to receive reasonable responses to any reasonable request made for service.
• To be involved in the initial and ongoing development and implementation of your plan of care.
• To receive information regarding any beneficial relationship between Community Hospice and agencies that refers to us.
• To be informed of the goals of hospice and the interventions that support those goals. To be informed of the value and purpose of a technical procedure that will be performed, including information about the potential benefits and risks as well as who will perform the procedure.
• To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care for personal needs. Case discussion, consultation, examination and treatment are confidential and will be conducted discreetly. You have the right to be advised as to the reason for the presence of any individual.
• To have your cultural, psychosocial, spiritual and personal values, beliefs, and preferences respected.
• To receive considerate and respectful care and to have your property treated with respect.
• To have staff communicate in a language or form you can reasonably be expected to understand.
• To be assured confidential treatment of personal and clinical records, to have access to and approve or refuse their release to any individual outside the hospice, except in the case of transfer to another health facility, or as required by law, or third-party payment contract. For a complete list of your rights under the Health Information Portability and Accountability Act (HIPAA) Privacy Rule please read Community Hospice’s Notice of Privacy Practices.
• To request amendment to, and receive an accounting of disclosures regarding your own health information as permitted under applicable law.
• To be fully informed of services available through Community Hospice limitations on these services and of related charges, including any charges for services not covered under Title XVIII or XIX of the Social Security Act.
• To know the cost of services that will be billed to your insurance(s) and/or self (verbally and in writing).
• To be advised, in advance, of any change in treatment.
• To formulate an advanced directive to receive a copy of our policy and procedure regarding Advanced Directives, and be informed of Community Hospice’s policy on withholding resuscitative services and the withdrawal of life sustaining treatment. To refuse to participate in research, investigational or experimental studies or clinical trials without compromise to your access to care, treatment or services.
• To be informed of what to do in an emergency.
• To terminate hospice services even against the advice of physicians.
• To be informed of continuing health care requirements should you discharge from Community Hospice.
• To voice complaints/grievances about treatment or care that is (or fails to be) furnished, or regarding lack of respect for property by anyone who is furnishing services on behalf of Community Hospice, without retaliation or discrimination for same and to be informed of the procedure to voice complaints/grievances with Community Hospice. Complaints or questions may be registered with Community Hospice by phone, in person, or in writing Monday – Friday 8:00 a.m. – 4:30 p.m. Address and phone are: 4368 Spyres Way, Modesto, CA 95356-9259, (209) 578-6300. Community Hospice documents and investigates all complaints.
• To be informed of the State Hotline. The California Department of Public Health has a hotline for complaints or questions about Advanced Directives or local hospice organizations. The number is (800) 554-0351. The California Department of Public Health is located at 7170 North Financial Drive, Suite 110, Fresno, CA 93720. Complaints may be registered confidentially and without retaliation or discrimination in any manner for such complaint or question.
• To ask questions about Community Hospice or complain about our hospice to Community Health Accreditation Program (CHAP) 24 hours a day, seven days a week at (800) 656-9656.

Patient Responsibilities

• To provide, to the best of your knowledge, complete and accurate information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to your health.
• To report perceived risks in your care and unexpected changes in your condition.
• To provide feedback regarding hospice services, your needs and expectations, and ask questions regarding care or services.
• To inform Community Hospice when you will not be able to keep your hospice appointments.
• To treat Community Hospice staff and property with consideration and respect.
• To follow directions and Community Hospice’s policies and procedures concerning patient care and conduct.
• To sign the required consents and release for insurance billing and provide insurance and financial records as requested and to promptly meet any financial obligation agreed to with CHI.
• To inform Community Hospice of any problems or dissatisfaction with patient care.
• To notify Community Hospice of any changes in address, telephone number, or insurance/payment information.
• To remain under a doctor’s care while receiving hospice services.
• To inform Community Hospice of any advance directives or any changes in advance directives and to provide Community Hospice with a copy.
• To cooperate with your primary doctor, hospice staff and other caregivers.
• To obtain medications, supplies and equipment ordered by the patient’s physician, if they cannot be obtained or supplied by Community Hospice.
• To accept the consequences of any refusal of treatment or choice of non-compliance with the care plan.
• To have adequate resources/plans to provide for up to twenty-four (24)-hour care in the home should your condition warrant it.
• To provide a safe environment in which care can be given. In the event that conduct occurs such that the patient’s or staff’s welfare or safety is threatened, services may be terminated.

Notice of Privacy Practices

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 describes how Community Hospice, Inc. (“CHI”) and its employees, staff, volunteers, students and personnel may use or disclose your protected health information.

To obtain further information about matters covered in this notice or if you have any questions about this notice, please contact our Compliance Officer at:

Community Hospice, Inc.
4368 Spyres Way
Modesto, CA 95356
Attention: Compliance Officer
Phone: (209) 578-6300

COMMUNITY HOSPICE’S COMMITMENT TO PROTECTING THE CONFIDENTIALITY OF YOUR HEALTH INFORMATION

Community Hospice will, as required by law, abide by the terms of this notice and will provide this notice of our legal duties and privacy practices.

This notice applies to all of the medical records and information Community Hospice has about you, including information collected and gathered by Community Hospice as well as our volunteers and students. This notice does not, however, apply to other physicians, health care providers or third parties that have access to your personal medical information. For example, if you receive care from your personal physician for an ailment unrelated to your terminal illness, the medical information collected by your physician will not be governed by this notice. Instead, your personal doctor will have different policies or notices regarding his or her uses and disclosures of your medical information.

Community Hospice has established policies and procedures to guard against a breach of unsecured protected health information.  Community Hospice will, as required, notify all affected parties should a breach occur.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

The following categories describe different ways that Community Hospice may use and disclose medical information. Not every use or disclosure in a category will be listed. However, all of the ways Community Hospice is permitted to use and disclose information will fall within one of these categories.

For Treatment. Community Hospice may use medical information about you to provide you with hospice services. Community Hospice may disclose medical information about you to members of its interdisciplinary team, to pharmacists or to your personal physicians. Community Hospice may disclose medical information about you to people outside Community Hospice who are involved in your medical care, such as hospitals, nursing facilities, doctors, nurses, pharmacies, family members involved in your care or other persons or organizations involved in your treatment. For example, if you are experiencing discomfort, we may contact your personal physician to discuss modifications to your medication. If your doctor prescribes a new medication, we may contact your pharmacist to ensure that this medication will not cause undesired side effects or otherwise interfere with your other medications.

For Payment. Community Hospice may use and disclose medical information about you so that the hospice services we provide may be billed and payment collected. For example, Community Hospice may need to give your health plan information about services and supplies you have been prescribed and/or received from Community Hospice so your health plan will pay us for the provision of these services. Community Hospice may also disclose information about you to one of your other providers, including your personal physician, so that they may bill for the services they have or will provide to you.

For Health Care Operations. Community Hospice may use and disclose medical information about you for purposes of our health care operations. These uses and disclosures are necessary to run Community Hospice and to ensure that all patients receive quality care and benefit from the collective Community Hospice knowledge. For example, Community Hospice may use medical information to review our treatment and services and to evaluate the performance of our staff in responding to your needs. Community Hospice may also use medical information about our patients to ascertain how Community Hospice can improve the hospice services we provide, what services are most important or beneficial to you or what services may need to be improved.

Reminders. Community Hospice may use and disclose medical information to contact you as a reminder that you have an appointment scheduled or to tell you about treatment alternatives or other related benefits and services that may be of interest to you.

Hospice House Facility. If you receive care in Community Hospice’s inpatient facility, the Alexander Cohen Hospice House, CHI may disclose certain information about you – including your name and what room you are in.  Community Hospice may disclose this information to members of the clergy and to other people who ask for you by name. If you are admitted to the Hospice House, please inform us if you do not want this information shared.

As Required By Law. Community Hospice will disclose medical information about you when we are required to do so by federal, state or local law.  For example, Community Hospice may disclose medical information about you if you or another person in a protected group (child, dependent adult or elder) is the victim of abuse or neglect.  We will only make this disclosure when specifically required or authorized by law.

To Avert a Serious Threat to Health or Safety. Community Hospice may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

SPECIAL SITUATIONS

Marketing. Community Hospice may ask to feature you or your loved ones in our newsletter, in a video, or in some other publication we prepare to explain hospice services generally and the special role Community Hospice fills. We will never include your name, except for listing any memorial contributions made in your honor, or otherwise feature you or your loved ones in any of our newsletters, videos, or other publications without first obtaining your prior written authorization.

Fundraising. In an effort to raise funds and to support our charitable mission, Community Hospice, through Community Hospice Foundation, mails fundraising materials to individuals in our database. Basic contact information about you and your loved ones, such as names, addresses, and telephone numbers, may be included in our database. You may opt out of receiving fundraising materials at any time.  Community Hospice Foundation does not share its database information with any other entity or individual except as required by law.

Public Health Risks. Community Hospice may disclose medical information about you for public health activities. These activities generally include the following:

• To prevent or control disease, injury or disability;
• To report reactions to medications or problems with products;
• To notify people of recalls of products they may be using;
• To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; or
• To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. Community Hospice will only make this disclosure if you agree or when required or authorized by law.

In addition, Community Hospice may remove certain information that identifies you (such as name, address (other than zip code), social security number, etc.) from this set of medical information so others may use it for public health purposes without learning who the specific patients are; Community Hospice will obtain a written agreement from the recipient of your medical information that the recipient will only use the information for public health purposes.

Health Oversight Activities. Community Hospice may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Law Enforcement. Community Hospice may release medical information if asked to do so by a law enforcement official:

• In response to a court order, subpoena, warrant, summons or similar process;
• To identify or locate a suspect, fugitive, material witness, or missing person;
• About the victim of a crime if, under certain limited circumstances, Community Hospice is unable to obtain your agreement;
• About a death Community Hospice believes may be the result of criminal conduct;
• About criminal conduct at Community Hospice;
• In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime;
• To notify coroner, medical examiner and funeral director;
• For matters of national security and intelligence activities; or
• To law enforcement officials if you are an inmate of a correctional institution or under the custody of law enforcement.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

You have a number of rights regarding medical information that Community Hospice maintains about you.

Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes.

To inspect and copy medical information that may be used to make decisions about you, please submit your request in writing to Community Hospice at the address printed on the first page of this Notice. If you request a copy of the information, Community Hospice may charge a fee for the costs of copying, mailing or other services and supplies associated with your request.

We may deny your request to inspect and copy your medical information in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by Community Hospice will review your request and the denial. The person conducting the review will not be the person who denied your request. Community Hospice will comply with the outcome of the review.

Right to Amend. If you feel that medical information Community Hospice has about you is incorrect or incomplete, you may ask Community Hospice to amend the information. You have the right to request an amendment for as long as the information is kept by or for Community Hospice.

To request an amendment, please submit your request in writing to the address written on the first page of this Notice. This document should explain in detail the information you wish to have amended and the reason to support your request for amendment.

Community Hospice may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, Community Hospice may deny your request if you ask Community Hospice to amend information that:

• Was not created by Community Hospice;
• Is not part of the medical information kept by or for the Community Hospice;
• Is not part of the information which you would be permitted to inspect and copy; or
• Community Hospice believes the record is accurate and complete.

Right to Submit Addendum. If we deny your request to amend your medical record, you may submit a statement of disagreement or “addendum” to be added to your medical record indicating that you believe information in your medical record is incomplete or incorrect.

Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures” of information disclosed by Community Hospice in the six years prior to the date requested.  To request this list or accounting of disclosures, please submit your written request to Community Hospice at the address listed on the first or last page of this Notice. The first accounting of disclosures you request within a 12-month period will be free. For additional lists, Community Hospice may charge you for the costs of providing you with the accounting.

Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information Community Hospice uses or discloses about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information Community Hospice discloses about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you can ask that Community Hospice not use or disclose information about your terminal diagnosis or the basis of your hospice eligibility to a family member.

Community Hospice is not required to agree to your request. However, if Community Hospice does agree to your requested restriction, Community Hospice will comply with your request unless the information is needed to provide you emergency treatment.

You have the right to restrict disclosures of protected health information to a health plan if you have paid for these services in full out of your own pocket.

To request restrictions, please submit your request in writing to Community Hospice at the address printed on the first page of this Notice. Only the Compliance Officer of Community Hospice can approve this type of special restriction. In your request, you must tell Community Hospice:

• What information you want to limit;
• Whether you want to limit Community Hospice’s use, disclosure or both; and
• To whom you want the limits to apply (for example, disclosures to your children).

Right to Request Confidential Communications. You have the right to request that Community Hospice communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that Community Hospice only discuss your medical condition or information when specific individuals are out of the room.

To request these types of confidential communications, please submit your request in writing to Community Hospice at the address printed on the first page of this Notice. Only the Compliance Officer of Community Hospice can approve this type of special restriction. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice. You have the right to retain a copy of this notice. You may ask Community Hospice to give you a copy of this notice at any time. You may ask that Community Hospice provide you with a copy at the time you are first given the notice or you may call the contact person listed above at any later time to request such a copy.

CHANGES TO THIS NOTICE

Community Hospice reserves the right to change this notice. Community Hospice reserves the right to make the revised or changed notice effective for medical information we already have about you as well as any information we will receive in the future. You may request a copy of this notice or an update of this notice at any time.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with Community Hospice or with the Secretary of the U.S. Department of Health and Human Services (DHHS). All complaints must be submitted in writing. You will not be penalized for filing a complaint.

To file a complaint with Community Hospice, write to:

Community Hospice, Inc.
4368 Spyres Way
Modesto, CA 95356
Attention: Compliance Officer
Phone: (209) 578-6300

OTHER USES OF MEDICAL INFORMATION

Other uses and disclosures of medical information not covered by this notice or the laws that apply to Community Hospice will be made only with your written permission. If you provide Community Hospice permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, Community Hospice will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that Community Hospice is not able to take back any disclosures Community Hospice has already made with your permission, and that Community Hospice is required to retain our records of the services that Community Hospice provided to you.

EFFECTIVE DATE

This notice is effective 09/23/13.

Nondiscrimination Policy

Patient services are provided without regard to race, color, creed, age, gender, sexual orientation, handicap (physical or mental), and ability to pay or place of national origin.