Assessment Form

5870 Faringdon Place #2 Raleigh, NC 27609
Office Hours: 9:00am-4:00pm
Office Phone: (919) 858-6618 (call first)
After Hours: (919) 637-9210

CONSENT FOR CARE/ SERVICES

I hereby consent and authorize the organization, its agent or associate to provide care and treatment to me at my home per program policy and/or as prescribed by my physician. A representative of the organization has explained my plan of care and all of my questions have been answered satisfactorily. I understand that the treatment plan may change, and if so, these changes will be discussed with me. I further understand that I and/or my family/caregiver will receive instructions to assist with my care and that my care will become my responsibility in the absence of the organization staff in my place of residence. I agree to notify my physician or others providing care of any adverse reactions or other significant events relating to my health.

RELEASE OF INFORMATION

I hereby consent to and authorize the organization to disclose and release information contained in my medical record to the healthcare providers involved in my care, third party payers, utilization review and professional standard review organizations, regulatory review entity, accreditation reviewers and other organizations, companies, community resources, etc. that may/will assist me to meet my home care and/or health needs.

LIABILTY FOR PAYMENT

I certify that all information given by me to the organization is correct to the best of my knowledge. I also understand that services provided to me by the organization will be billed to the following.

I request that payment to the authorized benefits on my behalf be made to the organization. I understand and agree to pay deductibles, copayment and any amount due after payment of benefit on my behalf by any and all third party payer.

ADVANCE DIRECTIVE FOR HEALTHCARE

I have received an explanation and written information regarding advance directives from the organization. I understand that it is the policy of the organization to respect individual choice and to avoid discrimination based on whether or not I have an advance directive.

RIGHTS AND RESPONSIBILITIES

I have received a copy and explanation of the patient right and responsibilities, which include information about how to use the organization's complain process and the state toll free hotline.

SAFETY AND INFECTION CONTROL

I have been informed about basic home safety, contacting the organization between visits (including after usual business hours), emergency/disaster planning related to a disruption in service, and infection control practices as appropriate to my care in the home. I understand that staff may provide ongoing instruction to me on these areas as needed.

This agreement is applicable only to this admission to this organization. I understand what I have read and what was explained to me and agree to the terms and conditions stated above. I also understand that either party may terminate the agreement at any time.

If applicable, the financial guarantor name must be the same as indicated on the insurance verification

Holiday/Overtime: all charges for service rendered on holidays or by the same individual, by my request, in excess of 40 hrs a work-week will be paid at one and a half times the applicable weekday or weekend rate.

Holidays affected are: New Year's Eve, New Year's Day, 4th of July, Labor Day, Memorial Day, Veteran's Day, Thanksgiving Day, Christmas Eve and Christmas Day.

Deposit: 1 agree to pay simultaneously with the signing of this agreement $_____________ in the form of Cash_____________ Check#_____________ or Credit Card type_____________ Card #_____________ Exp. Date_____________ as deposit for services to be rendered. This deposit will be applied to the first invoice of service.

Unanticipated service interruptions: I understand that Omega Healthcare Services uses reasonable effort to provide uninterrupted services, however, sometimes interruptions are unavoidable. During interruptions of essential service, I agree to provide arrangements for backup care or Omega Healthcare Services will assist in arranging for transfer to an appropriate emergency facility.

Time documents: I agree and acknowledge that the time slip record that the agency provides constitutes the basis for billing.

Equipment: I agree that any leased, loaned or rented equipment received by me from A1-Omega Healthcare Services for my treatment remains the property of Omega Healthcare Services. I agree to use and maintain the equipment as taught and per the manufacturer's guidelines and to return the equipment in good condition, no later than ten days upon completion of therapy or when I am no longer receiving services from Omega Healthcare Services. I understand that I will not lose the equipment and I will return it.

Hiring Omega Healthcare Service Employees: I understand that if I hire one of Omega Healthcare Services' employees, I must give notice or a pay fee. I also understand that I must give 60 (sixty) days notice, prior to hiring the individual, or pay 15% of the employee's annualized billing rate to Omega Healthcare Services.

Termination: I understand I may terminate this agreement by giving at least 4 (four) hours notice. Additionally, Omega Healthcare Services may terminate this agreement by providing at least 72 (seventy two) hours notice, or such other minimum notice required by applicable state law, except for emergency terminations necessitated to protect patient/staff safety or to comply with legal requirements. In the event of termination by either party, for any reason, the obligations contained in this document shall survive such termination: Services, charges, authorization for payment, payment, late fees, overtime rates, deposit, hiring one of our employees and authorization to release information.

A1-Omega Healthcare Services is NOT in the transportation business. Therefore, we are excluded from any liability for the accident that may arise as a result of the use of the Caregiver's (or your) vehicle.

It is not our duty to transport clients or run errands for them. However, if such is necessary, the arrangement will be between the aid and the client. So the client is solely responsible for any form of accident that may occur to property, bodily harm, or the death of the caregiver and the client as a result of transporting or running errands for the assigned client.

A1-Omega Healthcare Services and the Caregivers in this respect are released and are held harmless from any claim or cause of action, which you or those for whom you are responsible may have for bodily injury, including death or property damage arising out of the use of the vehicle by the Caregiver in connection with his/her assignment.

I have read, understand, and agree to the above release of liability.

Our agency representative will provide each client with a written notice of the client's rights and responsibilities in advance during the initial evaluation visit or immediately before the initiation of services.
As a client, you have the right to:

1. To participate in the development and future changes in his/her plan of care.
2. To be treated with respect, consideration, dignity, and full recognition of his or her individuality and right to privacy.
3. To receive care and services that are adequate, appropriate, and in compliance with relevant federal and State laws and rules and regulations.
4. To voice grievances about his or her care and not be subjected to discrimination or reprisal for doing so.
5. To have his or her personal medical records kept confidential and not be disclosed without appropriate written consent.
6. To be free of mental and physical abuse, neglect, and exploitation.
7. To receive a written statement of services provided by the agency and the charges the client is liable for paying.
8. To be informed of the process for acceptance and continuance of service and eligibility determination.
9. To accept or refuse service.
10. To be informed of the agency's on-call service.
11. To be informed of the supervisory accessibility and availability.
12. To be advised of the agency's procedures for discharge.
13. To receive a reasonable response to his or her requests of the agency.
14. To be notified within 10 days when the agency's license has been revoked, suspended, cancelled, annulled, withdrawn, recalled, or amended.
15. To be advised of the agency's policies regarding patient responsibilities.
16. To be provided a copy of the agency's policies regarding client responsibilities as it relates to safety and care plan compliance.
17. To be advised of the address and telephone number for information, questions, or complaints about services provided by the agency:
A1-Omega Healthcare Services, Inc
5870 Faringdon Place Ste. #2
Raleigh NC 27609
(919)-858-6618
18. Division of Health Service Regulation complaints hotline number:
Complaint Intake Unit
Division of Health Service Regulation
2711 Mail Service Center
Raleigh, NC 27699
800-624-3004 (Toll Free) (919) 855-4500 (Out of Town)
19. To be provided a copy of the declaration of home care clients' rights in advance care being furnished.
20. To expect that the agency shall investigate, within 72 hours, complaints made to the agency by a client or the client's family.

1. Client and/or family participate in the development of the Plan of Care and subsequent modifications.
2. Client/family is responsible for assisting in providing a safe, non-abusive environment.
3. Client/family has responsibility to notify A1-Omega Healthcare Services when scheduled visits cannot be kept.
4. Client/family is responsible for supplying accurate and complete information about the client's medical history.
5. Client/family is responsible for his/her actions if the Plan of Care is not observed.
6. Client/family is responsible for notifying A1-Omega Healthcare Services if they do not understand the instructions or if they cannot be followed.
7. Client/family has the responsibility to inform the agency of admission and discharge to any institution that conflicts with their care, scheduled or unscheduled.

A1-Omega Healthcare Services is required to maintain an Emergency Preparedness Plan designated to provide care and appropriate support to each client in the event of any kind of natural emergencies (IE: earthquakes, hurricanes, floods, tornadoes, snow or ice storms), in the event of any kind of "home disasters" (IE: fire or flooding), as well as medical emergencies. The primary responsibility is to get the client to safety.

In the event of any of the above-named disasters, please contact the On-Call Nursing Supervisor at: (919) 771-3429.

The agency's clients are categorized based on the following criteria, so help will be given based on the level of risk, determined at the time of assessment:

• Extremely ill – needing close observation by an RN.
• No caregiver at home.
• Requiring continuous licensed home care assistance with ADLs (care, bathing, turning and repositioning, transferring, meals, etc.).
• Terminally ill (IE: incontinent).
• Client has an acute or chronic illness requiring dependency on resources which may be endangered (IE: intermittent IV antibiotics, daily wound care, etc.), deemed as necessary and unable to be interrupted by the client's physician or nurse.

Based on these selective criteria, clients will be assigned a risk level appropriate for their level of care that is needed:

Who decides about my medical care or treatments?
If you are 18 yrs old or older and have the capacity to make and communicate health care decisions, you have the right to make decisions about your medical and mental health treatment. You should talk to your doctor or other health care provider about any treatment or procedures so that you understand what will be done and why. You have the right to say yes or no to treatments that are recommended by your doctor or mental health care provider. If you want to control decisions about your physical and mental health care, even if you become unable to make or express them yourself, you will need an “Advance Directive.”

What is an “Advance Directive”?
An Advance Directive is a set of directions that you give about the physical and mental health care that you want to receive, if you should ever lose the ability to make those decisions for yourself. North Carolina has three ways for you to make a formal Advance Directive:
1. Create a "Living Will"
2. Create a "Health Care Power of Attorney"
3. Create an "Advance Instruction for Mental Health Treatment"

Do I have to have an Advance Directive and what happens, if I don't?
Making a Living Will, a Health Care Power of Attorney, or an Advance Instruction for Mental Health Treatment is your choice. If you become unable to make your own decisions and you don't have any of those documents in place (or anyone named to make those decisions for you), your doctor or mental health care provider will consult with someone close to you about your care.

Living Will: What is a "Living Will"?
In North Carolina, a Living Will is a document that tells others that you want to die a natural death if you should become terminally ill, incurably sick, or are in a persistent vegetative state (from which you will not recover). In a Living Will, you can direct your doctor to NOT use heroic treatments that will delay your dying (IE: using a ventilator or respirator, etc.) or to STOP such treatments if they have already been started. You can also direct your doctor to NOT begin or STOP giving you food or water through a tube (IE: artificial nutrition or hydration).

Health Care Power of Attorney: What is a "Health Care Power of Attorney"?
In North Carolina, you can name a person to make medical and mental health care decisions for you if you later become unable to decide for yourself. This person is called your "Health Care Agent." In the legal document, you name who you want as your agent. You can say what medical and/or mental health treatments that you would want or NOT want provided. Your Health Care Agent then knows what choices to make on your behalf.

How should I choose a Health Care Provider?
You should choose an adult that you trust and have discussed your wishes before putting it all in writing.

Advance Instruction for Mental Health Treatment: What is an “Advance Instruction for Mental Health Treatment”?
In North Carolina, an Advance Instruction for Mental Health Treatment is a legal document that tells your doctors and Health Care Providers what treatments you would want or NOT provided if you should become unable to make those decisions for yourself. The designation of someone to make those decisions on your behalf must be established as part of a valid Health Care Power of Attorney.

How do I make an “Advance Directive”?
You must follow several rules when making any of these legal documents. These rules are made to protect you and ensure that your wishes are clear to the doctor or any other provider who may be asked to carry them out. They must all be written and signed by yourself while you're still able to understand your condition and the treatment choices you will want to be carried out. Two qualified people must witness all three types of Advance Directives. The Living Will and the Health Care Power of Attorney must be notarized.

Are there any forms I can use to make an Advance Directive?
Yes! There is a Living Will form, a Health Care Power of Attorney form, and an Advance Instruction for Mental Health Treatment form that you can use. These forms all meet the rules for a formal Advance Directive. Using the special forms is the best way to make sure that your wishes are carried out.

When does an Advance Directive go into effect?
A Living Will goes into effect when you are going to die soon and cannot be cured, or when you are in a persistent vegetative state. The powers granted by your Health Care Power of Attorney go into effect when your doctor states, in writing, that you are not able to make your own health care choices. (When you make a Health Care Power of Attorney document, you can name the doctor or your mental health care provider as your advocate.) The doctor will follow your instructions as listed in your documents.

What happens if I change my mind?
You can cancel your Living Will anytime by informing your doctor you want to cancel it and by destroying all copies of it. You can change your Health Care Power of Attorney while you are still able to make competent decisions by signing a revised document and telling your doctor (as well as your health care agent) of the change. You can cancel your Advance Instructions for Mental Health Treatment while you are still able to make those decisions by telling your doctor or other provider of your wishes to cancel it.

Whom should I talk to about an Advance Directive?
You should talk to those closest to you about an Advance Directive and your feelings about the health care that you would like to receive. Your doctor or health care provider can answer any of your medical questions that you may have. A lawyer can answer any questions about the North Carolina state laws that apply. You could even discuss the process with your respected clergy leaders or other trusted advisors.

Where should I keep my Advance Directive?
Keep a copy in a safe place where your family members can get to it. Give copies to your family, your doctor and/or mental health care provider, your Health Care Agent, and any close friends who might be asked about your care if you should become unable to make decisions for yourself.

What if I have an Advance Directive from another state?
An Advance Directive from another state may not meet all of North Carolina's rules. You may want to consult with your lawyer to review all of your current documents or update them to meet NC requirements.

Where can I get more information?
Your primary doctor or health care provider can tell you how to get more information.

This document was developed by the North Carolina Division of Medical Assistance in cooperation with the Department of Human Resources Advisory Panel on Advance Directives.