The mission of Addison County Home Health & Hospice, Inc., a nonprofit agency, is to provide high quality, comprehensive community health care to residents of Addison County. Quality patient care occurs through thoughtful, deliberate planning by clinicians using a well-defined body of knowledge and established standards of practice. Standards of practice are determined by Addison County Home Health & Hospice, Inc. and by each discipline's national professional organization.

In addition to excellence in clinical practice, the Agency is committed to maintaining full compliance with all applicable laws and regulations established by the state and federal government. As a healthcare provider, the Agency must meet the Conditions of Participation established by the federal government before providing services to and billing for Medicare and/or Medicaid patients. The reputation of the Agency since its inception in 1968 has been based upon honesty and integrity. It is the intent of Addison County Home Health & Hospice, Inc. to continue to maintain these values by holding all employees to the highest ethical standards.

While the Agency is small in size, the continued commitment to excellence and compliance remains central to the basic philosophy of the staff. In order to assist all individuals associated with the Agency, whether employees, members of the Board of Directors, contractors, or volunteers, the following Corporate Compliance Program is presented.

Leadership Statement

While all of the Agency staff are expected to follow the agency Code of Conduct, we expect our leaders to set the example and be a model in every aspect. Management will ensure that those they supervise have sufficient information to comply with laws, regulations and policies and are given the resources and support to resolve ethical dilemmas. They will help to create a culture within the Agency that promoted the highest standards of ethics and compliance that encourages everyone to share concerns should they arise.

The Corporate Compliance Program exists to provide all employees, associates and agents an understanding of the Agency's commitment to adhering to all federal and state laws and regulations. It also provides employees, associates and agents the means to help ensure the compliance to these laws and an understanding of the ramifications of violating the law.

The Addison County Home Health & Hospice Compliance Program Goals are as follows:

• Maintain a work environment in which honesty and integrity continue to be valued.
• Provide employees with appropriate information regarding compliance with state and federal laws and regulations.
• Provide a document, which outlines the components of the program and serves as a reference to all employees.
• Provide an open environment in which employees may raise compliance issues.
• Maintain and enhance effective audit systems.

A Corporate Compliance Program, as defined by the Office of the Inspector General (OIG), is a system of internal policies, controls and procedures that promotes adherence to statutes and regulations governing government health programs and minimizes the risk of civil and criminal penalties, or administrative sanctions.

As a patient of the Addison County Home Health & Hospice you have the right to considerate circumstances. Among your rights is the right to be competent care by qualified personnel, the right to be fully informed about your condition and the assurance that all details about your case are kept in strict confidence. Your rights include but are not limited to the following:

Informed Consent: You have the right to:

• Information on organization ownership and control.
• Information regarding liability upon request.
• Receive disclosure information regarding beneficial relationships, which may result in profit for the referring organization.
• Written notice of your rights before service is provided.
• Be given the information you need to give informed consent for treatment prior to your treatment being started and to consider use of alternative services which may be available to you.
• Receive written information about available services.
• Participate in the development of, and/or changes in your treatment plan and approve any procedure or treatment.
• Refuse treatment within the confines of the law and be informed of the consequences of such action.
• To formulate advance directives for the purpose of directing your health care in the event you are unable to make health care decisions.
• Information about the qualifications of the people responsible for your care.
• Be fully informed of agency policies and charges for services including information about the extent to which the services will be paid by Medicare, Medicaid or other sources and the extent to which payment will be required from you.
• To be informed of billing policies and payment procedures and of any changes in the information within 15 days from the date ACHH&H is informed.
• To be referred to another provider if your needs cannot be met or you are not satisfied with the care provided.

Privacy and Confidentiality: You have the right to:

• Expect that all communications and records pertaining to you are treated as confidential and that these records cannot be released unless approved in writing by you.
• Refuse observation by those not directly involved in your care.
• Expect that any discussion or consultation about your care be conducted discreetly and that individuals not involved will not be included without your permission.

(Your privacy rights are detailed in the Notice of Privacy Practices you receive from ACHH&H)

Access to Quality Service: You have the right to:

• Considerate and respectful care by qualified personnel.
• To have your property treated with respect.
• The most appropriate medical treatment available regardless of race, color, creed, sex, sexual orientation, age, national origin, religious beliefs, disability, marital status, ancestry, military status or the source of payment for your care.
• A careful assessment of nursing, therapy and social needs.
• A timely response to your request for service.
• Be informed within a reasonable time of anticipated transfer or termination of service.
• Not to be physically or mentally abused or exploited or neglected.
• Not be physically or chemically restrained unless the restraint is (1) necessary in an emergency to protect the patient or others from injury after the patient harms or threatens to harm herself or himself or another; or (2) legally authorized in writing by a physician for a limited and specified period of time.
• Not be discriminated against in the presence or absence of advance directives.
• Not be denied from communicating in your primary language if you are unable to communicate in English, to facilitate acquiring or providing any type of treatment, care or services.
• To be instructed and fully informed of continuing care needs upon discharge and participate in the selection of alternatives and referral process.

Problems: You have the right to:

• Terminate service at any time and to know the consequences of that action.
• Register complaints or concerns without fear of reprisal or discrimination (see the section of this manual entitled "IF YOU HAVE CONCERNS ABOUT YORU HEALTH CARE" for additional information and phone numbers).
• Have your complaint or concern documented and resolved.
• A fair hearing in which you can voice your complaint, grievance or action, demand an explanation about the care given and work out a solution to your problem.

Whenever there are rights, there are also responsibilities.

Patient's Responsibilities: In addition to your rights, you have the responsibility, within the limits of your abilities to:

• Provide accurate and complete information about your present complaints, past illnesses, medications and other matters relating to your health.
• Report unexpected changes in your condition.
• Indicate whether you clearly understand the plan of treatment and what is expected of you, follow your treatment plan.
• Provide the information necessary for insurance processing.
• Fulfill your financial commitment when there is an ability to pay.
• Inform the agency if a visit must be canceled, or if there is a change of physician.

Abuse, neglect and exploitation of a vulnerable adult is unlawful

Vermont State statute requires all health care practitioners to report adult or child abuse, neglect or exploitation. Abuse or exploitation may also be reported by a patient or a family member. State statutes provide immunity from liability or retribution when reporting abuse or neglect.

Abuse is defined as any action that threatens a vulnerable adult's physical or emotional health or welfare. Example: Unnecessary or unlawful restraint of a vulnerable adult.

Neglect is defined as purposeful or reckless failure of a caregiver to provide adequate care to a vulnerable adult.

Example: Failure to report a significant change in the health status of a vulnerable adult.

Exploitation is defined as the misuse of a vulnerable adult's money or property.

Example: Willfully using, withholding, transferring or disposing of funds or property of a vulnerable adult.

Individuals found guilty of abusing, neglecting, or exploiting a vulnerable adult can face a range of consequences, including:

• loss of employment
• loss of profession license
• fines up to $10,000 and/or a prison sentence up to 25 years

Reporting Suspected Abuse

To make a report, you may contact Sharon Thompson, Clinical Director, Addison County Home Health and Hospice, Inc. at 802-388-7259 and she will assist you in the process.

Reports may also be made to the State of Vermont Department of Disabilities, Aging and Independent Living (DAIL) by contacting the Division of Licensing and Protection, Adult Protective Services (APS) at 1-800-564-1612 or by writing to the division at 103 South Main Street, Ladd Building, Waterbury, VT 05671-2306.