Appendix
B ____YES ____No What types of services does the home care or hospice provide? Does it offer services for children? ____YES ____No How long has the home care or hospice been in business? ____YES ____No Does the home care or hospice accept payment from Medicare and Medicaid? Does it have a list of its fees and services? Can the home care or hospice help you find financial help if you need it? ____YES ____No How does the home care or hospice train and manage its staff? Does a supervisor come to the patient's home to review the care being given? Are the home care workers licensed and bonded? ____YES ____No Is the home care or hospice prepared in case of an emergency like a power failure or a natural disaster? Will it still be able to deliver the services you need? ____YES ____No Does the home care or hospice have volunteers who visit the patient at home? ____YES ____No Does an independent group like the Joint Commission on Accreditation of Healthcare Organizations review the home care or hospice? Accreditation means that the home care or hospice has met national standards for patient care and safety. ____YES ____No Will the home care or hospice create a care plan just for you or your loved one? You and your home care professional should agree on the services the patient will receive, how often the visits will take place, and how long treatment will last. ____YES ____No Does a nurse or therapist conduct an initial visit and review the type of care the patient needs at home? Are family members, doctors or other health care professionals involved in this review? ____YES ____No If medical equipment like a suction machine, oxygen or wheel chair is needed, will the home care or hospice teach the patient or responsible family members how to use the equipment in the home? ____YES ____No How often is medical equipment checked? Are replacements included? ____YES ____No Does the home care or hospice explain the patient's rights and responsibilities? Will you receive a copy of a “Patient Bill of Rights?” ____YES ____No Does the home care or hospice have a 24-hour telephone number you can call when you have questions or complaints? ____YES ____No Does the home care or hospice have a list of references, such as doctors and patients and their family members that you can contact? |