Ga. Medicaid Part II Policies & Procedures for Hospice Services, Appendix H

The Patient Self Determination Act as enacted by the Omnibus Budget Reconciliation Act of 1990 (Sections 4206 and

4751) mandates that effective December 1, 1991, Medicare and Medicaid certified hospitals, nursing facilities, hospices,

and providers of home health care or personal care services give adult patients information about their right to make

decisions concerning medical care. This includes the right to formulate advance directives such as a living will or

durable power of attorney for health care.

A. Definitions:

“Advance Directive” means written instruction, such as a durable power of attorney for health care, or a

living will, recognized under applicable state law, and relating to the provision of health care to an individual

when the individual is no longer able to make such decisions.

“Durable Power of Attorney” means an advance directive, recognized under applicable state law, by which

an individual designates and the person to make medical care decisions about his or her treatment in the event

the individual is no longer able to make such decisions.

“Living Will” means an advance directive, recognized under applicable state law, by which individual

expresses, in advance, his or her wishes regarding medical treatment in the event the individual is no longer

able to make such decisions.

B. Agreement:

As a condition of participation in the Georgia Medical Assistance (Medicaid) program,

__________________________________________________________________________________ agrees

to:

i. Provide written information to all adult individuals (ages 18 years and older) about their

rights under Georgia State law to make health care decisions, including the right to accept or

refuse treatment and the right to execute advance directives. The written information

required by the law must be given out by hospitals at the time of the individual’s admission

as an inpatient; by nursing facilities when the individual is admitted as a resident; by a

provider of home health or personal care services in advance of the adult individual receiving

care; and by hospices at the time if initial receipt of hospice care.

ii. Maintain written policies and procedures with respect to advance directives and provide

written information to patients and residents about the facility’s policy on implementing

advance directives.

iii. Document in the individual’s medical record whether the individual has executed an advance

directive. If the individual has executed a document for advance directives, a copy of the

document of the advance directive must be included in the individual’s medical record.

iv. Not discriminate against an individual based on whether that individual has executed an

advance directive.

v. Ensure compliance with requirements of Georgia State law.

vi. Provide for educating staff and the community on advance directives. (As long as education

campaigns are conducted, this requirement is met. This can be accomplished by newsletters,

articles in the local newspapers, local news reports, or commercials.)

vii. Provide appropriate forms to members, residents or clients upon request.

viii. Communicate advance directives verbally and in writing in case of the transfer of the

individual within or between agencies/facilities, or between the individual’s home and

agencies/facilities.

_______________________________________

Signature of Authorized Official

_______________________________________

Print or Type Name

_______________________________________

Title

_______________________________________

Name of Provider

_______________________________________

Date Signed