Advance Directives and the Home Health Plan of Care

An advance directive is a document by which a person makes a provision for health care decisions in the event that, in the future, he/she becomes unable to make those decisions. Advance directives are centered on the principle of allowing a beneficiary the right to die and death with dignity. With an advance directive, you can express how much or how little you want done for you when you are no longer able to make these decisions. It may include, but is not limited to:

• A Living Will – a signed, witnessed (or notarized) document called a “declaration” or “directive.” Most declarations instruct health care providers to withhold or withdraw medical interventions from its signer if he/she is unable to make decisions about medical treatment
• Durable Power Of Attorney For Health Care – a signed, witnessed (or notarized) document in which the signer designates an agent to make health care decisions for the signer if the signer is temporarily or permanently unable to make such decisions
• Combination Advance Directive – a signed, witnessed document which contains specific written directions that are to be followed by a named agent

The CMS-3819-F Medicare and Medicaid Program: Conditions of Participation for Home Health Agencies Interpretive Guidelines §484.60(a)(2) state that information related to any advanced directives must be included in the beneficiary’s plan of care. This would be the initial plan of care and subsequent plans of care. Please become familiar with the laws as outlined for your states as the directives are applicable to all 50 states and the District of Columbia.

For more information:

Terms defined on the Patients Rights Council website
Advanced Directives at eMedicineHealth
§ 484.60 Condition of participation: Care planning, coordination of services, and quality of care