{"ref":"CA-HH-PR-02","title":"Advance Directives, POLST, and Do-Not-Resuscitate Orders","category":"Client rights","summary":"Sets the Agency’s written policies and procedures on advance directives (22 CCR §74743(c)(2)(B); 42 CFR §489.102): written information on California law (the Health Care Decisions Law, Probate Code Division 4.7) before care starts; asking about and recording advance health care directives, powers of attorney for health care, surrogates, POLST forms, and prehospital do-not-resuscitate forms; honoring them in the home; conscience objections; and never conditioning care on whether a patient has a directive.","inShort":["Give every adult patient the advance directive information before any care starts.","Ask if the patient has an advance directive, a POLST form, or a DNR form. Record the answer and ask for a copy.","Care never depends on whether the patient has a directive.","In an emergency, look for the POLST form. If it does not say no CPR, call 911 and start CPR if trained.","Never witness a patient’s advance directive and never pressure a patient to sign or change one.","If a patient says they want to change or cancel a directive, write it down and tell the nurse supervisor the same day."],"primaryCitation":"22 CCR §74743(c)(2)(B)","citations":["22 CCR §74743(c)(2)(B)","Cal. Prob. Code §4600 et seq.","Cal. Prob. Code §§4670-4743","Cal. Prob. Code §4673","Cal. Prob. Code §4674","Cal. Prob. Code §4695","Cal. Prob. Code §4701","Cal. Prob. Code §4711","Cal. Prob. Code §4712","Cal. Prob. Code §4731","Cal. Prob. Code §4734","Cal. Prob. Code §4736","Cal. Prob. Code §4780","Cal. Prob. Code §4781.2","Cal. Prob. Code §4781.4","Cal. Prob. Code §4782","Cal. Health & Safety Code §443.15"],"federalCitations":["42 CFR §489.102","42 CFR §484.50(a)","42 CFR §484.50(c)(4)","42 CFR §484.60(a)(2)(xv)"],"surveyorAsks":["Show me the written information on advance directives and California law that you gave this patient before care started.","Where in the record do you show whether the patient has an advance directive or a POLST form?"],"forms":[{"ref":"CA-HH-PR-02-A","title":"Advance Directive Information and Acknowledgment"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (22 CCR §74743(c)(2)(B))","5. Written Information Before Care Starts","6. California Law: What the Patient Is Told","7. Recording and Keeping Copies","8. Honoring Directives and POLST Forms in the Home","8.1 Advance health care directives and agents","8.2 POLST forms","8.3 Medical emergency during a visit","8.4 Good-faith reliance","9. Revocation and Changes","10. Staff Conduct","11. Conscience Objections","12. Staff and Community Education","13. Responsibilities","14. Records and Compliance Monitoring","15. Staff Training","16. References","17. Related Policies and Forms","18. Approval","19. Revision History"],"version":"1.0","sample":false,"pack":"ca-hha","state":"California","service":"Home health","guides":[{"path":"/guides/home-health-agency-policies/","h1":"What policies and procedures are required for home health agencies?"},{"path":"/guides/home-health-conditions-of-participation/","h1":"Home health Conditions of Participation: which policies each one needs"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}