{"ref":"NC-HSP-PR-03","title":"Advance Directives, Portable DNR Orders and MOST","category":"Client rights","summary":"Protects the patient's right to have an advance directive, gives written information on the Agency's policy and on North Carolina law (living will, health care power of attorney, portable DNR order, MOST, advance instruction for mental health treatment) when hospice care begins, records in a prominent place whether the patient has one, never conditions care on it, and explains how staff honor a portable DNR order or MOST in the home.","inShort":["Give Form NC-HSP-PR-03-A when hospice care starts and ask about a living will, health care power of attorney, DNR or MOST.","Record clearly at the front of the record whether the patient has an advance directive, and file copies.","Never make care depend on whether the patient has an advance directive.","Follow an original portable DNR order or MOST unless you have good reason to doubt it or know it was revoked.","Do not act as a witness for a patient's living will or health care power of attorney.","Check code status and the documents in the home at every care plan review."],"primaryCitation":"10A NCAC 13K .0301(a)(3)","citations":["10A NCAC 13K .0301(a)(3)","G.S. 90-21.17","G.S. 90-320 to 90-323","G.S. 32A-15 to 32A-27","NC Medicaid Clinical Coverage Policy 3D, section 7.2"],"federalCitations":["42 CFR §418.52(a)(2)","42 CFR Part 489 Subpart I (§489.100 to §489.104)","42 CFR §418.104(a)(6)"],"surveyorAsks":["Where in this record is it documented whether the patient has an advance directive?","Show me the written advance directive information you gave this patient. Does it describe North Carolina law?"],"forms":[{"ref":"NC-HSP-PR-03-A","title":"Advance Directive Notice and Acknowledgment"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (10A NCAC 13K .0301(a)(3))","5. North Carolina Advance Directives and Orders","6. At Admission","7. Decisions for a Patient Who Lacks Capacity","8. Portable DNR Orders and MOST in Practice","9. Conscience Objections and Changes in State Law","10. Witnessing","11. Responsibilities","12. Records and Compliance Monitoring","13. Staff Training","14. References","15. Related Policies and Forms","16. Approval","17. Revision History"],"version":"1.0","sample":false,"pack":"nc-hospice","state":"North Carolina","service":"Hospice","guides":[{"path":"/guides/hospice-policies/","h1":"What policies are required for hospice?"},{"path":"/guides/hospice-conditions-of-participation/","h1":"Hospice Conditions of Participation: which policies each one needs"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}