You have the right to give instructions about your own health care. You also have the right to name someone else to make health care decisions for you. This form lets you do either or both of these things. It also lets you express your wishes regarding donation of organs and the designation of your primary physician. If you use this form, you may complete or modify all or any part of it. You are free to use a different form.
Part 1 of this form is a power of attorney for health care. Part I lets you name another individual as agent to make health care decisions for you if you become incapable of making your own decisions or if you want someone else to make those decisions for you now even though you are still capable. You may also name an alternate agent to act for you if your first choice is not willing, able, or reasonably available to make decisions for you. (Your agent may not be an operator or employee of a community care facility or a residential care facility where you are receiving care, or your supervising health care provider or employee of the health care institution where you are receiving care, unless your agent is related to you or is a coworker.)
Unless the form you sign limits the authority of your agent, your agent may make all health care decisions for you. This form has a place for you to limit the authority of your agent. You need not limit the authority of your agent if you wish to rely on your agent for all health care decisions that may have to be made. If you choose not to limit the authority of your agent, your agent will have the right to:
Part 2 of this form lets you give specific instructions about any aspect of your health care, whether or not you appoint an agent. Choices are provided for you to express your wishes regarding the provision, withholding, or withdrawal of treatment to keep you alive, as well as the provision of pain relief. Space is also provided for you to add to the choices you have made or for you to write out any additional wishes. If you are satisfied to allow your agent to determine what is best for you in making end-of- life decisions, you need not fill out Part 2 of this form.
Part 3 of this form lets you express an intention to donate your bodily organs and tissues following your death.
Part 4 of this form lets you designate a physician to have primary responsibility for your health care.
After completing this form, sign and date the form at the end. The form must be signed by two qualified witnesses or acknowledged before a notary public. Give a copy of the signed and completed form to your physician, to any other health care providers you may have, to any health care institution at which you are receiving care, and to any health care agents you have named. You should talk to the person you have named as agent to make sure that he or she understands your wishes and is willing to take the responsibility.
You have the right to revoke this advance health care directive or replace this form at any time.
If you are involved in a natural disaster such as a hurricane, tornado, flood, earthquake or fire follow these instructions:
Under disaster conditions, One Source Homecare will try to contact you. Calling into an area which has been involved in a natural disaster, however can be very difficult, and telephone lines are typically jammed. Therefore, please try to call out and establish contact with us at 866-466-2273 or 914-287-2410. We will then make plans and coordinate with you regarding your specific emergency needs.
Upon admission to One Source Homecare, it will be your responsibility to arrange for transportation to the nearest hospital in the event of an emergency. It will also be your responsibility to contact your power company in order to place yourself on a priority list. This is necessary if you have life sustaining equipment that requires electricity.
One Source Homecare has classified you according to the help you may need in an emergency. Please call the office for that code.
WCBS, 880 AM
WZ, 1010 AM
WABC, 770 AM
ESPN, 98.7 FM
CBS, Channel 02
FOX, Channel 05
NJ Twelve, Channel 12
American Red Cross 877-733-2767
Disaster Information Hotline NYC (311)
Always read your medication labels carefully to verify: correct name, correct medication, correct dose, and correct frequency.
Most of your I.V. medications need to be stored in the refrigerator as stated on the label. Always check the label for instruction, name, and medication. Some medications need to be stored in the freezer and this will be indicated on the label if necessary. Everything else is stored at room temperature. If you have any questions, please call One Source Home Care.
Aseptic technique refers to the method used to perform a procedure that will keep the sterile materials free from bacteria. There are bacteria on the skin, which is not harmful as long as it remains on the skin. Most areas inside the body are free from bacteria that is, sterile.
Bacteria can enter into these areas through contaminated solutions or supplies. Touching sterile parts of supplies can cause contamination and lead to an infection.
Using aseptic technique when working with your supplies, solutions and equipment can prevent infection: Aseptic technique is the most important procedure you will learn. It cannot be stressed enough. Again, this is the most important thing you can do to prevent infection.
The following are basics of aseptic technique:
1. Hand Washing
Hands that are not visibly dirty need to be washed just as thoroughly as visibly dirty hands. Bacteria normally found on the skin of the hands and those bacteria otherwise collected during daily activity on the hands can cause infection.
REMEMBER: Always wash your hands before handling equipment before doing any procedures.
2. HANDLING STERILE EQUIPMENT AND SUPPLIES
Most of the supplies you will use for your therapy have been sterilized, packaged and sealed.
All solutions you will use are prepared and sealed using sterile technique. To keep solutions, equipment, and supplies sterile carefully follow these instructions:
Home care may generate some items that are classified as medical waste. These items are defined as “sharps waste". For example, hypodermic needles, pen needles, intravenous needles, lancets, and other devices that are used to penetrate the skin for the delivery of medications. Syringes without sharps (needles) attached can be disposed of in your home waste container.
The Medical Waste Management Act requires all home-generated sharps to be placed in approved containers for transport and disposal. Home-generated sharps should not be disposed of in bleach bottles, soda containers, etc. Store sharps waste in red bio-hazardous containers for easy identification.
If you use needles and lancets for self-injections or to add medications to IV bags, make sure you are disposing them into your sharps container. This includes needles that are permanently attached to your syringe (e.g. insulin syringes or prefilled syringes with needle permanently attached) or needles that are permanently attached to the administration set (e.g. subcutaneous administration sets).
For the disposal of syringes without needles (e.g. prefilled saline and heparin syringes) after use, remove the plunger from the barrel and dispose of the syringe in your household trash. No other items need to be disposed of in your sharps disposal container, including used gloves, used dressings, or used administration sets in which a needle is not permanently attached.
Bring used sharps to any hospital or nursing home in New York State. All NY hospitals and nursing homes are required by law to act as collection centers for the take-back of used household sharps, including syringes and lancets, with no identification required. Make sure sharps are packaged safely and call hospitals and nursing homes for drop-off times and instructions prior to transporting materials to their facility.
In addition to hospitals and nursing homes, various local pharmacies and other health sites may voluntarily and anonymously accept sharps. Visit Take-It-Back NYC to find locations near you that accept sharps.
Never place loose sharps in the trash and never place sharps containers in your recycling bin. (NYC residents will not be penalized for placing a recyclable container containing sharps in their regular household garbage if the container is clearly marked "Home Sharps - Not for Recycling".)
For more information regarding sharps disposal in your area visit New York State Department of Health
You can prevent injury, illness, and pollution by following some simple steps when you dispose of the sharp objects and contaminated materials.
You should place:
Along with the new law that was passed that requires for all sharps to be disposed of in the approved Sharps container only, they have also implemented sharps return kit programs, mail-in programs.
You can purchase specially designed sharps containers that come with a prepaid-postage shipping container. Select pharmacies (such as CVS, Rite Aid, and Walgreens) are offering free sharps containers. The first container is free and then the 2nd and 3rd will cost five dollars apiece.