Public Disclosure Statement
Public Disclosure Statement of Heart of Hope Asian American Hospice Care
Date issued: 03/31/2017
Heart of Hope Asian American Hospice Care is a nonprofi¬t 501(c)(3) professional medical organization. We specialize in providing physical, social, psychological and spiritual holistic support to patients with end stage illnesses. Anchored in love and professionalism, we strive to provide culturally and linguistically competent care, helping the patients and their families go through their final journey of life in peace and serenity. We serve the community in most of the Silicon Valley of the San Francisco Bay area.
Heart of hope Asian American Hospice Care will annually complete a written public disclosure statement and signed by the CEO/Administrator. Heart of Hope Asian American Hospice Care will comply with the reporting requirements of Part 420, Subpart C of Title 42 in the Code of Federal Regulations as they apply to the agency.
Upon request, the following information will be made available to the patients of Heart of Heart of Hope Asian American Hospice Care, or the public:
A. Names and, addresses of individuals or corporations having direct/indirect ownership or controlling interest of 5% or more in agency or in any subcontractor in which the agency has direct/indirect ownership interest of 5% or more.
B. Name and addresses of those persons directly related (spouse, parent, child, sibling) to individuals named in “A”.
C. Names and addresses of individuals in “A” or “B” with an ownership or controlling interest in a Medicare or Medicaid facility.
D. When the organization is a corporation, the names and addresses of the Board of Directors, officers or partners as applicable.
E. Description of any criminal offense conviction involving title V, XVIII, XIX or XX brought against any persons listed in A, B, C or D (of any person or organization, agent or managing employee.)
F. Names and addresses of any individual currently employed in a managerial, accounting, auditing, or similar capacity who were employed by the organization’s fiscal intermediary within the previous 12 months.
G. Changes in the Administrator, Director of Patient Care Services, or Medical Director during the previous 12 months.
H. The dates of any of the following :
- Change in ownership or control in the previous or next 12 months
- Anticipated bankruptcy filings
- Operational changed by a management company
- Leasing agreements by another organization
- Address changes for the parent, subunits, or branches
I. Agency mission statement
J. Proof of licensure/accreditation status
K. Policies and procedures regarding patient rights
Public Disclosure Statement will be made available to the public upon request and/or as required (i.e.: Medicaid/Medicare regulations). Such circumstances include but are not limited to:
- To regulatory agency (including state, accrediting agency, CMS etc.) at the time of initial request for certification and for each subsequent survey by the given regulatory agency thereafter.
- Disclosure will also be made within 35 days of any change in ownership or management to regulatory agencies as required.
Blanche Weishan Chen, LCSW
Heart of Hope Asian American Hospice Care