ACKNOWLEDGMENT FORMS AND AGREEMENTS

Direct Personal Care, Inc.

Contents

CORPORATE COMPLIANCE EDUCATION ACKNOWLEDGEMENT FORM

This is to certify that I,

This is to certify that I am in receipt of Corporate Compliance Training and Educational Materials from my Consumer enrolled in Direct Personal Care, Inc.’s CDPAP pertaining to the Federal False Claims Act, New York FalseClaims Act, Whistleblower Protection and Identifying Fraud and Abuse Law, as well as where to report these issues should they be suspected or uncovered.

Print Name:
Signature:

Date:

HIPPA ACKNOWLEDGEMENT

I have been informed regarding HIPAA Privacy Rules by as provided to me by Direct Personal Care, Inc. and I acknowledge compliance with these rules as per N.Y.S. mandate.

I understand that the major goal of the privacy rule is to assure that all of our consumer’s health information is properly protected, while allowing the flow of vital healthcare /clinical information to all employees participating in providing patient care/services. As such, we can provide and promote high quality, safe and effective home health care.

Direct Personal Care, Inc. also protects the public's health and their well-being by implementing disciplinary action upon notifications on any HIPAA violations by our employees.

Print Name:

Date:

Direct Personal Care, Inc.

CONSUMER DIRECTED PERSONAL ASSISTANCE PROGRAM EMPLOYMENT/WAGE AGREEMENT

THE PERSONAL ASSISTANT (PA) AGREES TO:

  1. Recognize the authority of the consumer as the Personal Assistant source of employment and supervisor.
  2. Respect the Consumer's health, wellbeing, privacy and property
  3. Authorize Direct Personal Care, Inc. to collect and appropriately distribute employment related information.
  4. Comply with the policies and practices of Direct Personal Care, Inc. Consumer Directed Personal Assistant Program

Direct Personal Care, Inc. CONSUMER DIRECTED PERSONAL ASSISTANT PROGRAM AGREES TO:

  1. Monitor the Consumer's or, if applicable the consumers designated representative, continuing ability to fulfill; the consumer's responsibilities and appropriateness for continued participation inDirect Personal Care, Inc. Consumer Directed Personal Assistance Program, either directly or indirectly using all available information, or notifying the Consumers Medicaid Managed Care Plan Provider as needed.
  2. Comply with Dept. of Health regulations contained in NYCRR 504.3
  3. Maintain the information needed for payroll processing and benefits administration and process the Consumer's payroll for each Personal Assistant
  4. Pay the Personal Assistant the prevailing wage in the industry for the hours of service indicated on the Consumer's time sheet or verification of hours worked utilizing an electronic time and attendance system.
  5. Coordinate all matters, which relate to each Personal Assistants withheld taxes and benefits and comply with workers compensation, disability and unemployment insurance requirements.
  6. Encourage the Consumer to provide equal employment opportunities to all prospective employees, regardless of their race, creed, color, national origin, sex, disability, marital status, and sexual orientation, in all in all employment decisions.
  7. Facilitate and monitor the completion of all Consumer and Personal Assistant documents that a required by Brooklyn, State or Federal Authorities either directly-or indirectly.
  8. Maintain directly a personal record for each Personal Assistant that will include, at a minimum the enrollment forms, the annual worker's health status assessments prior to delivery of service pursuant to 10 NYCRR 766.11(c)and (d) or any successor regulation.
  9. Maintain a Consumer Record which includes authorizations from the consumers Medicaid Managed Care Plan Provider the Consumer Agreement, and all other documents required to monitor and maintain information required for participation in the CDPAP provided by the Consumers Medicaid Managed Care Plan
  10. Identify and Evaluate community resources that may be available to the Consumer to assist with Consumer for Recruitment Assistance Services.
  11. Maintain a Consumer Advisory Committee and Grievance Committee.
  12. Provide statistical and pertinent information to the various regulatory, legal and programmatic entities as required or requested.

Direct Personal Care, Inc.
CONSUMER DIRECTED PERSONAL ASSISTANCE PROGRAM EMPLOYMENT/WAGE AGREEMENT
ACKOWLEDGEMENT OF RECIEPT OF CONSUMER & PERSONAL ASSISTANT EMPLOYMENT WAGE AGREEMENT

CONSUMER/DESIGNATED REPRESENTATIVE ACKNOWLEDGEMENT

I HAVE READ AND UNDERSTAND MY RIGHTS AND RESPONSIBILITIES FOR PARTICIPATION IN Direct Personal Care, Inc., AND CONSUMER DIRECTED PERSONAL ASSISTANCE PROGRAM.


Consumer/Designated Representative:

Print Name

Signature

PERSONAL ASSISTANT ACKNOWLEDGEMENT

I HAVE READ AND UNDERSTAND THE RULES AND RESPONSIBILITIES AS THE EMPLOYEE OF THE ABOVE CONSUMER FOR PARTICIPATION IN Direct Personal Care, Inc., CONSUMER DIRECTED PERSONAL ASSISTANCE PROGRAM.

Personal Assistant:

Print Name:

Signature:

ACKNOWLEDGEMENT OF RECEIPT

CONSUMER/ DESIGNATED REPRESENATIVE

POLICY PERTAINING TO FALSE CLAIMS AND FALSE STATEMENTS,

  1. I acknowledge that I have received a copy of the Direct Personal Care, Inc., POLICY PERTAINING TO FALSE CLAIMS AND FALSE STATEMENTS
  2. I will inform my Personal Assistants regarding the Federal & State False Claims Act.

Print Name of Consumer/Designated Representative:

Signature of Consumer/Designated Representative:

I have been informed by my Consumer/Designate Representative about the policy regarding the Federal & State False Claims Act.

Print Name of Consumer/Designated Representative:

Signature of Consumer/Designated Representative:

PROGRAM ORIENTATION HOME VISIT FORM

Referral Date:Visited By:Start of Service Date:
Consumers MLTC:Authorized Hours:
Consumer Name:
Address:APT:City, StateZip:

Primary Phone: (H):Mobile:Email:

Language: Special Adaptive Devices

if yes, does he or she attend school? YesNo

Is Consumer on a Ventilator: YesNo
If yes is Consumer registered with Con Ed in the event of a power outage? YesNo


Type of Residence:

Handicap accessible? YesNo

Smoke detector/Carbon Monoxide Detector in Home? YesNo

Pets:
Designated Representative: Relationship:
Address:APT:City,State, Zip:
Phone: (H) Mobile:Email:
Emergency Contact other than Physician: Name: Phone:

Address: City,State:State:Zip:

Name & Phone Number of PA:

Name:

Phone:

Physician Names:
Phone Number:
Fax Number:

Other Service Requirements or Special Needs:

Consumer Service Representative Note:

Direct Personal Care, Inc.
ACKNOWLEGEMENT OF RECIEPT OF INFORMATION AND PROCEDURES

I am a Consumer or a Designated Representative of a Consumer who is enrolled in the Direct Personal Care, Inc.Upon my enrollment into the CDPAP I received an in-home orientation visit byDirect Personal Care, Inc. Consumer Service Representative.

At the time of this home visit, the rules and regulations for participation in the Direct Personal Care, Inc., have been explained to me, and I have had my questions answered. If I have anyquestions in the future, I have been provided with the name and contact information of my Consumer Service Representative who I can call at any time.

I have had the opportunity to ask questions received printed information on the rules of participation for the Direct Personal Care, Inc.

In addition, I have been provided with information both written and verbal on the following topics and procedures:

  • Direct Personal Care, Inc. Guide
  • CDPAP Consumer Rules of Participation & Code of Ethics
  • The Consumer- PA Wage Agreement
  • The Consumer/Surrogate Agreement
  • Copy of New York State Handbook on Advanced Directives Law & Health Care Proxy
  • Acknowledgement & Receipt of Federal & State False Claims Act
  • Emergency Disaster Preparedness Plan for People with Disabilities
  • Infection Control Printout
  • Home Safety Printout
  • Notice of Privacy Practices (HIPAA)
  • PA Handbook

CONSUMER or DESIGNATED REPRESENTATIVE

DATE:

CONSUMER SERVICE REPRESENTATIVE

DATE:

Direct Personal Care, Inc.
EMPLOYMENT/WAGE AGREEMENT

A consumer or, if applicable, the consumer's designated representative has the following responsibilities under Direct Personal Care, Inc.

THE CONSUMER AGREES TO:

1. Manage the plan of care;
2. Responsible for recruiting, interviewing and hiring a sufficient number of Personal Assistants to provide authorized services that are included in the consumer's plan of care established in conjunction with the consumer or designated representative by the Medicaid Manage Care Provider;
3. Provide equal employment opportunities to all prospective employees, regardless of their race, creed, color, national origin, sex, disability marital status, and sexual orientation or affectional preference;
4. Accept full responsibility for any personal injury or loss of property that may result from the action or inaction of the consumers Personal Assistant;
5. Responsible for training, supervising and scheduling each Personal Assistant; and assuring that each consumer directed personal assistant competently and safely performs the personal care tasks, home health aide tasks and skilled nursing tasks that are included in the consumer's plan of care;
6. Arrange and schedule back-up Personal Assistant coverage for vacations, holidays and absence due to illness;
7. Responsible for terminating(if need be) the Personal Assistant's employment;
8. Responsible for the timely notification of the fiscal Intermediary- Direct Personal Care, Inc. and the Consumers Medicaid Managed Care Provider of any changes in the consumer's medical condition or social circumstances, including, but not limited to, any hospitalization of the consumer or change in the consumer's address, phonenumber or employment;
9. Timely notification toDirect Personal Care, Inc.of any changes in the employment status of each Personal Assistant working for the Consumer; to include any changes in name, address, employment status and hours worked;
10. Process and submit in a timely manner the required Consumer and Personal Assistant enrollment documents, annual worker health assessments and other required employment documents;
11. Ensuring that each consumer directed Personal Assistant utilizes the Electronic PhoneVerification system to clock in and clock out when working for the Consumer, and mediate all payroll/personal problems;
12. Having the consumer directed Personal Assistant's utilize paper time sheets when the Electronic PhoneSystem is not used, or is not available; and submit the paper time sheets to the fiscal intermediary according to its procedures;
13. Timely distributing each consumer directed personal assistant's paycheck, or allow Personal Assistant participation in a direct deposit payroll distribution system;
14. Arranging and scheduling substitute coverage when a consumer directed Personal Assistant is temporarily unavailable for any reason;
15. Train the Personal Assistant as to the rights and responsibilities of all involved parties;
16. Comply with New York State Dept. of Health requirements regarding receiving notification/information from the Fiscal Intermediary regarding Advanced Directives;
17. Comply with the Department approved CDPAP Agreement between the Medicaid Managed Care Provider and the Consumer/Designated Representative that describes the parties' responsibilities under the CDPAP.