CONSUMER ACKNOWLEDGMENT FORM
I have completed the required training time provided by 24/7 HOMECARE AGENCY OF NY, INC.. I understand the responsibilities of all involved parties and agree to abide by them
I have received training in the following areas:
Assessing my needs Recruitment and Hiring Contents of an Advertisement Screening Applicant, Conducting and Interview, Checking References
Back-up Assistants Conflict Resolution
Personal and Property, Safety, Training my Personal Assistant
I acknowledge that I will meet with and interview my employee’s according to guidelines provided through my training program. I understand that I am responsible for completing the requested paperwork.
EMPLOYMENT AND CONFIDENTIALY AGREEMENT
This is an agreement between and This defines the conditions of employment.
(client) (Personal Care Assistant)
You employ me, as a participant in the Consumer Directed Program. I understand that I am directly responsible to you and not to 24/7 HOMECARE AGENCY OF NY, INC.
I agree to work on the assigned days and times of my employment. I understand that I must contact you at least two hours before my assigned work in case of an illness or any other emergency.
I understand that I have to perform the tasks as listed on the care plan in a responsible, courteous, and prompt manner, and will be expected to respect your possessions, your lifestyle, and your home.
I understand that no confidential information is to be discussed or disclosed in any way without permission of 24/7 HOMECARE AGENCY OF NY, INC. or you the client.
Receipt of Notice of Privacy Practices
I acknowledge that I have been provided with a copy of 24/7 HOMECARE AGENCY OF NY, INC. Notice of Privacy Practices that provides a description of protected information uses and disclosures, and that I have had an opportunity to ask questions about anything that I did not understand.
Consumer Acknowledgement Form
I have completed the required training required by 24/7 HomeCare Agency of NY , Inc. I understand the responsibilities of all involved partied and agree to abide by them.
I have received training in:
- Assessing my Needs
- Recruiting and Hiring
- Contents of advertisement
- Screening Applicants
- Conducting Interview
- Checking References
- Back-up Assistants
- Conflict Resolution
- Personal and Property Safety
- Training my Personal Assistant
I understand that I will meet and interview my employee’s according to guidelines provided by my training program. I also Understand that I am responsible for the completion of all requested paperwork.
Confidentialiry/conflict of Interest Statement
Responsibilities of the Consumer
- Manage the plan of care authorized by the MCO, including recruiting and hiring a sufficient number of CDPAs to provide authorized services as set forth in the plan of care authorized by the MCO; training, supervising and scheduling each CDPA; terminating the CDPA’s employment with the consumer; and assuring that each CDPA completely and safey performs the personal care services on consumer’s MCO plan of care
- Notify the MCO within 5 business days 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 or telephone number.
- Timely notify the FI of any changes in the employment status of each CDPA.
- Attest to the accuracy of each time record for each CDPA.
- Transmit the CDPA’s time records to the FI according to the FI’s policies and procedures.
- Arrange and schedule substitute coverage when a CDPA is temporarily unavailable for any reason
- Acknowledge and agree that: 1) any person who receives, directly or indirectly, an overpayment from the Medicaid program is obligated to report and return the over payment within sixty days of the identification of the over payment. Failure to do so will expose the person to liability under the False Claims Act, including whistle blower actions and (2) that the Office of the Medicaid Inspector General or MCO may suspend payments to the FI and CDPA, if applicable, pending an investigation of a credible allegation of fraud against the FI or CDPA, as applicable, unless the state determines there is good cause not to suspend such payments.
- Comply with applicable labor laws and provide equal employment opportunities to CDPAs in accordance with applicable laws.
- Any arrangements regarding transportation of the Consumer, as a duty of the Personal Assistant shall be an agreement made strictly between the Consumer and the Personal Assistant. It is Understood that 24/7 HomeCare Agency of NY, Inc. accepts no liability in the event of any accident or injury