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Consumer/Designated Representative Responsibilities
- I understand that I must manage my plan of care developed post assessment/reassessment.
- I understand that “Plan of care management” includes the recruiting and hiring a sufficient number of individuals who meet the definition of a personal assistant.
- I understand that if I am a minor, the parent or guardian, takes full and complete responsibility for the recruitment, hiring, training and termination of any and all Personal Assistants who provide service. That same parent or guardian cannot be my personal assistant or designated representative.
- I understand that I cannot employ my spouse, or designated representative to be my personal assistant. If I am a minor child, I cannot appoint my parent or other person who is legally responsible for me to serve as my personal assistant or designated representative.
- I understand that I will be responsible to arrange and schedule substitute coverage when my Personal Assistant is temporarily unavailable. It is understood that Committed Home Care Inc. does not have a replacement list of Personal Assistants and is not allowed to hire an assistant on your behalf. Committed Home Care Inc. will not be responsible in the event of an accident or injury incurred by the Consumer when the Consumer does not receive care during the approved scheduled hours.
- I understand that I will direct my personal assistant(s) to provide only the total hours of services that are authorized on the plan of care written by the provider and that no additional hours will be scheduled or permitted to be worked.
- I understand that I must have Medicaid and prove assurance that it remains current.
- I understand that I am responsible for notifying the MLTC (your Health Plan i.e., Fidelis, United, iCircle...) within five (5) business days of any change in my medical condition or change in social/environmental circumstances to include hospitalization or demographic changes.
- I understand that personal assistance services under the CDPAP will not be paid for by the FI until all paperwork is completed and the personal assistant is confirmed as being authorized to work in CDPAP.
- I understand that I must attest to the accuracy of the personal assistant(s) time sheets.
- I understand that timesheets must be submitted according to Committed Home Care Inc.'s Time and Attendance procedures, which will be communicated, with written documentation and I will confer with my personal assistant to ensure compliance.
- I will be informed when my personal assistant’s immunizations and health assessment are coming up for updating/re-certification. I understand that I cannot schedule my personal assistant when his/her health assessment is expired. Should I schedule or allow my personal assistant to work when he/she is not authorized to work due to an outdated health assessment, I understand that the fiscal intermediary is not authorized to process payment for such services.
- I understand that I am responsible to notify Committed Home Care Inc. of any changes in the employment status (e.g., terminations) of each Personal Assistant employed by me.
- I understand that it is my responsibility for any and all items removed from or destroyed within my primary residence or vehicle without my consent.
- I understand that New York Social Services Law § 365-f (3) prohibits my Personal Assistant from being my spouse, my Designated Representative, or any other person legally responsible for my care and support.
- The above-named Personal Assistant is NOT my spouse, my Designated Representative, or any other person legally responsible for my care and support.
- I understand that if my spouse, my Designated Representative, or any other person legally responsible for my care and support is my Personal Assistant, it may be considered Medicaid fraud. If Medicaid fraud is found, I agree to repay to the fiscal intermediary all wages and other compensation fraudulently paid to my Personal Assistant(s), plus any applicable penalty and interest.
- I will immediately notify the fiscal intermediary if the above-named Personal Assistant becomes my spouse, my Designated Representative, or legally responsible for my care and support.
- If the above-named Personal is currently my relative through blood, marriage or adoption, I will immediately notify the fiscal intermediary if the above-named Personal Assistant is no longer my relative through blood, marriage or adoption.
- I understand that the fiscal intermediary is not responsible for providing emergency back-up services or securing a replacement worker if my Personal Assistant(s) is/are not available for a shift or for a period of time. It is my responsibility and/or my designated representative’s responsibility to find alternate Personal Assistant(s) to provide services. I will instruct my Personal Assistant(s) to call-off from work to me, and not to the fiscal intermediary, since the fiscal intermediary has no responsibility for the scheduling or rescheduling of my Personal Assistant(s). The following persons have been/will be registered with the fiscal intermediary as back-up Personal Assistants if my regular Personal Assistant(s) are not available for work:
- If I am a consumer in NYC or Westchester county I understand that i am responsible to schedule my assistant for vacation and paid time off, and ensuring that the fiscal intermediary is informed of such paid time off so that the fiscal intermediary can process payment for such paid time off.
- I understand that I am responsible for ensuring compliance with all anti-harassment and discrimination laws.
I have reviewed, understand and agree to all Corporate Compliance Policies. (A copy of the Corporate Compliance Policies can be found on our Website www.committedhc.com)
I hereby acknowledge that I agree to my responsibilities described above. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Fiscal Intermediary, Committed Home Care Inc Responsibilities
- Committed Home Care will ensure that the health status of each Personal Assistant is assessed prior to service delivery to the Consumer according to 10 NYCCRR 766.11.
- Committed Home Care will process each Personal Assistant(s)’s wages and benefits according to the Home Care Worker Wage Parity regulation as applicable.
- Committed Home Care will process all income tax and other required wage withholdings for each Personal Assistant and comply with worker's compensation, disability and unemployment requirements.
- Committed Home Care will accept time slips and issue paychecks in the name of each Personal Assistant employed by the Consumer for the authorized number of hours per week.
- Committed Home Care will compensate the Consumer's Personal Assistant(s) for only the authorized weekly hours worked.
- Committed Home Care will maintain personnel records for each personal assistant.
- Committed Home Care will maintain consumer records for a period of six (6) years after the date of service. In the case of a minor the later date of either three years after the age of majority or six (6) years after the date of service, or for such a period as required by law, regulation or the contractual arrangement.
I hereby acknowledge that I understand the responsibilities of Committed Home Care described above. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Acknowledgement of receipt of information on fraud waste and abuse
Please read carefully the copy of policies related to federal and state laws regarding fraud, waste and abuse for the Consumer Directed Personal Assistance Program.
The copy of the Policies can be found on our website. www.committedhc.com
I hereby acknowledge that I have been provided with a copy of policies related to federal and state laws regarding fraud, waste and abuse and the Consumer Directed Personal Assistance Program. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Acknowledgment of receipt of notice of privacy practices
Please read carefully the copy of Notice of Privacy Practices that provides a description of protected information uses and disclosures. The copy of the Policies can be found on our website. www.committedhc.com
I hereby acknowledge that I have been provided with a copy of Notice of Privacy Practices that provides a description of protected information uses and disclosures. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Authorization for Release of Health Information
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Signature of Patient {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
Date Signed {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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A few things to know about Payroll
- Committed Home Care’s payroll week runs from Saturday to Friday and pay date is the following Friday.
- For Payroll Processing, timesheets for the Personal Assistant are due no later than end of business day on Monday of the following week.
- Timesheets must be signed by both the Personal Assistant and the Consumer/Designated Representative. Time slips may be submitted as follows:
Email: timesheet@committedhc.com
Fax: 716-557-1200
Pay checks will be mailed to the personal assistant or direct deposit if requested.
I have had the opportunity to ask questions about anything that I did not understand.
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Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Untitled
If you have a concern about any Compliance Violation, Code of Conduct Violations or Ethics Issue, please let us know!
Call: 716.557.1100 Ext: 8 | Email: compliance@committedhc.com | Anonymous Reporting: 716-351-4700
All calls are strictly confidential - Do the right thing!
For office use only
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