CDPAP Personal Assistant...

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PA application cover page CDPAP Personal Assistant Application All forms and requested information must be completed before employment can be authorized. Authorization must come from South Shore Home Health Services, Inc. Below is a directory assistance to help you with this process. Please call (631) 567-6555 or 1-800-404-9060. Application completion requirements/questions Nora Duran Ext. 301 Program Questions Jackie Datkun ext. 316 Benefits/health insurance Jayne Rizzo ext.324 Payroll Ext. 326 Ext. 322

Transcript of CDPAP Personal Assistant...

Page 1: CDPAP Personal Assistant Applicationsouthshorehomehealth.com/wp-content/uploads/2015/01/CDPAP-packet.pdf · Personal Assistant Application All forms and requested information must

PA application cover page

CDPAP Personal Assistant Application

All forms and requested information must be completed before employment can be authorized. Authorization must come from South Shore Home Health Services, Inc. Below is a directory assistance to help you with this process. Please call (631) 567-6555 or 1-800-404-9060.

Application completion requirements/questions Nora Duran Ext. 301

Program Questions

Jackie Datkun ext. 316

Benefits/health insurance Jayne Rizzo ext.324

Payroll

Ext. 326 Ext. 322

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CDPAP hiring checklist

South Shore Home Health Services, Inc. Consumer Hiring Requirements

Complete top portion only

Personal Assistant Name:___________________________________ Date: ___________

Consumer’s Name:_____________________________________ New: Yes No

Consumer’s Address_______________________________________________________

Consumer’s County ___________________ ie: Suffolk, Nassau or Westchester

Office Use Only

Hiring Requirements ❑ Application Form

❑ W-4 Form

❑ Guide to the CDPAP acknowledgement

❑ Health Insurance waiver

❑ DOL Acknowledgement of wage rate/payday

❑ Transportation Waiver

❑ Insurance Card exp. Date _________________

❑ Live-in agreement

❑ I-9 Form

❑ Drivers license / US Passport or other: ____________________

❑ Social Security Card (original ID only)

❑ Health Assessment

❑ PPD Mantoux date: ______________

❑ Chest x-ray (if needed)

❑ Physical (within the past year)

❑ Rubella Titre

❑ Rubeola Titre

or ❑ MMR 1st date: _____________ 2nd date : _______________

❑ Hepatitis B Acceptance /Declination Form

❑ Picture Taken, Badge sent out: ____________________

❑ Kchecks

❑ Criminal Background Disclosure Form (Westchester only)

_______No ______Yes Letter to sent to consumer Date: ________________

OFFICE USE ONLY

❑ PA Application Complete Date: _________________

❑ Notified ___________________________ Date:_________________

❑ Consumer Notified Date: ________________ Comments:_______________________________________________________________________________________________________________________________________________________

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SOUTH SHORE HOME HEALTH SERVICES, INC. CONSUMER DIRECTED PERSONAL ATTENDANT PROGRAM

NAME Last First S.S # Street Address City/Town State Zip Home Phone Cell Phone EDUCATION High School Name City/Town College PROFESSIONAL TRAINING Name of School City & State

Date of Entrance

Graduate Yes/NO

Cert/Degree

SKILLS CHECKLIST (please circle any that apply) Home Care

Special Diets Kosher Cooking

Household Maintenance

Laundry

Bed Bath

Denture Care

Range of Motion

Transfer Techniques

Hoyer Lift

Foyer Lift Ostomy Care

Non-Sterile Dressing

Vital Sign

Urine Testing

Geriatrics

Child Care Newborn

Orthopedics

Diabetes

Patient Teaching

Other:_______________

____________________ ____________________

TRANSPORTATION Convenient Transportation to Assignment Bus/Train/Car? Yes No Routes:________________________________________________ Valid Licenses? Yes No *Do you give permission for a criminal screen to be conducted by the consumer? Yes No *I have received the Personal Assistant guide to the Consumer Directed Personal Assistance Program. Yes No SIGNATURE: __________________________________________________ DATE: _________________

HOURS AVAILABLE

Days Nights Live-In Mon ___________ Tues___________ Wed ___________ Thurs __________ Fri ____________ Sat ____________ Sun____________

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Form W-4 (2015)Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2015 expires February 16, 2016. See Pub. 505, Tax Withholding and Estimated Tax.Note. If another person can claim you as a dependent on his or her tax return, you cannot claim exemption from withholding if your income exceeds $1,050 and includes more than $350 of unearned income (for example, interest and dividends).

Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee:• Is age 65 or older,

• Is blind, or

• Will claim adjustments to income; tax credits; or itemized deductions, on his or her tax return.

The exceptions do not apply to supplemental wages greater than $1,000,000.Basic instructions. If you are not exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations.

Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.Head of household. Generally, you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing Information, for information.Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 505 for information on converting your other credits into withholding allowances.

Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity income, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P.Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 505 for details.Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for 2015. See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married).Future developments. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at www.irs.gov/w4.

Personal Allowances Worksheet (Keep for your records.)A Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . . A

B Enter “1” if: { • You are single and have only one job; or• You are married, have only one job, and your spouse does not work; or . . .• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.

} B

C Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . . C

D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . . DE Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . . EF Enter “1” if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit . . . F

(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.) G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.

• If your total income will be less than $65,000 ($100,000 if married), enter “2” for each eligible child; then less “1” if you have two to four eligible children or less “2” if you have five or more eligible children. • If your total income will be between $65,000 and $84,000 ($100,000 and $119,000 if married), enter “1” for each eligible child . . . G

H Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) ▶ H

For accuracy, complete all worksheets that apply. {

• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions and Adjustments Worksheet on page 2. • If you are single and have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.

Separate here and give Form W-4 to your employer. Keep the top part for your records.

Form W-4Department of the Treasury Internal Revenue Service

Employee's Withholding Allowance Certificate▶ Whether you are entitled to claim a certain number of allowances or exemption from withholding is

subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

OMB No. 1545-0074

20151 Your first name and middle initial Last name

Home address (number and street or rural route)

City or town, state, and ZIP code

2 Your social security number

3 Single Married Married, but withhold at higher Single rate.

Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.

4 If your last name differs from that shown on your social security card,

check here. You must call 1-800-772-1213 for a replacement card. ▶

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 56 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $

7 I claim exemption from withholding for 2015, and I certify that I meet both of the following conditions for exemption.• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7

Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.

Employee’s signature (This form is not valid unless you sign it.) ▶ Date ▶

8 Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 10220Q Form W-4 (2015)

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Form W-4 (2015) Page 2 Deductions and Adjustments Worksheet

Note. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.1 Enter an estimate of your 2015 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state

and local taxes, medical expenses in excess of 10% (7.5% if either you or your spouse was born before January 2, 1951) of your income, and miscellaneous deductions. For 2015, you may have to reduce your itemized deductions if your income is over $309,900 and you are married filing jointly or are a qualifying widow(er); $284,050 if you are head of household; $258,250 if you are single and not head of household or a qualifying widow(er); or $154,950 if you are married filing separately. See Pub. 505 for details . . . . 1 $

2 Enter: { $12,600 if married filing jointly or qualifying widow(er)$9,250 if head of household . . . . . . . . . . .$6,300 if single or married filing separately

} 2 $

3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 3 $4 Enter an estimate of your 2015 adjustments to income and any additional standard deduction (see Pub. 505) 4 $5 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to

Withholding Allowances for 2015 Form W-4 worksheet in Pub. 505.) . . . . . . . . . . . . 5 $6 Enter an estimate of your 2015 nonwage income (such as dividends or interest) . . . . . . . . 6 $7 Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 7 $8 Divide the amount on line 7 by $4,000 and enter the result here. Drop any fraction . . . . . . . 89 Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . . 9

10 Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet, also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 10

Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)Note. Use this worksheet only if the instructions under line H on page 1 direct you here.1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 12 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if

you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more than “3” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter “-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . . . . . . . . . 3

Note. If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additional withholding amount necessary to avoid a year-end tax bill.

4 Enter the number from line 2 of this worksheet . . . . . . . . . . 45 Enter the number from line 1 of this worksheet . . . . . . . . . . 56 Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . 67 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . . 7 $8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . 8 $9 Divide line 8 by the number of pay periods remaining in 2015. For example, divide by 25 if you are paid every two

weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2015. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck 9 $

Table 1Married Filing Jointly

If wages from LOWEST paying job are—

Enter on line 2 above

$0 - $6,000 06,001 - 13,000 1

13,001 - 24,000 224,001 - 26,000 326,001 - 34,000 434,001 - 44,000 544,001 - 50,000 650,001 - 65,000 765,001 - 75,000 875,001 - 80,000 980,001 - 100,000 10

100,001 - 115,000 11115,001 - 130,000 12130,001 - 140,000 13140,001 - 150,000 14

150,001 and over 15

All Others

If wages from LOWEST paying job are—

Enter on line 2 above

$0 - $8,000 08,001 - 17,000 117,001 - 26,000 226,001 - 34,000 334,001 - 44,000 444,001 - 75,000 575,001 - 85,000 685,001 - 110,000 7

110,001 - 125,000 8125,001 - 140,000 9140,001 and over 10

Table 2Married Filing Jointly

If wages from HIGHEST paying job are—

Enter on line 7 above

$0 - $75,000 $60075,001 - 135,000 1,000

135,001 - 205,000 1,120205,001 - 360,000 1,320360,001 - 405,000 1,400405,001 and over 1,580

All Others

If wages from HIGHEST paying job are—

Enter on line 7 above

$0 - $38,000 $60038,001 - 83,000 1,00083,001 - 180,000 1,120

180,001 - 395,000 1,320395,001 and over 1,580

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person who claims no withholding allowances; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.

The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return.

If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.

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guide to the CDPAP SSHH November 2013/rev 9/2015

The Personal Assistant’s Guide to the Consumer Directed Personal Assistance Program (CDPAP) __________________________________________ Fiscal Intermediary for the Consumer Directed Personal Assistance Program South Shore Home Health Svc., Inc. Corporate office 1225-2 Montauk Hwy. Oakdale, NY 11769 (631) 567-6555 Fax (631) 567-7923 The Consumer Directed Personal Assistance Program (CDPAP) is an alternative to traditional home care. The CDPAP is Medicaid program that enables self-directing individuals or their designated

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guide to the CDPAP SSHH November 2013/rev 9/2015

representative, to assume the responsibilities of their own care. The consumer and/or designated representative are responsible for recruiting, interviewing, hiring, training, supervising, scheduling and termination. What is my role as a Personal Assistant? As a Personal Assistant you are hired by the consumer and/or designated representative to assist the consumer with their individual needs to live safely in their home within the approved hours authorized by NYS Medicaid/Managed Care. By accepting this position, you are agreeing to accept training and supervision at the direction of the consumer or their designated representative. It is your responsibility to speak to your consumer directly if you cannot report to work for any reason. You are responsible to complete the full application and submit the documents needed to work on the CDPAP. You may not submit a time slip or clock in until your application forms are completed and submitted for approval. This approval must be given by South Shore Home Health Svc., Inc. As a Personal Assistant, the Department of Health requires that you pass and submit a physical within the past year, provide proof of immunizations, a PPD or Chest x-ray (if you have a history of a positive PPD), and complete a health assessment. All forms are in the Personal Assistant application. It is your responsibility to keep your compliance up to date yearly. As a Personal Assistant you may not work on the consumer directed program while the consumer is hospitalized. These hours will not be paid to you by South Shore Home Health Services, Inc. and will not be billed to NYS Medicaid/Managed Care. What is the role of South Shore Home Health Services, Inc.? As the Fiscal Intermediary South Shore Home Health Svc., Inc. will keep a record which consists of the Personal Assistant’s original application forms, annual health assessments and the information needed for payroll processing and benefit administration. We act as an employer of record for insurance, unemployment and worker compensation benefits for each Personal Assistant. Who is my employer? As a Personal Assistant you are employed by the consumer or their designated representative. They are responsible for creating your schedule. You must call them directly if you are unable to work for any reason. Safety In the case of accidents that result in injury, regardless of how insignificant the injury may appear, Personal Assistants should immediately notify your consumer or designated representative and South Shore Home Health Services, Inc. Such reports are necessary to comply with OSHA regulations and workers compensation benefits laws. Live in All Personal Assistants who work on a live in case are to be present in the consumer’s home for 24 hours each working day. During each live in day, Personal Assistants are to perform tasks in

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guide to the CDPAP SSHH November 2013/rev 9/2015

accordance with the verbal and written care plan. Personal Assistants may not work in excess of 13 hours in any day. During each 24 hour day, Personal Assistants are to take eleven hours for personal time which will include hours of sleep, meal breaks and other personal time, remaining on premises at all such times. Transporting the client You must provide South Shore Home Health Svc., Inc with your current unexpired driver’s license and insurance card in order to be authorized to transport your consumer in your car or your consumer’s car. Corporate compliance Purpose To ensure South Shore Home Health Services, Inc. complies with applicable federal and state laws and regulations and to make a sincere effort to prevent, detect and correct any fraud, abuse or waste in connection with federally funded health care programs and private health plans. Policy It is the policy of South Shore Home Health Services, Inc.to be in compliance with all federal and state rules, laws and regulations. This includes compliance with all reimbursement rules as required by Medicare, Medicaid, and relevant third party payers. It also includes compliance with relevant federal and state abuse laws including but not limited to the Deficit Reduction Act of 2005 and the Federal and NYS False Claims Act. Compliance issues relating to accurate and truthful documentation, honest and lawful dealing with others and prohibitions against receiving or giving renumeration in turn for referrals are also included. As part of this compliance program, all Personal Assistants are urged to raise any concerns about the accuracy or propriety of any documentation or billing practice or any other compliance issue without concern for retaliation. Such issues may be raised to the South Shore Home Health Services, Inc. Compliance Officer, Kathy McCarthy , at 631-567-6555 ext. 317. All concerns will be reviewed and appropriate action will be taken. Deficit Reduction Act Of 2005 South Shore Home Health Services, Inc. takes fraud and abuse very seriously. It is our policy to provide information to all employees, contractors and agents about the federal and state false claims acts remedies available under these acts and how employees and others can use them, and about whistleblower protections available to anyone who claims a violation of federal or state false claims acts. We also will advise our employees, contractors and agents of the steps the agency has in place to detect health care fraud and abuse. This act is designed to improve federal and state oversight and enforcement actions against fraud and abuse in the Medicaid program. It requires any entity receiving more than 5 million dollars in Medicaid funds per year must instruct their workforce on the following issues: • The Federal False Claims Act • The Federal Program Fraud Civil Remedies Act • State laws pertaining to civil or criminal penalties for false claims and statements • Role of such laws in preventing and detecting fraud, waste and abuse • Whistleblower protections under such laws • Policies and procedures of South Shore Home Health Systems (provider) for preventing and detecting fraud, waste and abuse.

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guide to the CDPAP SSHH November 2013/rev 9/2015

Federal False Claims Act The False Claims Act is a law that prohibits a person or entity from knowingly presenting or causing to be presented a false or fraudulent claim for payment or approval to the Federal Government and from ‘knowingly” making, using or causing to be made a false record or statement to get a false or fraudulent claim paid or approved by the Federal Government. These prohibitions extend to claims submitted to federal healthcare programs, such as Medicare and Medicaid. A person or entity found guilty of violation can be obligated to civil penalty up to 11,000 plus three times the amount of actual damages. A person or entity can also find themselves excluded from the Medicaid programs if found in violation. New York False Claims Act The NY False Claims Act closely tracts the federal False Claims Act. It imposes penalties and fines on individuals and entities that file false or fraudulent claims for payment from any state or local government, including health care plans such as Medicaid. The penalty for filing a false claim is 6,000-12,000 per claim and the recoverable damages are between two and three times the value of the amount falsely received. How do I get paid? Federal and state laws require South Shore Home Health Svc., Inc. to keep accurate records of time worked in order to calculate Personal Assistant pay and benefits. Time worked is all the time actually spent on the job performing assigned duties within the authorized time. You are not permitted to work anywhere else at the same time you are working for your consumer. All Personal Assistants are required to submit all paperwork to the office weekly by noon on Tuesdays. Paperwork received after 12 noon will be considered late and processed the following week. The payroll cycle is from Monday 12:00am to Sunday 11:59pm. All paperwork must be signed by the consumer/designated representative and Personal Assistant at the end of each day. Dates, times, signatures and patient information must be filled out correctly. We will not be able to process incomplete paperwork. Some contracts require the use of an Automatic Time and Leave system (ATL) (Crestel) when working with their consumer. If you are required to use the ATL system please make sure to ask for your pin number and instructions on how to use the Crestel System. It is prohibited to allow anyone else to use your pin number. Personal Assistants must clock in and out for each shift that is worked. Failure to use the call in system properly will cause a delay in your pay due to the additional processing time needed for timesheets. Checks are mailed weekly to the consumer’s home or to your home. This determination is made by the consumer.

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guide to the CDPAP SSHH November 2013/rev 9/2015

Personal Assistant Benefit overview Compensation and Benefits Rate of pay Your rate of pay varies depending on the contract the consumer is being serviced under and county, state and federal wage laws. Compensated days off Personal Assistants who qualify for compensated days off will receive 12 days per calendar year. These days are accrued at the rate of one day per month based on average hours worked to a maximum of eight hours. This benefit will be paid out to you on a monthly basis. Compensated days off will not be counted as hours worked for purposes of determining whether overtime premium pay is due to the Personal Assistant. Benefits offered through the CDPAP Health benefits, Dental/Life/Vision. Health Benefits Health benefits are offered to personal assistants who work 30 hours a week on a weekly basis. Health insurance premiums are deducted weekly through payroll. Each personal assistant that qualifies has the option to enroll or waive the benefits. For questions please contact Human Resources @ (631) 567-6555 ext. 324 **South Shore Home Health pays administrative costs associated with all benefits programs and any Personal Assistant contributions are deducted in installments from Personal Assistant’s weekly pay.

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guide to the CDPAP SSHH November 2013/rev 9/2015

THE PERSONAL ASSISTANT’S GUIDE TO THE CONSUMER DIRECTED PERSONAL ASSISTANCE PROGRAM ACKNOWLEDGMENT OF RECEIPT I have received the Personal Assistant’s guide and I have chosen to participate in the CDPAP as a Personal Assistant. I understand that South Shore Home Health Services, Inc. is the fiscal intermediary and I am hired, supervised, scheduled and trained by the consumer and/or designated representative. I understand that failure to accurately complete the time slip or the automated time and leave call in system may be construed as fraudulent and may result in disciplinary action. I understand that my timeslips and automated time and leave call in must reflect the exact hours worked and that the work I do is for the consumer only. I understand that I must report my patient’s hospitalization to the agency immediately and that I can not be paid if the consumer is in the hospital. I understand it is my responsibility to report any act of fraud or abuse. If you are aware of any fraudulent activity and do not report it, you could be punished. Whistleblower laws protect employees against retaliation for reporting. All reports will remain confidential and can be filed in person or writing or verbally over the phone with: Kathy McCarthy RN , Corporate Compliance Officer @ 631-567-6555 ext. 317. Print Name: Signature: ___________________________ ______ Date:_______

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PA transportation waiver

Personal Assistant Transportation (sign one)

I will provide South Shore Home Health Services, Inc. with my drivers license and insurance card in order to transport my patient in my car and/or the patient’s car. ________________________ _____________ personal assistant signature Date

OR I will not be transporting my patient in my car and/or my patient’s car. __________________________ ______________ personal assistant signature Date

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Public/CDPAP/live in form for PA

Agreement Between South Shore Home Health and Personal Assistant Live-In

1. All personal assistants (PA’s) assigned to live-in cases are to be present

in the consumer home for 24 hours each working day. 2. During each live in day, based on a 13 hour day, PA’s are to perform

tasks in accordance with the verbal or written care plan. PA’s may not work in excess of 13 hours in any day and no more than 5 live in days per week.

3. During each 24 hour day, PA’s are to take eleven hours for personal

time which will include hours of sleep, meal breaks and other personal time, remaining on premises at all such times.

♥ 8 hours of sleep time ♥ 2 hour meal breaks ♥ 1 hours of personal time – reading, watching television, etc. 4. If any PA finds it impossible to take the specified breaks from work

duties because such times are constantly interrupted by the needs of the patient, she/he must call the administrator and South Shore Home Health Services, Inc.

I understand and will abide by the agency’s rules stated in this agreement regarding time worked on live-in cases

____________________________________ Signature _____________________________________ Print Name ______________________________________ Date Rev 5/09,1/10

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HR/word/ PA requirements

THE FOLLOWING REQUIREMENTS

MUST BE SUBMITTED AND APPROVED PRIOR TO WORKING

FOR YOUR CONSUMER

• Completed application. • 2 original and unexpired forms of ID (please see list of

acceptable documents listed on the back of the I-9 form included in the application).

• A work release physical completed within the past year. • Rubella and Rubeola lab report showing immunity. • PPD upon hire or chest x-ray ( if you have history of a

positive PPD) • Completed Health Assessment.

It’s your responsibil ity to make sure your application is approved before you start working. If you have any questions please call Nora Duran at (631)567-6555 ext. 301.

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Public/Word/Health Assessment

SOUTH SHORE HOME HEALTH SERVICES, INC. 1225-2 Montauk Hwy, Oakdale, N.Y. 11769 631-567-6555 fax 631-567-7923 185 Willis Ave., Suite 5, Mineola, N.Y. 11501 516-741-0400 fax 516-741-0942 2 William St Suite 305 White Plains, N.Y. 10601 914-285-0516 fax 914-285-0518

HEALTH ASSESSMENT This is a health questionnaire. Please complete on hire and annually on this form only.

Name:___________________________________ Date:___________ Position: _______ Height: _______ Weight: _______ Pulse: _______ B/P: ________ Respiration: _______

(Vital signs optional)

Known Allergies: __________________________________________________________

Do you have a personal physician? Yes□ No□ when did you last see him? ________

Do you feel that you are in good health? Yes□ No□ Would there be any difficulty in performing the job you are being hired to do? Yes□ No□ Be specific and list any medication that you are currently taking.______________________ __________________________________________________________________________________

*****If you have a history of a positive PPD please answer questions 1-4***** Since your last assessment, 1. Have you had a prolonged, productive or bloody cough? Yes□ No□ 2. Have you had a persistent fever and/or “Night Sweats”? Yes□ No□ 3. Have you had significant, unplanned weight loss? Yes□ No□ 4. Have you had any unexplained lethargy or weakness? Yes□ No□ If you answered “YES” to any of the above, the Agency Directors strongly suggest that you consult with your personal physician concerning the possibility of obtaining a repeat Chest X ray and follow-up medical care. I, _______________________________, certify that I am free from any health impairments which may pose potential risks to patients, families or other employees, or which might interfere with the performance of my duties. This includes, but is not restricted to, habituation or addiction to depressants, stimulants, narcotics, alcohol or any drug or substance which may alter my behavior. _________________ _______________________________________________ Date Your Signature ------------------------------------------------------------------------------------------------------------------------------------------------------------------ For SSHH Office use only _____________________ __________________________________________________________ Date Reviewer’s Signature

UTH SHORE HOME HEALTH SERVICES, INC. 1225-2 Montauk Highway

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physical.doc

PHYSICAL EXAM

NAME:___________________________________D.O.B._______________ ADDRESS:____________________________________________________ Street Address City, State Zip Code Medical History:_______________________________________________ ___________________________________________________________ Family History:________________________________________________ ___________________________________________________________ Social Habits: Alcohol________ Tobacco________ Drugs__________ History of Substance Abuse: _____________________________________ Physical Findings: Height:__________ Weight:_________

Heart:____________ Lungs:_________ Abdomen:___________ Blood Pressure: _________ Pulse: _______ Respiration:________

Laboratory findings:*Office must have a copy of the actual Laboratory Results. Rubella Titre: Date:____________ Attach copy lab of Results*: ________ If results are NEGATIVE, Vaccination is MANDATORY. Vaccination Date 1:________ Vaccination Date 2:_________

Rubeola Titre: Date:__________ Attach copy lab of Results*: ________ If results are NEGATIVE, Vaccination is MANDATORY. VaccinationDate1:_________ Vaccination Date 2: __________ PPD:Date Given:_______ Date Read:_______ Reactive:______ Non-Reactive: ____ If PPD is Positive: Attach CHEST X-RAY REPORT Date: ________ Results:____ The above named is free from health impairments which are of potential r isk to patients, famil ies or other employees or which might interfere with the performance of his/her duties and is able to work with no restrictions. If no, please explain ___________________________________________ _____________________ _______________________ ____________ Examiner’s Signature Examiner’s Name Printed Date Examiner’s Telephone No.: __________________ Lic.# or Office Stamp

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Hepatitis B/public

HEPATITIS B VACCINE DECLINATION (Mandatory)

I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with the hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future, I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me. ___________________________________________ Name (Printed) ___________________________________________ ________________ Signature Date

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Public/word/ PPD permission

South Shore Home Health Services, Inc.

Name: ________________________ Date: ______________ Product Name: __________________ PPD dose: ________ Lot #:________ Exp. Date: ________ Date given:_____________ By:______________________ Site Planted: left forearm right forearm Reaction: Positive (mm):_____________ Negative: ______________ Date Read: _______________ By:___________________ Note: Please include nurse license # or Dr. Office stamp thanks. Lic# or stamp_________________ Comments: ____________________________________________________________________________________________________________