Homemaker/Personal Care/Supportive Home Care Aide

I. Service Capacity

Provide the number of regular full- and part-time employees in the following positions. (Do not duplicate. That is, report personal care/homemakers at the highest level of training only. If a PCHM is trained as a SHCA, do not count employee as an HM, PC, and SHCA, but SHCA only.

Homemaker:

Personal Care/Homemaker:

Supportive Home Care Aide – Alzheimer’s:

Supportive Home Care Aide – Mental Health:

LPN:

RN:

Provide the number of per diem contract employees for the following:

LPN:

RN:

Provide an overview of workforce capacity initiatives, including recent turnover rates, ratio of service requests to staffing capacity, workforce adequacy evaluation, recruitment initiatives, linguistic or other special capabilities, etc.

What is the pay range for each of the positions listed above in C. 1-4?

Provide a detailed, concrete description of how staffing is managed day-to-day, including scheduled and unscheduled worker absences, ensuring service to Risk Level 1 and 2 as well as other high need consumers, orientation of substitutes, notifications, evening and weekend coverage, etc.

What percentage of your direct care workforce is available to work the following schedules:

Evenings:

Overnights:

Weekends:

Describe your agency process for maintaining a current list of Risk Level 1 and 2 consumers that is accessible in the event of an emergency.

II. Staff Qualifications

Describe in detail the qualifications (professional experience, education, licensure, etc.) for the following staff:

Coordinators

Field supervisors

List the name, title, licensure (if any), and date(s) of training for all employees who have attended the Habilitation/Train the Trainer program given by the Alzheimer’s Association, Massachusetts Chapter.

What is the process, including documentation procedures and persons responsible, for verifying the training qualifications of HMPCs and SCHAs?

III. Training and In-Service Education

Describe your agency’s training facilities for HMPCs. If certain that the required facilities are accessed via an arrangement with another organization (e.g., a nursing facility), provide details.

Does your agency provide the initial training mandated by Elder Affairs for:

Homemakers (40 hour training)

Personal Care Homemakers (60 hour training)

Supportive Home Care Aide (87 hour training)

If yes, does your agency currently use the Home Care Aide Council curriculum for HMPCs?

If no, attach a copy of the curriculum in use.

If your agency does provide initial training for HMPCs, describe the in-house training program, including instructors and their qualifications, frequency with which the program is offered, average number of students, approximate completion rate, etc. Provide name person responsible for in-service training.

Attach a copy of the in-service training calendar for the current and previous calendar years. Describe how you ensure employees have the required number of in-service training hours.

Has your agency used the Homemaker Training Waiver Procedure (as outlined by the Home Care Aide Council) within the last two years to exempt an employee from the required basic Homemaker training?

If yes, list the employees:

If your agency provides SHCA-Mental Health, attach a copy of the 12-hour curriculum.

Describe your process for ensuring that all staff understands the requirements of 105 CMR 155.00 and receives mandatory annual training on the topic.

IV. Supervision

Describe the procedures for supervision, including frequency, documentation, and credentials/qualifications of supervisors for each position (direct care, coordinators, supervisors, etc.).

Describe the systems and procedures employed to ensure that services are delivered to consumers as authorized, including telephony, unannounced field visits, quality assurance calls, etc.

For SHCA, provide a detailed description of the supervision and support provided in accordance with the requirements found in Attachment A: Homemaker Standards, including the title and licensure of individuals providing supervision and support. Indicate location of quarterly team meetings and describe process in the event a SHCA is not able to attend.

Describe the supervisory support available to direct care workers during non-business hours, including how supervisors are contacted, the titles and, as applicable, licensure of available supervisors.

Attach a copy of the field supervision report from currently in use for your employees.

Provider employee who completed this form

Name: __________________________________	Date: ____________________

Homemaker/PC/SHCA

Please note the documents and records which will be required for the Consumer files and/or Employee files to be reviewed at the time of On Site Evaluation

CONSUMER Record Review
Provider Date Monitor
ASAP Authorization
Referral date (specify date)
Service start date & termination date, if applicable (specify dates)
Medical/social diagnosis
Relevant consumers info and preferences
Authorized tasks
Progress notes maintained?
PC Care Plan. Date and signature of orientation/review (specify date)
Money handling release form
Comments
NOTE: Shaded data elements are only required in the Consumer File if provider is not on Provider Direct. Otherwise the PD Demonstrator will be asked to illustrate “on screen”.
Name and Position of Provider Direct Demonstrator

Homemaker/PC/SHCA

EMPLOYEE Record Review
Provider Date Monitor
HM/PC/SHCA
start date & termination date, if applicable
Number of references
CORI check
DPH Nurse Aide Check
Physical date
Orientation date (3 hours)
Job description(s)
TB: latest date
OIG monthly checks
HM Training (37 hours) Or Waiver
PC Training (17 +3 hours)
HHA/CNA, etc. Training certificate
Skills/Competency Checklist
RN orientation 1st day of service?
SHCA training certificate	Alzheimer Behavioral	Alzheimer Behavioral	Alzheimer Behavioral	Alzheimer Behavioral	Alzheimer Behavioral
Quarterly Supervisions:
In-service training
Annual performance appraisal
Comments