agy 1314 non certified

7/30/2019 AGY 1314 Non Certified

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HOME CARE ALLIANCEM A S S A C H U S E T T Sof

AGENCY MEMBERSHIP APPLICATION(Non-certifed, Private Duty, Associated, or Limited Member)

Membership Year Ending June 30, 2014Agency Membership in the Home Care Alliance o Massachusetts, Inc. is open to any provider o home care servicesconducting business in Massachusetts. This orm is only or members that are not Medicare Certied; to download the ap

plication or Medicare Certied agencies, visit www.thinkhomecare.org/joinand download the application.

Contact Inormation

Primary Fax # Reerral Fax # (only i dierent than primary)

Agency Name (required) CEO/President/Primary Contact/Voting Member (required)

Street Address (required) City, State, Zip

Primary Telephone # (required) Toll Free/Reerral Telephone # (only i dierent than primary)

Primary Contact Email Address (required)Website

Twitter Handle Publicly Displayed Email Address (only i dierent rom primary)

@

2. What was your total home carerevenue during the most recent FY?

$ (required)

Defnitions

NON-CERTIFIED AGENCIES are organizations, programs, or agencies which is engaged in the provision o health or supportive homecare service, such as a hospice, home care aide program, private care agency, home care program, inusion therapy company or simi-lar service.

ASSOCIATE AGENCIES are within the same corporate-like structure as another Agency member, but with a separate legal identityAll Agency members with certied aliates that meet the denition o an Associate member are required to have a separate Associatemembership or each certied aliate. An Associate member must be related to a Certied Agency member in good standing.

LIMITED MEMBERS are neither located, nor doing business, in Massachusetts. Limited members have no voting rights.

1a. Member Category:

(required, select one; definitions below)

□ Non Certied Agency

□ Associate Agency

□ Limited Agency

1b. Agency Type:(required, select one)

□ Proprietary, chain/ranchise

□ Proprietary, reestanding

□ Proprietary, hospital based

□ Proprietary, health syst.□ Non-prot, reestanding

□ Non-prot, health system

□ A hospital department

Agency Basics

www.

http://www.thinkhomecare.org/join

http://www.thinkhomecare.org/join



Ownership & Sta

□ Adaptive Equipment□ Adult Day Health□ Alz./Dementia Care□ Appointment Escorts□ Care Management□ Chores & Cleaning□ Companions□ CWOCN

□ Durable Med. Equip.□ Home Modication□ Homemaking□ Hospice□ Intravenous Therapy□ Live-in Aides□ Matern. & Child Health□ Medical Social Work

□ Medication Mngmnt□ Nursing□ Nutritionist□ Occupational Therapy□ Pain / Palliative Care□ Pediatric Nursing□ Personal Care / HHA□ Pers. Emrg. Rsp. Sys.

□ Physical Therapy□ Private Duty Nursing□ Psychiatric Nursing□ Respiratory Therapy□ Speech/Lang. Therapy□ Stang□ Telehealth Monitoring□ Transportation

3. Check all services that your agency provides:

4. Describe your agency in 200 characters or less for our directories:It is not necessary to repeat your contact inormation, Accreditation status, or any o the services listed above. The Alliance reserves the right to editany description over the 200-character limit; a character is any keystroke, including spaces and punctuation.

__________________________________________________________

__________________________________________________________

__________________________________________________________

CEO: ________________________________________

email: __________________________________

CFO: ________________________________________

email: ___________________________________

Clinical Director: _______________________________

email: __________________________________

Medical Director: _______________________________

email: __________________________________

QI Manager: __________________________________

email: __________________________________

Private Care Mngr: _____________________________

email: __________________________________

HC Aide Mngr: ________________________________

email: __________________________________

Rehab Serv. Mngr: _____________________________

email: __________________________________

HR Manager: _________________________________

email: ___________________________________

Marketing/PR/Sales Mngr.: _______________________

email: ___________________________________

Maternal/Child Health Mngr.: _____________________

email: ___________________________________

Mental Health Manager: _________________________

email: __________________________________

IS Manager: __________________________________

email: __________________________________

Soc. Work Manager: ____________________________

email:

Education Manager: ____________________________

email: __________________________________

Owner 1 Owner 2 Owner 3 Owner 4

5. Individuals or entities that own a 25%+ stake in this agency:

List all applicable employees’ names and email addresses below. Each will receive a unique www.thinkhomecare.org prole, allowing them to register or events, receive discounts, and access our weekly newsletter, Update .

I all your employees have the same email domain, list it here @_________________________________________

6. Leadership & Key Employees

http://www.thinkhomecare.org/

http://www.thinkhomecare.org/



Branches & Service Area

Satellite branches must be wholly owned by your agency and have their revenue count toward your revenue on page 1.

Branch 1: __________________, _______________________________, (______) _______ — __________City Street Address Telephone





Barnstable Cty

□ Barnstable□ Bourne□ Brewster□ Chatham□ Dennis□ Eastham□ Falmouth□ Harwich□ Hyannis□ Mashpee□ Orleans□ Provincetown□ Sandwich□

Truro□ Wellfeet□ Yarmouth

Berkshire Cty

□ Adams□ Alord□ Becket□ Cheshire□ Clarksburg□ Dalton□ Egremont□ Florida□ G. Barrington

□ Hancock□ Hinsdale□ Lanesbrough□ Lee□ Lenox□ Monterey□ Mt. Washing.□ N. Ashord□ N. Marlborgh□ No. Adams□ Otis□ Peru□ Pittseld□ Richmond□

Sandiseld□ Savoy□ Sheeld□ Stockbridge□ Tyringham□ Washington□ W. Stckbrdge□ Williamstown□ Windsor

Bristol Cty

□ Acushnet□ Attleboro□ Berkley

□ Dartmouth□ Dighton□ Easton□ Fairhaven□ Fall River□ Freetown□ Manseld□ N. Bedord□ N. Attleboro□ Norton□ Raynham□ Rehoboth□ Seekonk□ Somerset□

Swansea□ Taunton□ Westport

Dukes Cty

□ Aquinnah□ Chilmark□ Edgartown□ Gosnold□ Oak Blus□ Tisbury□ W. Tisbury

Essex Cty

□ Amesbury□ Andover□ Beverly□ Boxord□ Danvers□ Essex□ Georgetown□ Gloucester□ Groveland□ Hamilton□ Haverhill□ Ipswich□ Lawrence□

Lynn□ Lynneld□ Manchester□ Marblehead□ Merrimac□ Methuen□ Middleton□ Nahant□ Newbury□ Newburyport□ N. Andover□ Peabody□ Rockport

□ Rowley□ Salem□ Salisbury□ Saugus□ Swampscott□ Topseld□ Wenham□ W. Newbury

Franklin Cty

□ Asheld□ Bernardston□ Buckland□ Charlemont□ Colrain

□ Conway□ Deereld□ Erving□ Gill□ Greeneld□ Hawley□ Heath□ Leverett□ Leyden□ Monroe□ Montague□ New Salem□ Northeld

□ Orange□ Rowe□ Shelburne□ Shutesbury□ Sunderland□ Warwick□ Wendell□ Whately

Hampden Cty

□ Agawam□ Blandord□ Brimeld□ Chester□ Chicopee

□ E. Longmdw□ Granville□ Hampden□ Holland□ Holyoke□ Longmdow□ Ludlow□ Monson□ Montgomery□ Palmer□ Russell□ Southwick□ Springeld

□ Tolland□ Wales□ W Springeld□ Westeld□ Wilbraham

Hampshire Cty

□ Amherst□ Belchertown□ Chestereld□ Cummington□ Easthampton□ Goshen□ Granby□ Hadley

□ Hateld□ Huntington□ Middleeld□ Northampton□ Pelham□ Plaineld□ South Hadley□ Southampton□ Ware□ Wsthampton□ Williamsburg□ Worthington

7. Satellite Branches

Please select the cities and towns your agency provides service in or use in our online and print directories. You maylist your agency in up to 25 towns at no charge; or each additional town or city beyond the rst 25, there is a $10 ee.

The Alliance lists all towns in Massachusetts plus major Boston neighborhoods and Hyannis; or all other unincorporatedvillages and census designated places, simply select the appropriate city or town.

9. Services Area Cities & Towns

□ This agency qualies or long term care insurance

reimbursement.

8. Private Care Options

□ There is a minimum visit length or our services,

which is _____ hrs.



# O Cities/Towns Selected Above

— 25 (Complimentary Towns)

Number o Additional Towns

X $10 (Price Per Town)

Additional Town Subtotal

Middlesex Cty

□ Acton□ Arlington□ Ashby□ Ashland□ Ayer□ Bedord□ Belmont□ Billerica□ Boxborough□ Burlington□ Cambridge□ Carlisle□ Chelmsord□ Concord□ Dracut□ Dunstable

□ Everett□ Framingh.□ Groton□ Holliston□ Hopkinton□ Hudson□ Lexington□ Lincoln□ Littleton□ Lowell□ Malden

□ Marlborgh□ Maynard□ Medord□ Melrose□ Natick□ Newton□ N. Reading□ Pepperell□ Reading□ Sherborn□ Shirley□ Somerville□ Stoneham□ Stow□ Sudbury□ Tewksbury□ Townsend□

Tyngsborgh□ Wakeeld□ Waltham□ Watertown□ Wayland□ Westord□ Weston□ Wilmington□ Winchester□ Woburn

Nantucket Cty

□ Nantucket

Norolk Cty

□ Avon□ Bellingham□

Braintree□ Brookline□ Canton□ Cohasset□ Dedham□ Dover□ Foxborough□ Franklin□ Holbrook□ Medeld□ Medway□ Millis

□ Milton□ Needham□ Norolk□ Norwood□ Plainville□ Quincy□ Randolph□ Sharon□ Stoughton□ Walpole

□ Wellesley□ Westwood□ Weymouth□ Wrentham

Plymouth Cty

□

Abington□ Bridgewater□ Brockton□ Carver□ Duxbury□ E. Bridgewtr□ Haliax□ Hanover□ Hanson□ Hingham□ Hull□ Kingston

□ Lakeville□ Marion□ Marsheld□ Mattapoisett□ Middleboro□ Norwell□ Pembroke□ Plymouth□ Plympton□ Rochester

□ Rockland□ Scituate□ Wareham□ W Bridgewtr□ Whitman

Suolk Cty

□ Allston□ Boston□ Brighton□ Charlestwn□ Chelsea□ Dorchester□ East Boston□ Hyde Park□ Jamaica Pl.□ Mattapan□ Revere

□ Roslindale□ Roxbury□ So. Boston□ W. Roxbury□ Winthrop

Worcester Cty

□ Ashburnhm□ Athol□ Auburn□ Barre

□ Berlin□ Blackstone□ Bolton□ Boylston□ Brookeld□ Charlton□ Clinton□ Douglas□ Dudley□ E Brookeld□ Fitchburg□ Gardner□ Graton□ Hardwick□ Harvard□ Holden□ Hopedale

□ Hubbardst.□ Lancaster□ Leicester□ Leominster□ Lunenburg□ Mendon□ Milord□ Millbury□ Millville□ N. Braintree□ N. Brookfd

□ Northboro□ Northbridge□ Oakham□ Oxord□ Paxton□ Petersham□ Phillipston□ Princeton□ Royalston□ Rutland□ Shrewsbury□ Southboro□ Southbridge□ Spencer□ Sterling□ Sturbridge□ Sutton

□ Templeton□ Upton□ Uxbridge□ Warren□ Webster□ W Boylston□ W Brookfd□ Westboro□ Westminstr□ Winchendn□ Worcester

9. Services Area Cities & Towns (continued)

10. Town Calculator



The Home Care Alliance o Massachusetts exists to support and empower our members to advance in-home care asthe therapeutic, compassionate, and client-preerred care choice o the uture. Its Board o Directors adopted this Codeo Business Ethics on May 11, 2011 as a statement that the Alliance and its member agencies stand or integrity andstrive to maintain the highest ethical standards. Compliance with the principles set orth in this code is a condition

o Agency membership.

Client/Patient Rights1. Each client/patient is treated with courtesy and respect. Clients have the right to be inormed concerning their

care, and to participate in planning and approving the care they receive. Clients’ wishes and preerences arehonored whenever possible.

2. Client privacy is careully guarded. Personal inormation is used only as needed or care planning and provi-sion, insurance eligibility, billing, and necessary business operations. Personal inormation is never shared withunauthorized individuals or discussed in public.

3. Oral and written statements to clients and to the public honestly and accurately represent services, benets,costs, and provider capability.

4. The agency has a procedure to accept, investigate, and respond to client complaints. Clients can le complaintswithout ear o retaliation.

5. The agency does not solicit or permit an employee to solicit clients or its services through coercion or harass-

ment.6. The agency makes reasonable eorts to ensure that clients have their on-going home care needs addressedand, whenever reasonably possible, gives advance notice beore discontinuing services.

Quality Standards

1. The agency ensures that all caregiving sta are properly qualied, adequately trained, and periodically super-vised to meet the needs o the clients they serve. The agency ensures that employees get continuing educationand in-service training to update their knowledge and skills.

2. The agency conducts a criminal background check and checks reerences or all caregiving sta beore they areassigned to provide care.

3. The agency develops a written plan o care, service plan, or care plan or each o its clients, and gives a copy othat plan to the client. Services comply with accepted standards o quality and proessional practice.

4. The agency perorms periodic supervisory visits or each o its clients to ensure that care is being provided con-sistent with the written plan o care, and that it is updated as necessary.

5. The agency has procedures to provide on-call or back-up sta to ll in or caregiving sta in case o illness oremergencies.

6. The agency has a written procedure in place to respond switly and compassionately whenever client abuse,neglect, or thet is suspected or alleged.

Business Practices

1. The agency conducts business in accordance with air business practices and complies with all applicable eder-al, state and local laws and regulations, including wage and hour, workers compensation, and anti-discriminationlaws.

2. The agency directly employs not less than 90% o all caregiving sta, or contracts with other agencies that di-rectly employ their workers. Caregiving sta are not treated as independent contractors.

3. The agency maintains comprehensive general liability insurance covering its employees while they are providingservices to its clients.

4. The amount billed or paid or goods and services is commensurate with the amount and type o goods and ser-vices provided. The agency does not engage in raud.

5. The agency does not, either directly or indirectly, solicit, oer, receive or provide illegal compensation, gits, kick-backs or ees to or rom any person or entity or the purpose o inducing or infuencing such person or entity toobtain reerrals rom or reer clients to the agency.

6. The agency does not require caregiving sta to agree to a non-compete clause as a condition o employment.7. The agency maintains records o all care and services provided and the client’s response to the care and ser-

vice.

Code o Business Ethics

agy 1314 non certified

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