Delaware Health and Social Services Division of Public Health APPLICATION FOR HOME HEALTH AGENCY LICENSE AGENCY NAME ________________________________________________________________________ Print AGENCY ADDRESS _____________________________________________________________________ ADDRESS 1 ___________________________________________________________________ ADDRESS 2 ______________________________ __________________ _______________ CITY STATE ZIP CODE ADMINISTRATOR/CEO __________________________________________________________________ Print SERVICES DIRECTOR __________________________________________________________________ Print Delaware Registered Nurse License Number ___________________________________________ PHONE NUMBERS _________________________________ __________________________________ AGENCY PHONE NUMBER AGENCY FAX NUMBER AGENCY TYPE PLEASE CHECK ALL THAT APPLY ______ PRIVATE ______ NOT FOR PROFIT ______ PUBLIC ______ PROPRIETARY ______ SKILLED ______ AIDE ONLY OTHER:______________________________________ GEOGRAPHIC AREA SERVED:_________________________________________________ Print ACCREDITED? ______ YES ______ NO IF YES, NAME OF ACCREDITING ORGANIZATION AND ACCREDITATION EXPIRATION DATE: ____________________________________________________________________________ Print PLEASE ATTACH THE MOST CURRENT COPY OF THE FOLLOWING: 1. A LIST SHOWING THE NAMES AND ADDRESSES OF EACH OFFICER, DIRECTOR, AND OWNER HAVING TEN (10) PERCENT OR MORE INTEREST IN THE AGENCY. 2. A LIST SHOWING THE NAMES AND ADDRESSES OF THE GOVERNING BODY, IF DIFFERENT FROM THE PRECEDING GROUP. 3. ACCREDITING AGENCY(IES) CERTIFICATE(S) 4. ACCREDITING AGENCY(IES) REPORT(S) 5. OTHER: _____________________________________________________________________ _____________________________________________________________________ ****PLEASE COMLETE THE TABLE ATTACHED AND RETURN WITH YOUR APPLICATION**** NAME OF PERSON COMPLETING THIS FORM:______________________________________________ Print TURE:______________________________________________ TITLE:______________________________________________ DATE:_____________________________ CHECKS SHOULD BE MADE PAYABLE TO: DELAWARE DIVISION OF PUBLIC HEALTH INITIAL APPLICATION FEE: $500.00 ANNUAL LICENSURE FEE: $300.00 PLEASE COMPLETE AND RETURN APPLICATION WITH LICENSURE FEE AND ATTACHMENTS TO OFFICE OF HEALTH FACILITIES LICENSING & CERTIFICATION 2055 LIMESTONE ROAD SUITE 200 WILMINGTON DE 19808 12/07 Services Provided Does Are the Number Are the Number Are services Total your services of services of provided by number of company provided persons provided by contractors both caregivers provide by employed contractors? providing employees in each these employees in each each and service services? of the service service contractors? agency? Yes No Yes No Yes No Yes No Licensed Nursing Physical Therapy Speech Therapy Audiology Services Occupational Therapy Nutritional Services Social Services Home health aide Homemaker Companion Services Durable Medical Equipment Intravenous Therapy Respiratory/Inhalation Therapy Pharmaceutical Services Other (please list): Doc. No. # 35-05-20/08/02/51 07/02 Delaware Health and Social Services Division of Public Health HOME HEALTH CARE AGENCY LICENSURE SURVEY FOR AGENCIES PROVIDING HOME HEALTH AIDE SERVICES ONLY License #_____________ Name of Agency:______________________________________________________________ DBA:_________________________________________________________________________ Address:_____________________________________________________________________ _____________________________________________________________________________ Please (check) _____ if this is a new address Name of Administrator:_______________________________________________________ Enclose a copy of Administrator’s resume. Date of Hire:_____________________ Services Director :__________________________________________________________ Enclose a copy of Service Director’s resume. Date of Hire:___________________ Has there been a change of ownership since the last survey? _____ Yes _____ No If yes, give date:______________ Does this agency have branches? ______ Yes ______ No If yes, attach a separate sheet of paper with date opened and address for each branch. Name of Contact Person if any Questions:___________________________________ Title:________________________________________ Phone Number:________________________________ LICENSURE SURVEY QUESTIONS All home health agencies providing home health aide services exclusively are required to meet the Delaware State Board of Health Rules and Regulations Pertaining to Home Health Agency Licensure, Sections 65.0 – 65.3 and 65.8 –65.11. 1. List the number of unduplicated intermittent unskilled patients admitted in the previous 12 months. Census:_______________________ 2. (a) Outline the organization and services of the state licensed home health agency (HHA) program (Ref. 65.8). Respond by listing services you provide attaching organizational chart(s) and report any changes in your organization that may have occurred since the last report. Exhibit 2A – Listing of Services 2B – Organizational Chart(s) including branches 2C – Changes in Organization (if applicable) (b) Please include copies of portions of agency documents such as governing body minutes that show: budget approval, approval of annual program evaluation and appointment of any new administrator since last state agency survey. (Ref. 65.8) Exhibit 2D – Portions of agency documents 3. (a) Date of last survey: Onsite ____________ Paper ___________ If changes have occurred in your agency since your last on-site or off-site survey, briefly describe the coordination of care for patients who receive home health aide services. (Ref. 65.9C) (b) Date of your last program evaluation _______. Please attach a summary of your last annual program evaluation. Identify what steps you took to resolve any problems. What were the results of your efforts? (Ref. 65.8I) Exhibit 3A – Attach a list of members involved in the evaluation 3B – Attach a list of findings and recommendations 3C – What follow-up is being done or planned to be done? 4. If changes have occurred in the policies for the establishment of the Plan of Treatment since your last survey (paper or on-site), please attach those policies. (Ref.65.9B) HOME HEALTH AIDE SERVICES 1. Home health aide services are provided directly ____, by contract _____, or both _____ ? 2. Provide evidence that the home health agency ensures that individuals who furnish home health aide services on behalf of the agency meet competency evaluation and skills assessment requirements. If changes have occurred since your last paper or on-site survey, please include sample copies of competency test and skills assessment. (a) Attach a listing of all home health aide inservices conducted in the previous year with attendance sheets. (b) Have all home health aides received quarterly in-service training in the previous 12 months? _____ YES _____ NO Explain a “no” response. NOTE: PLEASE COMPLETE LICENSURE RENEWAL APPLICATION AND AFFIRMATION BELOW Application is made to operate a home health agency in accordance with Chapter 16 Delaware Code §122(3)(n) and the Delaware State Board of Health Rules and Regulations Pertaining to Home Health Agency Licensure. I attest that all employees/contractors have had a criminal background check, drug testing, child and adult abuse checks as required in Chapter 11 Delaware Code §8563 and §8564; Chapter 16 Delaware Code §1141 and §1142; and Chapter 19 Delaware Code §708. I affirm that all of the information provided herein is COMPLETE and true. Incomplete or inaccurate information IS REASON FOR NON-RENEWAL OF THE AGENCY’S LICENSE. I further agree to conduct said agency in accordance with the laws of the State of Delaware and with the rules and regulations of the Department of Health and Social Services, Division of Public Health. _________________________________________________________________________ Signature of Agency Administrator ______________________ Date Doc. No. 35-05-20/08/02/52