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 SKILLED SERVICES 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:______________________ Supervising Registered Nurse:_________________________________________________ Enclose a copy of Supervising Nurse’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/subunits? _____ Yes _____ No If yes, attach separate sheet of paper with date opened and address for each branch/subunit. Name of contact person if any questions:______________________________________ Title:_____________________________ Phone:____________________________ LICENSURE SURVEY QUESTIONS All home health agencies providing skilled services are required to meet the Delaware State Board of Health Rules and Regulations Pertaining to Home Health Agency Licensure, Sections 1.0 – 7.7.1. 1. List the number of unduplicated intermittent patients admitted in the previous 12 months. Census:_______________________ Skilled:_________________ Unskilled:_______________ 2. (a) Outline the organization and services of the state licensed home health agency (HHA) program (Ref. 4.1). 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 subunits/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, appointment of new members of the group of professional personnel, and appointment of any new administrator since last state agency survey. (Ref. 4.1 – 4.2) Exhibit 2D – Portions of agency documents 3. Date of most recent 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 skilled nursing, other therapeutic services and/or home health aide services. (Ref. 5.4) 4. (a) Provide a listing of members of the Group of Professional Personnel that includes their discipline. How frequently do they meet? Please attach relevant portions of the group minutes (including dates of meetings) showing participation in annual review of agency policies and annual program evaluation. (Ref 4.2 and 4.10.2) Exhibit 4A – Listing of members indicating their discipline 4B – Frequency of meetings 4C – Portions of minutes (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. (Ref. 4.10.2) Exhibit 4D – Attach a list of members involved in the evaluation 4E – Attach a list of findings and recommendations 4F – What follow-up is being done or planned to be done? 5. 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. 5.2). 6. If policy changes related to drug and treatment orders have occurred since your last paper or on-site survey, please provide evidence that agency staff administers drugs and treatments and contracted services only as ordered by the physician. (Ref. 5.3) (Answer narratively or attach relevant portion of policies as Exhibit 6A – Relevant Policies.) HOME HEALTH AIDE SERVICES 1. Home health aide services are provided directly _____ , by contract _____ , both _____ , N/A _____ . 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 and the sign in sheets. (b) All home health aides have received in-service training as required: i) 12 hours per year for federally certified agencies _____ YES _____ NO Explain “No” response ii) Quarterly per year for state licensed agencies _____ YES _____ NO Explain “No” response OR (c) If state licensed only, have all home health aides received quarterly in-service training in the previous 12 months? _____ YES _____ NO Explain “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. # 35-05-20/08/02/57