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["Agency Name: "]
["Agency Contact Name:"]
["Agency Contact E-mail Address:"]
["Agency Contact Phone Number:"]
["Date Submitted: "]
["Date Review Completed:"]
["Review Completed By:"]
[]
["3345 Personal Assistance Services Agencies (PASA) Part 1\nOffice of Health Facilities Licensing and Certification (OHFLC)\nDocument Compliance Checklist"]
[]
[]
["Directions:"]
["Agencies  seeking licensure must provide evidence of compliance through documentation.  This documentation will include, but is not limited to, policies, procedures, handbooks and forms."]
["Please develop your documentation in accordance with the regulations found at: "]
["OHFLC WEBSITE"]
["Prepare your documentation as follows:"]
["· Develop the policy/document which establishes compliance with the regulation."]
[]
["• Number all pages of the submission (i.e. 1, 2, 3, 4, etc.) and organize the submission in numerical order."]
["• In the column of this document entitled \"Page Number\", write the page number of your submission that contains the language that demonstrates compliance with that specific regulation. The Office of Health Facilities Licencing and Certification (OHFLC) will review and mark met or not met the compliance for those specific regulations with comments. "]
[]
[" \n\t"]
["DHSS_DHCQ_OHFLCFax@delaware.gov"]
["Upon receipt of your \"Document Compliance Checklist\" and notification:"]
[]
["· Prepare and deliver your document submission, initial licensure application and initial licensure fee (Certified Check or Money Order) payable to:  State of Delaware when complete."]
["Address:  OHFLC at 263 Chapman Road, Suite 200, Newark, DE 19702"]
["• The OHFLC will retain all of the documents."]
["**** Please note ****"]
[" "]
["• The initial licensure fee is not refundable"]
["Please update OHFLC with any change of contact information"]
["Do not spend any money on business license, insurance, office space, hiring personnel, etc. until you are recommended for licensure by our office."]

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["Regulation \nNumber ","Licensure Application Part 1","Page\n Number(s)","Met","Not\n Met","Comments or Instructions "]
["2.2.2","Part 1 Application for Personal Assistance Services Agency",null,null,null,"•\n•\n•\n"]
["2.2.2.1","Names, addresses and types of  agencies  owned or managed by the applicant;",null,null,null,"• \n•\n•\n"]
["2.2.2.3.4","Identity of: Proof of not-for-profit status if claiming tax-exempt status; and,",null,null,null,"• \n•\n•\n"]
["2.2.2.3.5","Identity of: Any officers/directors, partners, or managing members, or members of a governing body who have a financial interest of five percent (5%) or more in a licensee's operation or related businesses;",null,null,null,"• \n•\n•\n"]
["Regulation Number ","Regulatory Requirement","Page\n Number(s)","Met","Not \nMet","Comments or Instructions "]
[3.2,"Policy regarding the rights and responsibilities of consumers",null,null,null,"• \n•\n•\n"]
[3.3,"Policy that addresses the handling and documentation of incidents, accidents and medical emergencies",null,null,null,"• \n•\n•\n"]
[3.5,"Policy which controls the exposure of consumers and staff to persons with communicable diseases",null,null,null,"• \n•\n•\n"]
[3.6,"Procedure including consumers and families right to report concerns/complaints to the Department at a telephone number established for that purpose, if any, to have their concerns addressed without fear of reprisal\n",null,null,null,"• \n•\n•\n"]
["3.10","Policies and an operational system which assure uninterrupted implementation of the service plan. At a minimum: 1) maintain a sufficient pool of qualified direct care workers to fulfill service plans and provide scheduled services; and 2) develop and maintain a back-up system to provide substitute direct care workers (DCWs) if regularly scheduled direct care workers are unavailable.",null,null,null,"• \n•\n•\n"]
["4.3.1","The PASA shall have written policies regarding qualifications, responsibilities and requirements for employment/referral for each job classification.\n",null,null,null,"• \n•\n•\n"]
["4.3.2.1","Written policies shall include: Pre-employment/referral requirements",null,null,null,"• \n•\n•\n"]
["4.3.2.2","Written policies shall include: Position descriptions",null,null,null,"• \n•\n•\n"]
["4.3.2.3","Written policies shall include: Orientation policy and procedure for all direct care workers",null,null,null,"• \n•\n•\n"]
["4.3.2.4","Written policies shall include: Annual performance review and competency testing policy and procedure",null,null,null,"• \n•\n•\n"]
["4.3.2.5","Written policies shall include: Program review and evaluation of the program",null,null,null,"• \n•\n•\n"]
["4.5.2.1","Orientation Program must include: Organizational structure of the agency",null,null,null,"• \n•\n•\n"]
["4.5.2.2","Orientation Program must include: Agency consumer care policies and procedures",null,null,null,"• \n•\n•\n"]
["4.5.2.3","Orientation Program must include: Philosophy of consumer care",null,null,null,"• \n•\n•\n"]
["4.5.2.4","Orientation Program must include: Description of consumer population and geographic location served",null,null,null,"• \n•\n•\n"]
["4.5.2.5","Orientation Program must include: Consumer rights (See Regulation 6.0)",null,null,null,"• \n•\n•\n"]
["4.5.2.6","Orientation Program must include: Agency personnel and administrative policies",null,null,null,"• \n•\n•\n"]
["4.5.2.7","Orientation Program must include: Principles of good nutrition",null,null,null,"• \n•\n•\n"]
["4.5.2.8","Orientation Program must include: Process of growth, development and aging",null,null,null,"• \n•\n•\n"]
["4.5.2.9","Orientation Program must include: Principles of Infection Control",null,null,null,"• \n•\n•\n"]
["4.5.2.10","Orientation Program must include: Observation, reporting and documentation of consumer status",null,null,null,"• \n•\n•\n"]
["4.5.2.11","Orientation Program must include: Maintaining a least restrictive environment",null,null,null,"• \n•\n•\n"]
["4.5.2.12","Orientation Program must include: Verbal/non-verbal communication skills",null,null,null,"• \n•\n•\n"]
["4.5.2.13","Orientation Program must include: Principles of body mechanics",null,null,null,"• \n•\n•\n"]
["4.5.2.14","Orientation Program must include: The needs of the elderly and persons with disabilities",null,null,null,"• \n•\n•\n"]
["4.5.2.15","Orientation Program must include: Activities of daily living",null,null,null,"• \n•\n•\n"]
["4.5.2.16","Orientation Program must include: Introduction to common assistive technology",null,null,null,"• \n•\n•\n"]
["4.5.2.17","Orientation Program must include: Meal planning, food purchasing and preparation of meals, including special diets",null,null,null,"• \n•\n•\n"]
["4.5.2.18","Orientation Program must include: Information on the emotional and physical problems accompanying illness, disability of aging",null,null,null,"• \n•\n•\n"]
["4.5.2.19","Orientation Program must include: Principles and practices in maintaining a clean, healthy, pleasant and safe environment that encourages morale building and self-help",null,null,null,"• \n•\n•\n"]
["4.5.2.20","Orientation Program must include: Items requiring referral to the PASA, including changes in the consumer’s condition or family situation",null,null,null,"• \n•\n•\n"]
["4.5.2.21","Orientation Program must include: Confidentiality of consumer information",null,null,null,"• \n•\n•\n"]
["4.5.2.22","Orientation Program must include: Service plan specific description",null,null,null,"• \n•\n•\n"]
["4.5.2.23","Orientation Program must include: Applicable state regulations governing the delivery of personal assistance services to consumers",null,null,null,"• \n•\n•\n"]
["4.5.2.24","Mandatory dementia specific training must include: communicating with persons diagnosed as having Alzheimer’s disease or other forms of dementia; the psychological, social, and physical needs of those persons; and safety measures which need to be taken with those persons. ",null,null,null,"• \n•\n•\n"]
["4.5.3","A copy of the competency test with questions addressing the competencies listed in 4.5.2.",null,null,null,"• \n•\n•\n"]
["5.1.1","Policies governing intake procedures of consumers to agency services, referral to direct care worker and case closures\n",null,null,null,"• \n•\n•\n"]
["5.1.4.1","Consumer Agreement Form must: Specify the services to be provided by the agency, including but not limited to: scheduled days, scheduled hours, transportation agreements as appropriate, emergency procedures and procedures for termination of services.",null,null,null,"• \n•\n•\n"]
["5.1.4.2.1","Consumer Agreement Form must: Specify financial agreement which shall minimally include: A description of services purchased and the associated cost;\n",null,null,null,"• \n•\n•\n"]
["5.1.4.2.2","Consumer Agreement Form must: Specify financial agreement which shall minimally include: An acceptable method of payment for these services",null,null,null,"• \n•\n•\n"]
["5.1.4.2.3","Consumer Agreement Form must: Specify financial agreement which shall minimally include: An outline of the billing procedures.",null,null,null,"• \n•\n•\n"]
["5.4.3","Provide an attestation that your agency plans to have DCW's participate in medication administration or an attestation that you are not participating in Medication administration and only doing medication reminders. If not participating, place N/A in the page number section and skip 5.4.3.1 through 5.5.2.5.2",null,null,null,"• \n•\n•\n"]
["5.4.3.1","If medication administration services are provided to the consumer, need a written policy regarding medication administration authorized by a responsible caregiver who has capacity to authorize the administration of prescription and/or non-prescription medication",null,null,null,"• \n•\n•\n"]
["5.4.3.1.1","An agreement form signed by the responsible caregiver who has capacity to authorize the administration of prescription and/or non-prescription medication and PASA agency regarding the administration of medication. The agreement must include confirmation by the responsible caregiver that both the medication to be administered and the process for administering the medication are safe and appropriate.",null,null,null,"• \n•\n•\n"]
["5.4.3.1.2","Medication policy must include the responsible caregiver provides prepackaged medication to be given by the DCW by date and time and provides DCW with written instructions regarding the administration procedure",null,null,null,"• \n•\n•\n"]
["5.4.3.1.2.1","Policy includes each medication must be packaged separately and labeled with the consumer name, medication name, medication dosage and date and time to be administered. The responsible caregiver may decide which medication is to be given to the adult consumer by the DCW.",null,null,null,"• \n•\n•\n"]
["5.4.3.1.3  & 5.43.1.4","Policy must include the routes of medication that are not to be administered: Injection; Intravenous therapy; Through the rectum or vagina; Through a catheter; or Through a feeding tube, including nasogastric, gastrostomy, or jejunostomy tube. Medications listed as Schedule II or Schedule IV under Subchapter 11 of Chapter 47 of Title 16 of Delaware Code may not be administered by a DCW.",null,null,null,"• \n•\n•\n"]
["5.5.2.5.1 & 5.5.2.5.2","A medication form which shall be part of the consumers record that includes in the documentation: the DCW who administers medication to the consumer, medication name, dosage, date and time administered. ",null,null,null,"• \n•\n•\n"]
["5.5.10","Policy regarding the authentication of any computerized records.",null,null,null,"• \n•\n•\n"]
["5.5.11","Policy regarding the use and removal of records and the conditions for release of information. ",null,null,null,"• \n•\n•\n"]
["6.4","Policy regarding the prompt resolution of consumer grievances which must include: the procedure for the submission of written or verbal grievances; the timeframes for review of the grievance and the provision of a response; and a written notice that contains the agency contact person, steps taken on behalf of the consumer to investigate the grievance, the results of the process and date of completion. ",null,null,null,"• \n•\n•\n"]
["8.0","Each agency shall prepare and maintain a comprehensive emergency management plan that is consistent with the national standards and shall include all of regulations from 8.2 ",null,null,null,"• \n•\n•\n"]
["8.3","Orientation Program must include: orientation to the disaster preparedness plan for all agency employees/contractors",null,null,null,"• \n•\n•\n"]
[null,"Please also e-mail your emergency management plan to: DHSS_DHCQ_OHFLCFax@delaware.gov                                                                                                                                                                                                                                                                                                                           "]
[null,"                             Additional Notes:"]

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[]
[]
["\nItems marked \"not met\" did not demonstrate the required regulatory compliance for licensure.  These items must be resubmitted for review no later than _______________________.  If your submission remains non-compliant after the second review, you will have to restart the licensure process and a license will not be issued. "]
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["_____________________________________________          __________________________"]
["                  OHFLC Representative                                                                  Date"]