I. General Policies and Procedures

Habilitation Therapy

A. Please describe your qualifications to perform this service.1 List of all persons at your agency who will

provide Alzheimer’s Coaching, their licensure, and attach copies of training certificates from the

Alzheimer’s Association.

B. What is your proposed rate for Habilitation Therapy? a. $ per

C. Describe your policy for notifying ASAP agency of problems encountered that affect, or would affect,

completion of the service authorized2:

D. Describe your procedure/capacity to respond to emergencies3:

E. Describe the process and tools used to assess the consumer and family. Attach copies of any tools

referenced.

1 See Habilitation Therapy, Attachment A, of Provider Agreement & Licenses, Certifications, Accreditation, Permits section of the provider Agreement.

2 ASAP Vendor Monitoring Manual 3 ibid. Page 1 of 5 Revised 2004 Habilitation Therapy

F. Describe the process and tools used to create a comprehensive habilitative plan of care. Attach copies of

any tools referenced.

G. Describe the process for care plan evaluation and modification.

H. Describe how Alzheimer’s Coaches will access supervision and consultation.

I. Describe your agency’s protocols for communication. Include an outline of coordination between the

consumer/family; BSHC care managers and RNs; and direct care workers, including Supportive Home

Care Aides.

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J. Enumerate the contents of the consumer record exclusive of information maintained in Provider Direct.

II. Personnel Procedure

A. Describe your policy for ensuring that those providing services for BSHC consumers are properly credentialed4:

Name of Provider employee who completed this form:

Signature: Date:

4 ibid. Page 3 of 5 Revised 2004 Habilitation Therapy Please note the documents and records which will be required for the Client files and/or Employee files to be reviewed at the time of On Site Evaluation.

Employee Records Review

Provider:

Monitor:

Start Date5 Termination Date5 Number of reference checks

Licenses, if appropriate6

Job Description(s) in file5

Annual performance appraisal5

CORI Check7

Comments

5 M.G.L. c.149 § 52C 6 Non-Homemaker Provider Agreement, Section 1.1 7 M.G.L. c.6 § 172C Page 4 of 5 Revised 2004 Habilitation Therapy

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