Written Agreement for PCA Choice

Access North Center for Independent Living of Northeastern Minnesota______http://accessnorth.net Assisting individuals with disabilities to live independently, pursue meaningful goals, and have equal opportunities and choices. HIBBING – 2104 E. 6th Ave. Hibbing, MN 55746 (218) 262-6675 (V/TTY) FAX (218) 262-6677

Agreement between ______(Consumer) and ______The Center for Independent Living of Northeastern Minnesota 2104 E. 6th Ave. Hibbing, MN 55746 (218)262-6675 Purpose: We enter into this agreement for the provision of fiscal intermediary services and supports for PCA services.

Consumer Roles and Responsibilities As a consumer in the PCA Choice Program, I, or my responsible party, agree to the following responsibilities: 1. Accept responsibility for my health and safety, meaning I will find staff or supports that ensures my needs for assistance are met. 2. Recruit and hire my own PCA staff. All staff must pass a criminal background check to ensure they have no prior criminal record which disqualifies them from being employed as a personal care assistant. 3. Ensure that PCA staff hired can adequately perform the tasks and care that I need. 4. Refer individuals to CILNM to fill out necessary forms to be paid as my PCA’s. 5. Ensure that I have adequate backup staff or supports in case a regularly scheduled PCA is unable to come. 6. Provide orientation and training to PCA staff. 7. Hire my own qualified professional (registered nurse or mental health professional) if I would like assistance in supervising/training of PCA staff or developing my service plan based on my doctor’s recommendations and my PCA assessment. 8. Verify and provide documentation of the credentials of my chosen qualified professional if I choose to have one. 9. Provide ongoing supervision, training and evaluation of PCA staff with assistance as needed from my doctor or qualified professional. 10. Monitor time worked, complete time cards, ensure accuracy of time worked and submit time cards for PCA staff or qualified professional to CILNM by alternate Fridays (see payroll schedule) to ensure payment occurs on alternate Fridays. Time cards may be submitted by U.S. mail, fax, or dropped off at the Hibbing CILNM office. 11. Abide by Department of Labor regulations regarding overtime. 12. Terminate PCA staff or qualified professional if necessary. I will immediately notify CILNM when termination occurs, and the effective date of that termination. 13. Monitor the use of my PCA allocated hours to ensure I do not use more then the allocated hours in my service plan. 14. To utilize all funds allotted prior to the end of the service agreement or any excess funds will revert to CILNM at service agreement end. 15. Notify CILNM in writing if I want to terminate this agreement at any time. 16. To renew my medical assistance or any other activity that maintains my eligibility. 17. To Provide CILNM with my care plan. PCA Choice Provider Roles and Responsibilities As your PCA Choice provider, CILNM, we agree to perform the following responsibilities 1. Enroll as a medical assistance fiscal intermediary CILNM with the Minnesota Department of Human Services Provider Enrollment. 2. Obtain releases and submit background checks for all PCA staff referred. 3. Bill the Department of Human Services for personal care assistant and qualified professional (if applicable) services. 4. Pay the personal care assistant(s) at the following rate of pay (SEE INDIVIDUAL PCA WRITTEN AGREEMENT) 5. Pay the qualified professional (if applicable) at the rate of $______per hour. _____ I choose to have CILNM provide the qualified professional. _____ I will be responsible for the qualified professional. 6. Withhold for the applicable benefits for personal care assistants that they arrange for with the CILNM Payroll Administrator. 7. Withhold all applicable state and federal taxes from personal care assistants’ and qualified professional’s paycheck. 8. Arrange for and pay unemployment insurance, employer’s share of payroll taxes, workers compensation and liability insurance for all staff. 9. Monitor the hours worked by personal care assistants and qualified professional (if applicable). 10. Paychecks will be issued at the following times: Alternate Fridays after an initial lag of up to two weeks in pay periods. Paychecks will be issued at the CILNM office, direct deposited or mailed out as arranged with the Payroll Administrator. 11. If a problem occurs with a paycheck, contact the CILNM Payroll Administrator.

As a PCA Choice Program Consumer, I fully understand and demonstrate my acceptance by signing this agreement: I understand that it is my responsibility to track my PCA hour usage. If I authorize PCA’s to work over the number of hours in my service agreement, I am responsible for paying my PCA out of my own pocket. I am also responsible for any related legal action and I hold CILNM harmless.

Regulatory Compliance Both parties are responsible for complying with all rules and regulations related to the PCA program. This includes, but is not limited to: state Vulnerable Adults Act, Data Privacy, PCA regulations, including medication administration, and Department of Labor laws governing overtime, etc.

It is a federal crime to provide false information on PCA billings for medical assistance payment. Your signature (or telephone input when using the Dial n Documents) verifies the time and services are accurate and that the services were performed as specified in the PCA Care Plan.

Cancellation and Amendments Either party may choose to cancel or amend this contract at any time by providing written notice 30 days in advance of contract change.

Signed ______Consumer/Responsible Party Date

Signed ______CILNM Representative Date 5/2008