<p> Habilitation Therapy</p><p>I. General Policies and Procedures</p><p>A. Please describe your qualifications to perform this service.1 List of all persons at your agency who will </p><p> provide Alzheimer’s Coaching, their licensure, and attach copies of training certificates from the </p><p>Alzheimer’s Association.</p><p>B. What is your proposed rate for Habilitation Therapy? a. $ per </p><p>C. Describe your policy for notifying ASAP agency of problems encountered that affect, or would affect, </p><p> completion of the service authorized2: </p><p>D. Describe your procedure/capacity to respond to emergencies3:</p><p>E. Describe the process and tools used to assess the consumer and family. Attach copies of any tools </p><p> referenced. </p><p>1 See Habilitation Therapy, Attachment A, of Provider Agreement & Licenses, Certifications, Accreditation, Permits section of the provider Agreement. </p><p>2 ASAP Vendor Monitoring Manual 3 ibid. Page 1 of 5 Revised 2004 Habilitation Therapy</p><p>F. Describe the process and tools used to create a comprehensive habilitative plan of care. Attach copies of</p><p> any tools referenced. </p><p>G. Describe the process for care plan evaluation and modification.</p><p>H. Describe how Alzheimer’s Coaches will access supervision and consultation.</p><p>I. Describe your agency’s protocols for communication. Include an outline of coordination between the </p><p> consumer/family; BSHC care managers and RNs; and direct care workers, including Supportive Home </p><p>Care Aides.</p><p>Page 2 of 5 Revised 2004 Habilitation Therapy</p><p>J. Enumerate the contents of the consumer record exclusive of information maintained in Provider Direct.</p><p>II. Personnel Procedure</p><p>A. Describe your policy for ensuring that those providing services for BSHC consumers are properly credentialed4: </p><p>Name of Provider employee who completed this form: </p><p>Signature: Date: </p><p>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.</p><p>Employee Records Review</p><p>Provider: </p><p>Date: </p><p>Monitor: </p><p>Start Date5 Termination Date5 Number of reference checks </p><p>Licenses, if appropriate6</p><p>Job Description(s) in file5</p><p>Annual performance appraisal5</p><p>CORI Check7</p><p>Comments</p><p>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</p><p>Page 5 of 5 Revised 2004</p>