Client Intake PCA 2022

PCA Recipient Detailed Intake Form
Name*

First nameMiddle Name or N/A if noneLast name
Date of Birth*

MonthDayYear
Date
Social security number*
Gender
Phone or Cell number*
Ok to leave a message on phone?

yesno
Address*
Type entire address with City, State, Zip
Client Email*
example@mybellamail.com
Type of Insurance
Blue Cross, Medica, Ucare, MA etc...
Insurance Member Number
Medical Assistance number
Other insurance information
Legal Status*

Responsible for SelfUnder guardianshipUnder commitment
Legal representative contact information
Name of Legal Rep or Parent

First nameLast name
Address
Type full address including city, state, zip
RP Email
example@example.com
Office number
Cell number
Primary emergency contact information
Name

First nameLast name
Relationship
Address
Type full address including city, state, zip
Emergency Contact Email
example@example.com
Phone Number
Please enter a valid phone number.
Case Manager contact information
Address
Name

First NameLast Name
Case Manager Email
example@example.com
Office number

Medical History
Special dietary needs
Allergies
Health care provider contact information
Primary physician name:
Clinic Name
Address
Type full address including city, state, zip
Phone number
This program is responsible for assisting this person in setting up medical appointments

YesNoOther

Health Insurance Portability and Accountability Act (HIPAA)

Recent federal law, the Health Insurance Portability and Accountability Act (HIPAA), has created new client protections surrounding the use of protected health information. Commonly referred to as the "medical records privacy law," HIPAA provides client protections related to electronic transmission of data, the keeping and use of client records, and the storage and access to health care records. HIPAA applies to all health care providers, including mental health care, and providers and health care agencies throughout the country are now required to provide clients a notification of their privacy rights as it relates to their health care records. You may have already received similar notices such as this one from your other health care providers.

As you might expect, the HIPAA law and regulations are extremely detailed and difficult to grasp if you don't have formal legal training. This Client Notification of Privacy Rights is designed to inform you of your rights in a simple yet comprehensive fashion. Please read this document, as it is important you know what client protections HIPAA affords all of us. In mental health care, confidentiality and privacy are central to the success of the therapeutic relationship and as such, you will find we will do all we can do to protect the privacy of your mental health records. HIPAA requires that we secure your signature indicating you have received or been offered the

Client Notification of Privacy Rights document.
I have accepted a copy of the Client Notification of Privacy Rights document.
Initial Here / copy will be emailed to you
Client or Responsible Party Signature

Clear
Date

MonthDayYear
Date
Client's or Responsible Party Name (print)

Release of Consent
A separate Consent for Exchange of Information form must be completed for each individual or agency you wish for Bella Mente Inc. to communicate with.*

I understand that my records are protected by data practice laws and cannot be released without my consent unless otherwise allowed by law. I understand that only the information and records indicated below will be released or obtained.

Iunderstand that this consent does not authorize the recipient of the information or records to re-disclose the information or records to any other person or facility unless authorized by law. I understand that the information will only be used for the purposes indicated below. Iunderstand that I may withdraw or modify this consent at any time but, that the revocation or modification will not affect any release of information that previously occurred. I understand that this consent with expire and no longer be valid one year from the date it was signed. I understand that the observation and/or assessment can take place in either setting.

Name of Staff: Meghann Lewis, President
To obtain records from or release records to:
Name of Agency
Name of Staff
Type of information released

Medical AssessmentsPublic Health RecordsMedical recordsAllOther:
Information may be shared in person or by mail. I also give permission to share information using the following methods:

FaxEmailPhoneAll
Cient, Parent or Guardian or Authorized Representative

Clear
Date

MonthDayYear
Date

Personal Care Assistance (PCA) Technical Change Request
CHANGE START DATE

MonthDayYear
Date
Member Information (this form will be auto filled with member information)
Program Type

PCA TraditionalPCA Choice
Additional Information
Member or Responsible Party- Required only when "New Provider" change requested
NAME OF PERSON SIGNING (please print)
RELATIONSHIP TO MEMBER
CHANGE START DATE

MonthDayYear
Date
DATE CURRENT PROVIDER WAS NOTIFIED

MonthDayYear
Date
SIGNATURE OF MEMBER OR RESPONSIBLE PARTY

Clear
DATE

MonthDayYear
Date

PCA Client Care Plan
Diagnosis
Care Plan Start Date

MonthDayYear
Date
Care Plan End Date

MonthDayYear
Date
Dressing
Dressing Instruction
Grooming
Grooming Instruction
Bathing
Bathing Instruction
Transfers
Transfer Instruction
Mobility
Mobility Instruction
Toileting
Toileting Instruction
Light Housekeeping
Light Housekeeping Instruction
Laundry
Laundry Instruction
Behavioral
Behavioral Instruction
Health Related
Health Related Instruction
Transportation
Health Related Instruction
Eating
Eating Instruction

Homemaking Services Care Plan
Housekeeping
Housekeeping Instruction
Laundry
Laundry Instruction
Home Management
Home Management Instruction
Health Related Functions
Health Related Instruction

Client will be compliant with services as described in the PCA care plan and will remain safe in the home. Client agrees not to exceed specified hours per period as described in this care plan without agency approval. Client agrees to ensure all timesheets are accurate and fraud free before signing and submitting to Bella Mente Inc. Client as well as PCA understand committing MEDICAID fraud or perjury are crimes punishable by MN State Law including but not limited to felony. Client understands that Bella Mente can discontinue services at any time if fraud or perjury are suspected.

Vulnerable adults may have difficulty reporting these crimes to law enforcement due to a variety of factors, including a lack of awareness that a crime has occurred, limited communication abilities, social isolation, dependence on the perpetrator, or fear of retaliation.

It is the policy of Bella Mente Inc. to protect the adults and children served by this program who are vulnerable to maltreatment and to require the reporting of suspected maltreatment of vulnerable adults and children. Bella Mente reports all serious injuries, a defined, and deaths to the Office of the Ombudsman for Mental Health and Developmental Disabilities.

Bella Mente shall ensure that each new mandated reporter receives an orientation within 72 hours of first providing direct contact services to a vulnerable adult and annually thereafter. The orientation and annual review shall inform the mandated reporter of the reporting requirements and definitions under Minnesota Statutes, sections 626.557 and 626.5572, the requirements of Minnesota Statutes, section 245A.65, Bella Mente's program abuse prevention plan, and all internal policies and procedures related to the prevention and reporting of maltreatment of individual receiving services.
QP Signature

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Date

MonthDayYear
Date
Client/Responsible Party Signature

Clear
Date

MonthDayYear
Date
PCA Signature(s)

Clear
Date

MonthDayYear
Date

PCA Choice Service Agreement

Client, PCA and Company agreement
This agreement is entered into effective thisblanks day of 20
Bella Mente Inc., an enrolled PCA Choice Provider with the state of Minnesota, hereby referred to as "Company" or Bella Mente";
First Name Last Name , hereby referred to as "Consumer" and;
First Name Last Name , hereby referred to as "Responsible Party" (If applicable and, First Name Last Name , hereby referred to as "Personal Care Assistant" or "PCA". We enter into this agreement to provide Personal Care Assistant services for the Consumer.
Consumer (or Responsible Party) Roles and Responsibilities

Asa Consumer using Bella Mente Inc. as my PCA Choice provider, I, or my Responsible Party (if applicable), agree to the following responsibilities:

1.Accept responsibility for my health and safety; meaning I will find staff or supports that ensure my health and safety needs are met. I ensure that I have adequate backup staff or support in case a regularly scheduled PCA is unable to fulfill their duties as scheduled.

2. Develop and revise, as needed, a Consumer Care Plan that details my health, safety and care needs and schedule based on my physician's orders and public health nurse assessment.

3. Recruit, interview and hire my own PCA staff. Before working any shifts, ALL of my staff must pass a criminal background check, facilitated by Bella Mente to ensure they have no prior criminal record that disqualifies them from being employed as a PCA.

4. As a joint employer with Bella Mente, enter into a written agreement with each of my PCAs before I receive their services.

5. Schedule my PCA staff and provide ongoing supervision and evaluation of my PCA staff.

6. Provide information, orientation and training to my PCA staff including safety and emergency procedures in their applicable service/working environment.

7.Provide and maintain my personal emergency contact information and any advance directives (if applicable), to my PCA staff for my own safety. I will also recommend to my PCA that they provide their emergency contact information to utilize in the event of emergency while on the job.

8. Manage the use of my PCA allocated hours/units to ensure I do not use more than allocated in my Service Authorization (SA I will monitor my use of flexible PCA units, and if I run out of units before my services authorization expires, I understand my care services will be suspended until the new SA starts or I will personally pay for my continued care.

9. Abide by Department of Labor regulations and Bella Mente policies regarding overtime.

10. Monitor, ensure accuracy and verify time worked by my PCAs. Sign verified time cards for my PCA staff. Submit time sheets to Bella Mente as outlined in the company policies and procedures.

11. Notify Bella Mente of my in-patient treatment or hospitalization dates throughout our service agreement.

12. Notify the county public health nurse, waiver service coordinator or otherwise appropriate individual when it is time for a reassessment of my need for PCA services or if there is a change in condition or change in the level of services that I need. I will inform them of my intent to use a PCA Choice provider.

13. As joint employers, I will notify Bella Mente prior to terminating any PCAs and inform them of the effective date. I will notify Bella Mente if assistance is needed in terminating an employee.

14. Contact the Bella Mente Program Manager in the event of a billing or payment complaint.

15. Notify Bella Mente in writing if I want to terminate this agreement at any time.

16. Comply with Bella Mente company policies and procedures.
Provider Roles and Responsibilities

As your PCA Choice provider, Bella Mente agrees to perform the following 1. Enroll and meet all standards as a PCA Choice Provider with the Minnesota Department of Human Services, including passing a criminal Background Study (BGS

2.As a joint employer with the Consumer or Responsible Party, enter into a written agreement with each PCA the Consumer chooses to hire before services are provided to the Consumer.

3. Obtain releases, request and secure background checks according to the State of MN human services licensing act for all PCAs referred by Consumer or Responsible Party.

4. Bill the Department of Human Services or appropriate health care plan for personal care assistant services rendered.

5. Pay the PCAs at the rate determined by the Consumer as provided on the Bella Mente PCA Pricing Schedule.

6. Issue paychecks, withhold and remit all applicable state and federal taxes from PCAs paychecks.

7. Arrange for and pay the employers share of payroll taxes, unemployment insurance, workers compensation insurance and liability insurance for all staff.

8. Keep records of the hours worked by PCAs as submitted by the Consumer or Responsible Party.

9. Assist Consumer in terminating PCAs, if requested to do so by the consumer.

10. Assess an administrative fee for the provision of PCA Choice Provider services. (Refer to the PCA Pricing Schedules for current Administrative Fees

11. Ensure arms length transactions and confirm Bella Mente is not related to with the Consumer and PCA.
Personal Care Assistant (PCA) Responsibilities

As a PCA employed by the Consumer and Bella Mente, I agree to the following responsibilities:

1. Enter into a written agreement with the Consumer and Bella Mente, as joint employers, before providing services to the consumer.

2. Complete all required forms and provide necessary information to Bella Mente, including criminal background study release and my Individual PCA Provider ID number prior to providing services to the Consumer.

3. Complete and pass a criminal Background Study with the BCA submitted through Bella Mente, before working any shifts, a requirement of eligibility to be a personal care assistant.

4. Obtain and maintain an active Individual PCA Provider ID number from the Minnesota Department of Human Services. I agree to complete and submit updated registration forms to Bella Mente any time my personal information (legal name, residential address, phone #, etc changes.

5. Obtain training from the Consumer (or Responsible Party), to ensure I can satisfactorily perform all responsibilities in the Consumer's Care Plan. Training includes proper use of equipment, review of care plan, medication procedures, safe transfers, emergency information form and procedures, and any other forms. I agree to communicate with the Consumer (or Responsible Party) directly, regarding any health or training concerns.

6. Provide and maintain my personal emergency contact information to the Consumer (or Responsible Party) for my own safety while on the job.

7.Work at scheduled times as determined by the Consumer, notifying the Consumer of changes as early as possible to arrange for backup assistance.

8. Provide personal care services to the Consumer as specified in their plan of care, following written and verbal directions from the Consumer. Communicate respectfully and directly to the Consumer regarding services.

9.Assist with Activities of Daily Living (ADLs) and Health Related Functions (HRFs) as directed, being observant and staying alert to ongoing instructions by the Consumer. Support the Consumer when they participate in community activities, relationships and involvement with others.

10. Inform the Consumer about all visible bodily changes that may need medical attention.

11. While working within the Consumer's home, maintain respect as a professional and focus on job related activities. Perform duties in an ethical matter, preserving and respecting the rights and dignity of the Consumer. Keep the Consumer's personal life as confidential, respect their personal property and adhere to Bella Mente data privacy policies.

12. Be present when working with the Consumer in their service environment and leave only when the shift is completed.

13. Follow safety and emergency procedures in my applicable service/working environment and work to identify my safety needs and along with those of the Consumer.

14. Accurately document time worked for Consumer by promptly completing and signing time sheets. Submit time sheets to Bella Mente as outlined in the company policies and procedures.

15. Understand that the Consumer's PCA services payment source and authorization is subject to change. If the authorization for services or payment source should stop, services may be suspended or discontinued immediately. The Consumer will be notified by Bella Mente staff and will notify me that services have stopped. No time sheets shall be submitted until services are re-authorized and Bella Mente informs the Consumer that my employment has been re-instated. I also understand that I cannot provide any services when the Consumer is receiving any type of in-patient treatment, in-patient hospitalization or nursing home.

16. Agree to monitor total hours worked with all agencies/consumer: actively employed with. PCAs cannot work more than 16 hours in a 24-hour period with a maximum of 275 hours per month. This is not per Consumer or per Agency, if you work for multiple Consumers or Agencies your totals cannot exceed these limits. PCAs who are found to have violated this policy will be required to reimburse wages paid or have future wages garnished due to exceeding the maximums allowed.

17. Report any service/working environment related injuries or accidents to the Consumer (or Responsible Party) AND Bella Mente Administrative Office within 24 hours of the incident, as outlined in the company policies and procedures.

18. Update Bella Mente staff anytime my status changes (name, address, phone #, tax exemptions, etc

19. Read, understand and comply with current Bella Mente Policies & Procedures. Bella Mente will publish any changes to the Policies & Procedures which are available on our web site.
Grievance Procedures

Bella Mente asks that if any PCA has any concerns they shall bring them up to their manager, the Consumer. Consumers are encouraged to address issues directly with their PCA. If the PCA/Consumer is unable to resolve the issue, they may bring the issue to the Bella Mente Program Manager. Bella Mente is committed to providing a timely response to concerns brought forward.

Regulatory Compliance

Both parties are responsible for complying with all rules and regulations related to PCA Choice. This includes, but is not limited to: State Vulnerable Adults Act, Data Privacy, PCA regulations, and Department of Labor Laws.

Cancellations and Amendments

Employees may resign their employment with the Consumer and Ability Care Partners, as joint employers, at any time for any or no reason, and the Consumer and Bella Mente reserve the same right regarding discontinuation of signed individual's employment. Any party may choose to cancel or amend this agreement at any time.
Signed Consumer / Responsible Party

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Date

MonthDayYear
Date
Provider (Bella Mente Representative)

Clear
Date

MonthDayYear
Date
PCA

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Date

MonthDayYear
Date

PCA Wage Statement
PCA Name
Effective Date

MonthDayYear
Date
These rates remain in effect until further notice and supersede any previously published rates.
Hourly Rate for Personal Care Assistants
Consumer / Responsible Party Signature

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Date

MonthDayYear
Date
PCA Signature

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MonthDayYear
Date
Provider Signature

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MonthDayYear
Date
Should be Empty:

PCA Recipient Detailed Intake Form

Release of Consent

Personal Care Assistance (PCA) Technical Change Request

Member Information (this form will be auto filled with member information)

Member or Responsible Party- Required only when "New Provider" change requested

Completed and Signed by Responsible Party

PCA Client Care Plan

Homemaking Services Care Plan

PCA Choice Service Agreement

PCA Wage Statement