Home Caregiving Client Contract by ywf31408

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									Department of Social and Health Services
AGING AND ADULT SERVICES ADMINISTRATION
Residential Care Services
PO Box 45600
Olympia, Washington 98504-5600
                                                                                   INSTRUCTIONS

                                                        Why must this CEA Form be completed?
                                                        Residential Care Services requires caregiving experience checks on each resident
                                                        manager and entity representative who will have responsibility for the daily
                                                        operations of an AFH. Accurate caregiving experience references will provide
                                                        information related to the direct care experience of the resident manager and entity
                                                        representative. Direct caregiving experience is defined as “having responsibility for
                                                        the caregiving of vulnerable adults and assuring that their personal or special care
                                                        needs were met”. Failure to provide the required information may result in action on
                                                        the AFH license. This requirement is pursuant to RCW 70.128.060(2), RCW 70-
                                                        128.120(10), WAC 388-76-550(3), and WAC 388-76-560(7). CEA Form B, with a
   AFH Caregiving Experience Attestation (CEA) Form B
    For Resident Managers and Entity Representatives




                                                        notarized signature, is the only document that meets the requirement.

                                                        Who must have this CEA Form completed?
                                                        The licensee must assure the CEA Form is completed for each potential resident
                                                        manager and entity representative to verify a total of 320 hours of successful
                                                        experience in a licensed or contracted setting. It may be necessary that more than
                                                        one CEA form be submitted by each resident manager and entity representative, in
                                                        order to document the required 320 hours.

                                                        When must this CEA Form be completed?
                                                        This form must be completed prior to employment of a new resident manager and
                                                        entity representative in an adult family home. “Experienced” resident managers who
                                                        change place of employment after September 1, 2001 are required to meet these
                                                        requirements.

                                                        Who must complete this CEA Form?
                                                        The information provided on the CEA Forms must be supplied by *persons with
                                                        personal knowledge of previous caregiving experience achieved, after age eighteen,
                                                        and provided to vulnerable adults within a **licensed or contracted setting.
                                                        * A former supervisor, a co-worker, or client/resident, or a family member of a
                                                           client/resident
                                                        ** Licensed by state agency for care of vulnerable adults, such as a nursing home,
                                                           boarding home, or adult family home; or having a contract with a recognized social
                                                          service agency for the provision of care to vulnerable adults in a care setting, such
                                                          as intensive tenant support, which has a contract with the Division of
                                                          Developmental Disabilities in DSHS.

                                                        What happens once the form has been completed?
                                                        The person providing the attestation (attester) shall mail the completed, notarized
                                                        CEA Form to the AFH licensee. The AFH Licensee must then retain the CEA
                                                        form(s) on the resident manager and entity representative in the AFH and make
                                                        them available to the licensor upon request.



CEA Form B - June 2002
Department of Social and Health Services
AGING AND ADULT SERVICES ADMINISTRATION
Residential Care Services
PO Box 45600
Olympia, Washington 98504-5600


                                                                                  SECTION 1:
                                                         RESIDENT MANAGER/ENTITY REPRESENTATIVE COMPLETE THIS SECTION

                                                      Check here to indicate whether you are a: ‫ ٱ‬Resident Manager       ‫ ٱ‬Entity Representative

                                                      1. Applicant Name: ____________________________________________________________________

                                                      2. Name of Licensee: ____________________ ________________    (      ) ____________________
                                                                                                                     Area Code/Phone Number
                                                         Address of Adult Family Home: ________________________________________________________

                                                          _________________________________________________________________________________
 AFH Caregiving Experience Attestation (CEA) Form B
  For Resident Managers and Entity Representatives




                                                      3. Have you ever contracted with the State of Washington or another state as an individual provider (COPES,
                                                         CHORE, Medicaid Personal Care)?
                                                         If yes, list county ___________________________ state ____________________________
                                                         AASA and DDD Case Managers cannot serve as references for this purpose.

                                                      4. Have you ever worked in a licensed facility providing care to vulnerable adults?
                                                         If yes, list county _____________________________ state ___________________________
                                                         One of the references must be by a supervisor from that licensed facility.

                                                                                            SECTION 2
                                                                                  ATTESTER COMPLETE THIS SECTION

                                                      All information in this section must be provided by the attester based upon his/her personal knowledge
                                                      (supervised/observed) of care provided in a licensed or contracted working environment** (see page one)
                                                      Write N/A (not applicable) for areas that do not apply.
                                                      1. Your Name: _________________________________________ Title or role: _____________________

                                                      2. Please provide two phone numbers where you can be reached between 8 AM and 5 PM weekdays.
                                                         What is the best time to call during these hours? ____________________

                                                        (        ) _______________________               (        ) ___________________________
                                                        Area Code/Phone Number                           Area Code/Alternate Phone Number

                                                      3. How do you know the applicant named above in Section 1, Item 1?
                                                         ‫ ٱ‬Co-worker        ‫ ٱ‬Employer/Supervisor ‫ ٱ‬Client/resident
                                                         ‫ ٱ‬Family member of client/resident

                                                      4. Did you personally observe the applicant providing care to a vulnerable adult? ‫ ٱ‬YES ‫ ٱ‬NO
                                                      5. How do you have knowledge of the applicant’s caregiving experience? How many hours did you spend
                                                         supervising or observing care. Describe the care and services provided:________________________
                                                         __________________________________________________________________________________
                                                         __________________________________________________________________________________




CEA Form B - June 2002
Department of Social and Health Services
AGING AND ADULT SERVICES ADMINISTRATION
Residential Care Services
PO Box 45600
Olympia, Washington 98504-5600


                                                         6. Did primary responsibilities include the provision of direct care and assistance to vulnerable
                                                            adults?        ‫ ٱ‬YES       ‫ ٱ‬NO If no, what other duties___________________________

                                                         7. Did total hours of direct care experience exceed 320 hours? ‫ ٱ‬YES         ‫ ٱ‬NO
                                                            If no, how many hours? ________

                                                         The following questions (#8-10) involve rating the applicant in various areas:
                                                         8. Ability to meet the physical and emotional needs of care recipients:
                                                         ‫ ٱ‬Poor             ‫ ٱ‬Below Average ‫ ٱ‬Average          ‫ ٱ‬Above Average ‫ٱ‬Excellent
                                                          Describe needs and tasks.
                                                         _______________________________________________________________
                                                         ____________________________________________________________________________
    AFH Caregiving Experience Attestation (CEA) Form B
     For Resident Managers and Entity Representatives




                                                         9. Reliability and integrity:
                                                         ‫ ٱ‬Poor              ‫ ٱ‬Below Average ‫ ٱ‬Average          ‫ ٱ‬Above Average ‫ٱ‬Excellent

                                                         10. Ability to follow procedures, guidelines, and instructions:
                                                         ‫ ٱ‬Poor              ‫ ٱ‬Below Average ‫ ٱ‬Average           ‫ ٱ‬Above Average ‫ٱ‬Excellent

                                                         11. Describe any special skills/knowledge the applicant demonstrated in the performance of his/her duties:




                                                         12. Describe any areas where improvement was needed.____________________________________
                                                             _______________________________________________________________________

                                                         13. If the applicant was an employee, why did the applicant leave? _______________________
                                                             If not an employee, check here ‫ ٱ‬N/A

                                                         14. Would you employ this person to be a caregiver for vulnerable adults? ‫ ٱ‬YES ‫ ٱ‬NO
                                                             If no, why not? ______________________________________________________________

                                                         15. Additional comments (attach additional sheets of paper, if needed) _____________________
                                                         _____________________________________________________________________________
                                                                                                 SECTION 3:
                                                                                        SIGNATURES AND NOTARIZATION
                                                         The attester completing this form must sign before a notary public and return the completed, notarized
                                                         form to the AFH licensee (listed under Section 1, Item 2)
                                                         Signature of person completing this form:
                                                         X _______________________________________________ Date ________________________

                                                         Notary Public Signature___________________________ Date ___________________________

                                                         County ________________________________________ My Appointment Expires: ___________


CEA Form B - June 2002

								
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