Thank you for interest and availability to be listed in the DSS Provider Directory. On behalf of the state of Connecticut, we maintain the directory list of active household providers for the Community First Choice (CFC), Connecticut Home Care Program for Elders (CHCPE), and Acquired Brain Injury (ABI) state waiver programs. The CFC Program offers non-medical personal care assistance to individuals 18-65 with various disabilities and the CHCPE Program is for people ages 65 and over. Personal care consists of help with the activities of daily living – assistance with bathing, dressing, feeding, toileting, and transfers. For this program, submit the DSS Provider Directory Application to Allied Community Resources. The ABI Program provides non-medical services, in the community, to individuals who have sustained a brain injury. Under that program, some of the more commonly provided services are:

PCA: Physical assistance with eating, bathing, dressing, personal hygiene, and other ADL’s. Prompting (cues) and/or supervision of these activities is also included. Companion: Non-medical care supervision and socialization with a therapeutic goal. Homemaker: General household activities including meal preparation and routine household chores such as dusting, bed-making, and vacuuming. Chore: Services needed to maintain the individual’s home in a clean, sanitary, and safe condition. Respite: Services provided on a short-term basis only in the individual’s home or place of residence, when the person normally performing such services is absent or in need of relief.

Some services on the ABI program, such as Companion and Respite, require that you attend an Allied Community Resources (ACR) sponsored free, approximately 2.5-hour ABI Basic Information Session on what a brain injury is and how it affects people. This is part of the application process and it is mandatory in order to be considered for these services. We have about 10 informational sessions per month which are held in different areas of the state. For this program submit the ABI Application Supplement. All DSS offices, Care Managers and individuals on the programs have access to this directory, and they will be the ones to initiate contact, interview you and offer employment. ACR will process employment application paperwork, timesheets and make payments to you on behalf of the client with his/her Medicaid program funds. Please Note if Hired: You would not be an employee of Allied Community Resources or the State of Connecticut. You would be a private-household employee of the individual receiving services. ACR would act as the payroll agency only. As an employee, you are not allowed to work more than 40 hours per week for one individual program participant; however, you are allowed to work for more than one individual on any program. The program participant who hires you will direct you on their expectations of the care needed, set your schedule and authorize timesheets submitted for payroll. You will discuss information about your rate of pay and payment schedule with your new potential employer. If you have any questions or need additional information, please do not hesitate to contact us at the number listed above and ask to speak with a Provider Services Program Assistant or the Outreach & Training Coordinator. Thank you for your interest and we are looking forward to working with you!

L16-V 6/18/19

FMS – Provider Services P.O. Box 479, East Windsor, CT 06088-0479 Phone: (860) 627-9500 Fax (860) 627-0230

www.acrfi.org

“Creating Opportunities for People”

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Date: From:

Fax to: 860-627-0230 # of Pages:

DSS Provider Directory Application Packet Cover Sheet

Please carefully review all forms in the enclosed packet. For accuracy, print all information legibly. All applicable forms must be completed and submitted to Allied Community Resources for processing. A representative will call you to review the information prior to creating the directory listing. You may use this page as a cover sheet when mailing or faxing your forms.

1. DSS Waiver Programs - Provider Directory Application – the

information collected on this 2-page form will be used to create the directory of information. Current working phone numbers are required. This information may be forwarded to a program participant interested in hiring you. It is important that you contact Allied periodically to update your contact information as needed to remain on the active provider listing.

2. DSS Waiver Programs - Provider Agreement – by signing this 2-page

form you agree to abide by the Connecticut DSS Waiver Program parameters established for continued employment.

3. DSS Waiver Programs – Provider Services Information – a listing of

the types of services and qualifications required under the Connecticut DSS Waiver Programs. Use the 2nd page, Connecticut Towns by Region, to assist in selecting the towns in which you are willing to work.

4. ABI Application Supplement - Private Providers – complete this 2-page

form only if you are interested in obtaining approval as a provider under the ABI Waiver Program. Service qualifications may be required.

F168-V08/27/15

FMS-Provider Services P.O. Box 479, East Windsor, CT 06088-0479 Phone: (860) 627-9500 Fax: (860) 627-0230

Toll-Free Phone: 877-722-8833

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1

FMS-Applications Department P.O. Box 479, East Windsor, CT 06088-0479 Phone: (860) 627-9500 Fax: (860) 627-0230

Toll-Free: 877-722-8833 www.acrfi.org

Connecticut DSS Waiver Programs - DIRECTORY APPLICATION

The Personal Care Assistance (PCA) Waiver Program and the CT Home Care Program for Elders (CHCPE) provide personal care assistance to eligible individuals. The Acquired Brain Injury (ABI) Waiver Program provides 19 home and community-based services to eligible individuals with an acquired brain injury. In order to be included in the ABI Directory, providers must meet the Department of Social Services requirements for qualification. This application is for the consumer and the fiscal intermediary records and provides information for the Provider Directory for these programs. This application must be completed in full and will be available for review by any program participant. APPLICANT INFORMATION: (Please print clearly)

Please indicate your choice(s) below by checking the applicable boxes.

Yes, I wish to be included on the P.C.A. Provider Directory

Yes, I wish to be included on the A.B.I. Provider Directory* - Some ABI Services require successful completion of the *Please complete supplement. Allied Community Resources sponsored ABI Informational Session.

No, I do not wish to be included in any Provider Directory at this time.

I am under 18 years of age. Providers under 18 years of age cannot work for individuals on the CT Home Care Program for Elders or ABI. SERVICE AREA: PLEASE LIST ALL TOWNS IN WHICH YOU WOULD CONSIDER WORKING - see Enclosure - CT Towns by Region

MY TOWN AND ALL SURROUNDING TOWNS

OR SPECIFY TOWNS:

1. PROVIDER NAME: FIRST MIDDLE LAST

(PLEASE LIST MAIDEN OR FORMER NAMES)

2. ADDRESS:

NO. STREET

CITY STATE ZIP CODE

3. MAILING ADDRESS:

(IF DIFFERENT)

4. Former address, if less than 5 years at above:

5. TELEPHONE: - - 5. FAX NUMBER: - -

6. CELL PHONE: - - 7. E-MAIL ADDRESS:

7. SOCIAL SECURITY NUMBER: - - 8. DATE OF BIRTH*: / / *Required for Criminal Background Check

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2

AVAILABILITY (to be listed on the Directory):

DAYS YOU ARE AVAILABLE TO WORK:

HOURS YOU ARE AVAILABLE TO WORK: ______________________________________________________

ARE YOU WILLING TO PROVIDE BACK UP ASSISTANCE WHEN CALLED (CHECK ONE): YES NO

LANGUAGES SPOKEN (CHECK THOSE THAT APPLY):

ENGLISH SPANISH OTHER (LIST): ________________________________________________

PROVIDER QUALIFICATIONS/EXPERIENCE/EDUCATION:

PLEASE LIST ANY SPECIAL TRAINING, SKILLS, OR CERTIFICATIONS YOU HOLD THAT WOULD PERTAIN TO THE POSITION YOU ARE APPLYING FOR BELOW:

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

PERSONAL OR EMPLOYMENT REFERENCES:

1) Name, address, phone: ____________________________________________________________________

2) Name, address, phone: ____________________________________________________________________

3) Name, address, phone: ____________________________________________________________________

Have you ever been convicted of a felony involving forgery, robbery, larceny, fraud, cruelty to persons, sexual assault, assault, assault of an elderly, blind, developmentally disabled, pregnant or for abuse of the elderly, blind, physically or developmentally disabled person in the United States and/or its territories? Yes No

If you have been convicted of any of the above felonies, you may be restricted from being listed on the Provider Directory. (Failure to disclose any criminal convictions that appear on the Criminal History Background check may prohibit you from being listed on the active Provider Directory or from employment under the DSS Waiver Programs.)

Any provider whose name appears on the list of exclusions of the Office of Inspector General is prohibited from receiving paid services under the DSS Waiver Programs.

By signing and dating below, I understand that a Criminal History Background check will be performed as part of the application process, before my name may be added to the DSS Provider Directory and before I am allowed to be hired by a DSS Waiver Program participant. I attest that all of the information outlined on my application is a true and accurate depiction of my personal information and qualifications. I also authorize full release of information from my listed employers or references.

Provider Name: (please print) ____________________________________________________________________

Provider Signature: __________________________________________ Date Signed: _______________________

Source code:

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Department of Social Services (DSS) Provider Agreement for Providers of Individual, Self-Directed Home

and Community-Based Services to Participants in the Connecticut Medical Assistance Program (CMAP):

Personal Care Attendants (PCAs), Independent Living Skills Trainers, Acquired Brain Injury Companions,

Personal Support Workers, Recovery Assistants and All Other Self-Directed Providers

I, ________________________________________________, understand and agree as follows:

Print Name of Provider

General Requirements

1. All the information I provided to DSS or the Fiscal Agent in my application and in my supporting

provider qualification documentation is true and accurate and I will immediately let DSS and the

Fiscal Agent know if any information changes;

2. I will follow all federal and state statutes, regulations and DSS policies and procedures that apply

to the services I provide and for which I am paid through DSS and CMAP.

3. I will submit all requested documentation to DSS or to the Fiscal Agent that fully discloses the

extent of the services I provide to CMAP participants;

4. I am physically and mentally able to perform to the highest standards the duties necessary to

provide the Home and Community Based Services for the position for which I have applied;

5. Except while the participant is in a hospital, nursing facility or other institution, I will provide all

services listed as those to be provided by my provider type in the participant’s service plan;

6. I am at least 16 years old (if I am PCA) or at least 18 years old (if I am a provider other than a PCA);

7. I am not an employee of the Fiscal Agent. The Fiscal Agent, acting on behalf of the participant,

will process payment/payroll and handle tax withholding for me;

8. If I have worked for any agencies in the past, I left those agencies in good standing and DSS or the

Fiscal Agent may contact said agencies and obtain any and all information and employment

records;

9. The rate DSS pays for my services under CMAP, through the Fiscal Agent, is payment in full. I will

not request or accept any payment directly from the participant for whom I am providing services.

10. I will comply with all requirements established by DSS for the type of service I provide to CMAP

participants, including, but not limited to, having and maintaining credentials and participating in

mandatory training. I will immediately notify DSS and the Fiscal Agent if I have not complied with

such requirements.

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11. If I have not obtained all required approvals and completed all required paper work for DSS or the

Fiscal Agent, I will not be paid for providing any services.

12. If there is a credible allegation of fraud against me and an investigation is pending, DSS must stop

payments for services I provide to participants and I will be removed from the Fiscal Agent’s

provider directory, unless DSS has good cause not to suspend payments.

Prohibited Activities

13. It is illegal, and considered fraud, if I report hours worked on my timesheet/enter time into the

electronic visit verification (EVV) system that I have not actually worked, and I may be prosecuted

for fraud to the fullest extent of the law under both state and federal laws should I commit this

crime;

14. If DSS or the Fiscal Agent finds that I have engaged in abuse of program requirements or fraud or

have otherwise failed to comply with any of the requirements in this Agreement, I may be

suspended or removed from the Fiscal Agent’s provider directory and will not get paid for services

provided to CMAP clients;

15. I will not engage in any conduct, including, but not limited to, health care fraud, patient abuse,

making false statements, misrepresenting material facts, or any other activities listed in state or

federal law, that could result in my not getting paid under state or federal health programs or in

the imposition of civil or criminal activities;

16. I will not bill for any services if the participant is in a hospital, nursing facility or other institution;

17. I will not use or disclose any protected health information (PHI) about participant, except as

permitted or required by law, and I will use safeguards to prevent improper use or disclosure of

PHI;

18. I will not bill DSS for PCA services (a) to a participant who is my spouse or my child under 18 years

old; or (b) to a participant for whom I am a conservator or a guardian.

19. I will not discriminate against any person or group of persons based on age, marital status,

religion, national origin, ancestry, color, race, sex, gender identity or expression, sexual

orientation, intellectual disability, learning disability, mental disability, physical disability,

including, but not limited to, blindness, or status as a veteran.

20. I will not provide any Home and Community-Based Services or submit a timesheet to the Fiscal

Agent /enter any time into the EVV system until I receive notification from the Fiscal Agent that I

am approved by the Fiscal Agent to provide services and am given an effective date of such

approval; have been named as a provider on a participant’s consumer plan; and have completed

all of the new-hire paper work required by the Fiscal Agent.

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Audits and Recoupment

21. Amounts paid to a provider by DSS, through the Fiscal Agent, are subject to review and adjustment

upon audit or if DSS or the Fiscal Agent has information that the amount paid was incorrect, or as

otherwise required by law;

22. If DSS or the Fiscal Agent determines that a provider has been overpaid, DSS or the Fiscal Agent

may take back (recoup) the amount of the overpayment and will work with the provider to

establish a schedule of recoupment.

Termination

23. This Agreement may be terminated

(a) by DSS or its Fiscal Agent upon 30 days written notice

(b) by the provider upon 30 days written notice, subject to any requirements in federal and state

law;

(c) by DSS or its Fiscal Agent if the provider fails to comply with any of the provisions of this

Agreement or any applicable law, rule or policy of CMAP, or if a participant’s safety or health

is or may be at risk, as determined by DSS;

24. There is no right to renew this Agreement.

By signing this agreement, I consent to the Fiscal Agent doing a criminal background check prior

to my providing services to CMAP clients, and to the Fiscal Agent releasing the results of the

criminal background check to the participant or the participant’s designated representative. If,

as a result of the criminal background check, DSS or the Fiscal Agent determines that I am not

suited to be a provider in CMAP, I may not be listed on the Fiscal Agent’s provider directory and

may not be permitted to obtain payment for services provided to CMAP clients.

This Agreement is in effect from ____________________ to ____________________________.

I have read, and understand, accept and agree to comply with the terms of this Agreement. I

further understand and agree that violation of the terms of the Agreement is grounds for

termination of the Agreement, and may be grounds for other sanctions as provided by state or

federal law.

________________________________________ ____________________

Provider’s Signature Date

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DSS WAIVER PROVIDER SERVICES DIRECTORY INFORMATION

Below is a description of the services which may be provided to participants of Connecticut Department of Social Services Waiver Programs. The ABI Waiver Program provides 22 home and community-based services to eligible individuals with an acquired brain injury. The PCA and CHCPE Waiver Programs offer personal care assistance services to individuals with various disabilities and the elderly. For questions regarding provider qualifications and requirements, please contact the Allied Community Resources. *Service approval may require attendance at an ABI Information Session.

Waiver Service Program Provider

Type

Required Qualifications and Documentation

Personal Care Assistance*Companion

*RespiteHomemaker

ABI I or II Private Hire Individuals must meet qualification of ABI application supplement; previous experience required to provide Personal Care Assistance

*Independent Living SkillsTraining & Development

Services ABI I or II Private Hire

Bachelor’s Degree with minimum of 1 year of experience implementing community-based cognitive behavioral interventions developed for a brain injured individual by a qualifying licensed clinician; 2 years of experience with less education; or meet qualifications of Cognitive Behavioral service provider

*ABI Recovery Assistant Iand II

ABI II Private Hire Recovery Assistant Training Certification required; Ongoing CEUs

Personal Care Assistance PCA

CHCPE Private Hire

No specific medical training is required to provide these services, just the desire to work with and improve the quality of life for persons with various disabilities. • Bathing • Transfers • Errands • Dressing• Mobility (in/out) • Taking Medicine• Eating • Grooming/Hygiene • Toileting • Meal Preparation• Exercise • Light Housework • Bladder Routine • Bowel Routine• Personal Business (bill paying, communications)• Laundry • Transportation

All Individual Providers are required to provide valid Identification cards, undergo a Criminal History Background check, Certified Nurse’s Aide Registry check, and Office of Inspector General List of Excluded Individual/Entities name search.

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Connecticut Towns by Region

Town Town Town Town Town TownAbington Norwich Amston New Britain Bantam OxfordAshford Oakdale Andover Newington Barkhamsted PequabuckBallouville Old Lyme Avon North Canton Bethel PlymouthBaltic Old Mystic Berlin North Granby Bethlehem ProspectBotsford Old Saybrook Bloomfield Pine Meadow Bridgewater ReddingBozrah Oneco Bolton Plainville Brookfield RidgefieldBrooklyn Plainfield Bristol Poquonock Canaan RivertonCanterbury Pomfret Broad Brook Rocky Hill Colebrook RoxburyChaplin Pomfret Center Burlington Simsbury Cornwall SalisburyColchester Preston Canton Somers Danbury SharonColumbia Putnam Collinsville Somersville East Canaan ShermanCoventry Quaker Hill East Berlin South Glastonbury Falls Village South KentDanielson Quniebaug East Glastonbury South Windsor Gaylordsville SouthburyDayville Rogers East Granby Southington Goshen TerryvilleEast Killingly Salem East Hartford Stafford Harwinton ThomastonEast Lyme Scotland East Hartland Stafford Springs Kent TorringtonEast Woodstock South Lyme East Windsor Staffordville Lakeville WarrenEastford South Willington East Windsor Hill Suffield Litchfield WashingtonFabyan South Windham Ellington Tariffville Middlebury Washington DepotGales Ferry South Woodstock Enfield Tolland Morris WaterburyGriswold Sprague Farmington Union Naugatuck WatertownGrosvenor Dale Staffordville Glastonbury Vernon Rockville New Fairfield West CornwallGroton Sterling Granby Weatogue New Hartford Winchester CenterHampton Stonington Hartford West Granby New Milford WinstedHanover Storrs Mansfield Hebron West Hartford Newtown WolcottJewett City Taftville Manchester West Hartland Norfolk WoodburyKillingworth Thompson Mansfield Center West Simsbury North CanaanLebanon Uncasville Mansfield Depot West SuffieldLedyard Versailles Marion Wethersfield Town TownLisbon Voluntown Marlborough Windsor Ansonia IvorytonMadison Waterford Middle Haddam Windsor Locks Beacon Falls MeridenMontville Wauregan Bethany MiddlefieldMoosup West Mystic Branford MiddletownMystic Westbrook Centerbrook MilfordNew London Willimantic Cheshire MoodusNiantic Willington Town Town Chester New HavenNorth Franklin Windham Bridgeport Pawcatuck Clinton North BranfordNorth Grosvenordale Woodstock Cos Cob Redding Cobalt North HavenNorth Stonington Woodstock Valley Darien Redding Ridge Cromwell NorthfordNorth Windham Yantic Easton Riverside Deep River Orange

Fairfield Sandy Hook Derby PlantsvilleGeorgetown Shelton Durham PortlandGreenwich Southport East Haddam RockfallHadlyme Stamford East Hampton SeymourHawleyville Stratford East Haven South BritainLakeside Trumbull Essex StevensonMonroe Westport Guilford WallingfordNew Canaan Weston Haddam West HavenNorwalk Wilton Hamden WoodbridgeOld Greenwich Higganum

FMS – Provider Services

P.O. Box 479East Windsor, CT 06088-0479Phone: (860) 627-9500 Fax: (860) 627-0230

StatewideConnecticut

Southwest

Please use this list of Connecticut Towns by Region to identify the specific towns in which you are willing to provide services by checking the box next to the individual town(s). This will make the Provider

Directory more user-friendly, efficient and accurate for program participants seeking potential providers.

NorthwestEastern North Central

South Central

Provider/Agency Name: ____________________________________________P13 - 12 of 14

Page 1 of 2 F21-V 11/26/19

ABI APPLICATION SUPPLEMENT: Private Household

This form is provided to help organize your experience and qualifications for becoming an ABI Waiver provider. Please

complete and return this application with the signed Provider Agreement. Please note that applications not completed and

approved within 90 days from the date they are initially received by Allied Community Resources (ACR) will be considered

expired and the applicant will be required to complete a new application and submit to ACR for review. Please complete

both sides of this form. **YOU MUST FILL OUT ALL PARTS, INCLUDING SPECIFIC EXAMPLES. If you use any

additional pieces of paper, please be sure to include your name, date, and written SIGNATURE on all additional

pages you are submitting,

Services Applying For: PCA Chore Homemaker Companion* Respite*

Applicant Full Legal Name: __________________________________ Former Name(s): _________________

Address: ________________________________ City: ________________ State: ______ Zip Code: _________

Phone: (_____)_____-______ Cell: (_____)_____-______ Email Address: ______________________________

*Social Security #: _____-_____-______ *Date of Birth: ____/____/______ *Required for Criminal History Background Check

Do you speak any languages other than English? YES: _____________________________________ NO

*ABI Waiver Program Requirement for Companion and Respite services:

Have you ever completed an ACR sponsored Informational Session on Acquired Brain Injury?

YES: Date completed: ____/____/______ NO

Experience and Training:

If you have experience that is pertinent to your meeting ABI Waiver Program qualifications, please describe (examples: a degree in Human Services, completion of a CNA course, previous PCA experience, first aid or CPR training):__________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Qualifications: Please read the items below and indicate whether you feel you are able to follow when working with and

ABI Waiver participant.

• Maintain Confidentiality YES NO

• Follow written and verbal instructions given by the participant and/or their conservator YES NO

• Meet the participant’s needs as stated in their case plan YES NO

• Be able to report changes in the participant’s condition or needs YES NO

• Complete any required record-keeping YES NO

• Be able to handle emergencies YES NO

• Demonstrate knowledge of basic first aid YES NO

• Be Physically able to perform the services required YES NO

Please describe, in your own words specific examples of when you performed at least three the above standards:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Page 2 of 2 F21-V 11/26/19

The following areas are standards that address the qualification guidelines for some ABI Waiver services. Please

read through the descriptions and describe specific examples that would meet the qualification guidelines when

completing the rest of the application.

Do you feel you are able to function as a member of an interdisciplinary Team? YES NO

Helpful Hint: An interdisciplinary team is a team made up of multiple people who are with, or for a person including, but not

limited to: person with a brain injury, family member(s) or conservators, neurologist, social worker, and others providing

services for the individual. During team meetings, they discuss what is best for the individual living in the community. You

may be asked to discuss with the team the service(s) you are providing.

Do you feel you can implement the cognitive behavioral interventions that a team agrees on? YES NO

Helpful Hint: Cognitive behavioral interventions are the strategies that providers use while working with individuals with an

acquired brain injury. The strategies are based on the needs of the individual and are used to help them learn, think, an act

in the world. Under this program, the Neurologist will develop the strategies and let you, the provider, know what strategies

to use.

Please describe a team environment in which you participated and contributed to accomplish an outcome:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Please state specific examples when you have received and followed directions given to you:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

If applying to provide respite services, please answer the question below:

Please state a specific example of being the sole provide of care for someone in their residence when their primary caregiver

was unable to provide services. Please be specific in what your duties were during this time.

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

I attest to all the information outlined is true and accurate depiction of my qualifications and that I have proper experience and knowledge

needed to provide services to a client on the ABI Waiver Program in the manner expected.

__________________________ _____________________________ ________________

Applicant Name (Print) Applicant Signature Date Signed