1ST CHOICE HOME CARE SERVICES, INC. CDPAP

CONSUMER DIRECTED PERSONAL ASSISTANCE PROGRAM EMPLOYMENT/ WAGE AGREEMENT

ACKNOWLEDGEMENT OF RECEIPT OF CONSUMER & PERSONAL ASSISTANT EMPLOYMENT WAGE

I have read and understand my rights and responsibilities for participation in the 1st Choice Home Care Services, Inc. Consumer Directed Personal Assistance Program.

Consumer/ Designated Representative

PERSONAL ASSISTANT ACKNOWLEDGEMENT

I have read and understand the rules and responsibilities as the employee of the above consumer for participation in the 1st Choice Home Care Services, Inc. Consumer Directed Personal Assistance Program.

CONSUMER DIRECTED PERSONAL ASSISTANCE PROGRAM

1st CHOICE HOME CARE SERVICES, INC.

I am a Consumer or a Designated Representative of a Consumer who is enrolled in the 1st Choice Home Care Services, Inc. CDPAP. Upon my enrollment into the CDPAP I received an in-home orientation visit by 1st Choice Home Care Services, Inc. CDPAP Consumer Service Representative At the time of this home visit, the rules and regulations for participation in the 1st Choice Home Care Services, Inc. CDPAP have been explained to me, and I have had my questions answered. If I have any questions in the future, I have been provided with the name and contact information of my Consumer Service Representative who I can call at any time. I have had the opportunity to ask questions about the received printed information on the rules of participation for the 1st Choice Home Care Services, Inc. CDPAP.

In addition, I have been provided with information both written and verbal on the following topics and procedures: 1st Choice Home Care Services, Inc. CDPAP Guide CDPAP Consumer Rules of Participation & Code of Ethics The Consumer - PA Wage Agreement The Consumer/Surrogate Agreement Copy of New York State Handbook on Advance Directives Law & Health Care Proxy Acknowledgement & Receipt of Federal & State False Claims Act Emergency Disaster Preparedness Plan for People with Disabilities Infection Control Printout Home Safety Printout Notice of Privacy Practices (HIPAA) PA Handbook

1st CHOICE HOME CARE SERVICES, INC. Acknowledgement of Receipt

CONSUMER/ DESIGNATED REPRESENTATIVE

1. I acknowledge that I have received a copy of the 1st Choice Home Care Services, Inc. CDPAP Policy Pertaining to False Claims and False Statements.

2. I will inform my Personal Assistants regarding the Federal & State False Claims Act.

I have been informed by my Consumer/ Designated Representative about the policy regarding the Federal & State False Claims Act.

1ST CHOICE HOME CARE SERVICES, INC. CDPAP

Consumer Declaration Regarding the Hepatitis-B Vaccination:

I understand as a participant enrolled in the 1st Choice Home Care Services, Inc. Agency CDPAP, I am responsible for the training of my PA. Included in my training is a discussion regarding the Hepatitis-B virus, the Hepatitis-B vaccine, and the use of Universal Precautions.

Use of Personal Protective Equipment:

I understand the use of Personal Protective Equipment such as gloves, gowns or face masks may be necessary to care for me. I understand that these items must be provided by me to maintain Universal Precautions for my PA, and provided at NO cost to the PA. These items may be provided by me with or without the assistance of the Medicaid funded program.

I have informed my PA and he/ she understands that due to his/ her occupational exposure to blood or other potentially infectious materials, they may be at risk of acquiring Hepatitis-B virus (HBV) infection. The PA has been given the opportunity to be vaccinated with the Hepatitis-B vaccine at no charge to them, if they choose to receive the vaccine.

If a work-related accident occurs, which may have caused my PA an exposure to Hepatitis-B virus, I agree to instruct the PA to contact their Physician or visit the local hospital Emergency Room immediately for treatment. I will also immediately notify 1st Choice Home Care Services, Inc. CDPAP to report this occurrence.

Consumer Offer Letter of Employment

Thank you for accepting the position as my Personal Assistant. As a participant in the 1st Choice Home Care Services, Inc. CDPAP, I am your employer. Please be advised that this letter will serve as your condition letter of employment.

Please note that 1st Choice Home Care Services, Inc. CDPAP is not your employer. The 1st Choice Home Care Services, Inc. CDPAP, is only the responsible to process your payroll and administer your benefits on my behalf. Your employment with me is contingent upon verification of your references, the submission of a completed physical examination, and your ability to provide acceptable proof of a residency, identification and eligibility to work in the United States. I have provided you with a job description and have reviewed the personal care tasks (and if necessary) the nursing procedures and other duties (light housekeeping, etc that you are required to perform according to my care plan. This plan of care was developed for me by my Physician and the Registered Nurse assessor working for my Managed Care Plan.

Hourly Compensation: $/hr. Your hire date is:

You will be paid weekly and your first pay date will be: You agree to use the TELEPHONE Electronic Verification Call in system at all-time unless otherwise instructed not to. If the ETVS is not available you will complete and sign a time sheet and will forward it to 1st Choice Home Care Services, Inc. CDPAP, for payroll processing.

, request you to appoint as my

If you have any questions or concern, feel free to reach me at

CONSUMER DIRECTED PERSONAL ASSISTANCE PROGRAM IST CHOICE HOME CARE SERVICES, INC. CDPAP EMPLOYMENT/WAGE AGREEMENT

A consumer or, if applicable, the consumer's designated representative has the following responsibilities under the 1st Choice Home Care Services, Inc. CDPAP

1. Manage the plan of care.

2. Responsible for recruiting, interviewing and hiring a sufficient number of Personal Assistants to provide authorized services that are included on the consumers plan of care established in conjunction with the consumer or designated representative by the Medicaid Manage Care Provider;

3. Provide equal employment opportunities to all prospective employees regardless of their race, creed, color, national origin, sex, disability marital status, and sexual orientation or affectional preference;

4. Accept full responsibility for any personal injury or loss of property that may result from the action or inaction of the consumers Personal Assistant;

5. Responsible for training, supervising and scheduling each Personal Assistant; and assuring that each consumer directed personal assistant competently and safely performs the personal care tasks, home health aide tasks and skilled nursing tasks that are included on the consumer's plan of care; 

6. Arrange and schedule back up Personal Assistant coverage for vacations, holidays and absence due to illness;

7. Responsible for terminating( if need be) the Personal Assistant's employment;

8. Responsible for the timely notification of the fiscal Intermediary- 1ST CHOICE HOME CARE SERVICES, Inc. CDPAP and the Consumers Medicaid Managed Care Provider of any changes in the consumer's medical condition or social circumstances including, but not limited to, any hospitalization of the consumer or change in the consumer's address, 718-575-9090 number or employment;

9.Timely notification to 1ST CHOICE HOME CARE SERVICES, INC. CDPAP of any changes in the employment status of each Personal Assistant working for the Consumer; to include any changes in name, address, employment status and hours worked

10. Process and submit in a timely manner the required Consumer and Personal Assistant enrollment documents annual worker health assessments and other required employment documents.

11. Ensuring that each consumer directed Personal Assistant utilizes the Electronic 718-575-9090 Verification system to clock in and clock out when working for the Consumer, and mediate all payroll/personal problems.

12. Having the consumer directed Personal Assistant's utilize paper time sheets when the Electronic 718-575-9090 System is not used, or is not available; and submit the paper time sheets to. the fiscal intermediary according to its procedures;

13. Timely distributing each consumer directed personal assistant's paycheck, or allow Personal Assistant participation in a direct deposit payroll distribution system;

14. Arranging and scheduling substitute coverage when a consumer directed Personal Assistant is temporarily unavailable for any reason; and

15. Train the Personal Assistant as to the rights and responsibilities of all involved parties;

16. Comply with New York State Dept. of Health requirements regarding receiving notification/information from the Fiscal Intermediary regarding Advanced Directives;

17. Comply with the Department approved CDPAP Agreement between the Medicaid Managed Care Provider and the Consumer/Designated Representative that describes the parties' responsibilities under the CDPAP.

The Personal Assistant (PA) agrees to:

1. Recognize the authority of the consumer as the Personal Assistant source of employment and supervisor.

2. Respect the Consumer's health, wellbeing, privacy and property

3.Authorize 1ST CHOICE HOME CARE SERVICES, INC. CDPAP to collect and appropriately distribute employment related information.

4. Comply with the policies and practices of 1ST CHOICE HOME CARE SERVICES, INC. Consumer Directed Personal Assistant Program

1ST CHOICE HOME CARE SERVICES, INC. AGENCY CDPAP Consumer Directed Personal Assistant Program Agrees to:

1. Monitor the Consumer's or if applicable the consumers designated representative continuing ability to fulfill; the consumer's responsibilities and appropriateness for continued participation i n the 1st Choice Home Care Services, Inc. CDPAP. Consumer Directed Personal Assistance Program, either directly or indirectly using all available information, or notifying the Consumers Medicaid Managed Care Plan Provider as needed.

2. Comply with Dept. of Health regulations contained in NYCRR 504.3

3. Maintain the information needed for payroll processing and benefit administration and process the Consumer's payroll for each Personal Assistant.

4. Pay the Personal Assistant the prevailing wage in the industry for the hours of service indicated on the Consumer's time sheet or verification of hours worked utilizing a electronic time and attendance system.

5. Coordinate all matters, which relate to each Personal Assistants withheld taxes and benefits and comply with workers compensation, disability and unemployment insurance requirements.

6. Encourage the Consumer to provide equal employment opportunities to all prospective employees regardless of their race, creed, color, national origin, sex, disability, marital status, and sexual orientation or affectional preference, in all in all employment decisions.

7. Facilitate and monitor the completion of all Consumer and Personal Assistant documents that a required by Brooklyn, State or Federal Authorities either directly-or indirectly.

8. Maintain directly a personal record for each Personal Assistant that will include, at a minimum the enrollment forms, the annual worker's health status assessments prior to delivery of service pursuant to 10 NYCRR 766.11(c)and (d) or any successor regulation.

9. Maintain a Consumer Record which includes authorizations from the consumers Medicaid Managed Care Plan Provider the Consumer Agreement, and all other documents required to monitor and maintain information required for participation in the CDPAP provided by the Consumers Medicaid Managed Care Plan

10. Identify and Evaluate community resources that may be available. to the Consumer to assist with Consumer for Recruitment Assistance Services.

11. Maintain a Consumer Advisory Committee and Grievance Committee.

12 Provide statistical and pertinent information to the various regulatory legal and programmatic entities as required or requested

 

STOP SEXUAL HARASSMENT ACT FACTSHEET

All employers are required to provide written notice of employees' rights under the Human Rights Law both in the form of a displayed poster and as an information sheet distributed to individual employees at the time of hire. This document satisfies the information sheet requirement. The NYC Human Rights LawRetaliation Is Prohibited Under the Law The NYC Human Rights Law, one of the strongest anti-discrimination laws in the nation, protects all It is a violation of the law for an employer to take individuals against discrimination based on gender, action against you because you oppose or speak which includes sexual harassment in the workplace, out against sexual harassment in the workplace in housing, and in public accommodations like stores The NYC Human Rights Law prohibits employers and restaurants. Violators can be held accountable from retaliating or discriminating "in any manner with civil penalties of up to $250,000 in the case of against any person" because that person opposed a willful violation. The Commission can also assess an unlawful discriminatory practice. Retaliation car emotional distress damages and other remedies manifest through direct actions, such as demotions to the victim, can require the violator to undergo or terminations, or more subtle behavior, such as ar training, and can mandate other remedies such as increased work load or being transferred to a less community service. desirable location. The NYC Human Rights Law protects individuals against retaliation who have a good faith belief that their employer's conduct is illegal, even if it turns out that they were mistaken. Sexual harassment, a form of gender-based discrimination, is unwelcome verbal or physical behavior based on a person's gender.Report Sexual Harassment If you have witnessed or experienced sexua Some Examples of Sexual harassment inform a manager, the equal employment opportunity officer at your workplace, or humar Harassment resources as soon as possible. unwelcome or inappropriate touching of Report sexual harassment to the NYC employees or customers Commission on Human Rights. Call threatening or engaging in adverse action after 212-416-0197 or visit NYC.gov/HumanRights tc someone refuses a sexual advance learn how to file a complaint or report discrimination making lewd or sexual comments about an You can file a complaint anonymously. individual's appearance, body, or style of dress conditioning promotions or other opportunities on sexual favorsState and Federal Government displaying pornographic images, cartoons, or Resources graffiti on computers, emails, cell phones, bulletin Sexual harassment is also unlawful under state and boards, etc. federal law where statutes of limitations vary. making sexist remarks or derogatory comments based on gender To file a complaint with the New York State Division of Human Rights, please visit the Division's website at www.dhr.ny.gov. To file a charge with the U.S. Equal Employment Opportunity Commission (EEOC), please visit the EEOC's website at www.eeoc.gov.

Sexual Harassment Under the Law

I, presently employed by the above-listed Consumer receiving the CDPAP services, acknowledge that I received annual training on sexual harassment prevention in the workplace provided by this Consumer. All the topics related to sexual harassment prevention training were discussed with me in my native language, including the "Stop Sexual Harassment Act Notice" and the "Stop Sexual Harassment Act Factsheet." The Consumer also gave me an opportunity to ask questions. All of my questions were answered to me clearly and in full.

By signing this Acknowledgement Form, I confirm that I understood all the topics about sexual harassment prevention in the workplace, "Stop Sexual Harassment Act Notice" and "Stop Sexual Harassment Act Factsheet," which were discussed during this training. I acknowledge the receipt of the sexual harassment policy, the sexual harassment poster, "Stop Sexual Harassment Act Notice" and "Stop Sexual Harassment Act Factsheet" provided to me by this Consumer. I agree to comply with all policies and procedures on sexual harassment prevention in the workplace.

The Consumer acknowledges that the sexual harassment prevention training was provided to the Personal Assistant to meet the minimum standards in the New York State for sexual harassment prevention policy in accordance with the provisions from Section 201-g of the Labor Law and New York State Model Sexual Harassment Policy available at the below link: https://www.ny.gov/combating-sexual-harassment-workplace/employers The Consumer acknowledges that the Personal Assistant received the sexual harassment policy, sexual harassment poster, "Stop Sexual Harassment Act Notice" and "Stop Sexual Harassment Act Factsheet."

Notice of Employee Rights: Safe and Sick Leave

If you work part time or full time at any size business or nonprofit in NYC or if you work in an NYC household as a domestic worker, you have the right to safe and sick leave to care for yourself or anyone you consider family. You have this right regardless of your immigration status. Your employer must give you this notice explaining your rights.

Amount of Safe and Sick Leave:

All employers must provide up to 40 hours of safe and sick leave each calendar year. Beginning January 1, 2021: Employers with 100 or more employees must provide up to 56 hours of safe and sick leave each calendar year. January 1 Your employer's calendar year is: First month Last month You earn safe and sick leave at a rate of 1 hour for every 30 hours worked. You have a right to PAID safe and sick leave if: Your employer has 5 or more employees.You work in someone's home as a domestic Your employer has fewer than 5 employees butworker; for example, babysitter, housekeeper, a net income of $1 million or more. or companionship worker. (effective January 1, 2021)Note: The law covers 1 or more domestic workers working in a household. You have a right to UNPAID safe and sick leave if: Your employer has fewer than 5 employees and a net income of less than $1 million.

You can carry over unused safe and sick leave to the next calendar year.

Use it for your health, including to get medical Use it when your job or your child's school closes care or to recover from illness or injury. due to a public health emergency. Use it to care for a family member who is sick Use it for your safety or for a family member's or has a medical appointment. safety because of domestic violence, unwanted sexual contact, stalking, or human trafficking. Your employer can require you to give advance notice of a planned use of safe and sick leave; for example, to attend a scheduled doctor's appointment or court hearing. You do not have to give advance notice of an unexpected use of safe and sick leave; for example, a sudden illness or medical emergency. You have a right to privacy. You do not have to give your employer details about why you used safe or sick leave.

If you use more than three workdays in a row of safe and sick leave, your employer can require documentation. Your employer must reimburse you for any fees you pay for required documentation. Documentation should not include the details of your private medical or personal situation.

Required Written Disclosures about Safe and Sick Leave:

Your employer must: Give you a written safe and sick leave policy that explains how to use your benefits. Tell you how much safe and sick leave you have used and have left each pay period. No Retaliation: It is illegal to punish or fire employees for requesting or using safe and sick leave or for reporting violations. NYCConsumer andWorker Protectiona complaint.Contact Consumer and Worker Protection to learn more or to file Visit nyc.gov/workers I Call 311 and ask for "Paid Safe and Sick Leave" Eric L. Adams You can also make an ANONYMOUS tip.

1st Choice Home Care Services, Inc. 8501 New Utrecht Avenue, Brooklyn, NY 11214 Phone: (347) 492-5982 * Fax: (347) 230-8663 E-mail: office@1stchoicehcsi.com * www.1stchoicehcsi.com

I, (Consumer) acknowledge that I provided training on Paid Sick and Safe Leave Law for the above-named PA.

I translated all of the training-related items and discussed what they mean in the language native to this PA, including the written policy on safe and sick time and the information from the "Notice of Employee Rights." I also gave this PA an opportunity to ask me questions. I answered all of the PA's questions as appropriate, and this PA stated to me that all information was clear, complete and addressed in full. By signing below, this PA acknowledges that he/she understood all the topics pertaining to Paid Sick and Safe Leave Law, the policy on safe and sick time and the "Notice of Employee Rights" that were discussed during this training. This PA confirms the receipt of the policy on safe and sick time and "Notice of Employee Rights" provided by the above-listed Consumer and agrees to comply with all corresponding policies and procedures.