Microsoft Word - PHCP Cover Letter

GEORGIA DEPARTMENT OF

COMMUNITY HEALTH

David A. Cook, Commissioner

Nathan Deal, Governor

2 Peachtree Street, NW

Atlanta, GA 30303-3159

www.dch.georgia,gov

PRIVATE HOME CARE PROVIDER LICENSURE PACKET

This letter is in response to your request for information about operating a Private Home Care

Provider service in Georgia. The Healthcare Facility Regulation Division (HFRD) of the

Department of Community Health (DCH) is responsible for licensing Private Home Care

Providers under Georgia State Law. O.C.G.A. § 31-7-300 et seq. requires agencies to obtain a

Georgia state license prior to providing Private Home Care Provider services.

Enclosed are the Private Home Care Provider rules and regulations, an application for a Private

Home Care Provider license, Criminal Records Check Legislation, House Bill 155 and a list of

all the documents required by HFRD in order to consider your application complete. Please note

that the document list is in a checklist format. Please use the checklist as an aid to ensure all

required documents are submitted for review with your application. HFRD will also utilize the

checklist in determining if the application is complete and whether the documents you submit are

sufficiently acceptable for you to be found in initial compliance with the regulations.

STATE LICENSURE APPLICATION PROCESS

STEP 1: APPLY FOR A PROVISIONAL LICENSE THROUGH ADMINISTRATIVE

REVIEW.

To begin the application process, you must first submit an application for a license to operate a

Private Home Care Provider along with all required application documents and the application

and licensure fees. The application must be signed and dated by the Private Home Care Provider

administrator or the executive officer of the governing body. Please refer to the attached

document checklist for guidance with preparation and submission of the required documents

which must accompany your application. HFRD will review your application upon receipt to

determine if all documents were included. If all essential documents were included, your

application will be considered complete and the initial administrative review process will begin.

Submit the application packet to: Department of Community Health

Healthcare Facility Regulation Division

Application and Waivers Unit

2 Peachtree St., NW Suite 31-447

Atlanta, GA 30303

Pursuant to HB 155 the owner(s) of Private Home Care Providers must submit to a

background check. Effective May 1, 2008 manual fingerprint cards were eliminated. The

owner(s) must submit to the use of electronic (live scan) fingerprints. The methods for

obtaining the electronic fingerprints are included in an attached memorandum.

Private Home Care Provider Application

Page Two

If any of the requested documents are determined to be absent, the application will be considered

incomplete and the application and documents will be returned to you along with information

identifying the missing documents. At that time the application will be considered to be

voluntarily withdrawn, but you may reapply when you have assembled all of the required

documents.

Once the application packet has been determined by HFRD staff to be complete, HFRD will

begin an administrative review of your application and supporting documents for compliance

with the Private Home Care Provider rules and regulations. This initial review may take up to

sixty (60) days. If the documents are determined to contain all the information required to obtain

a provisional license and a satisfactory criminal record determination has been obtained on

the owner, you will be considered to be in compliance with applicable Private Home Care

Provider rules and regulations and issued a provisional license. You can begin to provide Private

Home Care Provider services upon receipt of your provisional license.

If the documents you have submitted do not contain sufficient acceptable information for

indicating compliance with the rules, you will be notified in writing as to which of the

documents were determined to be unacceptable. You will be allowed a period of time in which to

submit corrected or revised documents. However, if you are unable to provide acceptable

documents within 90 days of the initial receipt of your application, your application for a

provisional license may be denied for failure to demonstrate compliance with the rules and

regulations.

STEP 2: ON-SITE SURVEY FOR A REGULAR LICENSE

Once your agency has provided Private Home Care Provider services to two or more clients,

and prior to the expiration date of the provisional license, you must request an initial on-site

survey. If HFRD surveyors determine at the on-site survey that your agency has demonstrated

substantial compliance with the rules and regulations, your Private Home Care Provider agency

shall become eligible for and be issued a regular license. Your facility must have been issued a

regular license to continue to serve clients beyond the expiration date of the provisional license.

Provisional licenses are not renewable and expire one year from the date issued. If you are

unable to become operational and obtain a regular license prior to the expiration of the

provisional license, please note that the provisional license will not be extended.

Should you have any questions concerning the information in this letter, completion of the

application or submission of required documents, please contact the Healthcare Facility

Regulation Division at (404) 657-5850.

Enclosures:

Rules and Regulations for Private Home Care Providers

Application for a License to operate as a Private Home Care Provider, with Instructions

Personal Identification Affidavit Form

Application and Licensure Fee Schedule

Document Checklist

Records Check Application

Memorandum regarding the methods for obtaining electronic/live scans fingerprints

GEORGIA DEPARTMENT OF

COMMUNITY HEALTH

David A. Cook, Commissioner

Nathan Deal, Governor

2 Peachtree Street, NW

Atlanta, GA 30303-3159

www.dch.georgia,gov

HEALTHCARE FACILITY REGULATION DIVISION

APPLICATIONS AND WAIVERS UNIT

PROGRAM PROCEDURE

NUMBER: 4

SUBJECT: Private Home Care Providers (Surveys and Licenses)

APPROVALS:

Division Chief:______________________ Deputy Chief:__________________________

Effective Date: _______________________ Subsequent Review Dates: __________________

______________________________________________________________________________

A. Initial Application Packet

Upon request, potential Private Home Care Providers (PHCP) can print an initial application packet from the

Department’s website located at www.dch.georgia.gov. The initial application packet shall consist of the

following:

1) Cover letter explaining the initial licensure process and application fee information (attachment #1);

2) Copy of the PHCP rules, Chapter 290-5-54 with the interpretative guidelines;

3) Application form with instructions, (attachment #2);

4) Licensing fee schedule, (attachment #3);

5) Provider application checklist for provisional license document submissions, (attachment #4); and

6) Personal Identification Affidavit Form (attachment #5)

7) Memorandum regarding the “Live Scan” fingerprint process/procedures (attachment #6)

8) Records Check Application – Form 5579 (attachment #7)

When the applicant assembles the requested information, and the application packet is received into the

HFRD office for review, the application is date-stamped and its receipt is entered into ACO as “pending”.

The applicant should be ready to begin offering the requested services for clients as soon as the provisional

license review is completed.

Prior to in-office review of documents for the initial provisional license, the following information must be

included in the packet submitted by the applicant:

1) Completed application form with a description of services to be offered and the geographic area that will

be served;

2) Date of electronic fingerprinting for owner(s)

3) Application fee;

4) Licensing fee;

5) Copy of business license;

6) Notarized Personal Identification Affidavit;

7) Days and hours of operation; and

8) Description of services to be offered and policies and procedures as required by the rules (refer to

asterisked items on the application checklist).

If all required documents are not received with the application, or cannot be located within the submitted

documents, the application packet is considered incomplete. All documents, including checks for fees, are

returned in entirety to the applicant with missing documents

identified. The applicant is advised that the application is considered to be voluntarily withdrawn

(attachment #9)

, and they may resubmit when they have assembled all required documents. The entry in

ACO is changed to “withdrawn”.

B. Provisional License Review

1) Once an application packet has been determined to be complete, the applicant shall be so notified

(attachment #10), and HFRD shall begin administrative review of the application and documents to

determine compliance with the PHCP rules and regulations. This initial review is conducted at the

Healthcare Facility Regulation Division, with a target of sixty (60) days for review. The reviewer must

find all documents requested in the application checklist to be submitted and acceptable. In addition,

verification from the Office of Inspector General/Background Investigations Unit of a satisfactory

criminal background check on the owner(s) must be received prior to issuance of the provisional

license. If all submitted documents are determined to indicate compliance, and a satisfactory criminal

background check has been received on the owner(s) a provisional license shall be issued.

2) If the documents submitted are not sufficient to indicate compliance with applicable rules and

regulations, or there are documents missing or requiring amendment, the applicant shall be notified in

writing of which of the documents were determined to be unacceptable (attachment #11)

. The applicant

shall be allowed a determined period of time to make corrections/additions to the application packet,

however, if the applicant is unable to provide acceptable documents in their entirety within 90 days of

the receipt of an application packet that has been determined to be complete, the provisional license may

be denied due to failure to demonstrate compliance with the rules and regulations (attachment #12).

Applicants in this category shall be advised that they have the option to withdraw their application

voluntarily during this period to avoid denial, as denial of the application may prohibit re-application for

up to 12 months (attachment #13). Applicants in this category shall not receive a refund of

application fee.

Note: In addition to the above requirements and pursuant to the Criminal Records Check Legislation,

House Bill 155, an owner with a criminal record (refer to the listed crimes) will not be issued a

provisional license.

3) The initial provisional license shall be effective for no longer than one year. Providers shall become

operational and begin providing services to clients within the one-year provisional period in order to be

eligible for an on-site survey for a regular license. Should a provider become operational and wish to be

surveyed earlier than the end of the one-year period, in order to be issued a regular license, they may

notify HFRD in writing, and may be scheduled earlier if staffing and scheduled allow. Should a provider

not be able to become operational and provide services to clients during this period, the provisional

license shall expire and the provider must cease operation and reapply at a later date.

C. First On-Site Survey

An on-site survey shall be conducted before the end of the provisional licensing period to determine if the

agency’s operational procedures comply with the rules, review evidence of implementation of policies and

procedures, evaluate client records, interview staff, clients and/or representatives, and make home visits.

Initial on-site surveys shall be scheduled by ORS prior to the expiration of the provisional license, during

regular business hours as indicated on the application. Changes in the scheduled survey date will not be

considered unless extraordinary circumstances can be shown. (See attachment #14, letter confirming survey

date.) The following criteria shall be utilized to determine the numbers and types of home visits and

patient/representative interviews to be conducted during the first and subsequent on-site surveys:

1) A representative sample of clinical records will be selected according to the following guidelines:

• Agencies with less than 150 clients shall have a minimum of six (6) client records reviewed.

• Agencies with 150 – 750 clients shall have a minimum of eight (8) client records reviewed.

• Agencies with more than 750 clients shall have a minimum of twelve (12) client records reviewed.

In addition to the client records reviews, all agencies shall have a minimum of one client selected for a

home visit and shall have two additional clients or their representatives contacted by telephone in order to

assess the client’s impression of the quality and frequency of the services provided by the agency.

2) Agencies providing 24-hour, 7-day-a-week care and supervision to any clients shall have a minimum of

one of these clients selected at for home visit and record review. Two additional of these clients or their

representatives shall be contacted via phone in order to assess the consumer’s impression of the quality

and frequency of services provided by the PHCP.

3) The home visits and client/representative interviews shall be documented on the back of the record

review form (attachment #15).

4) Inspection Report form 3899 (attachment #16) shall be completed by the surveyor/s and signed by the

administrator at the exit conference. Record reviews shall be documented on the record review form

(attachment #15) and employee file reviews shall be documented on the staff documentation review

form (attachment #17).

5) If no deficiencies are cited at the first on-site survey, a regular license shall be issued for the remainder

of the one-year licensing period (attachment #18). If the agency is in substantial compliance but

deficiencies are cited, the agency shall be notified of the requirement for an acceptable plan of

correction (attachment #19). Once an acceptable plan of correction is received, the agency shall be

notified of the acceptance (attachment #20), and the regular license may be issued. Failure to

demonstrate substantial compliance with the rules at follow-up may result in subsequent rescinding of

the regular license.

D. Survey Intervals

The following guidelines shall be followed for determining on-site survey intervals:

1) New agencies shall be surveyed for two consecutive years in order for the Office to compile a history

regarding the agency’s compliance with required rules. During this two-year period, the Office shall

conduct at a minimum the provisional license review, first on-site survey and one annual survey.

2) After this two-year period, the agency will be eligible to go on a periodic survey interval, if the

following criteria are met:

a) the agency has had no deficiencies scoped “D” or higher using the HCS Scope and Severity

matrix for any surveys/complaint investigations over the last two years;

b) there have been no adverse actions initiated against the agency; and

c) no change of ownership has occurred.

E. Periodic or Annual Surveys

Periodic or annual surveys are announced by letter correspondence to the administrator of record at least

two weeks prior to the scheduled survey date (attachment_#14). Scheduled survey dates are at the

discretion of the Office, and shall no t be changed at the request of th e agency, except in extraordinary

instances. (Administrator inconvenience shall not be cons idered a reason to alter the survey schedule, if

the agency continues to be in operation.) Administrators are notified that should they not be available on

the scheduled date, they are expected to assu re that docu ments are availab le for review and that an

individual familiar with the business be available to assist the surveyor.

F. Follow-Up Surveys

On-site follow-up surveys are unannounced, and are conducted during the agency’s regular business hours as

stated on their application. On-site follow-up surveys are conducted based on the following criteria:

1) any deficiencies related to patient care and supervisory visits;

2) six or more deficiencies cited;

3) any deficiencies cited at the first on-site visit;

4) repeat deficiency from previous year;

5) any deficiencies that reflect the employment of unqualified staff; and

6) at the discretion of the Program Director, HFRD Director, or HFRD Deputy Director.

Should a surveyor arrive for an unannounced survey and find the office closed during regular business hours,

the surveyor is to contact the administrator by telephone, and inform the administrator that the surveyor must

be provided access within one hour of the call. Should the administrator be providing client care at the time,

the surveyor may begin the survey at the location where the care is being provided.

In-office follow-up surveys will be conducted whenever possible for deficiencies related to documents such

as policies and procedures or other deficiencies for which compliance can be determined without an on-site

survey.

G. Deemed Agencies

The Office may exempt a PHCP agency from periodic inspections if the agency is certified or accredited by a

certification entity recognized and approved by the Department. Currently the Joint Commission on

Accreditation of Healthcare Organizations (JCAHO) and the Community Health Accreditation Program

(CHAPS) are approved for deeming periodic inspections of PHCP agencies.

Agencies seeking exemption from on-site inspection are required to submit to the Office documentation of

certification or accreditation, including a copy of its most recent certification or accreditation report.

Certification or accreditation shall not be construed to prohibit the Office from conducting inspections of any

provider as the Office determines necessary.

H. Failure to be Operational

Agencies that have not provided services to clients within a three-month period prior to the expiration of

their license shall be issued a renewal license along with a letter stating if the agency provides no client

services during the one-year renewal period, their license will not be renewed again (attachment #21). No

on-site survey shall be required for the one-year license renewal in these cases.

If the agency fails to provide client services over the subsequent one-year renewal period, the owner shall be

notified via certified letter (attachment #22) that their agency is considered voluntarily closed. The owner

shall be advised via a certified letter that PHCP services cannot be provided without a valid license from this

Office. The owner shall be instructed to

return their license to this Office and informed that they may apply for an initial license at a later date if it is

anticipated that services will be provided to clients.

I. Issuance of Renewal Licenses and Payment of Annual Fees

1) Two months prior to the expiration date of the PHCP’s license, a renewal letter, handout, application, and

a fee schedule shall be sent to agencies (attachment #23).

2) A license shall be issued upon receipt of the licensing fee.

J. Failure to Pay Annual Fees

1) Agencies failing to pay the annual fee by the expiration date of their license shall be sent a certified

letter, return receipt requested, notifying the agency that their license has

expired (attachment #24), and that if they are continuing to operate they are considered to be operating

without a license. A license application and fee schedule shall be enclosed. The letter shall state that

unless the renewal application and annual fee, which now is at the involuntary rate, are received within

30 days of receipt of the letter, the agency shall be considered voluntarily closed.

2) When the agency is considered to be voluntarily closed, the agency shall be advised that per O.C.G.A. §

31-7-301, they are not allowed to provide Private Home Care Provider services without a valid license

from this Office and instructed to return their license to this Office.

3) An on-site follow-up visit will be conducted after the voluntary closure date to verify that the agency has

actually ceased operations as a Private Home Care Provider.

K. Changes of Ownership

Agencies that have had a change of ownership shall be required to submit a new application for licensure,

and must complete the application process as described above. After two years, the agency shall be eligible

to be considered for periodic surveys, if they meet the criteria above. (Note: a change in owners in a

corporation when the corporation does not change is not considered a change of ownership).

L. Reports of Unlicensed Agencies

When the office receives information that someone or an agency is providing PHCP services and is not

licensed, a complaint shall be initiated against the agency, and an on-site survey shall be performed to verify

the unlicensed practice. If the agency is found to be providing services for which licensure is required, a

certified letter shall be sent notifying the agency that they must cease operations or apply for a license within

a defined period of time (attachment #25

), or the Department will initiate a civil action against the agency.

The Office may consider owner/provider history, agency history, or other relevant factors in the

determination of the length of time allowable for compliance with the terms in the letter. If the agency

notifies the Office that they have ceased operation, the Office may at its discretion send a surveyor to verify.

If the agency elects to apply for license, the involuntary fee schedule shall be utilized for the initial licensing

process.

M. Complaints

Complaints for the private home care provider agency shall be processed and investigated via the procedures

outlined in the Healthcare Facility Regulation Division Complaint Procedure. Complaint investigations shall

be unannounced, but performed during the agency’s regular business hours. For complaint investigations that

result in no deficiencies, both the provider (attachment #26) and the complainant (attachment #27) shall be

so notified. For complaint

investigations that result in deficiencies being cited, a plan of correction shall be requested from the provider

(attachment #19). After the plan of correction is received and accepted, the provider shall be notified of its

acceptance (attachment # 20).

After such acceptance, the

complainant shall be notified that deficiencies were cited, and shall be provided instructions on how to obtain

a copy of the statement of deficiencies (attachments #28 and #29)

.

N. Adding Service Areas

Private Home Care Provider service areas are not subject to certificate of need laws. Service areas should be

designated by counties on the initial and subsequent applications for licenses. Staff who review requests for

service areas shall consider the type and frequency of services provided by the applicant and the number of

direct care and supervisory staff working for the provider in order to determine if the provider has the

resources to adequately provide care in the requested geographical area. Providers requesting expansion of

their service area shall be notified in writing of the decision (attachment #30) . If a new provider submits a

business plan that outlines how and when expansion to additional counties will be accomplished, the initial

approval can include the expanded counties.

GEORGIA DEPARTMENT OF COMMUNITY HEALTH

HEALTHCARE FACILITY REGULATION DIVISION

2 PEACHTREE STREET N.W.

SUITE 31.447

ATLANTA, GA 30303-3142

APPLICATION FOR A LICENSE TO OPERATE AS A PRIVATE HOME CARE PROVIDER

Pursuant to provisions of O.C.G.A. 31-7-300 et seq. Application is hereby made to operate as a Private Home Care Provider which is identified as follows:

SECTION A: IDENTIFICATION Date of Application: ___________________________

Type of Application: Initial Change of Ownership Administrator Name Change

R enewal Business Name Change Change in Governing Body

A ddress Change O ther______________________

Business Name

Street Address City State County Zip Code

E-Mail Address

Phone Fax

Mailing Address (If different from street address) City State County Zip Code

Phone (Office) Cell Fax

Name of Administrator Business Hours

SECTION B: TYPE OF OWNERSHIP (Circle only one)

PROPRIETARY (FOR PROFIT): Individual Partnership Corporation (Attach copy of Certificate of Incorporation) Other_______________

(Specify)

NON-PROFIT: State County City Church Hospital Authority Other (Specify) _________________________

SECTION C: GOVERNING BODY AND OWNERSHIP INFORMATION

Name of Legal Governing Body

List names and addresses of all owners with 5% or more interest:

Do you own and operate another licensed PHCP facility in the State of Georgia? _____Yes ______No

If yes, please contact the Home Care Services Unit for additional information prior to the submission of

your application packet.

Revised 12/2011

2

SECTION D: GEOGRAPHIC SERVICE AREA

List Georgia Counties:

SECTION E: STAFFING (For the services applicable to your agency, circle how staffing is provided)

NURSING SERVICES

 Direct Employment

 Contracted Individuals

 Combination

PERSONAL CARE SERVICES

 Direct Employment

 Contracted Individuals

 Combination

COMPANION/SITTER SERVICES

 Direct Employment

 Contracted Individuals

 Combination

SECTION F: FULL-TIME EQUIVALENT STAFF**

Registered Nurses

_________.__________

Licensed Practical Nurses

__________.__________

Personal Care Assistants

__________.__________

Companion / Sitters

__________.__________

Paraprofessionals/Others

__________.__________

**Personnel are to be described in terms of full-time equivalents. To arrive at full-time equivalents, add the total number of hours worked by

personnel in each category in the week ending prior to the week of filing the request. Divide this number by the number of hours in the standard

workweek as defined by your facility’s policy. If the result is not a whole number, express it as a quarter fraction only. (i.e.: 2.25, 6.50, 3.75)

SECTION G: CLIENTS

1

. Do you currently have any clients?  Yes  No

2. If “No”, have you had any clients within the past 12 months

?

SECTION H: STATEMENT OF COMPLIANCE

As required, the owner(s) completed the electronic / live scan fingerprints on _____________________.

(date)

I certify that this provider will comply with the Rules and Regulations for Private Home Care Providers, Chapter 290-5-54, pursuant to the Official

Code of Georgia Annotated (O.C.G.A.) § 31-7-300 et seq. I further certify that the above information is true and correct to the best of my

knowledge.

Signature of Administrator or Officer Authorized to Complete this Application Title of Signing Administrator or Authorized Officer Date

_________________________________________________________________________________________

TO BE COMPLETED BY HFRD PERSONNEL ONLY

Licensure Application Fee Paid-In-Full:  Yes  No ____________ ____________

Date Initials

Payment Information:____________________ ____________________ ____________________

Check or Money Order # Deposit Number Amount Paid

License Information: _________________ _________________

License Number Effective Date

Approved By:_____________________________________________________________________________

Name Title Date

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Private Home Care

Fingerprinting Process Using COGENT/GAPS

You must have an email account to complete this process. You may obtain

free email accounts at many web sites. Two possible sites are

www.yahoo.com

and www.hotmail.com.

A. Agreement (Step 1)

1. Go to www.ga.cogentid.com

2. Under the “Agency Use (secure)” tab

Click on “How to Enroll Your Agency or Business”

3. At Step (1) Complete the GCICService Agreement, click on form to be downloaded and

print the “Georgia Crime Information Center Service Agreement” (3 pages)

4. Complete last page of the GCIC Service Agreement

Agency Name – Print the name of Private Home Care (PHC), e.g. ABC Private Home

Care

Agency Address – Print the address of the your PHC or mailing address if different

from the PCH address

Agency Phone Number – Print the most accessible phone number Agency ORI

or OAC# – Circle OAC# and leave line blank

NOTE: If you already have an OAC# (OAC Numbers begin with GAP), print

your OAC on this line.

Write “Yes” in the blank after “Will ORI or OAC # be used for

Enrollment in Georgia Applicant Processing Services (GAPS) Agency

Head – Print the name/title of Owner/CEO/President of PHC

Agency Contact – Print the name/title of person that should be

contacted regarding fingerprinting process

5. Make a copy of the form for your records and mail original form to the address at the bottom of

the page. In 7-10 days you will receive the form back, completed by the GCIC with your OAC

number on the “Agency ORI or OAC#” line. If you do not receive an OAC number within 10

business days, send an email to [email protected]

and include your business name,

address and contact information. Once you receive the OAC number, proceed to Step 2.

If your business already has an OAC number and you have included it on the GCIC Service

Agreement, you may now proceed to Step 2.

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B. Enrollment (Step 2)

Only after receiving your OAC# by return mail or email should you begin this step.

1. Go to www.ga.cogentid.com

2. Under the “Agency Use (secure)” tab

Click on “How to Enroll Your Agency or Business”

3. At Step (2) Complete the GAPS Agency Enrollment Form, click on the “Enroll online

by clicking here” link to begin the enrollment process

(All yellow areas MUST be completed)

ORI/OAC – enter OAC number received on agreement letter

(It will be GAP+6 numbers)

Agency Name – Verify that the name of your PHC is correct

Verification Code – Use OAC number without the GA (P+6 digits)

Address – Enter street address, city, state, and zip code of the your PCH or

the mailing address if different from the PCH address

Contact Person – Must be the same as on the Agreement form in Step 1

Email Address – Email address must be entered

Billing Address – Complete if different from mailing address or click on box

indicating billing address and mailing address are the same

Authorized Person – Must be the same name as on the Agreement form as the

Agency Head in Step 1

Click on “Billing Account” only if you wish to have the cost of the fingerprinting billed

to you. Do not click on this if you are paying by credit card during the Registration

process or by money order at the time of fingerprinting.

4. When the form is completed – Click on “Save”

5. Print the form

6. Form must be signed by the Agency Head or Authorized Person

7. Mail to address shown on web site:

Cogent Systems

GAPS Enrollment

5450 Frantz Road, Suite 250

Dublin, OH 43016

NOTE: For expedited service you may fax a copy of the Enrollment form to Cogent

Systems at 614-718-9694 but the original signed copy must also be mailed to Cogent

Systems within seven (7) days.

8. You will receive an e-mail confirmation from Cogent confirming your enrollment within 10

business days. The email will include any necessary Usernames and Passwords. If you do not

receive an e-mail confirmation within 10 business days, call Cogent Systems or Georgia Bureau

of Investigation GCIC CCH Helpdesk. Contact information can be found under Useful Links on

the main GAPS web page.

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C. Registration for Fingerprinting (Step 3)

This step may be completed ONLY after Step 1 and Step 2 are completed and you have received an

e-mail confirmation from Cogent with your Username and Password.

1. Go to www.ga.cogentid.com

2. Under the “Registration” tab, click on Single Applicant Registration or Multiple Applicant

Registration depending on whether there is only one person to be fingerprinted (single) or

more than one (multiple).

3. For each applicant or person to be fingerprinted, all fields with a red (*) must be completed:

Last Name, First Name, Date of Birth, Place of Birth, Sex, Race, Eye Color, Hair Color, Height,

Weight

4. Social Security Number – Although this is not required, it is strongly recommended that this

field be completed to ensure an accurate search can be made, if needed

NOTE: If the SSN is not entered, the applicant must take the Registration ID number

assigned at the end of this registration process to the GAPS Print location in order to be

fingerprinted.

5. Country of Citizenship – Select correct country

6. Driver’s License Number – Enter ONLY numbers if you have a Georgia Driver’s License, for

all other states enter exactly as shown on the Driver’s License

7. Driver’s License State – Select correct state

8. Address – Applicant’s address, city, state, zip, phone

Under Transaction Information

9. Reason – Click on the arrow on the right side of the box and click on the reason for being

fingerprinted. If you need assistance with selecting the correct reason, contact the Department

of Community Health (DCH) at: (404) 656-0464 or (404) 463-7370 or by email at

[email protected]

f) “DCH – Private Home Care (Owner)”

NOTE: Failure to select the correct Reason from the drop-down menu may cause your

fingerprint submission to be rejected and/or possible sanctions levied against your

business by the Healthcare Facility Regulation Division (formerly the Office of Regulatory

Services).

10. Payment

Choose Credit Card if paying at this time. You will be given an opportunity to

enter your credit card information during this registration process, so be sure

the credit card is available.

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Choose Money Order if paying at the GAPS Print location when the applicant

goes to be fingerprinted.

NOTE: This will only be an option on the single applicant entry. All money orders

should be made payable to Cogent Systems/GAPS and in the amount of

$52.90.

Choose “Agency” if you selected to be setup of billing by Cogent Systems during the

Enrollment process. A Billing Code and Billing Password should be found in the

Enrollment confirmation email from Cogent Systems, if you selected to be setup for billing.

The agency (PCH) will be billed for the service in the amount of $52.90 per individual

registered through Single or Multiple Applicant Registration.

11. ORI/OAC – Use the OAC number (GAP + 6 digits) shown on the Enrollment email

12. Verification Code – Use code given in your Enrollment confirmation email

13. “Does another agency make the fitness determination?” – Check the box.

FAILURE TO CHECK THE BOX FOR “Does another agency make the fitness

determination?”, AND COMPLETE THE INFORMATION BELOW MAY CAUSE A

REJECTION IF THE TRANSACTION IS ACCEPTED. THE APPLICANT WILL HAVE

TO BE RE-REGISTERED AND REPAY FOR THE FINGERPRINT SERVICES.

-Choose Agency – Select Dept of Community Health

-Determining Agency ORI – Enter GA922960Z

Click on “Next” at the bottom of the page

14. Verify that the information is correct. If anything needs to be corrected, click Back to

return to the previous screen and make the corrections.

15. If no corrections are needed, Click on “Next”

Print the “Thank you for registering” page with the Registration ID number.

NOTE: Bring this page with the Registration ID to the GAPS Print location to be

fingerprinted.

D. Identification Needed For Fingerprinting (Step 4)

1. Go to www.ga.cogentid.com

2. Under the “GAPS Print Site Location” tab, click the link for ‘Identification Needed

for Fingerprinting’. In addition to the Registration ID number the applicant will also be

asked to present identification documents prior to being fingerprinted. This link provides a list

of acceptable identification documents.

E. Fingerprinting at GAPS sites (Step 5)

1. Go to www.ga.cogentid.com

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2. Under the “GAPS Print Site Location” tab, find a location nearest to your address.

3. Click on underlined company name to get phone number and hours of operation

4. You MUST be a currently licensed facility or have a letter of verification that your new

application has been received by the Healthcare Facility Regulation Division before

having your fingerprints completed.

5. On the day of your fingerprinting, contact the site you plan to visit and confirm the

hours they do fingerprinting and that a trained individual is going to be available.

6. After your fingerprints are taken and transmitted to GCIC, the results are usually

available on the GAPS website to DCH within 48 hours. You should receive a

determination from DCH within ten (10) days after you are fingerprinted. If you have

not received a determination within fourteen (14) days, contact DCH at (404) 656-

0464 and/or email at dos[email protected].gov for a status.

Cogent and GBI cannot provide a status of the fitness determination

Note: If a site is no longer providing fingerprint services, please send an email to

[email protected]

and provide the Print Location’s name, address and

phone number if available and the date the applicant was told the location is no

longer providing the service.

O.C.G.A. § 50-36-1(e)(2) Affidavit

By executing this affidavit under oath, as an applicant for a license, permit or

registration, as referenced in O.C.G.A. § 50-36-1, from the Department of Community

Health, State of Georgia, the undersigned applicant verifies one of the following with

respect to my application for a public benefit:

1) _________ I am a United States citizen.

2) _________ I am a legal permanent resident of the United States.

3) _________ I am a qualified alien or non-immigrant under the Federal Immigration and

Nationality Act with an alien number issued by the Department of

Homeland Security or other federal immigration agency.

My alien number issued by the Department of Homeland Security or other

federal immigration agency is:____________________.

The undersigned applicant also hereby verifies that he or she is 18 years of age or older

and has provided at least one secure and verifiable document, as required by O.C.G.A.

§ 50-36-1(e)(1), with this affidavit.

The secure and verifiable document provided with this affidavit can best be classified as:

_______________________________________________________________________.

In making the above representation under oath, I understand that any person who

knowingly and willfully makes a false, fictitious, or fraudulent statement or

representation in an affidavit shall be guilty of a violation of O.C.G.A. § 16-10-20, and

face criminal penalties as allowed by such criminal statute.

Executed in ___________________ (city), __________________(state).

____________________________________

Signature of Applicant

____________________________________

Printed Name of Applicant

SUBSCRIBED AND SWORN

BEFORE ME ON THIS THE

___ DAY OF ___________, 20____

_________________________

NOTARY PUBLIC

My Commission Expires:

Page 1 of 2

INSTRUCTIONS FOR COMPLETING AFFIDAVIT

REQUIRED TO BECOME LICENSED

In order to obtain a license from the Department of Community Health to operate your

business, Georgia law requires every applicant to complete an affidavit (sworn written

statement) before a Notary Public that establishes that you are lawfully present in the

United States of America. This affidavit is a material part of your application and must be

completed truthfully. Your application for licensure may be denied or your license may be

revoked by the Department if it determines that you have made a material misstatement of

fact in connection with your application to become licensed. If a corporation will be

serving as the governing body of the licensed business, the individual who signs the

application on behalf of the corporation is required to complete the affidavit. Please follow

the instructions listed below.

1. Review the list of Secure and Verifiable Documents under O.C.G.A. §50-36-2 which

follows these instructions. This list contains a number of identification sources to

choose from that are considered secure and verifiable that you can use to establish

your identity, such as a U.S. driver’s license or a U.S. passport. Locate one original

document on the list to bring to the Notary Public to establish your identity.

2. Print out the affidavit. (If you do not have access to a printer, you can go to your

local library or an office supply store to print out the document for a small fee.)

3. Fill in the blanks on the Affidavit above the signature line only—BUT DO NOT

SIGN THE AFFIDAVIT at this time. (You will sign the affidavit in front of the

Notary Public.) Fill in the name of the secure and verifiable document (for example,

Georgia driver’s license, U.S. passport) that you will be presenting to the Notary

Public as proof of your identity. CAUTION: Put your initials in front of only ONE

of the choices listed on the affidavit and described here below:

• Option 1) is to be initialed by you if you are a United States citizen; or

• Option 2) is to be initialed by you if you are a legal permanent resident of the

United States. You are not a U.S. citizen but you have a green card; or

• Option 3) is to be initialed by you if you are a qualified alien or non-immigrant

(but not a U.S. citizen or a legal permanent resident) with an alien number

issued by the Department of Homeland Security or other federal immigration

agency. Fill in the alien number, as well.

4. Find a Notary Public in your area. Check the yellow pages, the internet or with a

local business, such as a bank.

5. Bring your affidavit and the identification you selected (from the list of Secure and

Verifiable Documents) to appear before the Notary Public.

Secure and Verifiable Documents Under O.C.G.A. § 50-36-2

Issued August 1, 2011 by the Office of the Attorney General, Georgia

The Illegal Immigration Reform and Enforcement Act of 2011 (“IIREA”) provides that “[n]ot

later than August 1, 2011, the Attorney General shall provide and make public on the

Department of Law’s website a list of acceptable secure and verifiable documents. The list shall

be reviewed and updated annually by the Attorney General.” O.C.G.A. § 50-36-2(f). The

Attorney General may modify this list on a more frequent basis, if necessary.

The following list of secure and verifiable documents, published under the authority of O.C.G. A.

§ 50-36-2, contains documents that are verifiable for identification purposes, and documents on

this may not necessarily be indicative of residency or immigration status.

• A United States passport or passport card [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

• A United States military identification card [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

• A driver’s license issued by one of the United States, the District of Columbia, the

Commonwealth of Puerto Rico, Guam, the Commonwealth of the Northern Marianas

Islands, the United States Virgin Island, American Samoa, or the Swain Islands, provided

that it contains a photograph of the bearer or lists sufficient identifying information

regarding the bearer, such as name, date of birth, gender, height, eye color, and address to

enable the identification of the bearer [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

• An identification card issued by one of the United States, the District of Columbia, the

Commonwealth of Puerto Rico, Guam, the Commonwealth of the Northern Marianas

Islands, the United States Virgin Island, American Samoa, or the Swain Islands, provided

that it contains a photograph of the bearer or lists sufficient identifying information

regarding the bearer, such as name, date of birth, gender, height, eye color, and address to

enable the identification of the bearer [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

• A tribal identification card of a federally recognized Native American tribe, provided that it

contains a photograph of the bearer or lists sufficient identifying information regarding the

bearer, such as name, date of birth, gender, height, eye color, and address to enable the

identification of the bearer. A listing of federally recognized Native American tribes may

be found at: http://www.bia.gov/WhoWeAre/BIA/OIS/TribalGovernmentServices/Tribal

Directory/ind/ex.htm [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

• A United States Permanent Resident Card or Alien Registration Receipt Card [O.C.G.A. §

50-36-2(b)(3); 8 CFR § 274a.2]

• An Employment Authorization Document that contains a photograph of the bearer

[O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

• A passport issued by a foreign government [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

• A Merchant Mariner Document or Merchant Mariner Credential issued by the United

States Coast Guard [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

• A Free and Secure Trade (FAST) card [O.C.G.A. § 50-36-2(b)(3); 22 CFR § 41.2]

• A NEXUS card [O.C.G.A. § 50-36-2(b)(3); 22 CFR § 41.2]

• A Secure Electronic Network for Travelers Rapid Inspection (SENTRI) card [O.C.G.A. §

50-36-2(b)(3); 22 CFR § 41.2]

• A driver’s license issued by a Canadian government authority [O.C.G.A. § 50-36-2(b)(3);

8 CFR § 274a.2]

• A Certificate of Citizenship issued by the United Stated Department of Citizenship and

Immigration Services (USCIS) (Form N-560 or Form N-561) [O.C.G.A. § 50-36-2(b)(3); 6

CFR § 37.11]

• A Certificate of Naturalization issued by the United States Department of Citizenship and

Immigration Services (USCIS) (Form N-550 or Form N-570) [O.C.G.A. § 50-36-2(b)(3); 6

CFR § 37.11]

• In addition to the documents listed herein, if, in administering a public benefit or program,

an agency is required by federal law to accept a document or other form of identification

for proof of or documentation of identity, that document or other form of identification will

be deemed a secure and verifiable document solely for that particular program or

administration of that particular public benefit. [O.C.G.A. § 50-36-2(c)]

Page 2 of 2

6. Show the Notary Public your secure and verifiable identification (anything on List

that follows these instructions) and state under oath in the presence of the Notary

Public that you are who you say you are and that you are in the United States

lawfully. Then sign your name.

7. Make certain that the Notary Public signs and dates the affidavit and puts when the

notary commission expires.

8. Make a copy of the affidavit and the identification that you presented to the Notary

Public for your own records.

9. Attach the ORIGINAL SIGNED AFFIDAVIT and a copy of the identification you

presented to your application for licensure. DO NOT SEND US YOUR

AFFIDAVIT SEPARATELY. IT MUST BE INCLUDED IN THE COMPLETE

APPLICATION PACKET WHICH YOU MAIL TO US.

List B

Documents That Establish Identity

For individuals 18 years or older:

• Driver’s license or ID card issued by a state or outlying

possession of the United States provided it contains a photograph

or information such as name, date of birth, sex, height, eye color,

and address

• ID card issued by federal, state or local government agencies or

entities provided it contains a photograph or information suchas

as name, date of birth, sex, height, eye color, and address

(including U.S. Citizen ID Card [INS Form I-197] and ID card

for use of Resident Citizen in the U.S. [INS Form I-179])

• School identification card with a photograph

• Voter’s registration card

• United States military card or draft record

• Military dependent’s identification card

• United States Coast Guard Merchant Mariner Card

• Native American tribal document

• Driver’s license issued by a Canadian government authority

Source: http://uscis.gov/graphics/lawsregs/handbook/hand_emp.pdf US Handbook for

Employers, page 23.

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RULES

OF

DEPARTMENT OF COMMUNITY HEALTH

CHAPTER 111-8

HEALTHCARE FACILITY REGULATION

111-8-65

RULES AND REGULATIONS FOR PRIVATE HOME CARE

PROVIDERS

TABLE OF CONTENTS

111-8-65-.01 Legal Authority

111-8-65-.02 Title and Purposes

111-8-65-.03 Definitions

111-8-65-.04 Governing Body

111-8-65-.05 Licenses

111-8-65-.06 Applications

111-8-65-.07 Exemptions

111-8-65-.08 Inspections and Plans of Correction

111-8-65-.09 Administration and Organization

111-8-65-.10 Private Home Care Provider Services

111-8-65-.11 Service Plans

111-8-65-.12 Client Rights, Responsibilities, and Complaints

111-8-65-.13 Enforcement and Penalties

111-8-65-.14 Waivers and Variances

111-8-65-.15 Severability

111-8-65-.01 Legal Authority.

These rules are adopted and published pursuant to the

Official Code of Georgia Annotated (O.C.G.A.) § 31-7-300 et seq.

Authority: O.C.G.A. §§ 31-2-4, 31-2-5, 31-2-7 and 31-7-300 et

seq.

111-8-65-.02 Title and Purposes.

Disclaimer: This is an unofficial copy of the rules that has been reformatted for the convenience of

the public by the Department of Community Health. The official rules for this program are on record

with the Georgia Secretary of State’s office. The Secretary of State’s website for reviewing the rules

is http://rules.sos.state.ga.us/cgi-bin/page.cgi?d=1 . An effort has been made to ensure the

accuracy of this unofficial copy. The Department reserves the right to withdraw or correct text in this

copy if deviations from the offi

cial text as published by the Georgia Secretary of State are found.

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These rules shall be known as the Rules and Regulations for

Private Home Care Providers. The purposes of these rules are to

provide for the licensing and inspection of private home care

providers.

Authority: O.C.G.A. §§ 31-2-5, 31-2-7 and 31-7-300 et seq.

111-8-65-.03 Definitions.

In these rules, unless the context otherwise requires, the

words and phrases set forth herein shall mean the following:

(a) "Ambulation and transfer" means the acts of moving or

walking about or walking or being moved from place to place with

or without assistance.

In these rules, unless the context otherwise requires, the

words and phrases set forth herein shall mean the following. . .

(b) “Applicant” means:

1. When the private home care provider is owned by a sole

proprietorship, the individual proprietor shall be the applicant for

the license, complete the statement of responsibility and serve as

the licensee;

2. When the private home care provider is owned by a

partnership, the general partners shall be the applicant for the

license, complete the statement of responsibility and serve as the

licensee;

3. When the private home care provider is owned by an

association limited liability company (LLC), the governing body of

the association or LLC shall authorize the application for the

license and complete the statement of responsibility and the

association shall serve as the licensee; and

4. When the private home care provider is owned by a

corporation, the governing body of the corporation shall authorize

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the application for the license and complete the statement of

responsibility and the corporation shall serve as the licensee.

(c) "Companion or sitter tasks" means the following tasks

which are provided to elderly, handicapped, or convalescing

individuals: transport and escort services; meal preparation and

serving; and household tasks essential to cleanliness and safety.

(d) “Criminal history background check” means a search as

required by law of the criminal records maintained by law

enforcement authorities to determine whether the applicant has a

criminal record as defined in these rules.

(e) “Criminal record” means:

1. Conviction of a crime; or

2. Arrest, charge, and sentencing for a crime where:

(i) A plea of nolo contendere was entered to the charge; or

(ii) First offender treatment without adjudication of guilt

pursuant to the charge was granted; or

(iii) Adjudication or sentence was otherwise withheld or not

entered on the charge; or

3. Arrest and being charged for a crime if the charge is

pending, unless the time for prosecuting such crime has expired

pursuant to Chapter 3 of Title 17 O.C.G.A.

(f) "Department" means the Department of Community

Health.

(g) "Director" means the chief administrative or executive

officer or manager.

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(h) "Home health agency" means a facility licensed as a

home health agency in accordance with the applicable licensing

statutes and associated rules.

(i) "Home management" means those activities normally

performed by a homemaker for the maintenance of a home's

essential services, including but not limited to activities such as

meal planning, shopping, and bill paying; any employee that is

authorized unlimited access to a client's personal funds for home

management shall be bonded through the provider.

(j) "Housekeeping or housekeeping tasks" means those

activities performed for the upkeep and cleanliness of the home,

including but not limited to such activities as laundry, changing

linens, trash disposal, and cleaning.

(k) "Inspection" means any examination by the department

or its representatives of a provider, including but not necessarily

limited to the premises, and staff, persons in care, and documents

pertinent to initial and continued licensing so that the department

may determine whether a provider is operating in compliance with

licensing requirements for has violated any licensing

requirements. The term inspection includes any survey,

monitoring visit, complaint investigation, or other inquiry

conducted for the purposes of making a compliance determination

with respect to licensing requirements.

(l) "Medically frail or medically compromised client" means a

client whose health status, as determined by appropriate provider

staff in accordance with accepted standards of practice, is likely to

change or has changed because of a disease process, injury,

disability or advanced age and underlying disease process(es).

(m) "Medically related activities" means activities such as but

not limited to observing and reporting changes in a client's

condition, arranging trips to the doctor, picking up prescription

drugs, accompanying clients on medical appointments,

documenting client's food and/or liquid intake or output, reminding

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clients to take medication, and assisting with self-administration of

medication; such activities shall not include professional services

that are subject to regulation under professional practice and

licensing statutes and associated rules.

(n) “Owner” means any individual or any person affiliated

with the corporation, partnership, or association with 10 percent or

greater ownership interest in a business or agency licensed as a

private home care provider and who:

1. Purports to or exercises authority of an owner in the

business or agency;

2. Applies to operate or operates the business or agency; or

3. Enters into a contract to acquire ownership of such a

business or agency.

(o) "Personal care home" means a facility licensed as a

personal care home in accordance with the applicable licensing

statutes and associated rules.

(p) "Personal care tasks" means assistance with bathing,

toileting, grooming, shaving, dental care, dressing, and eating;

and may include but are not limited to proper nutrition, home

management, housekeeping tasks, ambulation and transfer, and

medically related activities, including the taking of vital signs only

in conjunction with the above tasks.

(q) "Private home care provider" means any person,

business entity, corporation, or association, whether operated for

profit or not for profit, that directly provides or makes provision for

private home care services through:

1. its own employees or agents;

2. contractual arrangements with independent contractors;

or

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3. referral of other persons to render home care services,

when the individual making the referral has ownership or financial

interest in the delivery of those services by those other persons

who would deliver those services.

(r) "Private home care services" means those items and

services provided at a patient's residence that involve direct care

to that patient and includes, without limitation, any or all of the

following:

1. nursing services, provided that such services can only be

provided by a person licensed as a Registered Professional Nurse

or Licensed Practical Nurse in accordance with applicable

professional licensing statutes and associated rules;

2. personal care tasks; and

3. companion or sitter tasks.

4. Private home care services shall not include physical,

speech, or occupational therapy; medical nutrition therapy;

medical social services; or home health aide services provided by

a home health agency.

(s) “Records check application” means two sets of

classifiable fingerprints, a records search fee to be established by

the department by rule and regulation, payable in such form as the

department may direct to cover the cost of a fingerprint records

check, and an affidavit by the applicant disclosing the nature and

date of any arrest, charge, or conviction of the applicant for the

violation of any law, except for motor vehicle parking violations,

whether or not the violation occurred in this state, and such

additional information as the department may require.

(t) "Residence" means the place where an individual makes

that person's permanent or temporary home, whether that

person's own apartment or house, a friend or relative's home, or a

personal care home, but shall not include a hospital, nursing

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home, hospice, or other health care facility licensed under

O.C.G.A. § 31-7-1 et seq.

(u) "Responsible Party" means any person authorized in

writing by the client or appointed by an appropriate court to act

upon the client's behalf; the term shall include a family member of

a physically or mentally impaired client unable to grant the above

authorization.

(v) “Satisfactory criminal history background check

determination” means a written determination that a person for

whom a records check was performed was found to have no

criminal record which includes one of the covered crimes outlined

in O.C.G.A. § 31-2-9, if applicable.

(w) "Transport and escort services" means accompanying

clients or providing or arranging transportation for clients to places

outside of their residences for purposes such as appointments,

entertainment, exercise, recreation, shopping, or social activities.

If the mode of transportation is not owned by the client and is

operated by an employee of the provider, the provider shall either

obtain a signed waiver by the client of any claims for damages

arising out of the operation of the vehicle or make reasonable

efforts to insure that there is current motor vehicle insurance that

will provide medical coverage for the client, in the event that the

vehicle is involved in an accident causing injuries to the client.

(x) “Unsatisfactory criminal history background check

determination” means a written determination that a person for

whom a records check was performed has a criminal record which

includes one of the covered crimes outlined in O.C.G.A. § 31-2-9,

if applicable.

Authority: O.C.G.A. §§ 31-2-5, 31-2-7 and 31-7-300 et seq.

111-8-65-.04 Governing Body.

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Each private home care provider shall have a governing body

empowered and responsible to determine all policies and

procedures and to ensure compliance with these rules.

Authority: O.C.G.A. §§ 31-2-5, 31-2-7 and 31-7-300 et seq.

111-8-65-.05 Licenses.

(1) No private home care provider shall operate without a

license or provisional license issued by the department.

(a) A license shall be issued and renewed periodically by the

department upon a providers’ compliance with these rules and

shall remain in force and effect until the license expires or is

suspended, revoked or limited.

(b) Prior to the issuance of any new license, the owner of the

business or agency applying for the license shall be required to

submit a records check application so as to permit the department

to obtain a criminal history background check.

1. An owner may not be required to submit a records check

application if a determination is made by the Department that the

owner does not do any of the following:

(i) Maintains an office at the location where services are

provided to clients;

(ii) Resides at a location where services are provided to

clients;

(iii) Has direct access to persons receiving care; nor

(iv) Provides direct personal supervision of personnel by

being immediately available to provide assistance and direction

during the time services are being provided.

2. In lieu of a records check application, the owner may

submit evidence, satisfactory to the department, that within the

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immediately preceding 12 months the owner has received a

satisfactory criminal records check determination.

(c) A private home care provider license shall not be issued,

and any issued license shall be revoked, where it has been

determined that the owner has received an unsatisfactory criminal

records check determination involving any of the following covered

crimes, as outlined in O.C.G.A. 49-2-14.1 et seq.:

1. A violation of Code Section 16-5-1, relating to murder and

felony murder;

2. A violation of Code Section 16-5-21, relating to

aggravated assault;

3. A violation of Code Section 16-5-70, relating to

aggravated battery;

4. A violation of Code Section 16-5-70 relating to cruelty to

children;

5. A violation of Code Section 16-5-100, relating to cruelty

to a person 65 year of age or older;

6. A violation of Code Section 16-6-1, relating to rape;

7. A violation of Code Section 16-6-2, relating to aggravated

sodomy;

8. A violation of Code Section 16-6-4, relating to child

molestation;

9. A violation of Code Section 16-6-5, relating to enticing a

child for indecent purposes;

10. A violation of Code Section 16-6-5.1, relating to sexual

assault against persons in custody, detained persons, or patients

in hospitals or other institutions;

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11. A violation of Code Section 16-6-22.2, relating to

aggravated sexual battery;

12. A violation of Code Section 16-8-41, relating to armed

robbery;

13. A violation of Code Section 30-5-8, relating to abuse,

neglect, or exploitation of a disabled adult or elder person; or

14. Any other offense committed in another jurisdiction that, if

committed in this state, would be deemed to be a crime listed in

this paragraph without regard to its designation elsewhere;

(d) An owner holding a valid private home care provider

license issued on or before June 30, 2007 shall be required to

obtain a fingerprint records check determination no later than

December 31, 2008.

1. An owner holding a valid private home care provider

license issued on or before June 30, 2007 who has received an

unsatisfactory criminal records determination which includes any

one of the covered crimes listed in Rule .05(c)(1)-(14) above, shall

not have the license revoked prior to a hearing being held before a

hearing officer pursuant to Chapter 13 of Title 50, the ‘Georgia

Administrative Procedures Act’.

2. An owner with a valid private home care provider license

who acquires a criminal record for any of the crimes listed in Rule

.14(7)(c)(1)-(14) above subsequent to the effective date of these

rules shall disclose the criminal record to the department.

(e) If at any time the department has reason to believe an owner

holding a valid license has been arrested, charged, or convicted of

any of the covered crimes listed in Rule .14(7)(c)(1)-(14) above,

the department shall require the owner to submit a records check

application immediately for determination of whether a revocation

action is necessary.

(f) A provisional license may be issued by the department

on a conditional basis for one of the following reasons:

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1. To allow a newly established provider a reasonable, but

limited, time to demonstrate that its operational procedures

comply with these rules; or

2. To allow an existing provider a reasonable length of time

to comply with these rules and regulations, provided that the

provider shall present a plan of improvement acceptable to the

department.

(2) Qualifications Requirement. In order to obtain or retain a

license or provisional license, the provider's administrator and its

employees must be qualified, as defined in these rules, to direct or

work in a program. However, the department may require

additional reasonable verification of the qualifications of the

administrator and employees either at the time of application for a

license or provisional license or at any time during the license

period whenever the department has reason to believe that an

administrator or employee is not qualified under these rules to

direct or work in a program.

(a) If a governing body maintains offices as a private home

care provider in more than one location, then each location shall

be separately licensed.

(b) The license shall be prominently and appropriately

displayed at the private home care providers licensed location.

(c) No license issued under these rules is assignable or

transferable. Each license or provisional license shall be returned

to the department in cases of changes in name, location,

ownership or governing body or if suspended, revoked, or limited.

The department shall be provided 15 days notice in advance of

any providers change in location.

Authority: O.C.G.A. §§ 31-2-5, 31-2-7, 31-2-9 and 31-7-300 et

seq.

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111-8-65-.06 Applications.

(1) Initial applications for a license as a private home care

provider must be submitted to the department on forms provided

by the department, and shall include the submission of an

application fee and a license fee established by the Board of

Community Health, and a records check application for the owner.

Such application shall include a description of the private home

care provider services to be offered by the applicant and the

geographic area that will be served.

(2) Renewal of Licenses. Licenses shall be renewed by the

department periodically from the date of initial issuance upon

submission of a renewal application, and a license renewal fee

established by the Board of Community Health. Such renewal

application shall include a description of the private home care

provider services offered by the licensee and the geographic area

served.

(3) Fees. Fees shall be reasonable and shall be set so that

the total of the fees approximates the total of the direct and

indirect costs to the state of the licensing program. Fees may be

refunded for good cause as determined by the department.

(4) False or Misleading Information. The application for any

license or renewal must be truthfully and fully completed. In the

event that the department has reason to believe that any

application has not been completed truthfully, the department may

require additional reasonable verification for the facts alleged.

The department may refuse to issue or renew any license where

false statements have been made in connection with the

application or any other documents required by the department.

Authority: O.C.G.A. §§ 31-2-4, 31-2-5, 31-2-8 and 31-7-300 et

seq.

111-8-65-.07 Exemptions.

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(1) These rules shall not apply to private home care services

which are provided under the following conditions:

(a) When those services are provided directly by an

individual, either with or without compensation, and not by agents

or employees of the individual and not through independent

contractors or referral arrangements made by an individual who

has ownership or financial interest in the delivery of those services

by others who would deliver those services.

(b) When those services are home infusion therapy services

and the intermittent skilled nursing care is provided only as an

integral part of the delivery and infusion of pharmaceuticals;

however, such skilled nursing care, whether hourly or intermittent,

which provides care licensed by these rules beyond the basic

delivery and infusion of pharmaceuticals is not exempt;

(c) When those services are provided through the temporary

placement of professionals and paraprofessionals to perform

those services in places other than a person’s residence;

(d) When those services are provided by home health

agencies which are licensed under state law;

(e) When those services are provided in a personal care

home by the staff of the personal care home; and

(f) When those services are services within the scope of

practice of pharmacy and provided by persons licensed to practice

pharmacy.

(g) RESERVED.

(2) A certificate of need issued pursuant to O.C.G.A. § 31-6-

1 et seq. is not required for licensure so long as the provider does

not operate as a licensed home health agency or personal care

home.

Authority: O.C.G.A. §§ 31-7-305 and 31-7-307.

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111-8-65-.08 Inspections and Plans of Correction.

(1) Providers shall be inspected by the department

periodically; provided, however, the department may exempt a

provider from such periodic inspections if it is certified or

accredited by a certification or accreditation entity recognized and

approved by the department.

(a) A provider seeking exemption from on-site inspection

shall be required to submit to the department documentation of

certification or accreditation, including a copy of its most recent

certification or accreditation report.

(b) Nothing contained herein shall be construed to prohibit

the department from conducting inspections of any provider as the

department determines necessary.

(2) Consent to Entry and Access. An application for a

license or the issuance and renewal of any license by the

department constitutes consent by the applicant or licensee and

the owner of the premises for the department's representatives to

enter the premises for the purpose of conducting any inspection

during regular business hours.

(a) Department representatives shall be allowed reasonable

and meaningful access to the provider's premises, all records

relevant to licensure and all provider staff. Providers shall assist

and cooperate in arranging for department representatives to have

meaningful access to provider's clients who consent to be

interviewed by department representatives in connection with any

licensure activity.

(3) Cooperation with Inspection. All provider staff shall

cooperate with any inspection conducted by the department and

shall provide, without unreasonable delay, any documents to

which the department is entitled hereunder.

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(4) If as a result of the inspection, violations of these

licensure regulations are identified, the provider will be given a

written report of the inspection which identifies the licensure

regulations violated. The provider must submit a written plan of

correction (improvement) in response to the inspection report

which states what the provider will do when to correct each of the

violations identified. The provider may offer any explanation or

dispute the findings of violations in the written plan of correction so

long as an acceptable plan of correction is submitted within ten

days of the receipt of the written report of licensure inspection.

Authority: O.C.G.A. §§ 31-2-5, 31-2-7, 31-2-8 and 31-7-300 et

seq.

111-8-65-.09 Administration and Organization.

(1) Services Description. A provider shall establish and

implement written policies and procedures that define the scope of

private home care services it offers and the types of clients it

serves. No provider shall provide services that are prohibited by

these rules, the applicable legal authority, or other laws.

(2) Service Agreements. No provider shall offer to provide a

client any private home care services that it cannot reasonably

expect to deliver in accordance with these rules.

(a) A provider shall establish and implement policies and

procedures for service agreements. All services provided to a

client shall be based on a written service agreement entered into

with the client or the client's responsible party, if applicable. The

service agreement must include the following:

1. Date that provider makes initial contact with client for

services;

2. Date of referral, i.e. the date on which the provider

received a specific request to deliver private home care services

to a particular client;

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3. Description of services needed as stated by client or

responsible party, if applicable;

4. Description of services to be provided and expected

frequency and duration of services;

5. Charges for such services, and mechanisms for billing

and payment of such charges;

6. Acknowledgment of receipt of a copy of client's rights and

responsibilities as outlined at rule .12;

7. A telephone number of the provider that a client can call

for information, questions, or complaints about services supplied

by the provider;

8. The telephone number of the state licensing authority, i.e.

the department, to call for information or questions about the

provider concerning a violation of licensing requirements that was

not resolved to the client's satisfaction by complaining to the

provider;

9. Authorization from client or responsible party, if

applicable, for access to client's personal funds when home

management services are to be provided and when those services

include assistance with bill paying or any activities, such as

shopping, that involve access to or use of such funds; similarly

approved authorization for use of client's motor vehicle when

services to be provided include transport and escort services and

when the client's personal vehicle will be used;

10. Signatures for the provider's representative and the client

or responsible party, if applicable, and date signed; if a client or

responsible party refuses to sign the agreement, such refusal shall

be noted on the agreement with an explanation from the provider's

representative.

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(b) For new clients, such initial service agreements shall be

completed not later than the second visit to the client's residence

to provide services if the second visit occurs on a different day

from the first visit or not later than seven calendar days after

services are initially provided in the residence, whichever is

earlier.

1. If the provider is unable to complete the service

agreement for good cause, the provider will document such

reason(s) in the client's file.

2. Subsequent revisions to the initial service agreement

may be handled by the provider noting in the client's record the

specific changes in service (e.g. addition or deletion of service,

changes in frequency, or duration, or charge for services, etc.)

that will occur and that the change was discussed with and agreed

to by the client and/or responsible party, as appropriate, who

signed the initial agreement prior to the change in services

occurring.

(c) A client has the right to cancel any service agreement at

any time and shall only be charged for services actually rendered

prior to the time that the provider is notified of the cancellation.

The provider may assess a reasonable charge for travel and staff

time if notice of the cancellation of the service agreement is not

provided in time to cancel the service prior to the provider's staff

member arriving at the client's house to perform the service.

(3) Administrator. The governing body shall appoint an

administrator who shall have full authority and responsibility for

the operation of the private home care provider.

(a) Any administrator employed after the effective date of

these rules must meet the following minimum qualifications:

1. Never have been shown by credible evidence (e.g. a

court or jury, a department investigation, or other reliable

evidence) to have abused, neglected, sexually assaulted,

exploited, or deprived any person or to have subjected any person

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to serious injury as a result of intentional or grossly negligent

misconduct as evidenced by an oral or written statement to this

effect obtained at the time of application;

2. Participate in the orientation and training required by

these rules;

3. Not have made any material false statements concerning

qualifications requirements either to the department or the

provider.

(4) Record keeping.

(a) Client Records. A provider shall maintain a separate file

containing all written records pertaining to the services provided

for each client that it serves and the file shall contain the following:

1. Identifying information including name, address,

telephone number, and responsible party, if any;

2. Current service agreement as described at rule .09(2);

3. Current service plan as described at rule .11;

4. Clinical and/or progress notes if the client is receiving

nursing services that have been signed and dated by the staff

providing the direct care;

5. Documentation of personal care tasks and companion or

sitter tasks actually performed for the client;

6. Documentation of findings of home supervisory visits by

the supervisor unless entered in service plan;

7. Any material reports from or about the client that relate to

the care being provided to the client including items such as

progress notes and problems reported by employees of the

provider, communications with personal physicians or other health

care providers, communications with family members or

responsible parties, or similar items;

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8. The names, addresses, and telephone numbers of the

client's personal physicians, if any; and

9. Date and source of referral.

(b) Retention and Confidentiality of Client Records. Written

policies and procedures shall be established and implemented for

the maintenance and security of client records specifying who

shall supervise the maintenance of records, who shall have

custody of records, to whom records may be released and for

what purposes and how long the records will be retained.

1. At a minimum, all client records shall be retained for five

years from the date of last service provided. The provider shall

maintain the confidentiality of client records.

2. Employees of the provider shall not disclose or knowingly

permit the disclosure of any information in a client record except to

appropriate provider staff, the client, responsible party (if

applicable), the client's physician or other health care provider, the

department, other individuals authorized by the client in writing or

by subpoena.

(c) Personnel Records. A provider shall maintain separate

written records for each employee and the records shall include

the following:

1. Identifying information such as name, address, telephone

number, and emergency contact person(s);

2. A five year employment history or a complete

employment history if the person has not been employed five

years;

3. Records of qualifications;

4. Documentation of a satisfactory TB screening test upon

employment and annually thereafter;

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5. Date of employment;

6. The person's job description or statements of the

person's duties and responsibilities;

7. Documentation of orientation and training required by

these rules;

8. Documentation of at least an annual performance

evaluation;

9. Documentation of bonding if the employee performs

home management services which permit unlimited access to the

client's personal funds. (If bonding is provided through a universal

coverage bond, evidence of bonding need not be maintained

separately in each personnel folder.)

(d) Reports of Complaints and Incidents. The provider shall

maintain files of all documentation of complaints submitted

pursuant to rule .12(2). A provider shall also maintain on file for a

minimum of five years all incident reports or reports of unusual

occurrences (e.g. falls, accidents, significant medication errors,

etc.) that affect the health, safety, and welfare of its clients.

Documentation required to be maintained shall include what

actions, if any, the provider took to resolve clients' complaints and

to address any incident reports or unusual occurrences required to

be retained.

(5) Staffing. The provider shall have sufficient numbers of

qualified staff as required by these rules to provide the services

specified in the service agreements with its clients. In the event

that the provider becomes aware that it is unable to deliver the

specified services to the client because of an unexpected staff

shortage, the provider shall advise the client and refer the client to

another provider if the client so desires.

(a) All staff employed by a provider shall have included in

their personnel records or files maintained by the particular

provider a written evaluation that was performed within one year

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before or after the effective date of these rules. The written

evaluation must reflect that the employee's performance of

required job tasks was observed personally by a supervisor either

by demonstration or observation and such performance was

determined to be competent for all job tasks required to be

performed. All staff hired after the effective date of these rules

must meet the following minimum qualifications:

1. Never have been shown by credible evidence (e.g. a

court or jury, a department investigation, or other reliable

evidence) to have abused, neglected, sexually assaulted,

exploited, or deprived any person or to have subjected any person

to serious injury as a result of intentional or grossly negligent

misconduct as evidenced by an oral or written statement to this

effect obtained at the time of application;

2. Participate in the orientation and training required by

these rules;

3. Not have made any material false statements concerning

qualifications requirements either to the department or the

provider.

(b) Nursing Personnel. Any persons employed by the

provider to provide nursing services shall be licensed in Georgia in

accordance with professional licensing laws and associated rules.

Such persons may also provide any other types of private home

care services offered by the provider.

(c) Personal Care Assistant (PCA). The provider may have

PCAs perform personal care tasks for clients. Such persons may

also perform companion or sitter tasks for clients, but shall not

provide nursing services unless qualified as stated in rule .09(5)(b)

above.

1. Any PCA hired after the effective date of these rules shall

have the following training and/or experience:

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(i) successful completion of a nurse aide training and

competency evaluation program pursuant to the requirements of

42 CFR Part 483, Subpart D, as revised or recodified, if

applicable; or

(ii) successful completion of a competency examination for

nurse aides recognized by the department; or

(iii) successful completion of a health care or personal care

credentialing program recognized and approved by the

department; or

(iv) successful completion or progress in the completion of a

40 hour training program provided by a private home care

provider, which addresses at least the following areas:

(I) Ambulation and transfer of clients, including positioning;

(II) Assistance with bathing, toileting, grooming, shaving,

dental care, dressing, and eating;

(III) Basic first aide and CPR;

(IV) Caring for clients with special conditions and needs so

long as the services are within the scope of the tasks authorized

to be performed by demonstration;

(V) Home management;

(VI) Home safety and sanitation;

(VII) Infection control in the home;

(VIII) Medically related activities to include the taking of

vital signs; and

(IX) Proper nutrition.

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2. A training program described in rule .09(5)(c)1.(iv) must

be conducted under the direction of a licensed registered

professional nurse, or a health care professional with

commensurate education and experience. Twenty hours of the

program must be completed by the employee prior to serving

clients and the additional twenty hours must be completed within

six months of the date the training initially began. No PCA shall be

assigned to perform a task for which training has not been

completed and competency has not been determined. No PCA

shall be assigned to care for a client with special conditions unless

the PCA has received training and has demonstrated competency

in performing such services related to such special conditions.

(d) Companions or Sitters. The provider may have

companions or sitters perform companion or sitter tasks for

clients.

1. Such persons may not provide other private home care

services to clients unless qualified as stated in rules .09(5)(b) and

(c).

2. Any companion or sitter hired after the effective date of

these rules must meet the following minimal requirements:

(i) Be able to read and write, follow verbal and written

instructions, and complete written reports and documents;

(ii) Successfully complete training or demonstrate

understanding and practical competency in the following areas:

understanding the needs and characteristics of elderly,

handicapped, or convalescing individuals; meal preparation and

serving; transportation and escort services; housekeeping to

include sanitation; home safety; handling medical emergencies in

the home; and infection control.

(6) Staff Training. Prior to working with clients, all employees

hired or used on or after the effective date of these rules and who

provide services to clients shall be oriented in accordance with

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these rules and shall thereafter receive additional training in

accordance with these rules.

(a) Orientation shall include instruction in:

1. The provider's written policies and procedures regarding

its scope of services and the types of clients it serves (rule .09 (1)

and clients rights and responsibilities and complaints (rule .12), as

well as other policies that are relevant to the employee's range of

duties and responsibilities;

2. The employee's assigned duties and responsibilities;

3. Reporting client progress and problems to supervisory

personnel and procedures for handling medical emergencies or

other incidents that affect the delivery of services in accordance

with the client's services plan;

4. The employee's obligation to report known exposure to

tuberculosis and hepatitis to the employer.

(b) Additional training consisting of a minimum of eight clock

hours of training or instruction shall be provided annually for each

employee after the first year of employment. Employees hired

prior to the effective date of these rules are also required to

receive eight clock hours of training or instruction annually

beginning with the effective date of these rules. Such training or

instruction shall be in subjects that relate to the employee's

assigned duties and responsibilities.

(7) Contracted Services. If a provider arranges with

independent contractors, individuals, or agents for them to provide

any authorized private home care services on behalf of the

provider in any way, such arrangements shall be set forth in

writing detailing the services to be provided. The provider must

assure that the independent contractor, individual, or agent

supplying the services follow the provisions of these rules and are

qualified to provide the services. The services must be

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supervised, as outlined in rule .10(2) (Supervision of Services), by

a supervisor of the licensed provider.

Authority: O.C.G.A. §§ 31-2-5, 31-2-7 and 31-7-300 et seq.

111-8-65-.10 Private Home Care Provider Services.

(1) A provider may provide three categories of home care

services as defined in these rules.

(a) Nursing Services. If a provider provides nursing services,

such services shall be provided by a licensed registered

professional nurse or a licensed practical nurse under the

direction of a supervisor as required by these rules. Such services

shall be provided in accordance with the scope of nursing practice

laws and associated rules, and the client's service plan.

1. Nursing services shall include the following: ...

(i) Regularly assess the nursing needs of the client;

(ii) Participate in the establishment and implementation of

the client's service plan;

(iii) Provide nursing services as needed and in accordance

with the client's service plan;

(iv) Report problems and progress of client to supervisory

personnel or the client's personal physician.

(b) Personal Care Tasks. If a provider provides personal

care tasks, such tasks, at a minimum, shall be performed by a

qualified PCA under the direction of a supervisor as required by

these rules, and in accordance with the client's service plan. In

addition to following the service plan, a PCA must report on the

personal care needs of the client, on changes in the client's

condition, and on any observed problems that affect the client.

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Licensed nurses are also authorized to perform personal care

tasks.

(c) Companion or Sitter Tasks. If a provider provides

companion or sitter tasks, such tasks, at a minimum, shall be

performed by a qualified companion or sitter under the direction of

a qualified supervisor as required by these rules, and in

accordance with the client's service plan. In addition to following

the service plan, a companion or sitter must report on the needs of

the client, on changes in the client's condition, and on any

observed problems that affect the client.

(2) Supervision of Services. Services shall be supervised by

qualified staff of the provider. Each staff member providing

services to a client shall be evaluated in writing by his or her

supervisor, at least annually, either through direct observation or

demonstration, on the job tasks the staff member is required to

perform. No supervisor shall knowingly permit an employee who

has been exposed to tuberculosis or hepatitis or diagnosed with

the same to provide services to clients until it is determined that

the employee is not contagious.

(a) Supervision of Nursing Services. If a provider provides

nursing services, it shall employ fully licensed Georgia registered

professional nurse to supervise the provision of such services and

the employees who provide the services. Such supervisor may

perform other duties provided he or she is able to fulfill the

supervisory responsibilities described in these rules. A supervisor

shall complete the client's service plan in accordance with rule .11

and in coordination with the appropriate staff who will be providing

the client's services.

(b) Supervision of Personal Care Tasks. If a provider offers

personal care task services, the provider shall employ

supervisor(s) that have been determined to be qualified by

education, training and experience to supervise the provision of

such tasks in accordance with accepted standards of care. A

licensed registered professional or practical nurse shall supervise

the provision of personal care tasks for clients determined to be

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medically frail or medically compromised. If such supervision is

provided by a licensed practical nurse, the licensed practical nurse

shall report to a licensed registered professional nurse who will

continue to be responsible for the development and management

of the service plan. Such supervisor may perform other duties

provided he or she is able to fulfill the supervisory responsibilities

described in these rules.

1. The appropriate supervisor as specified in these rules

shall complete the client's service plan in accordance with rule .11

and in coordination with the appropriate staff who will be providing

the client's services. For clients who are determined to be

medically frail or compromised, a licensed registered professional

nurse shall complete the initial service plan. Subsequent revisions

to the service plan may be made by a licensed practical nurse

who is supervising the provision of personal care tasks services to

the client. Revisions made by the licensed practical nurse will be

reviewed in a timely manner by the provider's licensed registered

professional nurse ultimately responsible for the management of

the client's care.

2. The appropriate supervisor shall make a supervisory

home visit to each client's residence at least every 92 days,

starting from date of initial service in a residence or as the level of

care requires to ensure that the client's needs are met. The visit

shall include an assessment of the client's general condition, vital

signs, a review of the progress being made, the problems

encountered by the client and the client's satisfaction with the

services being delivered by the provider's staff. Such supervision

shall also include observations about the appropriateness of the

level of services being offered. Routine quarterly supervisory visits

shall be made in the client's residence and shall be documented in

the client's file or service plan.

(c) Supervision of Companion or Sitter Tasks. If a provider

provides companion or sitter tasks, supervision of such tasks shall

be provided by a qualified supervisor (e.g. registered professional

nurse, licensed practical nurse, the administrator, or any other

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staff member assigned responsibility for supervision of the

delivery of care.)

1. The appropriate supervisor, as specified in these rules,

shall complete the client's service plan in accordance with rule .11

and in coordination with the appropriate staff who will be providing

the client's services.

2. The appropriate supervisor shall make a supervisory

home visit to each client's residence at least every 122 days

starting from date of initial service in the residence or when the

provider receives a complaint concerning services and the

complaint raises a serious question concerning the services being

delivered. The visit shall include an assessment of the client's

general condition, a review of the progress being made, the

problems encountered by the client and the client's satisfaction

with the services being delivered by the provider's staff. Such

supervision shall also include observations about the

appropriateness of the level of services being offered. Routine

supervisory visits shall be made in the client's residence. All

supervisory visits shall be documented in the client's file or service

plan.

(d) When employees or subcontractors are performing

personal care tasks for clients who are medically frail or medically

compromised in the clients' residences, the provider shall have a

representative on call and accessible who shall be able to contact

a nurse supervisor by telephone or other means to provide

appropriate consultation to the employees or subcontractors

concerning responding to the clients' medical needs.

(3) Documentation of Home Care Services Provided. A

provider shall establish and implement written policies and

procedures for documenting the services actually performed for its

clients each day. Such documentation shall be incorporated into

the client's file in accordance with rule .09(4)(a).

(4) Quality Improvement Program. The provider must have

and maintain documentation reflecting that there is an effective

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quality improvement program that continuously monitors the

performance of the program itself and client outcomes to ensure

that the care provided to the clients meets acceptable standards

of care and complies with the minimum requirements set forth in

these rules. At a minimum, the quality improvement program must

document the receipt and resolution (if possible) of client

complaints, problems with care identified and corrective actions

taken.

Authority: O.C.G.A. §§ 31-2-5, 31-2-7 and 31-7-300 et seq.

111-8-65-.11 Service Plans.

(1) Service Plan Content. A provider shall establish and

implement written policies and procedures for service planning. A

written plan of service shall be established in collaboration with

the client and the responsible party, if applicable, and the client's

personal physician if the services to be provided are nursing

services and the client has a personal physician.

(a) The service plan shall include the functional limitations of

the client, types of service required, the expected times and

frequency of service delivery in the client's residence, the

expected duration of services that will be provided, the stated

goals and objectives of the services, and discharge plans.

(b) When applicable to the condition of the client and the

services to be provided, the [service] plan shall also include

pertinent diagnoses, medications and treatments, equipment

needs, and diet and nutritional needs.

(2) Service plans shall be completed by the service

supervisor within seven working days after services are initially

provided in the residence. Service plans for nursing services shall

be reviewed and updated at least every sixty-two days. Other

service plans shall be reviewed and updated at the time of each

supervisory visit. Parts of the plans must be revised whenever

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there are changes in the items listed in rules .11(l)(a) and (b),

above.

Authority: O.C.G.A. §§ 31-2-5, 31-2-7 and 31-7-300 et seq.

111-8-65-.12 Client Rights, Responsibilities and

Complaints.

(1) A provider shall establish and implement written policies

and procedures regarding the rights and responsibilities of clients,

and the handling and resolution of complaints.

(2) Such policies and procedures shall include a written

notice of rights and responsibilities which shall be provided to

each client or responsible party, if applicable, when the service

agreement described in rule .09(2) is completed. The required

notice shall include the following items:

(a) Right to be informed about plan of service and to

participate in the planning;

(b) Right to be promptly and fully informed of any changes in

the plan of service;

(c) Right to accept or refuse services;

(d) Right to be fully informed of the charges for services;

(e) Right to be informed of the name, business telephone

number and business address of the person supervising the

services and how to contact that person;

(f) Right to be informed of the complaint procedures and the

right to submit complaints without fear of discrimination or

retaliation and to have them investigated by the provider within a

reasonable period of time. The complaint procedure provided shall

include the name, business address and telephone number of the

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person designated by the provider to handle complaints and

questions;

(g) Right of confidentiality of client record;

(h) Right to have property and residence treated with

respect;

(i) Right to receive a written notice of the address and

telephone number of the state licensing authority, i.e. the

department, which further explains that the department is charged

with the responsibility of licensing the provider and investigating

client complaints which appear to violate licensing regulations;

(j) Right to obtain a copy of the provider's most recent

completed report of licensure inspection from the provider upon

written request. The provider is not required to release the report

of licensure inspection until the provider has had an opportunity to

file a written plan of correction for the violations, if any, identified.

The facility may charge the client reasonable photocopying

charges;

(k) Right to be advised that the client and the responsible

party, if applicable, must advise the provider of any changes in the

client's condition or any events that affect the client's service

needs.

(3) Such policies shall also include procedures for clients

and others to present complaints, either orally or in writing, about

services and to have their complaints addressed and resolved as

appropriate by the provider in a timely manner.

(4) A provider shall supply all clients and responsible parties,

if applicable, with the specific telephone number of the provider for

information, questions or complaints about services being

delivered by the provider.

Authority: O.C.G.A. §§ 31-2-5, 31-2-7 and 31-7-300 et seq.

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32

Effective Date: 3/12/13

111-8-65-.13 Enforcement and Penalties.

(1) Enforcement of these rules and regulations shall be

conducted in accordance with Rules and Regulations for

Enforcement of Licensing Requirements,

(2) If the department finds that an applicant for a license has

violated any provisions of these rules or other laws, rules,

regulations, or formal orders related to initial or continued

licensing, it may, subject to notice and an opportunity for hearing,

refuse to grant any license or limit or restrict any license.

(3) If the department finds that a provider has violated any

provision of these rules or other laws, rules, regulations, or formal

orders related to initial or continued registration, it may, subject to

notice and an opportunity for hearing, take any of the following

actions: administer a public reprimand; limit or restrict a license;

suspend a license; impose a fine; refuse to renew a license; or

revoke a license.

Authority: O.C.G.A. §§ 31-2-5, 31-2-7 and 31-2-8.

111-8-65-.14 Waivers and Variances.

(1) The department may, in its discretion, grant waivers and

variances of specific rules upon application or petition being filed

on forms provided by the department. The department may

establish conditions which must be met by the provider in order to

operate under the waiver or variance granted. Waivers and

variances may be granted in accordance with the following

conditions:

(2) Variance. A variance may be granted by the department

upon a showing by the applicant or petitioner that the particular

rule or regulation that is the subject of the variance request should

not be applied as written because strict application of the rule

would cause undue hardship. The applicant or petitioner must

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33

Effective Date: 3/12/13

also show that adequate standards affording protection for the

health, safety and care of persons in care exist and will be met in

lieu of the exact requirements of the rule or regulation in question.

(3) Waiver. The department may dispense entirely with the

enforcement of a rule or regulation by granting a waiver upon a

showing by the applicant or petitioner that the purpose of the rule

or regulation is met through equivalent standards affording

equivalent protection for the health, safety and care of persons in

care.

(4) Experimental Variance or Waiver. The department may

grant waivers and variances to allow experimentation and

demonstration of new and innovative approaches to delivery of

services upon a showing by the applicant or petitioner that the

intended protections afforded by the rule or regulation which is the

subject of the request are met and that the innovative approach

has the potential to improve service delivery.

Authority: O.C.G.A. §§ 31-2-5 and 31-2-7.

111-8-65-.15 Severability.

(1) In the event that any rule, sentence, clause or phrase of

any of these rules and regulations may be construed by any court

of competent jurisdiction to be invalid, illegal, unconstitutional, or

otherwise unenforceable, such determination or adjudication shall

in no manner affect the remaining rules or portions thereof.

(2) The remaining rules or portions thereof shall remain in full

force and effect, as if such rule or portions thereof so determined,

declared, or adjudged invalid or unconstitutional were not

originally a part of these rules.

Authority: O.C.G.A. §§ 31-2-5, 31-2-7 and 31-7-300 et seq.

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34

Effective Date: 3/12/13

6/2007

PRIVATE HOME CARE PROVIDER APPLICATION REVIEW CHECKLIST

Please use the following checklist to ensure you include all the documents required for HFRD to review your application for a provisional PRIVATE

HOME CARE PROVIDER license. Please use the Applicant Check colum n for your own review; to be sure all necessary documents are included.

Under each document, you will see content which must be acceptable in order to p ass review. Be aware that your application packet may be

considered incomplete and in eligible for review if all major documents are notLncluded. It mus t be clear to the reYLewer what each

document is, so it is advisable to have them clearly marked.

Be advised that th ese are the m inimum documents necessary for re view for your initial license, but it is not intend ed to be a c omplete list of all

policies, procedures, forms, etc., which you will need to operate your Private Home Care Provider service effectively.

Applicant HFRD Office Use Only Review Date:_____________

Use Acceptable Not Accept. Notes xxxxxxxxxxxxxxxxxxxxxxxxxx

________

290-5-54-.06

1. A completed application for a license to operate as a private

home care provider, signed and dated.

_________

________

_______________________________

________

2. Notarized Personal Identification Affidavit.

_________

________

_______________________________

________

3. Copy of Business License, or, if not required, evidence of

such communication with local government.

_________

________

_______________________________

________

4. Copy of Certificate of Incorporation, if incorporated;

or if not incorporated, listing of IRS Tax ID number.

_________

________

_______________________________

________

*5. Cashiers check or money order for application fee and

license fee.

_________

________

_______

*6. Please refer to mem o concerning Private Hom e Care

Fingerprinting Process Using COGENT/GAPS.

_______________________________

6/2007

________

_______

290-5-54-.09

7. A description of services.

Describes scope of services offered.

Describes types of clients served.

8. Copy of policy and procedures for Service Agreements, and

a copy of the Service Agreement form.

Requires written service agreement with each client.

Requires timeline for completion of initial service agreement as

required by .09(2)(b).

Describes procedure for revision to the service agreement as

needed, including appropriate documentation of revisions.

Includes date of referral

Includes date of initial client contact

Requires description of services client claims are needed

Requires description of services the provider agrees to provide

Requires documentation of duration and frequency of services

to be provided

Requires documentation of charges for the services to be

provided

Requires documentation of the client’s receipt of a copy of the

clients’ rights and responsibilities.

________

_______

________

_______________________________

________________________________

6/2007

Policy addresses the client’s right to cancel the agreement and

how charges will be handled upon cancellation.

Includes a telephone number for the provider for the client to

use to contact the provider for information, questions, or a

complaint.

Includes the telephone numbers for HFRD complaint line and

for PHCP licensing information.

Includes policy for obtaining authorization for use of client’s

funds or motor vehicle, if those services are provided.

Requires signature of the client or the client’s responsible

party.

________

_________________________________

________

9. Name, qualifications and job description (including copy of

professional license if applicable) of administrator.

Includes evidence of having no history of misconduct as

described in 290-5-54-.09(3)(a)1.

Job duties include full authority and responsibility for the

operation of the PHCP.

Evidence of completion of orientation training.

_________

_______________________________

________

10. A description of all elements to be included in each client’s

record, and copies of any forms to be used to record this

information.

Identification form to include documentation of name, address,

telephone number, and responsible party.

_________

_______________________________

6/2007

Requirement to include the service agreement and service plan

in the record.

Form for recording clinical progress notes.

Form for documentation at each visit of personal care tasks and

companion or sitter tasks which are actually performed for the

client at the time of that visit.

Form for documentation of home supervisory visits performed

for that client.

Form for recording names, addresses, and telephone numbers

for the client’s personal physician(s).

Entry for date of referral.

_________

_______________________________

________

11. Written policies and procedures for maintenance and

security of client records.

Includes who (by position) supervises the maintenance of the

records, who has custody of the records, to whom records may

be released and for what purposes, and how long the records

will be maintained (at a minimum, five years from the date of

service provided).

Explains how confidentiality of the records will be assured, and

with whom employees may discuss client information (must be

limited to the client, appropriate provider staff members, the

client’s responsible party, the client’s physician or other

healthcare provider, DCH, or others authorized in writing by

the client or by subpoena).

_________

_______________________________

6/2007

________

12. Copy of forms for logging complaints and incidents, and

description of procedures for management and documentation.

Describes maintenance of such records for a minimum of five

years.

Requires documentation of actions taken by the provider in

response to reports of incidents and to complaints.

_________

_________________________________

________

13. List of current employees (administrator and at least one

other employee required to open a PHCP) and copies of

personnel records for those employees, and job descriptions

and qualifications requirements of current and prospective

employees.

Includes appropriate types of employees for provision of

services for which permit is requested.

Includes statements, or forms for statements, as to history of

abuse or neglect of others.

Includes documentation of TB testing.

Includes forms for documentation of identifying information

and emergency contacts.

Includes documentation of any employment history available.

PCA qualifications require a GA-registered CNA, completion

of the NLN exam on-line and assessment of competency for

services to be performed, or completion of a provided 40-hour

training curriculum and assessment of competency.

_________

_________________________________

6/2007

Nursing positions require a GA license.

Companion or sitter positions require ability to read, write, and

follow instructions and completion of training or pass

competency assessment, as appropriate, for understanding

needs of populations served, basic meal preparation, provision

of transportation services, housekeeping, home safety, handling

emergencies in the home, and infection control.

________

14. Copy of orientation curriculum and forms to document

completion of each aspect of orientation.

Includes instruction in the provider’s policies and procedures,

including client rights and the handling of complaints, TB

exposure reporting, procedures for reporting client progress and

problems to supervisors, procedures for handling emergencies,

and review of the employees’ job responsibilities.

_________

_________________________________

_______

15. A written description of whether the program will employ

only certified nurse aides to perform personal care tasks or

whether the program will be providing their own training

curriculum for PCAs.

_________

_________________________________

________

16. If the provider will be providing the 40-hour training

program for PCAs, a copy of the training curriculum and forms

for documenting the training and the observed competencies

for those activities the PCA will be providing.

_________

_________________________________

6/2007

Includes:

Ambulation, transfer, and positioning of clients;

Assistance with bathing, grooming, shaving, dental care,

dressing, and eating;

Basic first aid and CPR;

Meeting clients’ special needs (as determined by assignment);

Home management;

Home safety and sanitation;

Infection control in the home;

Medically related activities including taking of vital signs;

Proper nutrition.

_________________________________

_________

17. Description of any contracted services, including

procedures for supervision of such services and for determining

qualifications of contracted individuals.

Requires that the PHCP will assess competencies for contracted

PCAs or companion or sitters, and will keep on site

documentation of qualifications of each.

_________

_________________________________

________

290-5-54-.10

18. If nursing services are to be provided, a copy of the

description of nursing services.

Requires that any nursing services provided are provided or

supervised by an RN.

Requires that for clients receiving nursing services, the nurse

participates in the development and implementation of the

service plan.

Requires that for clients receiving nursing services, a nurse

_________

________

_________________________________

6/2007

regularly reassesses the needs of the client.

________

19. A description of how PCAs, nursing services, and

companion or sitter services are to be supervised, and copies of

forms, used to document supervision.

Requires appropriate training for supervisors for each type of

service.

Requires that an RN be responsible for supervising any

services provided for medically frail clients, and defines those

types of clients appropriately.

Requires that the supervisor annually assesses the performance

of the supervisees, by direct observation or demonstration of

the tasks they are assigned to perform.

Requires and documents that the supervisor participates in the

development and review of each client’s service plan.

Requires that for PCA services, the supervisor performs

supervisory home visits to each client’s residence at least every

92 days, and at least on some occasions when the aide is

present and performing services.

Requires that for companion and sitter services, the supervisor

performs supervisory home visits to each client’s residence at

least every 122 days, and at least on some occasions when the

employee is present and performing services.

Forms reflect documentation by the supervisor at the

time of the visit of assessment of the client’s condition,

vital signs, review of progress, any problems, the

appropriateness of the current level of services and the

client’s satisfaction with services.

_________

________

_________

________

_________________________________

6/2007

________

20. Copy of policies and procedures for documenting the

services actually performed for each client each day, and the

form(s) used for documenting such.

Includes specific instructions for staff on how and what to

record on the service delivery form, and how and when the

forms will be incorporated into the client’s record.

_________

________

_______

_________________________________

________

21. Description of the quality improvement program, including

any forms, review sheets, etc. used in this program.

Describes what methods the PHCP will use to monitor itself

and client outcomes.

Includes monitoring the reporting and resolution of complaints

or problems with care and corrective actions taken.

_________

________

_________________________________

________

290-5-54-.11

22. Copy of policies and procedures for service planning and

form used for the Service Plan.

Includes collaboration of the client’s physician if nursing

services are to be provided, and how physician’s orders are

obtained and documented, including verification of verbal

_________

________

_________________________________

6/2007

orders, and signatures obtained.

Specifies timeframe for completing the plan document (at least

within seven days of the initial visit, integrating assessment

findings).

Specifies when the service plan is to be reviewed or revised (at

least every 62 days for nursing services; for other services at

least at every supervisory visit and whenever the condition or

needs of the client change).

Service Plan document includes the specific functional

limitations of the client, the services required, the expected

times and frequency of service delivery, duration of services,

statements of goals and objectives of services, and discharge

plans.

Form provides for description of the how the specific tasks are

to be performed (e.g. tub bath, bed bath, applying lotion to

back, etc.) rather than just general itemization of services.

If applicable to the client, the service plan can accommodate

pertinent diagnoses, medications and treatments, equipment

needs, and diet and nutritional needs.

_________

________

_________

_________________________________

________

290-5-54-.12

23. Copy of policies and procedures related to client rights and

responsibilities and the handling and resolution of complaints.

Requires notice to clients at the time the service agreement is

completed.

Notice includes:

Right to be informed about the plan for services and to be

_________

________

_________________________________

6/2007

involved in the development of the plan.

Right to be informed promptly about any changes in services

(before the change).

Right to accept or refuse services.

Right to be informed of the charges for services provided.

Right to be informed of the contact number(s) for the

supervisory personnel.

Right to be informed of complaint procedures.

Right to confidentiality of client information.

Right to have property and residence treated with respect.

Right to written notice of the contact information for the state

licensing authority.

Right to a copy of the PHCP’s most recent report from a

licensure inspection.

Responsibility of the client and/or responsible party to inform

the provider of any changes in the client’s condition.

_________________________________

Reviewed by: ___________________________________

Date: __________________________________________

.