Community Policy. Simple 3 Step Compliance
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- Janel Morris
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1 Community Policy All Third-Party Healthcare Providers and Non-Healthcare Vendors must comply with the following requirements set forth by community management. Failure to meet the below requirements within 30 days of account creation may result in denied access to the community and/or interruption in service. Simple 3 Step Compliance 1. Create an Account at the Accushield Kiosk a.) Enter your mobile number to create a Unique User Account & receive pertinent messages to avoid interruption in service such as retrieving your PIN b.) Enter your Known Legal Name, as it would appear in official documents c.) Spell out your complete company name and select it. If your company cannot be found, spell out your complete company name d.) Follow prompts in Accushield Kiosk to complete Initial Account Registration 2. Have Your Employer Complete the Registration Packet and Return to Accushield a.) to: support@accushield.com b.) Fax to: (404) Employer Will Need to Submit Payment Upon Receipt of Any Invoice The fee is for the collection, validation and management of credentials and visit information per the community s request. See more details at 1
2 All documents listed below are REQUIRED to meet current community standards. Do NOT submit portions of requirements without current contact information (i.e. phone # and/or ) Required Documents from Employer: 1. Agency or Vendor Company Registration Form (Completed one time, until information changes, page 3) 2. Certificate of Liability Insurance (See detailed instructions for standards, page 6) 3. Employment Verification Letter (MUST provide employees mobile number for account establishment & to insure continuity of care. Submitted for every employee for which you provide credentials. Multiple employees can be verified on the same form.) 4. Agency or Vendor Agreement (Completed one time, page 10) 5. Payment Instructions (Completed one time, page 14) Documents Required per Individual: (Submit for each individual for whom you provide documentation) 6. Criminal Background Check (See detailed instructions, page 7) 7. Proof of Negative TB (See detailed instructions, page 8) Community standards are detailed in the following pages. 2
3 Registration Form Please fill out ALL fields carefully for accuracy and speed of service. Compliance Contact (please print): Title: Phone Number: Fax Number: Submitting As: Corporate Owner (Please attach a list of all branches for which requirements will apply. List each branch locations contact info as illustrated below) Branch Location Sole Proprietorship Franchisee Franchisor Staffing Agency Branch/Local Office: Company Name: Address: City: State: Zip Code: Company Main Phone: Contact Name: Title: Contact Phone: 3
4 Corporate Office Information (If Applicable): Company Name: Address: City: State: Zip Code: Company Main Phone: Contact Name: Title: Contact Phone: Billing Location Information: Company Name: Address: City: State: Zip Code: Company Main Phone: Contact Name: Title: Contact Phone: Check to receive invoice electronically Billing If billing is centralized, please attach a list of all your branches with the Branch Name, Branch Address, Company , Main Phone, Contact Name & Title, and Contact Phone. 4
5 List ALL Accushield Partner Communities in which you are active: Service Type (Check All That Apply): Doctor DME Home Care Home Health Hospice Marketer Maintenance Nurse/PA Private Duty Sitter/Provider Other: 5
6 Community Standards for Third-Party Providers A. Certificate of Liability Insurance (COI) Standards The following 2 document(s) must include*: Name of the insurance company, policy number, and the expiration date. All DBAs, and/or Subsidiaries, and/or Independent contractors covered under the policy. Name of company included on policy must match the Accushield account name. Updated annually upon expiration; If an employee works for more than one company, each company must submit proof of insurance. All insurance is required to be written by insurance companies with an A.M. best rating of not less than A-. 1. Commercial General Liability Insurance LIMITS NOT LESS THAN: $1,000,000 Each Occurrence combined single limit for bodily injury, property damage, and disease per occurrence - and $3,000,000 general aggregate. ABOVE TO BE WRITTEN ON AN OCCURRENCE FORM AND TO INCLUDE: Blanket contractual liability Products and completed operations Employees and Independent contractors of the Insured (if applicable) Broad form property damage Personal injury 2. Workers Compensation Insurance (For employees or contractors working for Agencies or Vendor Companies) Private companies are not required to provide workers compensation insurance in the state of Texas. Texas employers who do not carry workers compensation insurance are required to report their non-coverage status and work related injuries and occupational diseases to the Division of Workers Compensation. Alternative coverage plans are NOT substitutes for workers compensation insurance. Some employers buy accident and health policies, employer indemnification agreements, and disability policies as cheaper alternatives to workers compensation. Even though these policies may provide benefits to an injured employee, Texas law does not recognize them as substitutes for workers compensation insurance. TDI rules prohibit insurance carriers from saying alternative coverages are substitutes for workers compensation insurance. 6
7 B. Criminal Background Check Submit for each employee for whom you are providing verification. The background check needs to include the following information: 1. State and local check based on 7-year address history 2. Federal Sex Offender Database check In the state of Florida the Agency for Health Care Administration (AHCA) Background Screening Result form will suffice. In the state of California, the California LiveScan results will suffice. DO NOT INCLUDE Social Security Numbers and Driver License Numbers on any documents submitted to Accushield directly. We accept a criminal background check from any reputable third-party service, AS LONG AS it meets the community standards listed above. If you need a Criminal Background Check for an employee: A volume discount has been negotiated with MLQ Attorney Services to conduct an adequate background check. A release form for MLQ Background Services is included in this packet and should be submitted directly to MLQ if you choose to use their services. Note: MLQ is unaffiliated with Accushield, and independently operated. For processing and accurate pricing information, please contact MLQ at: ORDERS@MLQAS.COM / PHONE
8 C. Proof of Negative TB (Tuberculosis Skin Test a.k.a. PPD, Mantoux, TST) Submit a copy for each employee for whom you are providing verification. Must be submitted annually (The Certificate may be issued by an MD, DO, RN, APRN, or PA). Must include the date of administration and reading of the PPD (The measurement in millimeters of the induration) and Must include the signature or stamp of the MD, DO, RN, APRN, PA, or clinic. In the case of positive test results: a. You will need to submit one clear x-ray result (valid for five (5) years) b. AND a statement (letter or form) from your physician that you are free of TB symptoms. c. The Symptom Check Sheet need to be updated and submitted annually starting AFTER one (1) year of original X-ray submission. d. Please DO NOT fax actual X-ray. We also accept negative results of Interferon Gamma Release Assay (IGRA) testing. We do not accept the BCG vaccine in lieu of the negative TB test results. 8
9 PERMISSION AND RELEASE FORM FOR A BACKGROUND INVESTIGATION (NAME) FIRST, MIDDLE, LAST MAIDEN/FORMER NAMES 7 YEAR ADDRESS HISTORY: (use additional sheet if necessary) MALE FEMALE (CURRENT ADDRESS) NUMBER, STREET, CITY/TOWN, STATE, ZIP CODE (PREVIOUS ADDRESS) NUMBER, STREET, CITY/TOWN, STATE, ZIP CODE (PREVIOUS ADDRESS) NUMBER, STREET, CITY/TOWN, STATE, ZIP CODE (PREVIOUS ADDRESS) NUMBER, STREET, CITY/TOWN, STATE, ZIP CODE HOW LONG AT THIS ADDRESS HOW LONG AT THIS ADDRESS HOW LONG AT THIS ADDRESS HOW LONG AT THIS ADDRESS DATE OF BIRTH PLACE OF BIRTH SOCIAL SECURITY NUMBER DRIVERS LICENSE STATE DRIVERS LICENSE NUMBER IN CONNECTION WITH PERFORMING SERVICES AT CERTAIN SENIOR LIVING COMMUNITIES, I HEREBY AUTHORIZE ACCUSHIELD, LLC AS AGENT FOR SUCH COMMUNITIES, AND ANY AUTHORIZED AGENTS ACTING ON ITS BEHALF, INCLUDING MLQ ATTORNEY SEVICES, TO PREPARE AN INVESTIGATIVE REPORT ON MY BACKGROUND INCLUDING A SOCIAL SECURITY TRACE FOR ADDRESS VERIFICATION. I THEREFORE AUTHORIZE, REQUEST AND REQUIRE ANY PERSONS OR INSTITUTIONS CONTACTED TO FURNISH MLQ ATTORNEY SERVICES, OR ITS AGENTS, ANY INFORMATION THEY HAVE CONCERNING ANY CRIMINAL RECORDS, MOTOR VEHICLE RECORDS, DRUG SCREENINGS, MY WORK HISTORY AND ACHIEVEMENTS, EDUCATION HISTORY AND ACHIEVEMENTS, AND GENERAL REPUTATION AND CHARACTER. AS AN INDUCEMENT TO PROVIDE THIS INFORMATION, I HEREBY RELEASE AND FOREVER DISCHARGE EACH AND EVERY SUCH PERSON OR INSTITUTION FROM ANY AND ALL CLAIMS OF LIABILITY IN LAW OR IN EQUITY THAT MAY ARISE OUT OF FURNISHING SUCH INFORMATION TO MLQ ATTORNEY SERVICES, OR ANY AUTHORIZED AGENT OF THAT COMPANY. I MAY, UPON WRITTEN REQUEST, RECEIVE FURTHER INFORMATION AS TO THE NATURE AND SCOPE OF SUCH INVESTIGATION. ANY INQUIRIES ARE TO BE DIRECTED TO ACCUSHIELD, LLC. MY SIGNATURE BELOW INDICATES MY UNDERSTANDING AND ACCEPTANCE OF ALL THE ABOVE TERMS AND STIPULATIONS. SIGNATURE DATE MY CONTACT INFORMATION: PHONE NUMBER: REQUIRED TO COMPLETE REQUEST (COMPLETED BY MLQ ATTORNEY SERVICES) PLEASE CHECK REQUESTED INFORMATION: MVR PRE-EMPLOYMENT VERIFICATION CRIMINAL HISTORY: STATE(S) OTHER: PLEASE LIST PERSON TO CONTACT: PHONE NUMBER EXT ADDRESS: SEND TO MLQ ATTORNEY SERVICES: FAX / ORDERS@MLQAS.COM / PHONE
10 Agency or Vendor Agreement This Agency or Vendor Participation Agreement (this Agreement ) is made by the undersigned service provider ( Provider ) for the benefit of Accushield, LLC ( Accushield ) as well as its affiliates and customers, as described below. BACKGROUND Provider desires to access the premises of one or more assisted living, independent living, continuing care or skilled nursing communities (each, a Community ) in order to perform certain services, either directly for such Communities or for one or more Community residents. Such Communities have contracted with Accushield to manage their credentialing program and implement risk management and access policies for third-party healthcare providers and other vendors. One or more Communities has directed Provider to register with Accushield for such purpose as a condition to accessing such Community s premises and performing services thereon. In consideration of the foregoing, and for other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, Provider hereby agrees as follows: 1. Provider hereby agrees to participate in Accushield s credential management program as described above. Provider has reviewed and completed the registration material available at and agrees to comply with the terms thereof, including (a) procuring, maintaining and providing evidence of the minimum required insurance coverages, (b) submitting employment, background, immunization and other specified credential information ( Information ) about Provider s employees, subproviders and independent contractors that will perform services at a Community location (such persons, Personnel ), (c) providing Accushield with updates to the Information as necessary to keep it from being inaccurate and (d) promptly paying the applicable credentialing fees for Provider Personnel, unless the Individual Payment option has been selected on the Registration Form. 2. Provider represents and warrants that it has received all required authorizations necessary to submit to Accushield the Information that it will provide from time to time, including Information relating Provider s Personnel. Provider authorizes Accushield to review such information and relay it to one or more Communities strictly for the purposes described herein, and further authorizes Accushield to obtain additional information regarding its Personnel as necessary to evaluate whether or not such 10
11 Personnel satisfy the credential criteria established by the Communities. All Information submitted by Provider to Accushield shall, to the best of Provider s knowledge, be true, correct and complete in all material respects. Provider shall comply with all applicable laws in connection with its participation in Accushield s credential management program or with Provider s provision of services at any Community, including, without limitation, all laws relating to data privacy and the protection of healthcare or other confidential or personal information. Without limiting the foregoing, Provider shall not submit to Accushield any social security number, driver license number or protected health information of any of its Personnel, or any other information that may not be disclosed or transferred under applicable law. 3. Provider acknowledges and agrees that, in providing services to any Community resident, directly or through its Personnel, Provider is doing so solely at the request and for the benefit of such resident as an independent contractor thereof and not for or at the request or direction of Accushield or such Community. Similarly, in performing any services directly for a Community, Provider shall do so solely as an independent contractor there- of and not of Accushield. Except for permitting access upon validation of credentials, neither Accushield nor any Community shall be required or permitted to direct in any manner Provider s Personnel or the performance of any of its services. Nothing contained in this Agreement, nor the review and validation of any Information, nor any determination as to whether or not access to a Community shall be granted, shall establish any employee, partnership, agency or joint venture relationship by and among Accushield or such Community on the one hand and Provider or any Personnel on the other hand. 4. Provider, for itself and, to the maximum extent allowed under applicable law, for its Personnel, hereby (a) fully and forever releases Accushield, each Community where Provider or its Personnel may perform any services, and each of their respective affiliates, successors and assigns (collectively, the Released Parties ), from and against any and all losses, damages, claims, demands, lawsuits, expenses, injuries (including death), and other liability of any kind, whether now known or hereafter arising or discovered (collectively, Losses ), that Provider or its Personnel may suffer or incur in connection with or arising out of Accushield s review, validation and handling of the Information, or the performance of Provider s services at the Community s facility or otherwise; and (b) agrees not to initiate any claim, lawsuit, demand, court action or similar proceeding on account of any Losses described in the foregoing clause (a), nor shall Provider or its Personnel join or assist any other party, including insurers (through right of sub-rogation or otherwise) in so doing. The foregoing release and covenant not to sue shall apply in all circumstances, including negligence of a Released Party, excepting only the gross negligence or willful misconduct of a Released Party. 11
12 5. In furtherance of each of the foregoing paragraphs, Provider agrees to indemnify and hold Accushield and each Community harmless against any and all Losses suffered or incurred by them as a result of any claim by Provider Personnel or any third party arising out of any act or omission of Provider or its Personnel in connection with the performance (or non-performance) of any service for any Community or resident, including claims by any Personnel that he or she was an employee or agent of Accushield or a Community. The foregoing indemnity shall not apply with respect to any Losses of Accushield or a Community to the extent caused by such party s gross negligence or willful misconduct. 6. Provider acknowledges and agrees that this Agreement is intended to be binding on its Personnel, and Provider agrees to inform and obtain the agreement of its Personnel as to the contents hereof. 7. Provider further acknowledges and agrees that each Community for which it may provide any services, together with the other Released Parties, are intended third party beneficiaries of this Agreement and shall be entitled fully to rely upon it. 8. This Agreement: (a) shall be binding upon and inure to the benefit of the parties successors and assigns; (b) contains the entire agreement of the parties relating to the subject matter hereof; provided, however, that this Agreement shall not supersede any existing written agreements between Provider and a Community, and any such existing agreement shall control; and (c) may not be amended except in a writing signed by Provider and Accushield. If any provision of this Agreement is determined by a court of competent jurisdiction to be invalid, such provision shall be modified solely to the extent necessary to make it valid and shall not affect any other provision hereof. BY SIGNING BELOW, THE UNDERSIGNED REPRESENTATIVE OF PROVIDER ACKNOWLEDGES THAT HE OR SHE HAS READ AND UNDERSTOOD ALL OF THE TERMS HEREOF AND THAT PROVIDER IS VOLUNTARILY RELEASING SUBSTANTIAL LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE. IN WITNESS WHEREOF, Provider has caused this Agreement to be signed as of the date set forth below. 12
13 Company Name: Signature: Name (please print): Title: Date: 13
14 Payment Instructions The $9/month, per individual, for unlimited visits to any Accushield partner community is for the collection, validation and management of credentials and visit information per the community s request. Please make your selections below: Our Agency/Vendor Company will provide payment for the credentialing of our employees and contractors Our Agency/Vendor Company requires that our employees and contractors pay personally for their credentialing Monthly Plan Accushield will bill your Agency/Company the monthly fee of $9 for each employee or contractor who accessed an Accushield-Partner Community (i.e. if 5 employees or contractors access Accushield-Partner Communities in a month, the monthly bill for your Agency/Company would be $45). The $9 fee covers unlimited visits to Accushield-Partner Communities where the provider meets all credential requirements. Annual Plan Accushield s Annual Plan also allows each provider an unlimited number of visits during a consecutive 12-month period to any Accushield-Partner Community where they meet all credential requirements. If you choose the Annual Plan, Accushield will bill your Agency/Company $98 per employee in advance for each employee or contractor who is signed up for annual membership. An additional payment of $98/employee for future employees may be required. If your employees or contractors will be responsible for the payment of their monthly or annual fee, please refer them to to access Accushield s payment page. Agencies can pay online by going to 14
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