DE ENTRE LOS MUERTOS
1. QUÉ SUCEDE EN LA RESURRECCIÓN DE JESÚS
Business name:
Permanent address of head office:
Telephone number of head office:
Fax number of head office:
Please indicate if you will meet the following mandatory requirements on April 1, 2010 and that you have submitted the information required under requirements numbered 24 through 31.
# Requirement Yes No
1 You will comply at all times with the requirements of the Home Oxygen Program (HOP) Administration Manual, including those that are set out below
2 You will adhere to all federal and provincial standards when transporting or handling hazardous materials.
3 You will provide clients of the HOP with an oxygen delivery system that meets their medical needs and you will maintain the necessary inventory of oxygen delivery systems.
See Section 4.4.1 of the Home Oxygen Program (HOP) Administration Manual.
4 You will have on staff employees knowledgeable in the administration of home oxygen therapy and oxygen delivery systems to teach the client, the family and/or the caregiver the operation, care and safe handling of home oxygen therapy and oxygen delivery systems.
This includes a Regulated Health Professional (RHP). A RHP is a health professional holding a valid certificate with a regulatory college specified by the Regulated Health Professions Act and whose scope of practice includes the assessment of individuals requiring home oxygen therapy.
See Section 4.4.2 of the Home Oxygen Program (HOP) Administration Manual
5 The RHP will be available during regular business hours.
6 You will provide clients of the HOP with follow-up visits by a Regulated Health Professional in accordance with the policies of the HOP.
See Sections 4.4.2, 4.4.3, 4.4.4, 4.4.5, 4.4.6 of the Home Oxygen Program (HOP) Administration Manual
7 You will provide clients of the HOP with other services in
# Requirement Yes No See Section 4.4.7 of the Home Oxygen Program (HOP)
Administration Manual
8 You do not have a conflict of interest with any person who determines eligibility or refers clients to your service?
See Section 4.5 of the Home Oxygen Program (HOP) Administration Manual
9 You will have the necessary personnel, equipment and other resources to provide the mandatory service requirements to clients of the HOP, without subcontracting out, unless approved by the ADP.
See Section 4.6 of the Home Oxygen Program (HOP) Administration Manual
10 You will adhere to the Ministry of Health and Long-Term Care policies on client confidentiality.
See Section 4.8 of the Home Oxygen Program (HOP) Administration Manual
See Sections 535, 700 and 705 of the Policies and Procedures Manual for the Assistive Devices Program 11 You will adhere to the HOP’s policy on oxygen equipment and
services not funded by the ADP.
See Section 4.9 of the Home Oxygen Program (HOP) Administration Manual
12 You will adhere to the HOP’s invoice processing and payment policies when billing the ADP for clients of the HOP.
See Section 5 of the Home Oxygen Program (HOP)
Administration Manual, including 5.2, 5.3, 5.4, 5.5.6, 5.5.9, 5.6.3, 5.6.7, 5.7
13 You will adhere to the HOP’s policy on reporting changes to client information or changes to the funding status of clients of the HOP.
See Sections 5.5.5, 5.5.6, 5.5.8, 5.6.6 of the Home Oxygen Program (HOP) Administration Manual
14 You will provide the HOP with the above information in a monthly report.
See Section 5.5.8 of the Home Oxygen Program (HOP) Administration Manual
15 You will have a staff training and education program in place.
See Section 4.11.1 of the Home Oxygen Program (HOP) Administration Manual
16 You will have an infection prevention and control program in place.
See Section 4.11.2 of the Home Oxygen Program (HOP) Administration Manual
17 For clients of the HOP, you will maintain client files in accordance to the policies of the HOP.
See Section 4.11.3 of the Home Oxygen Program (HOP) Administration Manual
# Requirement Yes No 18 All new employees, hired on or after April 1, 2010, that provide
direct service in the home of clients of the HOP will undergo a Vulnerable Persons Police Check every 5 years.
See Section 4.11.4 of the Home Oxygen Program (HOP) Administration Manual
19 You will maintain appropriate financial records and permit staff of the Ministry of Health and Long-Term Care to audit these records.
See Section 525 of the Policies and Procedures Manual for the Assistive Devices Program
20 You will adhere to the policies of the ADP regarding change of ownership of the Vendor of Record business or bankruptcy of the Vendor of Record business.
See Section 530 and 565 of the Policies and Procedures Manual for the Assistive Devices Program
21 You will adhere to the policies of the ADP regarding solicitation of business.
See Section 540 of the Policies and Procedures Manual for the Assistive Devices Program
22 You will adhere to the policies of ADP regarding advertising.
See Section 545 of the Policies and Procedures Manual for the Assistive Devices Program
23 When you are approached by an applicant requesting home oxygen therapy, you will inform the applicant that there is a government program available which provides funding assistance to eligible individuals if they meet the program’s medical eligibility criteria.
You will inform any applicant of the HOP that if funding assistance is denied, the applicant is responsible for the full cost of the home oxygen therapy.
Clients of the HOP who incur costs will be provided with a detailed explanation of all costs.
See Section 550 of the Policies and Procedures Manual for the Assistive Devices Program
See Section 2.10.8 and 4.2.1 of the Home Oxygen Program (HOP) Administration Manual
24 You have included a complete list of all the
sites/branches/locations that will be providing service to clients of the HOP containing the information and in the form as attached to this Appendix as Attachment A
25 You have included a complete list of all Regulated Health Professional currently employed by your company and in good standing with the appropriate Regulatory College
containing the information and in the form as attached to this Appendix as Attachment B
26 You have included a complete list of all oxygen delivery systems currently in your inventory
containing the information and in the form as attached to this
# Requirement Yes No Appendix as Attachment C
27 You have included all necessary business documentation containing the information and in the form as attached to this Appendix as Attachments D and E.
28 You have included a copy of your Staff Training and Education Program
29 If a Staff Training and Education Program is not included, you will provide the ADP with a copy of the Staff Training and Education Program by April 1, 2011
30 You have included a copy of your Infection Prevention and Control Program (including all policies and procedures) 31 You have included a copy of your policies and procedures for
maintaining client files and records
I, PRINT NAME confirm that the above information is correct.
Signature:
Business name:
Title/Position:
Date:
APPENDIX D – Attachment A
VENDOR OF RECORD FOR HOME OXYGEN SERVICE COMPLETE LIST OF BRANCHES/LOCATIONS/SITES Business Name:
Complete mailing address for
each location Phone number for
each location Fax number for
each location Contact person for each location
Complete mailing address for
each location Phone number for
each location Fax number for
each location Contact person for each location
APPENDIX D – Attachment B
VENDOR OF RECORD FOR HOME OXYGEN SERVICES COMPLETE LIST OF REGULATED HEALTH PROFESSIONALS Business Name:
Employee name Professional
qualifications Name of Regulatory
College Length of
employment with the company
Employee name Professional
qualifications Name of Regulatory
College Length of
employment with the
For each Regulated Health Professional you must provide a copy of their certificate of registration showing that they are currently in good standing with the appropriate Regulatory College.
APPENDIX D – Attachment C
VENDOR OF RECORD FOR HOME OXYGEN SERVICES INVENTORY LIST OF OXYGEN DELIVERY SYSTEMS Business Name:
Type of oxygen delivery
system Manufacturer Make and/or Model
APPENDIX D – Attachment D
VENDOR OF RECORD FOR HOME OXYGEN SERVICES CONDITIONS PRECEDENT
Business Name:
# Required Documentation for the Following Yes No NA 1 Ownership
2 Business location and hours of operation for all sites/locations/branches
3 Insurance Coverage
4 Vendor of Record Leasing Space from a Hospitals
5 Hospitals as A Vendor of Record 6 Bank Reference Letter
7 Service Agreements
8 Manufacturer/Distributor Agreements
Refer to the Conditions Precedent (attachment E) for a more detailed explanation of what documentation is required.
APPENDIX D – Attachment E The Assistive Devices Program Ministry of Health and Long-Term Care
CONDITIONS PRECEDENT TO BECOME A VENDOR OF RECORD FOR HOME OXYGEN SERVICE
All interested parties applying to the Ministry of Health and Long-Term Care’s (MOHLTC) Assistive Devices Program (ADP) to become a Vendor of Record for Home Oxygen Services must supply the following documentation and meet the conditions specified below:
1. Ownership
Businesses who are the sole proprietor or partners of a firm must provide the ADP with
an up-to-date copy of their business/partnership registration,
a list of the names and addresses of the partners if applicable.
Businesses who are corporations must provide the ADP with
all copies of the Articles of Incorporation,
a copy of any amendments to the Articles of Incorporation and any other corporate changes,
a list of names and addresses of all shareholders and members of the Board of Directors (including silent partners) and,
if the Corporation is carrying on business under a name or style other than its corporate name, a Certificate of Registration of the name or style under which it is carrying on business.
2. Business Location and Hours of Operation
The business must maintain a permanent business location which is open to the public at least five (5) days per week and at least seven (7) hours per day.
Documentation must be submitted showing that the business location legally conforms to all applicable zoning bylaws and regulations (Federal, Provincial, Municipal).
3. Insurance Coverage
The business must submit a copy of the insurance coverage certificate and the relevant portion or portions of the insurance policy incorporating the terms and clauses referred to below.
The address and registered name or style of the business must be specified as insured in the policy;
"Her Majesty the Queen in Right of Ontario as represented by the Minister of Health" shown as an additional insured (worded exactly as quoted);
A clause requiring the insurer to provide thirty (30) days prior written notice to the Minister in the manner set forth in the policy in the event of the termination or expiry with no renewal of the insurance policy, or material modification to the insurance policy;
A minimum comprehensive liability insurance of $3,000,000 (three million dollars), and the following clause endorsements acceptable to the Minister:
a) Cross-liability;
b) Contractual Liability;
c) Independent Contractor’s Liability;
d)Products and Completed Operations Liability;
e) Employers Liability and Voluntary Compensation;
f) Tenant’s Legal Liability; and
g) Non-Owned automobile coverage with blanket contractual and physical damage coverage for hired automobiles.
A minimum of $1,000,000 (one million dollars) automobile liability insurance, shown separately.
4. Businesses in Hospitals
If the business is located in the hospital, the business must provide the ADP with a copy of the lease agreement and details of any other agreements the business has with the hospital.
5. Bank Reference Letter
The business must submit a letter of reference from their bank manager confirming that all accounts held by the business are in good standing.
6. Service Agreements
Businesses who do not offer repair services on their premises must submit a copy of all service agreements.
7. Manufacturer/Distributor Agreements
Businesses must provide a letter from, at minimum, 2 manufacturers/distributors from whom they purchase, confirming that they are an authorized dealer.