Navigating the responsibilities and commitments involved in the Minnesota Health Care Programs (MHCP) Personal Care Assistance (PCA) Program requires clarity and understanding from all parties involved. The DHS-5856-ENG form plays a pivotal role in ensuring this understanding is well-established and documented. Designed for use within the PCA program, it mandates that each responsible party or their delegate formally acknowledge their roles and responsibilities on an annual basis. This not only facilitates the smooth operation of personal care assistance services but also establishes a firm commitment to the well-being and safety of the recipient. The form involves several critical sections, including the identification of the responsible party and the recipient, an agreement to participate actively in assessments, the development of the PCA care plan, the verification of services through the signing of time sheets, and a commitment to regularly monitor the care provided. Moreover, it emphasizes the necessity of being reachable and involved when services are rendered, underlining the importance of active engagement in the recipient's care. The requirement for an annual completion of this agreement ensures ongoing communication and reaffirms the responsibilities that each party has agreed to uphold, thereby laying a foundation for accountability and quality care in the PCA program.
| Question | Answer |
|---|---|
| Form Name | Dhs 5856 Eng Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | dhs 5856 eng form, dhs 5856 form, responsible party agreement sample, dhs 7576d eng |
Minnesota Health Care Programs (MHCP)
Personal Care Assistance (PCA) Program Responsible Party Agreement and Plan
Personal care assistance (PCA) agencies must have each responsible party or their delegate complete the following agreement annually to ensure they are aware of their roles and responsibilities. You must keep a copy of the completed agreement in the recipient’s file and provide a copy to the recipient and their responsible party or delegate.
Completed by Responsible Party
RESPONSIBLE PARTY NAME (Last/First/MI)
RELATIONSHIP TO RECIPIENT
RECIPIENT NAME (Last/First/MI)
RECIPIENT MHCP ID NUMBER
I agree to be the responsible party for the above named recipient for the following time period:
(MM/DD/YYYY) to |
|
(MM/DD/YYYY) and agree to (initial each): |
Attend assessments for PCA services for the recipient to help the recipient make informed choices Determine if the recipient’s health and safety are assured with the current PCA services
Help develop the PCA care plan with the qualified professional Actively participate in planning and direction of PCA services
Sign the PCA time sheets after services are provided to verify the services
Monitor the PCA weekly to ensure the care plan is followed and the care outcomes are met as described below Be accessible to the recipient and PCA when services are provided as described below
RESPONSIBLE PARTY PLAN TO MEET THE ABOVE REQUIREMENTS (Be specific - attach additional pages as needed)
Acknowledgement and Signature (check below)
l l
I am at least 18 years of age
I am not the owner or employee of the PCA provider agency
I understand that I am responsible for and have agreed to all of the duties outlined above.
Completed and Signed by Responsible Party
RESPONSIBLE PARTY SIGNATURE
DATE
ADDRESS
CITY
STATE
ZIP CODE
PHONE NUMBER
()
The PCA agency is required to make a referral to the county common entry point for any failure to provide the support as required by the recipient.
Completed by Agency
AGENCY CONTACT NAME
TITLE
AGENCY NAME
DATE