Policies and Procedures Manual

Section 1: Agency Overview and Mission

1.1 Agency Information

Agency Name: Deerwood Health Group LLC Business Address: 220 W Congress St Fl 2, Detroit, MI 48226 NPI: 1568308427 SIGMA Vendor Code: VS0377968 Provider Type: Michigan Medicaid Home Help Program Provider (CHAMPS-Enrolled) Program: Michigan Home Help Program (HHP)

1.2 Mission Statement

Deerwood Health Group LLC is committed to delivering dignified, high-quality personal care services to Michigan Medicaid beneficiaries. We support our clients’ independence and quality of life in their homes through reliable, compassionate, and professionally supervised care.

1.3 Scope of Services

Deerwood Health Group LLC provides the following services under the Michigan Home Help Program:

• Personal care assistance (bathing, grooming, dressing, toileting)
• Mobility assistance and transfers
• Medication reminders (non-skilled)
• Meal preparation assistance
• Light housekeeping directly related to the client’s care

Deerwood does not provide skilled nursing, wound care, injections, or any services requiring a licensed clinical professional unless separately authorized.

1.4 Service Area

Deerwood Health Group LLC serves Medicaid-eligible clients throughout the state of Michigan, with initial operations focused in Wayne County and surrounding areas.

Section 2: Organizational Structure

2.1 Agency Administrator

Role: Naftali Treitel, Owner and Agency Administrator Responsibilities: – Overall agency operations and compliance oversight – CHAMPS enrollment maintenance – Caregiver hiring and HR decisions – Billing and claims oversight – Policy development and annual review – Communication with MDHHS and regulatory bodies

2.2 Field Supervisor

The Agency Administrator is responsible for overall supervision and may designate a Field Supervisor or local representative to assist with in-person functions. Supervision is conducted through a combination of remote oversight (EVV data review, phone and electronic communication) and periodic in-person visits as needed. A designated local contact in Michigan will be identified prior to active service delivery to assist with in-person client assessments and urgent field issues.

2.3 Caregivers

All caregivers are W-2 employees of Deerwood Health Group LLC. They are not independent contractors. Caregivers are responsible for: – Delivering authorized personal care services – Completing EVV clock-in and clock-out for every visit – Reporting incidents, concerns, or changes in client condition to the supervisor – Maintaining professional conduct at all times

Section 3: Client Rights and Responsibilities

3.1 Client Rights

Every client of Deerwood Health Group LLC has the right to:

1. Be treated with dignity and respect at all times
2. Receive services without discrimination based on race, color, national origin, religion, sex, disability, age, or sexual orientation
3. Be informed of their plan of care and participate in care decisions
4. Privacy and confidentiality of their personal and health information
5. Refuse services at any time without fear of retaliation
6. File a complaint or grievance without fear of retaliation
7. Know the name and qualifications of their assigned caregiver
8. Receive safe and competent care
9. Be informed of any changes to their services in advance

3.2 Client Responsibilities

Clients are expected to:

1. Provide accurate information about their health and home environment
2. Treat caregivers with respect
3. Notify the agency of schedule changes with reasonable advance notice
4. Ensure a safe working environment for caregivers
5. Report concerns promptly to the agency

Section 4: Intake and Admission Policy

4.1 Eligibility

All clients must be: – Enrolled in Michigan Medicaid – Authorized for Home Help Program services by MDHHS – Assigned an Adult Services Worker (caseworker) through MDHHS

4.2 Intake Process

1. Agency receives referral from MDHHS caseworker, discharge planner, or other referral source
2. Agency administrator or field supervisor contacts client and family within 48 hours
3. A home assessment is conducted prior to service start
4. Client Rights and Responsibilities are reviewed and signed by client
5. Caregiver is assigned and introduced to client
6. Services begin per the MDHHS-authorized service plan

4.3 Service Authorization

Deerwood Health Group LLC will only deliver services that have been authorized by MDHHS through the client’s approved service plan. Services will not exceed authorized hours without prior approval.

Section 5: Service Delivery Policy

5.1 Standards of Care

All caregivers must: – Arrive on time for every scheduled visit – Clock in and out via EVV (HHAeXchange) at the client’s location – Deliver only authorized services – Document any concerns or observations at the end of each visit – Never leave a client in an unsafe condition

5.2 Scheduling

• Schedules are created and managed through HHAeXchange
• Caregivers receive schedules at least 48 hours in advance when possible
• Changes to schedules must be communicated through the agency, not directly between caregiver and client

5.3 Missed Visits

• Caregivers must notify the agency at least 2 hours before a scheduled visit if unable to attend
• The agency will arrange coverage or notify the client
• Repeated missed visits without notice are grounds for disciplinary action

Section 6: Caregiver Hiring and Credentialing

6.1 Minimum Requirements

All caregivers must meet the following requirements prior to hire:

• Must be 18 years of age or older
• Must have legal authorization to work in the United States
• Must pass a criminal background check (see Section 7)
• Must complete agency orientation and training before first client assignment
• Must have reliable transportation to client homes

6.2 Required Documentation at Hire

• Completed employment application
• Government-issued photo ID
• Social Security card or work authorization document
• Signed W-4 and I-9 forms
• Direct deposit form
• Signed acknowledgment of agency policies

6.3 Orientation and Training

All new caregivers must complete a minimum of 8 hours of agency orientation prior to their first client assignment, covering: – Client rights and dignity – EVV system usage (HHAeXchange) – Abuse, neglect, and exploitation recognition and reporting – Emergency procedures – Infection control and personal protective equipment – Agency policies and code of conduct. Completion of orientation is documented in the employee file with date, topics covered, and supervisor signature.

Section 7: Criminal Background Check Policy

7.1 Policy Statement

Deerwood Health Group LLC requires a criminal background check for all employees prior to placement with any client. No caregiver will begin working with a client until the background check has been reviewed and cleared.

7.2 Process

• Background checks are conducted through Michigan’s ICHAT (Internet Criminal History Access Tool) system for state criminal history, supplemented by a third-party background screening vendor as needed for federal checks
• Background checks include Michigan state criminal history and sex offender registry
• Federal background checks are conducted as required

7.3 Disqualifying Offenses

The following will result in automatic disqualification:

• Conviction for abuse, neglect, or exploitation of a vulnerable adult or child
• Conviction for any felony involving violence, fraud, or theft within 10 years
• Presence on the Michigan Nurse Aide Registry as having findings of abuse or neglect
• Any offense listed as disqualifying under Michigan Public Act 218 of 2014

7.4 Ongoing Monitoring

Background checks are repeated every two years for all active employees. Any caregiver arrested or charged with a relevant offense must notify the agency immediately.

Section 8: Supervision and Performance Management

8.1 Supervision Structure

• The Agency Administrator conducts ongoing remote supervision through weekly review of EVV data, HHAeXchange visit records, and direct communication with caregivers and clients. In-person client check-ins are conducted at least once every 90 days, or more frequently if a concern is identified. Caregivers are observed in person during at least one visit per quarter. All supervision activities are documented in writing, including call logs, EVV review summaries, and visit observation notes, and retained in agency files.
• The Agency Administrator reviews EVV data weekly and documents findings in a written supervision log
• The Agency Administrator reviews EVV data weekly for attendance and compliance issues

8.2 Performance Reviews

• All caregivers receive a written performance review at 90 days and annually thereafter
• Performance criteria include: punctuality, EVV compliance, client feedback, incident history

8.3 Corrective Action

Progressive corrective action is used for performance issues: 1. Verbal warning with documentation 2. Written warning 3. Final written warning with performance improvement plan 4. Termination

Immediate termination may occur for: client abuse or neglect, theft, EVV fraud, or any conduct posing immediate risk to client safety.

Section 9: Electronic Visit Verification (EVV) Policy

9.1 EVV Requirement

Michigan Medicaid requires Electronic Visit Verification for all Home Help Program visits. Deerwood Health Group LLC uses HHAeXchange as its EVV platform in compliance with state requirements.

9.2 Caregiver Requirements

Every caregiver must: – Clock in at the start of every visit using the HHAeXchange mobile app at the client’s location – Clock out at the end of every visit from the client’s location – Never clock in or out from a location other than the client’s home (EVV fraud)

9.3 Missed or Failed EVV

• If a caregiver forgets to clock in or out, they must notify the agency supervisor immediately
• Manual visit corrections require supervisor approval and documentation of reason
• Repeated EVV failures are subject to corrective action

9.4 EVV Fraud

Clocking in or out from a location other than the client’s home, or falsifying visit times, is considered Medicaid fraud and will result in immediate termination and may be reported to MDHHS and law enforcement.

Section 10: Abuse, Neglect, and Exploitation Policy

10.1 Zero Tolerance

Deerwood Health Group LLC maintains a zero-tolerance policy for abuse, neglect, or exploitation of any client. Any employee found to have abused, neglected, or exploited a client will be immediately terminated and reported to the appropriate authorities.

10.2 Definitions

• Abuse: Intentional or reckless physical, emotional, or sexual harm to a client
• Neglect: Failure to provide necessary care, resulting in harm or risk of harm
• Exploitation: Unauthorized use of a client’s funds, property, or resources

10.3 Mandatory Reporting

All employees are mandatory reporters under Michigan law. Any suspected or observed abuse, neglect, or exploitation must be reported immediately to:

• Agency supervisor
• Michigan Adult Protective Services: 855-444-3911
• If the client is in immediate danger, call 911

Reports must also be documented in writing and submitted to the agency within 24 hours.

Section 11: Grievance and Complaint Procedure

11.1 Policy

Every client has the right to file a grievance or complaint without fear of retaliation. Deerwood Health Group LLC will investigate all complaints promptly and fairly.

11.2 How to File a Complaint

Complaints may be submitted by: – Calling the agency administrator directly – Submitting a written complaint to the agency address – Contacting MDHHS directly

11.3 Resolution Process

1. Complaint is received and logged within 1 business day
2. Investigation is completed within 10 business days
3. Client is notified of findings and resolution within 7 business days
4. If unsatisfied, client may escalate to MDHHS

11.4 External Complaints

Clients may also file complaints with: – Michigan Department of Health and Human Services (MDHHS) Home Help Program: 800-292-2550 – MDHHS Adult Services/APS Hotline: 855-444-3911 – LARA Bureau of Community and Health Systems: 517-241-0199

Section 12: Confidentiality and HIPAA Policy

12.1 Policy

Deerwood Health Group LLC protects the privacy of all client information in accordance with HIPAA and Michigan state law. Client information will not be shared with any unauthorized party without written consent from the client.

12.2 Authorized Disclosures

Client information may be disclosed without written consent only to: – MDHHS for billing and program administration – The client’s assigned caseworker – Law enforcement when required by law – Other providers when necessary for continuity of care

12.3 Employee Responsibilities

All employees must: – Never discuss client information in public settings – Never share client information on social media – Report any suspected privacy breach to the agency administrator immediately – Sign a confidentiality agreement upon hire

12.4 Breach Response

In the event of a suspected HIPAA breach, the agency will: 1. Investigate and contain the breach within 24 hours 2. Notify affected clients within 60 days as required by law 3. Report to the U.S. Department of Health and Human Services if required

Section 13: Emergency and Disaster Plan

13.1 Purpose

This plan ensures continuity of care and client safety during emergencies including natural disasters, power outages, public health emergencies, and other crises.

13.2 Client Emergency Protocols

• Each client file includes emergency contact information
• Caregivers are trained to call 911 first in any life-threatening situation
• After calling 911, caregiver notifies the agency supervisor immediately

13.3 Agency Continuity

In the event the agency cannot operate normally: – The agency administrator will contact all active clients and caregivers within 24 hours – Backup supervisory coverage will be arranged – MDHHS will be notified if service delivery is disrupted for more than 24 hours

13.4 Caregiver Safety

Caregivers are not required to report to client homes during declared states of emergency if doing so poses a personal safety risk. The agency will communicate via HHAeXchange messaging and phone regarding operational status during emergencies.

Section 14: Incident Reporting Policy

14.1 Reportable Incidents

The following must be reported to the agency supervisor immediately: – Client falls or injuries during or around the time of a visit – Client hospitalization or emergency room visit – Death of a client – Suspected abuse, neglect, or exploitation (see Section 10) – Caregiver injury during a visit – Property damage at a client’s home – Any situation requiring 911 response

14.2 Reporting Process

1. Caregiver calls agency supervisor immediately
2. Written incident report submitted within 24 hours
3. Agency administrator reviews and determines if MDHHS or other authority must be notified
4. Incident report is retained in agency files for a minimum of 5 years

Section 15: Workers’ Compensation Policy

Deerwood Health Group LLC maintains Workers’ Compensation insurance coverage for all W-2 employees in accordance with Michigan law. All caregivers are covered from their first day of employment.

15.1 Reporting On-the-Job Injuries: Any caregiver injured during a client visit or while performing agency duties must: – Notify the Agency Administrator immediately by phone – Seek medical attention as needed – Submit a written incident report within 24 hours – Not return to work until cleared by a medical provider if the injury affects their ability to deliver care safely.

15.2 Safe Working Environment: The agency expects clients to maintain a reasonably safe home environment. Caregivers are not required to perform services in conditions that pose an unreasonable safety risk. Any unsafe conditions must be reported to the Agency Administrator immediately.

Section 16: Family Caregiver Policy

Michigan’s Home Help Program permits family members to serve as paid caregivers for eligible Medicaid clients. Deerwood Health Group LLC supports this model and hires qualified family caregivers as W-2 employees subject to the same standards as all agency caregivers.

16.1 Eligibility: A family member may be hired as a caregiver provided they meet all standard hiring requirements including background check clearance, orientation completion, and I-9 employment eligibility verification. Spouses and legally responsible relatives may be subject to additional restrictions under MDHHS program rules.

16.2 Conflict of Interest Disclosure: All family caregivers must sign a Conflict of Interest Disclosure Form acknowledging their relationship to the client. This form is retained in the employee file.

16.3 EVV and Documentation: Family caregivers are subject to the same EVV clock-in/clock-out requirements as all other caregivers. No exceptions to EVV compliance are made based on family relationship.

16.4 Relationship Changes: If the caregiver-client relationship changes (e.g., the family member can no longer provide care, or a dispute arises), the agency must be notified immediately. The agency will arrange alternative coverage and reassign or terminate the caregiver employment as appropriate.

Section 17: Non-Discrimination Policy

Deerwood Health Group LLC does not discriminate in the provision of services or employment on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, age, disability, or any other protected characteristic. This policy applies to clients, caregivers, and all business operations.

Clients or employees who believe they have been discriminated against may file a complaint with: – The agency administrator – U.S. Department of Health and Human Services Office for Civil Rights: 800-368-1019

Section 19: Infection Control and Prevention Policy

19.1 Purpose

Deerwood Health Group LLC is committed to preventing the spread of infectious disease in client homes and protecting both clients and caregivers. This policy applies to all caregivers and agency staff during any client visit or agency activity.

19.2 Standard Precautions

All caregivers must observe standard precautions during every client visit, regardless of the client’s known health status. Required practices include: – Handwashing with soap and water for a minimum of 20 seconds before and after providing care – Use of gloves when providing personal care or handling body fluids – Use of masks and additional PPE as required by client condition or public health guidance – Proper disposal of used PPE and contaminated materials in accordance with applicable guidelines

19.3 Illness Reporting and Exclusion

Caregivers who are experiencing symptoms of a communicable illness (including fever, vomiting, diarrhea, or respiratory symptoms) must notify the Agency Administrator before reporting to a client visit. The agency will arrange substitute coverage. Caregivers may not return to work until they are symptom-free for at least 24 hours without the use of symptom-suppressing medication, or as directed by a medical provider.

19.4 Public Health Emergencies

During a declared public health emergency, Deerwood Health Group LLC will follow all applicable guidance from the Michigan Department of Health and Human Services (MDHHS) and the Centers for Disease Control and Prevention (CDC). Enhanced PPE requirements, testing protocols, or service modifications will be communicated to all caregivers promptly via HHAeXchange messaging and phone.

Section 18: Document Retention Policy

The agency will retain the following records for the minimum periods listed:

All records are stored securely and accessible only to authorized personnel.