STATE OF CONNECTICUT
STATE OF CONNECTICUT
DEPT OF PUBLIC HEALTH
FACILITY LICENSING & INVESTIGATIONS SECTION
410 CAPITAL AVENUE
HARTFORD, CT 06134-0308
HOME HEALTH CARE AGENCY
|Agency Name |
|Address (no. & Street) |(City & Town) |(State) |(Zip) |
|Administrator (Per Section 19-13-D68 (d) |Supervisor of H-HHA Program Section 19-13-69 (d) (4) (c) |
|Administrator Supervisor (Per Section 19-13-D68 (e) (4) |RN w/other responsibilities (Section 19-13-D69 (d) (4) (c) HHA PROGRAM |
|Supervisor of Clinical Services (Per Section 19-13-D68 (e) |Physical Therapy Supervisor (Section 19-13-D67 (c) |
| |Occupational Therapy Supervisor (Section 19-13-D67 (d) |
| |Speech Therapy Supervisor (Section 19-13-D67 (e) |
| |Medical Social Worker Supervisor (Section 19-13-D67 (f) |
| | |
| | |
|Person designated to act in the absence of Administrator per Section 19-13D68 (d): |
|Name |Title |
|Person designated to act in the absence of Supervisor of Clinical Services per Section 19-13D68(e)(5) |
|Name |Title |
|OTHER PATIENT CARE SERVICE OFFICERS |
|Address |Address |
|Name of SCS |Name of SCS |
|RN to Act in Absence |RN to Act in Absence |
|H-HHA Supervisor |H-HHA Supervisor |
|Address |Address |
|Name of SCS |Name of SCS |
|RN to Act in Absence |RN to Act in Absence |
|H-HHA Supervisor |H-HHA Supervisor |
|DO NOT MAKE ENTRIES BELOW THIS LINE-FOR HOME HEALTH SECTION USE ONLY |
|INSPECTOR’S |Signature |Title |Date |
|VERIFICATION |X | | |
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ADMINISTRATIVE
SUPERVISION TYPE OR
ORGANIZATION PRINT IN INK
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