Provider Responsibilities

Title XX Social Services (DFI)
Program Manual FY21

  1. Audit Trail
  2. Community Outreach Plan
  3. Reporting Requirements
  4. Confidentiality
  5. Records Retention

A. Audit Trail

The fundamental requirement that must be met by service providers is that reporting and record keeping systems be organized in such a manner that logical progression from service provision to payment for the service can be readily ascertained. This constitutes an audit trail.

The organization of records must be such that any and all reports can be reconstructed and traced back to primary source documents. There are five major areas in which records must be maintained to validate service claims. They are participant eligibility determination, participant eligibility redetermination, service delivery, measurable participant outcomes, and service costs. There are numerous types of records that constitute primary source documentation in the above five areas. The following represents examples, but not a complete listing, of primary source documentation:

  1. Approved applications/or request for service forms, confirmation forms and any other documents on which participant eligibility information is recorded. This primary source documentation must be maintained in the participant case record. Provisions must also be made to document continuing eligibility.
  2. Needs assessment and goal establishment for new and continuing participants.
  3. Service Delivery Records

Casework notes, participant attendance records or timecards, counselor time sheets, monthly logs to summarize service billing on the C-13 Invoice Vouchers or Reimbursement Requests, service reports approved by IDHS, and any other documents which indicate for each individual participant: 

  1. the type of service received
  2. the dates service received
  3. narrative of service contact or appropriate service code and service activity.

These should be maintained in chronological order in the participant's case record and should support all services reported to IDHS. Narrative descriptions should describe the service interaction. The length of the narrative should be appropriate for the length of time providing the service. Services provided to more than one individual at the same time should be recorded as group service. A listing of each participant, date, service time, and a narrative summary describing the activity should be recorded on a group form in each participant's file or in a separate group file. 

Group hours are recorded and reported on the basis of the staff's time. For example, if 20 clients participate in a one-hour session with two staff, only the staff time or two hours would be recorded and reported unless otherwise detailed in the Program Plan and approved.

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  4. Service Levels/Service Activity/Records

  • IDHS establishes, through the Title XX Social Services Block Grant Donated Funds Initiative program plan and service level document, the expectations for the funded services. The records maintained by the Provider must document the type and level of service activities and the result of the service goals. Providers are required to maintain records and report necessary service information on a quarterly basis. From this information IDHS will monitor provider performance throughout the fiscal year, and at the conclusion of the fiscal year evaluate the Provider's actual versus contracted performance.

  5.  Cost of Service Records

  • These records include, but are not limited to, payroll registers or payroll ledgers, employee time records, appropriate in-kind documentation, canceled checks, bank statements and reconciliations, cash receipt and disbursement journals, general ledger accounts, purchase of service invoices, agreements, cost allocation plans and work papers and any other records to determine the cost of the service. These should be maintained in the fiscal records of the service provider to support line item costs reported to IDHS.

 6. Match Records

  • Documentation must indicate the source(s) of local 25% match (cash and/or in-kind), and that the match was received directly into the program or expenses were certified by public agencies. The documentation must verify that the match was received prior to submitting a request for payment.
    • IDHS requires that providers maintain a separate revenue/cost center for each Title XX Social Services Block Grant Donated Funds Initiative program. An acceptable, well-maintained and up-to-date accounting system includes bank reconciliations, a trial balance, separate identification of program expenses in accounting books of entry, i.e. separate revenue/cost centers for each Title XX Social Services Block Grant Donated Funds Initiative program, justification for allocations, segregation of duties for internal control, and written, detailed administrative policies and accounting procedures.

 7.  Agency Audit Report According to Federal and State rules.

  • The State's 75% reimbursement to DFI providers are Federal funds from the U.S. Department of Health and Human Services. The Catalog of Federal Domestic Assistance number is 93.667. Two provider audit reports must be submitted to IDHS within 120 days after the end of the contract period.

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B. Community Outreach Plan

All contractors must have a community outreach plan. This plan must include a detailed description for notifying the community of the program, hours of operation, and admittance/eligibility requirements into the DFI funded program(s). Linkage agreements or memorandums of understanding with other community services agencies, IDHS Family and Community Resource Centers (local offices) and other outreach entities must be available for inspection by IDHS. At a minimum, one annual mandatory meeting with the appropriate IDHS Family and Community Resource Center (local office) must be included as part of the plan. IDHS must approve any publication and distribution of flyers, printed materials and brochures that are part of the IDHS funded program. All contractors must have a referral process that assists program participants with enrollment into public benefit programs such as TANF, SNAP, KIDCARE, medical and disability assistance, as well as other resources that address the needs of the population targeted for service.

C. Reporting Requirements

In addition to basic record keeping requirements, certain service and fiscal reports must be submitted. If reports are not received in a timely manner and arrangements are not made for the submittal of reports by an approved date, payment will be withheld until reporting requirements are satisfied. The Provider will receive written notification of payment suspension and be provided the opportunity to resolve reporting issues.

If the Provider does not contact the Department within 30 days from the date of the written notification, the Department will initiate action to terminate the Community Services Agreement. The Provider will receive written notification of the Department's intent to terminate the Agreement.

1.  Expenditure Reporting 

With the exception of the Approved Residential Services Treatment providers, each provider is required to submit monthly expenditure data.  Expenditure data must be reported on the Donated Funds Initiative Request for Reimbursement form Monthly expenditure data must be reported by the 30th day after the end of the service month.

Approved Residential Services Treatment providers are required to submit monthly Donated Funds Initiative Verification of Donation (IL 444-2715).

2.  Quarterly Reporting for Service Activity

Each provider is required to submit a quarterly Donated Funds Initiative Quarterly Report (IL 444-4132). The report details the actual numbers of clients served and services provided for the quarter. The Service Activity Report and instructions are included in Exhibit IV and is available from the IDHS Website.

EDS providers will report utilizing a form prescribed by the Department. Crisis Nursery providers will report electronically. The information included for Crisis Nursery reporting will be established annually by the Crisis Nursery Coalition each year and conveyed to the Department.

Quarterly reports are due within 15 days from the end of the quarter, October 15, January 15, April 15, and July 15. If reports are not received in a timely manner and arrangements are not made for the submittal of reports by an approved date, payments will be suspended. Providers will receive written notification of payment suspension and will be provided the opportunity to resolve reporting issues.

3. Annual Final Report

At the conclusion of each fiscal year, each provider is required to submit an Donated Funds Initiative Final Report (IL 444-4130). This report must be submitted in a format approved by IDHS. As IDHS may maintain year-to-date statistics for expenditures from Reimbursement Requests and quarterly reports, the report may be limited to information not available on previously submitted reports.

The Final Program Report is available on the IDHS website. The Annual Final Report is due within 30 days subsequent to the end of the State fiscal year.

4. Minority Seniors Report (IL 444-1947)

Public Act 88-0254 required the Illinois Department of Aging (IDOA) to prepare an annual report on all programs and services provided to "Minority Senior Citizens" to the Governor and the General Assembly. IDHS, along with other state agencies, must submit information on program/service participation of minority senior citizens to the IDOA. At the conclusion of the fiscal year, the provider is required to report this information to the Department. The approved report is shown as Exhibit VI and is available on the IDHS website.

For the purposes of this report, except for IDOA sponsored providers, the definition of a senior citizen is a person 55 years of age or older. The reporting  categories are African American, Hispanic, Asian American, American Indian or Alaskan Native and Caucasian. The Caucasian category is included in the report for comparison purposes.

IDHS reserves the right to negotiate other reporting requirements at any time during the Community Services Agreement period. Providers will receive written notification of any additional requirements.

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D. Confidentiality

Providers must observe State and Federal laws and regulations with respect to safeguarding the use and disclosure of information on applicants for and recipients of services. Such disclosures are permissible under regulations only for purposes directly connected with the administration of the program:

  1. To establish eligibility.
  2. To determine service need and fee assessment.
  3. To provide service.
  4. To meet sponsoring agency and lead state agency reporting requirements.
  5. To conduct official reviews, evaluations, management studies, audits of the program.
  6. To certify Temporary Assistance for Needy Families participants' status to an employer for tax credit purposes.
  7. To establish income for Illinois' Temporary Assistance for Needy Families claiming.
  8. To aid in any investigation, prosecution, or legal proceeding regarding administration of the program.

IDHS maintains the right to request and use any of the above information to support its claim for federal reimbursements as it deems necessary. In such circumstances, IDHS will exercise utmost caution to preserve the integrity of all confidential documentation.

The types of information that the Federal regulations consider as within the purview of the safeguarding requirement include, but are not limited to:

  1. Names and addresses of applicants or participants.
  2. Types and amount of assistance a particular individual applies for or receives.
  3. Information related to the social and economic circumstances of a particular individual.
  4. Evaluation or diagnosis of a particular individual.

The release of any information included under the safeguarding requirement, unless otherwise authorized by the applicant/participant in writing, may only be to persons who are subject to standards of confidentiality no less rigorous than those of the releasing agency.

E. Record Retention

The State requires providers through the Community Services Agreement to retain program records connected with their participation for a minimum of five (5) years from the later of the date of final payment or the expiration of the Agreement.

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