Fiscal Intermediary Review QR5700

REVISED 09/12/23

Fiscal Intermediary File Review

Agency:

Date:

Reviewer:

Review Type: _ (A) AHBS _ (B) CSW

Reference #:

Section Letter	A	B	C	D
Record Participant's Name:
Does this person have a PSW? If Yes then select one PSW and record their name. If no proceed to next record.	_ Yes Name: _ No	_ Yes Name: _ No	_ Yes Name: _ No	_ Yes Name: _ No
Is the PSW eligible based on their relationship to participant? Spouse cannot be PSW for Adult participant. A legally responsible person cannot be PSW for participant in children's waiver. As of 1/1/23, for CSW participants 18 & older, a parent who is not the legally responsible individual may be a PSW	_ Yes _ No _Explain	_ Yes _ No _Explain	_ Yes _ No _Explain	_ Yes _ No _Explain
Is there a current Service Authorization for PSW?	_ Yes _ No	_ Yes _ No	_ Yes _ No	_ Yes _ No
PSW Hire Date or 1st day in paid status *:
Background check requirements:
Date of initial Health Care Worker Registry(HCWR) and Adult Protective Services (APS) checks: 2	_ Yes _ No	_ Yes _ No	_ Yes _ No	_ Yes _ No
Were the initial HCWR and APS checks completed no sooner than 30 days prior to hire and no later than the 1st day in paid status?	_ Yes _ No	_ Yes _ No	_ Yes _ No	_ Yes _ No
If HCWR public website used, was the SSN verified?	_ Yes _ No _ N/A	_ Yes _ No _ N/A	_ Yes _ No _ N/A	_ Yes _ No _ N/A
Initial HCWR determination:	Eligible Ineligible Not Yet Determined	Eligible Ineligible Not Yet Determined	Eligible Ineligible Not Yet Determined	Eligible Ineligible Not Yet Determined
Initial APS determination:	_ Eligible - Ineligible	_ Eligible - Ineligible	_ Eligible - Ineligible	_ Eligible - Ineligible
Date of the most recent Health Care Worker Registry/HCWR) and Adult Protective Services (APS) checks: (2)	-	-	-	-
Were the most recent HCWR and APS checks completed within the past 13 months?	_ Yes _ No	_ Yes _ No	_ Yes _ No	_ Yes _ No
If HCWR public website used, was the SSN verified?	_ Yes _ No _ N/A	_ Yes _ No _ N/A	_ Yes _ No _ N/A	_ Yes _ No _ N/A
Most recent HCWR check determination:	Eligible Ineligible Not Yet Determined	Eligible Ineligible Not Yet Determined	Eligible Ineligible Not Yet Determined	Eligible Ineligible Not Yet Determined
Most recent APS check determination:	_ Eligible - Ineligible	_ Eligible - Ineligible	_ Eligible - Ineligible	_ Eligible - Ineligible
For ALL PSWs Date of Illinois State Police (ISP) check (FEE_APP date): (3)
Was the ISP Check (FEE_APP) initiated no sooner than 30 days prior to hire and no later than 1st day of paid status?	_ Yes _ No _ Completed by prior employer	_ Yes _ No _ Completed by prior employer	_ Yes _ No _ Completed by prior employer	_ Yes _ No _ Completed by prior employer
For ALL PSWs Was the ISP check (FEE_APP) received and no disqualifying offenses found?	_ Yes _ No _Explain	_ Yes _ No _Explain	_ Yes _ No _Explain	_ Yes _ No _Explain
Date of initial DCFS CANTS check: (Date is the Aces$ date stamp next to PSW's signature date - see below.) (4)
Was the initial DCFS CANTS check initiated within 30 days prior to and no later than the 1st day in paid status?	_ Yes _ No	_ Yes _ No	_ Yes _ No	_ Yes _ No
Initial DCFS CANTS finding:	_ No Priors _ No response yet _ Finding Indicated _ Waiver granted	_ No Priors _ No response yet _ Finding Indicated _ Waiver granted	_ No Priors _ No response yet _ Finding Indicated _ Waiver granted	_ No Priors _ No response yet _ Finding Indicated _ Waiver granted
Date of most recent DCFS CANTS check: (Date is the Aces$ date stamp or PSW's signature date - see below.) (4)
Was the most recent DCFS CANTS check completed within the past 13 months?	_ Yes _ No	_ Yes _ No	_ Yes _ No	_ Yes _ No
Most recent DCFS CANTS finding:	_ No Priors _ No response yet _ Finding Indicated _ Waiver granted	_ No Priors _ No response yet _ Finding Indicated _ Waiver granted	_ No Priors _ No response yet _ Finding Indicated _ Waiver granted	_ No Priors _ No response yet _ Finding Indicated _ Waiver granted
Date of initial Illinois Sex Offender Registry check: (5)
Was the Illinois Sex Offender Registry check completed no sooner than 30 days prior to and no later than the 1st day of paid status?	_ Yes _ No	_ Yes _ No	_ Yes _ No	_ Yes _ No
Initial Illinois Sex Offender Registry check findings:	_ Employee not found _ Employee found on registry	_ Employee not found _ Employee found on registry	_ Employee not found _ Employee found on registry	_ Employee not found _ Employee found on registry
Date of most recent Illinois Sex Offender Registry check: (5)
Was the most recent Illinois Sex Offender Registry check completed within the past 13 months?	_ Yes _ No	_ Yes _ No	_ Yes _ No	_ Yes _ No
Most recent Illinois Sex Offender Registry check findings:	_ Employee not found _ Employee found on registry	_ Employee not found _ Employee found on registry	_ Employee not found _ Employee found on registry	_ Employee not found _ Employee found on registry
Date of initial Illinois HFS Office of Inspector General (OIG) Sanctions List check: (5)
Was the initial Illinois HFS Office of Inspector General (OIG) Sanctions List check completed within 30 days prior to and no later than 1st day of paid status?	_ Yes _ No	_ Yes _ No	_ Yes _ No	_ Yes _ No
Initial Illinois HFS OIG Sanctions List findings:	_ Employee not found _ Employee found on registry	_ Employee not found _ Employee found on registry	_ Employee not found _ Employee found on registry	_ Employee not found _ Employee found on registry

Section Letter

Record Participant's Name:

Does this person have a PSW? If Yes then select one PSW and record their name. If no proceed to next record.

_ Yes

Name:

_ No

_ Yes

Name:

_ No

_ Yes

Name:

_ No

_ Yes

Name:

_ No

Is the PSW eligible based on their relationship to participant?
Spouse cannot be PSW for Adult participant.
A legally responsible person cannot be PSW for participant in children's waiver.
As of 1/1/23, for CSW participants 18 & older, a parent who is not the legally responsible individual may be a PSW

_ Yes

_ No

_Explain

_ Yes

_ No

_Explain

_ Yes

_ No

_Explain

_ Yes

_ No

_Explain

Is there a current Service Authorization for PSW?

_ Yes

_ No

_ Yes

_ No

_ Yes

_ No

_ Yes

_ No

PSW Hire Date or 1st day in paid status *:

Background check requirements:

Date of initial Health Care Worker Registry(HCWR) and Adult Protective Services (APS) checks: 2

_ Yes

_ No

_ Yes

_ No

_ Yes

_ No

_ Yes

_ No

Were the initial HCWR and APS checks completed no sooner than 30 days prior to hire and no later than the 1st day in paid status?

_ Yes

_ No

_ Yes

_ No

_ Yes

_ No

_ Yes

_ No

If HCWR public website used, was the SSN verified?

_ Yes

_ No

_ N/A

_ Yes

_ No

_ N/A

_ Yes

_ No

_ N/A

_ Yes

_ No

_ N/A

Initial HCWR determination:

Eligible
Ineligible
Not Yet Determined

Eligible
Ineligible
Not Yet Determined

Eligible
Ineligible
Not Yet Determined

Eligible
Ineligible
Not Yet Determined

Initial APS determination:

_ Eligible

- Ineligible

_ Eligible

- Ineligible

_ Eligible

- Ineligible

_ Eligible

- Ineligible

Date of the most recent Health Care Worker Registry/HCWR) and Adult Protective Services (APS) checks: (2)

Were the most recent HCWR and APS checks completed within the past 13 months?

_ Yes

_ No

_ Yes

_ No

_ Yes

_ No

_ Yes

_ No

If HCWR public website used, was the SSN verified?

_ Yes

_ No

_ N/A

_ Yes

_ No

_ N/A

_ Yes

_ No

_ N/A

_ Yes

_ No

_ N/A

Most recent HCWR check determination:

Eligible
Ineligible
Not Yet Determined

Eligible
Ineligible
Not Yet Determined

Eligible
Ineligible
Not Yet Determined

Eligible
Ineligible
Not Yet Determined

Most recent APS check determination:

_ Eligible

- Ineligible

_ Eligible

- Ineligible

_ Eligible

- Ineligible

_ Eligible

- Ineligible

For ALL PSWs
Date of Illinois State Police (ISP) check (FEE_APP date): (3)

Was the ISP Check (FEE_APP) initiated no sooner than 30 days prior to hire and no later than 1st day of paid status?

_ Yes

_ No

_ Completed by prior employer

_ Yes

_ No

_ Completed by prior employer

_ Yes

_ No

_ Completed by prior employer

_ Yes

_ No

_ Completed by prior employer

For ALL PSWs
Was the ISP check (FEE_APP) received and no disqualifying offenses found?

_ Yes

_ No

_Explain

_ Yes

_ No

_Explain

_ Yes

_ No

_Explain

_ Yes

_ No

_Explain

Date of initial DCFS CANTS check: (Date is the Aces$ date stamp next to PSW's signature date - see below.) (4)

Was the initial DCFS CANTS check initiated within 30 days prior to and no later than the 1st day in paid status?

_ Yes

_ No

_ Yes

_ No

_ Yes

_ No

_ Yes

_ No

Initial DCFS CANTS finding:

_ No Priors

_ No response yet

_ Finding Indicated

_ Waiver granted

_ No Priors

_ No response yet

_ Finding Indicated

_ Waiver granted

_ No Priors

_ No response yet

_ Finding Indicated

_ Waiver granted

_ No Priors

_ No response yet

_ Finding Indicated

_ Waiver granted

Date of most recent DCFS CANTS check: (Date is the Aces$ date stamp or PSW's signature date - see below.) (4)

Was the most recent DCFS CANTS check completed within the past 13 months?

_ Yes

_ No

_ Yes

_ No

_ Yes

_ No

_ Yes

_ No

Most recent DCFS CANTS finding:

_ No Priors

_ No response yet

_ Finding Indicated

_ Waiver granted

_ No Priors

_ No response yet

_ Finding Indicated

_ Waiver granted

_ No Priors

_ No response yet

_ Finding Indicated

_ Waiver granted

_ No Priors

_ No response yet

_ Finding Indicated

_ Waiver granted

Date of initial Illinois Sex Offender Registry check: (5)

Was the Illinois Sex Offender Registry check completed no sooner than 30 days prior to and no later than the 1st day of paid status?

_ Yes

_ No

_ Yes

_ No

_ Yes

_ No

_ Yes

_ No

Initial Illinois Sex Offender Registry check findings:

_ Employee not found

_ Employee found on registry

_ Employee not found

_ Employee found on registry

_ Employee not found

_ Employee found on registry

_ Employee not found

_ Employee found on registry

Date of most recent Illinois Sex Offender Registry check: (5)

Was the most recent Illinois Sex Offender Registry check completed within the past 13 months?

_ Yes

_ No

_ Yes

_ No

_ Yes

_ No

_ Yes

_ No

Most recent Illinois Sex Offender Registry check findings:

_ Employee not found

_ Employee found on registry

_ Employee not found

_ Employee found on registry

_ Employee not found

_ Employee found on registry

_ Employee not found

_ Employee found on registry

Date of initial Illinois HFS Office of Inspector General (OIG) Sanctions List check: (5)

Was the initial Illinois HFS Office of Inspector General (OIG) Sanctions List check completed within 30 days prior to and no later than 1st day of paid status?

_ Yes

_ No

_ Yes

_ No

_ Yes

_ No

_ Yes

_ No

Initial Illinois HFS OIG Sanctions List findings:

_ Employee not found

_ Employee found on registry

_ Employee not found

_ Employee found on registry

_ Employee not found

_ Employee found on registry

_ Employee not found

_ Employee found on registry

1 - PSW selections are based on a representation of both Initial PSW background checks (PSW hired within the last 12 months) and annual PSW background checks

(PSW hired longer than 12 months ago).

2 - How to access Adult Protective Services (APS) Registry information. how-to-check-aps-registry.pdf (illinois.gov)

If the PSW does not appear on the HCWR, both the HCWR and APS checks shall reflect "Eligible".
APS Checks - - HCWR portal.
- If APS = "No" and HCWR check is "Eligible" or "Not Yet Determined", response is "Eligible".
- If APS = "Unavailable" and HCWR check is "Eligible" or "Not Yet Determined", response is "Eligible".
- If APS = "Yes" or HCWR check is "Ineligible", response is "Ineligible".

3 - For recently hired PSWs, the results of FEE_APP may not be received on 1st day of paid status (however, the provider must initiate the FEE_APP process no

sooner than 30 days prior to hire and no later than 1st day of paid status). The FEE_APP application is valid for 10 working days, during which time the PSW

must provide the application to the appropriate vendor and complete their fingerprinting. Thus, the FEE_APP date may fall within this 10 working day timeframe

after date of hire.

IDPH Health Care Worker Registry: A FEE_APP, which stands for a Fee Applicant Inquiry, is a fingerprint-based criminal history records check

requested through the Illinois State Police (ISP). When a FEE_APP background check is conducted, ISP stores the fingerprints for the HCWR.

UCIA, which stands for the Uniform Conviction Information Act, is the type of background checks used by the HCWR prior to the implementation

of the fingerprint-based background checks (prior to October 2007). A UCIA background check is no longer valid for use with the HCWR.

4 - DCFS CANTS (effective 9/1/21). Date for initial and annual checks, use:

1st: Aces$ date stamp - - date emailed to DCFS (with staff initials, shown on CANTS Master Signature log, to the right of applicant's signature).
2nd: Applicant's signature date if CANTS form (a) does not have date stamp and/or staff initials; (b) has multiple date stamps.

(If multiple forms without date stamps or with multiple date stamps, utilize applicant's signature date for duration of review)

5 - IL Sex Offender Registry and IL HFS OIG Sanctions List checks should be searched by LAST NAME ONLY - no first names, city, or zip codes should be added to

the search. Using additional demographic information (such as first name) may cause the search results to be too narrow. For employees with more common

last names, agency should at a minimum have the first page (showing date run and last name searched) as well as the page where the employee's name would

have appeared if it was present (lists are alphabetical). Background Check and Clearance

Guidance

Participant-directed PSWs do not have to complete DSP training:

Changes to CSW PSW requirements 1/2023: