HBS review QR6700

REVISED 9/13/23

Agency Name:  

Individual's Name:  

W#

Sample #:  

Reviewer:  

Date of Review:  

Guidelines refers to the DHS Person Centered Planning Policy and Guidelines for DD Waiver Services

Implementation Strategy (IS) Guidelines:

Consumer Handbook for Home-Based Services:

EOR Implementation Strategy instructions PDF

FAQ HBS: 

SDA Guidelines:

Employer of Record (EOR)

Yes No N/A Item: Remediation on / Required by:
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1. Were the following documents in the agency's records?
Discovery Tool Date:  ___
Personal Plan Date:  ___
EOR Implementation Strategy Date: ___ (for SDAs & participant-directed PSWs)
Implementation Strategy Date: ___ (for agency-based DSPs/PSWs)
(Must have the first two and the applicable EOR and/or Implementation Strategy document(s) to be 'Yes'. DT date is ISC signature date; PP date is the latest of Individual/Guardian/ISC signature dates; EOR date is EOR signature date; IS date is QIDP signature date.)
Reviewer will save a copy of the Implementation Strategy(ies) to the Agency review folder in the G: drive.

Comments:

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- - - 2. Is the EOR / Implementation strategy signed by the appropriate person? (EOR or Individual/Guardian as applicable)
EOR Implementation Strategy  Implementation Strategy (if applicable)
EOR date signed: ___
Person date signed: ___
Guardian date signed: ___		 -
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3. Was the SDA's Provider Signature Page signed within 10 days from Provider's receipt of the Personal Plan?

Personal Plan received:
Date:
Provider Signature Page Signed:
Date:

Comments:

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4. For those who purchase Self Direction Assistance (SDA) was the EOR Implementation Strategy completed within 20 days of the SDA-signed Provider Signature Page?

Comments:

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5. Does the record contain a current written Service Agreement completed between the participant and each service provider identified on the current Aces$ Service Authorization Form and Summary of Services and Supports Page of the current Personal Plan?

Comments:

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6. Do all of the current Service Agreements define the terms of the services to be provided including  the effective date(s), the rate of payment, the maximum units of service to be provided each month, and the maximum monthly charge?

Comments:

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7. For agency based PSWs only, did the provider develop an Implementation Strategy per DDD guidelines? (Implementation Strategy Guidelines above)

Comments:

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8. Does the EOR Implementation Strategy reflect the same Personal Plan outcomes that the Summary of Services and Supports page identifies as the responsibility of the participant-directed Personal Support Worker?

Comments:

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9. If SDA services are purchased, is there evidence that the SDA provider agency maintains a detailed chronological log of all activities performed for audit purposes and to verify their billing? (Log should only include allowable SDA services [per SDA guidelines above] and dates/hours of services billed.)

Comments:

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10. If SDA services are purchased, is the SDA a QIDP?

Comments:

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11. Does the individual's record indicate that ALL CIRAS-reportable events in the past 12 months were reported to CIRAS?

Comments:

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