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EARN

EMPLOYMENT ADVANCEMENT AND RETENTION NETWORK

PROGRAM POLICY AND PROCEDURES MANUAL

APPENDIX A OF THE STATEMENT OF WORK

PROGRAM YEAR 15-16

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TABLE OF CONTENTS

Program Overview……………………………………………………………………………3 Eligibility Criteria…………………………… ....…. …………………….……………..…….3 Enrollment……………………………………………………………………………………..3 Project Referral Rejection Codes…………………………………………………………....3 Determining Hours of Participation…………………………………………………...……..4 Activity Compliance Rate (ACR)……………………………………………………………..4 Service Plan……………………………………………………………………………………4 Data Entry………………………………………………………………………………………5 Service Activity Codes.....................................................................................................6 Excused Absences……………………………………………………………..……….……..7 Holidays………………………………………………………………………………….…..….7 Case Record Requirements……………………………………………………………..……7 Service Activity Closing Codes……………………………………………………..……..….8 Project Termination Codes……………………………………………………………….…...8 Confidentiality…………………………………………………………………………………..9 Limited English proficiency (LEP)…………………………………………………..….……..9 Service Provider Performance Requirements............................…………………….….....9 Client Incentives…....……………………………………………………….…………….……11 Supportive Services……………………………………………………………………....……11 Direct Service Team.........................................................................................................11 Monitoring………………………………………………………………….……………...……11 ATTACHMENTS ATTACHMENT A Attendance Sheet ATTACHMENT B Definition of Activities ATTACHMENT C Community Service Desk Guide ATTACHMENT D PA 1694 ATTACHMENT E PA 590 ATTACHMENT F Confidential Release of Info ATTACHMENT G EVF ATTACHMENT H Validation

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Program Overview

EARN is designed to assist clients in their transition from welfare to the workforce. The focus of all programming is to decrease dependency on public assistance and move towards self-sufficiency. While the primary focus of the program is to move clients into the workforce, the program is still to provide other activities that will aid in the pursuit of that goal.

Eligibility Criteria

CAO staff will determine eligibility for the EARN program and refer clients to EARN based on CAO policy and procedures.

Enrollment CAO staff will determine which clients to refer to EARN and create an electronic referral in CIS which will transfer to CWDS. If the client does not show for orientation or refuses to cooperate at the orientation, the EARN service provider will referral reject the client with the appropriate code listed below.

Project Referral Rejection Codes

Referral rejection codes will be used to track the reason a client’s referral to EARN is terminated prior to enrollment. The EARN service provider must data enter these codes on CWDS.

The following project referral rejection codes may be used with EARN:

Code 1 – Failed to report; Code 2 – Refused to cooperate; Code 4 – No Action Taken (System Generated); Code 5 – Other; Code T – Referred in error.

The EARN service provider must enroll the client the date that they report and data enter the clients in CWDS within 7 working days of receiving the referral from the CAO.

NOTE: All code 5 rejections are subject to further review and must be duly narrated in CWDS.

When a client is enrolled, the EARN service provider will conduct a case review to become familiar with the client’s background and situation. If available, the EARN service provider will review the information below:

Case narratives

Agreement of Mutual Responsibility (AMR)

Medical information, including physician, clinic, and hospital records

Work history

Family and Social History

Information regarding the client’s current and past participation in E&T programs

Educational activities and the outcome of those experiences

Information regarding services the participant is receiving from other agencies/providers

Any other pertinent information.

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During the client orientation, the EARN service provider will review the following:

EARN policies and client requirements, including hourly requirements.

EARN service provider’s responsibilities, including tracking client progress.

Authorization for Release of Information. Determining hours of participation

The number of hours a client is required to participate is to be determined by the CAO and recorded on the client’s AMR. The EARN service provider shall ensure that the client participates for at least all of the hours as determined by the CAO caseworker and recorded on the AMR.

NOTE: For clients that do not meet their required number of hours in any week, the

EARN service provider is required to develop a plan for that client to make up the hours during the month in which the hours were missed.

NOTE: If a client is TANF when referred to the EARN service provider and their TANF

closes due to income, the provider remains eligible to include that client in the ACR at the same amount of hours that they were required to meet under the TANF rules.

Activity Compliance Rate (ACR)

The Activity Compliance Report (ACR) displays the degree to which clients enrolled with a specified provider are engaged and participating in activities that contribute toward achievement of the state-wide Work Participation Rate (WPR).

The CWDS logic is capable of sorting the client data and comparing it to the parameters necessary for achievement of the ACR. Service Providers that have a low ACR will be given technical assistance by the Department of Human Services (DHS) in an effort to improve their ACR.

Service Plans

A Service Plan will be developed by the EARN service provider and the client to address the needs of the client and the household. It will contain all recommended services, activities and supports, and will address all barriers and concerns. The plan may be updated, as needed, as determined by client circumstances.

NOTE: The EARN service provider is to create service plans in CWDS using the Create Plan screen.

In order to remain enrolled in EARN, the client must agree to the terms of the Service Plan and sign it.

NOTE: If a client does not meet the requirements of the service plan, he or she is to be

terminated from the EARN service provider.

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Data Entry

EARN service providers may have their own data information system to track program referrals, rejections, enrollments, participant data, services (activities) and terminations. However, CIS and CWDS are the official data systems that DHS will use to validate a client’s activities and evaluate achievement of outcomes. EARN service providers hired to perform data entry are required to attend CWDS training.

DHS has instituted restrictions on timeframes for the data entry of client information into CWDS. These restrictions are necessary to ensure the timely transfer of information from CWDS to CIS, for federal and state reporting purposes, and for timely action by CAOs affecting clients’ eligibility for benefits or continued participation in EARN. The EARN service provider must complete data entry into CWDS as follows:

Hours of participation can be data entered into CWDS based on the attendance form. Data Entry can then be reconciled when the verification is received.

For all activities other than AC33 – activity and hours must be entered and, if needed, updated

by 15th of the month after the month of participation Example: For July hours must be entered by August 15.

For AC 33 – activity must be entered by the end of the month following the month of participation and hours must be entered and, if needed, updated by the end of the second month after the month of participation. Example: For July hours must be entered by August 31 and can be edited until September 30.

Any data not entered by the data entry deadlines will not count towards the performance based payments or performance outcomes. Mathematical rounding will be utilized to round clients’ hours: round down to the next whole hour if the fraction is below .49 and round up to the next whole hour if the fraction is .5 or above. Mathematical rounding will be instituted at the end of each week per activity.

To enroll a client in an EARN service provider (Project Code D or NC for Philadelphia), the EARN service provider will enter a start date in CWDS. After enrolling the client in the program, the EARN service provider must open at least one Service (Activity) Code to track participation. Under no circumstances is a client to have an open project with no open Service (Activity) Code.

EARN service providers must promptly and correctly data enter information into CWDS. It is essential to capture all client activity hours towards meeting federally mandated TANF participation requirements.

All information entered into CWDS must match the information on the EARN attendance sheets (Attachment A). All service providers must develop a data reconciliation process to ensure that all information in CWDS is accurate. If the client’s TANF closes for any reason the system will move the client from the enrolled screen to the 45 day hold screen in CWDS. If the client is not in retention and volunteers to remain in EARN, the EARN service provider is to move the client onto the Extended Hold Status and to continue to enter hours for the client under all appropriate Service (Activity) Codes.

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NOTE: EARN service providers may refer to the CWDS manual for further information

on the operation of the CWDS system. Data entry questions can be directed to the CWDS helpdesk at 1-866-236-6297.

Service (Activity) Codes

Service (Activity) Codes will be used to track the activities the EARN client is engaged in at any specific time. The EARN service provider will data enter the Service (Activity) Codes in CWDS. Multiple Service (Activity) Codes can be entered at the same time; however, the Service (Activity) Codes in CWDS and the service (activities) listed on the Service Plan must agree.

The EARN service provider must enter participation hours after the client actually attends the service or activity.

Below are Service (Activity) Codes that may be used with EARN.

TANF clients CORE:

Code 6 – Providing child care for a community service participant Code 18 – General Equivalency Diploma(GED)/High School - Preparation for GED (ONLY IF

CLIENT IS UNDER AGE 22) Code 20 – Community Service Code 22 - On the Job Training Code 23 – Subsidized Employment Code 24 – Vocational Education Code 26 – Paid Work Experience Code 33 – Unsubsidized Employment Code 42 – Job Search/Prep Training and ongoing job search Code 49 – Rehabilitative Services Code 51 – Vocation –specific Work Experience (VWE) NON-CORE: Code 11 – English as a Second Language (ESL) Code 12 – Adult Basic Education/Literacy (ABE) Code 34 - Non-Core Voc education- for a client without a high school diploma or GED Code 35 - Non-Core Voc education- for a client with a high school diploma or GED Code 38 - Job Skills Training Directly Related to Employment

NOTE: For additional information on Service (Activity) Codes and their definitions, please refer to Attachment B.

NOTE: Specific forms need to be completed by the client and community service site

when a client is participating in community service (Attachments C, D, E). The number of hours that a client may participate in community service is listed on his or her AMR.

NOTE: When clients participate in a location other than the EARN center the EARN

service provider is to collect documentation from a 3rd party describing or

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documenting activities the client participated in. For clients participating in activities at the EARN center they must complete and have signed the EARN attendance sheet.

NOTE: Employment hours must be verified through paystubs, documentation from the

employer, DHS approved EVF or the Work Number (or similar service). Documentation must include at least monthly income verification to determine if the client met the performance standards for placement and retention. Hours entered must be verified and cannot be projected based on a single pay stub.

NOTE: Vocational Education is time limited to 12 months in a lifetime. The Vocational

Education time limit includes time spent in activity codes 14, 15, 16, and 24. NOTE: Vocational Education activities that are conducted in-house must be

accompanied by a curriculum that has been submitted to and accepted by the Bureau of Policy (BOP) prior to implementation. If changes are made to the approved curriculum, the updated curriculum must be re-submitted for endorsement to BOP 10 days prior to implementation. Curriculums should be submitted to the Resource Account, RA-BOPEARNPOLICY@PA.GOV.

Excused Absences Clients engaged in unpaid work activities may be given participation credit for excused absences. A client may receive excused absence credit for up to 16 hours in a calendar month and no more than 80 hours of excused absences within a 12-month period, excluding DHS recognized holidays. For a client to receive credit for excused time they must have been scheduled to participate on that day. When available, the EARN service provider is to collect documentation from a 3rd party describing or documenting the reason for the absence. If 3rd party verification is not available for a particular absence the EARN is to document the reason for the use of excused time in the case narrative and list the time as excused on the EARN attendance sheet.

Clients can be excused from participation for the following reasons:

Medical appointments for the client or dependents

CAO appointments

WIC appointments

Legal appointments

School appointments including school events

Counseling appointments

Housing appointments

Obtaining child care

Child support appointments

Obtaining birth certificates

Obtaining documents needed for eligibility for DHS programs

Obtaining transportation

Other appointments deemed necessary by the contractor

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Holidays

Clients receive credit for participation on the following days recognized by DHS as holidays: New Year’s Day, Martin Luther King, Jr. Day, Presidents’ Day, Memorial Day, Independence Day, Labor Day, Columbus Day, Veterans Day, Thanksgiving Day and Christmas Day. For a client to receive credit for a holiday they must have been scheduled to participate on that day.

EARN Case Record Requirements

The EARN service provider will create a confidential EARN Case Record. The EARN Case Record must be kept in a secure location with limited accessibility. Staff not associated with the EARN case may not have access to the EARN Case Record or narrative. The EARN service provider will document the following in the EARN Case Record narrative:

Date, time, and location of all EARN related contacts;

Purpose and outcome of all EARN related contacts;

Any changes in the client’s conditions or circumstances;

Solutions offered and the client’s responses;

Services and supports requested or provided

Any other relevant information.

NOTE: The EARN service providers are encouraged to document their narratives using the CWDS Create Case Progress Notes screen.

The following documents should be maintained in the client’s file and must be available for upload on Docushare for validation purposes.

AMR

Service Plan

Attendance Sheets

Release of Information Form

Employment Verification Form (EVF)

Verification of Retention

Other Relevant Information

All documentation with the client’s signature must be kept in paper format.

Service (Activity) Closing Codes The EARN service provider is required to data enter an appropriate Service (Activity) Closing Code when ending the client’s participation in a service (activity).

The code used to terminate will indicate the completion of the service (activity) and must be entered before terminating the project on CWDS.

NOTE: All services (activities) and sub-projects must be end-dated before a termination

code can be data entered on the Edit Participant Case Details Screen to end the client’s project enrollment.

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Service (Activity) Closing Code 1 – Not Completed

Service (Activity) Closing Code 9 – Complete

Project Termination Codes

Project termination codes primarily reflect whether or not the client secured employment. The EARN service provider must include the reason for termination in the narrative of the client’s case record.

Termination codes may not be dated more than three days prior to the date that the information was entered into CWDS.

The termination codes available to EARN are:

Code Description 1 Employment of 20 hrs/wk or greater (part-time)

3 Withdraws or terminates without Good Cause 5 Completion of planned AMR activities - no employment 7 Other 8 Employment of 30 or more hrs/wk (full-time)

NOTE: If a client has 3 consecutive days of unexcused absence they are to be termed from the service provider.

NOTE: If a client does not participate for all of their required hours during a month they

are to be termed within 3 working days of the end of the month. NOTE: If the above listed circumstances occur, a client may be retained in the program

if the CAO agrees that good cause would be granted and the client would benefit from remaining in the program.

Confidentiality

All clients must be assured that the personal data they provide will be confidential.

The EARN service provider will keep client information obtained from the client or other sources confidential. It will only be released upon the client’s written approval, obtained on DHS approved Authorization for Release of Information Forms (Attachment F), and only for the purpose specified by the client.

To comply with the Health Insurance Portability and Accountability Act (HIPAA), the privacy regulations at 45 CFR, Sections 160-504 and 164.530 indicate that all Personal Health Information should be retained for a period of 7 years. All EARN information should be kept for a period of 7 years, after which the information should be shredded.

Limited English Proficiency (LEP)

Each EARN service provider will provide or arrange for the provision of adequate interpretive services for all EARN services and activities.

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Service Provider Performance Requirements

There are performance standards that will be used to assess the effectiveness of the service provider. The following chart outlines the goals that need to be obtained by the EARN service provider.

Performance Standards

Performance Goal

Definition GOAL Percentage of Payment

Placement Clients must attain Unsubsidized Employment (AC 33), working a minimum of 80 hours in a four consecutive week period. The four week period must begin

within the 180 days of the enrollment date.

50% of clients

enrolled

45%

Retention After a Client meets the Placement Goal the client must retain Unsubsidized Employment (AC 33) of at least 80 hours in any given calendar month for up to

6 months following the placement month. A client may meet the retention goal up to six times in the six months immediately following the placement

month. A client may not have hours counted in the same calendar month for both placement and retention.

30% of clients

enrolled

45%

Activity Compliance Rate (ACR)

Clients enrolled must be in a core activity that meets their Work Participation Requirements as validated using the ACR reports.

65% of clients

enrolled

10%

The Job Placement, Job Retention, and ACR performance standards will be calculated from reports generated by CWDS and will be verified for accuracy by DHS. All three performance standards will be paid based on a per individual basis. For each client meeting the standard listed above the grantee will be eligible, upon verification and available budget, for a payment based on the client meeting that particular goal. DHS requires that any and all performance funds awarded to EARN providers must be reinvested into the EARN program. EARN service providers that do not meet minimum outcomes and expectations will be asked to submit a corrective action plan addressing the deficiencies within 15 days of notification of the deficiencies. Regular progress reports on actions to correct the deficiencies will also be required.

EARN service providers that have multiple areas of deficiencies or those who do not show progress as a result of the corrective action plans are at risk of being placed in remediation status. Service providers in remediation status will have additional expectations for corrections. These include participation in meetings to plan and review progress, reduction of funding or funding termination.

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Client Incentives Client Incentives are positive reinforcements to promote client participation. The EARN service provider must maintain a list of all incentives issued that includes at a minimum the following information; amount and type of incentive issued, name of individual receiving incentive, date issued and reason for issuance of incentive.

Supportive Services EARN service providers will not issue special allowances to clients. Clients may continue to be eligible for CAO issued special allowances.

Local Management Committee (LMC) Meetings The frequency of the meetings is to be determined locally. However, service providers must

cooperate with their local partners. All local E&T program providers should be encouraged to attend as this meeting is responsible for the coordination of operations and services provided in the local areas to welfare recipients.

Direct Service Team (DST) Meetings The frequency of the meetings is to be determined locally. However, service providers must

cooperate with their local partners. Monitoring

DHS will monitor the EARN service providers, including and not limited to review of data systems, as well as site visits to review program compliance. DHS will also conduct training and information sessions with the service providers.

Questions regarding EARN program policy should be addressed to the Bureau of Policy at RA-BOPEARNPOLICY@PA.GOV Questions regarding EARN program validation requirements should be addressed to the Bureau of Program Evaluation at RA-BPE-DPI@PA.GOV.

EARN PROGRAM ATTENDANCE SHEET

SERVICE PROVIDER NAME

CLIENT NAME

WEEK ENDING

ACTIVITY (Name and CWDS Code) Sun Mon Tues Wed Thurs Fri Sat TOTAL HOURS

TOTAL HOURS

Client Signature Date

Staff Signature Date

ATTACHMENT A

TOTAL ACTIVITY HOURS

_____/______/______

ATTACHMENT B PY 14-15

Definition of EARN Services (Activities)

TANF Activity Code 6- Caring for a community service participant’s child The hours a TANF client spends caring for a child of another TANF client who is participating in a community service. AC 6 is a core-activity for TANF. Activity Code 11- English as a Second Language (ESL) ESL is part of a training plan specifically designed to improve the individual's English language proficiency needed to compete successfully in the current job market. The ESL curriculum focuses on vocabulary and reading assignments which relate to the participant's current plan for obtaining employment. AC 11 is non- core activity for TANF Activity Code 12 - Adult Basic Education (ABE) ABE is designed to increase literacy and computational levels consistent with employment goals. The educational activity must be embedded with other skills training activities that have been determined necessary in order to meet the goals set on the participant's EDP. AC 11 is non- core activity for TANF Activity Code 18 – Satisfactory Attendance in High School/GED Educational activity offered by an accredited high school or GED provider. AC – 18 is only a core activity for TANF clients under age 22 Activity Code 20 – Community Service Community service is a beneficial activity available for clients who have a negligible work history, or who live in communities where there is minimal employment. Community Service must be unpaid work for the federal, state or local government, or a non-profit organization to increase skills and attain an employment history including AmeriCorp Vista Volunteer Community Service. CAO Caseworker is to note the number of hours on the client’s AMR. AC 20 is a core activity for TANF. Activity Code 22 – On the Job Training On the Job Training provides public or private section employers with a wage subsidy for a negotiated period of time. On the Job Training programs require the employer to provide specialized training to the participant. In order to use subsidized employment as an activity, programs must enter into a written agreement with the employer. AC 22 is a core activity for TANF

Activity Code 23 - Subsidized Employment Subsidized employment provides public or private section employers with a wage subsidy for a negotiated period of time. Subsidized employment programs do not require the employer to provide special training to the participant other than that which any other employees in the same position should receive. In order to use subsidized employment as an activity, programs must enter into a written agreement with the employer. AC 23 is a core activity for TANF

ATTACHMENT B PY 14-15

Activity Code 24 – Vocational Education Skill/vocational training is a time limited TANF activity. Clients are limited to 12 months in a lifetime. Vocational Education provides training in specific occupational skills needed in the current job market. AC 24 is a core activity for TANF clients.

Activity Code 26 - Paid Work Experience (PWE) PWE is an opportunity for clients’ to enhance workplace skills and employability. PWE is subsidized employment. Current DPW regulations allow this activity for a maximum of six months in an individual’s lifetime with the following exceptions. PWE may be extended if an individual has a disability covered under the provisions of the ADA or if an individual has to withdraw from PWE for good cause such as injury. AC 26 is a core-activity for TANF Activity Code 31- Work Study Work Study is employment at the community college that is subsidized by funds from a federal or state work study program. Work study normally combines an academic program with paid employment in which a student gains practical experience in the workplace. Income received from work study is exempt from the client’s TANF computation and does not have a financial effect on the amount of the family’s TANF grant. AC 31 is a core-activity for TANF Activity Code 33- Unsubsidized Employment Unsubsidized employment is full or part-time employment, including self-employment, in which neither the employer nor employee receives a subsidy from TANF or other public funds. The program must document the job start by obtaining a copy of a pay stub or on a letter from the employer on company stationery. AC 33 is a core-activity for TANF. Activity Code 34 – Vocational Education This code is for clients without a high school diploma or GED. Vocational Education provides training in specific occupational skills needed in the current job market. AC 34 is a non –core activity for TANF clients. Activity Code 35 – Vocational Education This code is for clients with a high school diploma or GED. Vocational Education provides training in specific occupational skills needed in the current job market. AC 35 is a non –core activity for TANF clients. Activity Code 38- Job Skills Training Directly Related to Employment Job skills training directly related to employment is formal training provided by a contracted employment and training vendor, that is specifically designed to improve an individual’s skills on the job, and may include continuing education or job skills courses. AC 38 is non –core activity for TANF Activity Code 42 – Job Search Job search is an activity that consists of seeking full-time or part-time employment that is combined with organized training that prepares an individual for the workplace. TANF

ATTACHMENT B PY 14-15

clients cannot participate in job search for more than four consecutive weeks. After a four-week consecutive period of job search, the client must be enrolled in another activity for at least a week. Clients may also not participate in job search for more than 12 weeks in a rolling 12 month period. . For the 12 week limit, one week of job search is defined as 20 hours for a work-eligible single custodial parent with a child less than six years of age for a total limit of 240 hours. One week of job search for all other work-eligible individuals is defined as 30 hours for a total limit of 360 hours. AC 42 is a core activity for TANF. Activity Code 49 – Rehabilitative Services Rehabilitative Services include family violence counseling, Office of Children Youth and Families (OCYF) specified family services plan, substance abuse treatment, mental health counseling and any other type of rehabilitative activity. Physical rehabilitation treatment is excluded from this activity. Rehabilitative services must be determined necessary and documented by a qualified medical, substance abuse or mental health professional. TANF students are allowed to participate for up to 12 weeks total or the combination of 6 weeks in Job Search (42) and 6 weeks in Rehabilitative Services. TANF students can participate up to 240 hours in a rolling 12-month period. AC 49 is a core activity for TANF Activity Code 51 – Vocation-Specific Work Experience (VWE) VWE is DPW-funded work experience, which is directly related to an individual’s field of study during their enrollment in vocational or post-secondary education. As in many adult education models, it is important that classroom theories are applied in a “real life” environment to ensure that students can more readily connect theory and practice, which results in helping them become more employable. VWE is intended to offer the individual the opportunity to apply their current course of vocational or post-secondary education in a vocation-specific work setting. AC 51 is a core activity for TANF

Community Service Calculation Desk Guide

Community Service (CS) is a beneficial activity available for individuals who have a minimal work history or who live in communities with limited employment. CS allows individuals who receive Temporary Assistance for Needy Families (TANF) the opportunity to work in their community, and gain valuable work experience. The CAO calculates the number of weekly hours an individual may participate in CS with consideration the Fair Labor Standards Act which takes into account the amount of the TANF grant, plus the amount of the SNAP grant (pure households only), less any child support that is collected by DPW. The weekly hours must be listed on the Agreement of Mutual Responsibility (AMR). A Community Service Agency Agreement (PA 1694) conveys the maximum number of weekly hours of participation. Upon agreement by the agency and the client, this form is returned to the County Assistance Office (CAO) to identify the location of the CS site and describe the job duties. When CS begins, a Community Service Weekly Participation Report (PA 590) must be signed by the CS agency representative and client and conveyed to the CAO on a weekly basis to validate participation. This form is due to the CAO no later than the Friday following the week-end date. Definition and application of a pure household:

A pure TANF/SNAP household exists when all members who receive SNAP also receive TANF benefits.

CS participants who are part of a pure TANF/SNAP household have the benefit of deeming, which can increase the calculated CS hours to equal 20, when the CS calculation results are less than 20 hours per week and the client participates in CS for the maximum number of hours.

Two (2)-parent family: In a pure TANF/SNAP household which does not receive federally funded child care, a 2-parent family can have hours deemed to = 30 hours per week and when a 2-parent family does receive child care, and both parents participate, the hours can be deemed to 50 hours per week if one or both parents participate in CS for the total maximum number of CS hours for the household.

NOTE: The SNAP grant is only added to the CS computation if the individual is part of a pure TANF/SNAP Household. STEP 1 Identifying Monthly Benefits

A. Amount of the monthly TANF cash assistance grant = ______________ B. Amount of the monthly SNAP grant (FOR PURE HOUSEHOLDS ONLY) = ______________ C. Total Monthly Benefit (A + B = C) ______________

STEP 2 Calculating the Net Monthly Benefit

C. Total Monthly Benefit ______________ D. Monthly child support collected by the DPW, including ‘support pass through’ ______________ E. Total Net Monthly Benefit (C – D = E) ______________

STEP 3 Calculating weekly hours of participation:

E. Total Net Monthly Benefit _____________ F. Minimum Wage _____________ G. Maximum number of monthly CS hours (E divided by F = G) _____________ H. Maximum number of weekly CS hours (G divided by 4 = H) _____________ NOTE: Fractions should be rounded down to the next whole number

PA 1694 3/12

COMMUNITY SERVICE AGENCY AGREEMENT

Participant’s Name: Maximum Weekly Hours County: Record Number:

Participant’s Address: Telephone Number:

County Assistance Office Address: County Assistance Office Fax:

Community Service Agency Name: Telephone Number:

Name and title of individual who will supervise the community service participant: Employer Identification Number

This agency is: □ Federal, State or Local Government □ Non-profit

501c(3) Number:

Describe the job duties of this community service position:

This position is available for _______________ hours per week beginning ________________________

By signing this form, this agency representative assures that the community service organization is meeting all applicable federal, state and local laws. In addition, the agency will:

• provide the community service participant with the opportunity for work experience which will help the participant prepare for the workforce, which includes but is not limited to:

1. instruction and/or training necessary to be able to perform the work indicated above, 2. on-site supervision;

• ensure that the individual does not exceed the maximum weekly hours which are indicated on this form and are determined by the county assistance office based on the Fair Labor Standards Act;

• validate weekly hours of participation to the county assistance office by fax and to the participant on a community service weekly participation report (PA 590).

Authorized Agency Representative Signature and Title Date

PA 590 1/12

COMMUNITY SERVICE WEEKLY PARTICIPATION REPORT

WEEK BEGIN DATE (SUNDAY) WEEK END DATE (SATURDAY) DUE DATE*

*DueatcountyassistanceofficenolaterthanFridayfollowingthe“WeekEndDate”

COMMUNITY SERVICE AGENCYAGENCYNAME PHONENUMBER FAXNUMBER

ADDRESS

COUNTY ASSISTANCE OFFICECOUNTY DISTRICT CO RECORDNUMBER

ADDRESS

ATTENTION PHONENUMBER FAX

COMMUNITY SERVICE PARTICIPANT IDENTIFICATIONPARTICIPANT’SNAME PHONENUMBER MAXIMUMWEEKLYHOURS

DAILY HOURS WORKED

SUN MON TUES WED THUR FRI SATTOTAL

WEEKLYHOURS

Thesesignaturescertifythattheinformationprovidedaboveisaccurate.

Participant Date

( ) -SupervisororAuthorizedAgencyRepresentative Date TelephoneNumber

TheCAOmustvalidate“DailyHoursWorked”andsignthisformonlyifthesignatureoftheAgencyRepresentativeisunattainablebythe“DueDate”.

CAORepresentativeSignature Date

FAILURE TO COOPERATE - The community service agency should complete and fax/mail this form to the county assistance office immediately.

DIDNOT REPORTFORASSIGNMENT

TERMINATED OTHER(EXPLAIN)

AuthorizedAgencyRepresentativeSignatureandTitle TelephoneNumber Date

Attachment F

Employment Advancement and Retention Network (EARN)

Authorization for Release of Information

I hereby authorize and request the disclosure to the EARN service provider any information

concerning education and training activities and any additional information involving eligibility

for myself. As a client in EARN, I give permission to the EARN service provider to discuss my

case with other agencies as needed to further my participation in EARN. It is understood that

the information obtained will be used only for purposes directly related to the participation and

eligibility with the EARN service provider.

Staff Signature: Date:

Client Signature: Date

EMPLOYMENT VERIFICATION FORM

Employment and Training Provider Employer Name: __________________________________ Name: ________________________________ Address: _______________________________ Address: ______________________________ _______________________________ ______________________________ Fax: ____________________________________ Phone: ________________________________ By signing this Employment Verification Form, I permit __provider name__ to obtain the employment data requested below, not to exceed a period of six (6) months following the date of my signature. Thank you for your cooperation.

________________________________________ _______________ EMPLOYEE SIGNATURE DATE

THIS SECTION TO BE COMPLETED BY THE EMPLOYMENT AND TRAINING PROVIDER

_________________________________________________________ ________ ______-_____-__________ SIGNATURE OF STAFF WHO OBTAINED INFORMATION BY PHONE DATE TELEPHONE NUMBER ________________________________________________________ __________ SUPERVISOR/PROGRAM COORDINATOR SIGNATURE DATE

THIS SECTION TO BE COMPLETED BY THE EMPLOYER 1. Employee Name*:

2. Social Security Number: XXX-XX-____________

3. Occupation:

4. First Day Worked*: _____/______/_____

5. Scheduled Weekly Hours (avoid ranges): _____per week

6. Frequency of Pay: ____ Weekly ____ Bi-weekly ____ Monthly ____ Other

7. Date of First Pay: ______/______/______

8. Hourly Wage: $_________ per hour

9a. Do you offer health insurance benefits for this Employee within six months of start date?* Yes _____ No ______

9b. Health Insurance Provider*: 9c. Premium: _____Full ____ Partial

11. Is individual still employed? Yes ____ No ____

12. If no longer employed, last day on job*: ___/___/___

13. Reason for leaving:

14. Date of Last Pay:___/___/___ Gross Amount: $______________

THIS SECTION TO BE COMPLETED BY THE EMPLOYER TO VERIFY HOURS If pay stubs are not issued, available or do not identify the name of the employee, name of the employer, pay period covered, number of hours worked

and rate of pay this section must be completed.

Please detail hours worked and gross pay: (Write N/A if employee did not work that week) Week Ending (Saturday End Date): Hours Worked: Gross pay: W/E: ______/______/___________ ____________ $______________ W/E: ______/______/___________ ____________ $______________ W/E: ______/______/___________ ____________ $______________ W/E: ______/______/___________ ____________ $______________ W/E: ______/______/___________ ____________ $______________ _________________________________ __________________ _________ PRINT NAME OF EMPLOYER STAFF* TITLE* DATE _______-________-_________________ ________________________ TELEPHONE NUMBER* E-MAIL ADDRESS All fields marked by an asterisk must be completed, including #12 if applicable.

EARN ATTACHMENT H PY 15-16

Department of Human Services

2nd Floor West Health and Welfare Building | Harrisburg, PA 17105 | 717.705.7714 | F 717.787.1302 | www.dpw.state.pa.us

Revised 05-21-15

Date: July 1, 2015

Subject: Bureau of Program Evaluation (BPE) Required Performance Documentation for Validation Reviews of Placement and Retention benchmarks

To: EARN Providers FROM: Crystal Taylor, Director Division of Program Implementation Bureau of Program Evaluation The Bureau of Program Evaluation (BPE) is responsible for monitoring all DPW/OIM employment and training programs to ensure compliance with applicable federal, state, and DPW regulations, as well as contract provisions. As part of the monitoring process, BPE will be completing monthly payment validation reviews for contracted providers currently administering the EARN program. The purpose of the reviews is to validate placement and retention payments made to your organization, verify compliance with your organization’s contractual obligations, and ensure that quality service is being provided to program participants. Reviews will be conducted for all participants for whom payment was issued. The following payment documentation must be provided & will be reviewed for placement:

Verification that client: was employed within 180 days of enrollment, worked 80 hours within a 4 consecutive week period that began within 180 days of enrollment, continued employment if they did not work or documentation is not provided for the 4th consecutive week:

Pay-stubs / Wage Documentation; The initial pay statement beginning the 4 consecutive weeks of employment

(not necessarily the 1st pay stub) The pay statement for the 4th consecutive week of employment, provided the

initial paystub and the last paystub contain the appropriate hour and /or wage year-to-date information to determine the hours worked for the undocumented weeks. If paystubs do not contain this information, all pay stubs must be submitted.

Or Or all pay statement documentation for the entire four week period.

EVF or Letter from Employer; Work Number Screen Prints

Commonwealth Workforce Development System (CWDS) Error Screens (if applicable); and

EARN ATTACHMENT H PY 15-16

Department of Human Services

2nd Floor West Health and Welfare Building | Harrisburg, PA 17105 | 717.705.7714 | F 717.787.1302 | www.dpw.state.pa.us

Revised 05-21-15

CWDS Hotline Ticket # Documentation (if applicable).

The following payment documentation must be provided & will be reviewed for retention: Pay-stubs / Wage Documentation;

The Initial pay statement documentation for the placement month (if this is already uploaded on Docushare, it is unnecessary to upload every month).

Last pay statement of each month of the claimed retention period provided the initial paystub and the last paystub contain the appropriate hour and /or wage year-to-date information to determine the hours worked for the undocumented weeks. If paystubs do not contain this information, all pay stubs must be submitted.

EVF or Letter from Employer; Work Number Screen Prints

Each job obtained during the retention period must have an EVF submitted Each pay stub submitted must clearly illustrate :

1. Program participant name 2. Pay Period end dates. 3. Hours worked or Year to Date (YTD) amounts hours /wages.

Note: In the absence of pay stub information, providers are permitted to submit the state standard EVF that illustrates the hours and wages achieved each week. The EVF would additionally need to be completed and signed by the employer or if completed by provider staff, employer contact name and number as well as individual staff name and number obtaining the information.

To obtain the listing of sample cases meeting the performance payment benchmarks, providers must review the Sample Database.

Log on to DocuShare using the following link:

https://www.dpwds.state.pa.us/docushare/dsweb/View/Collection-84391

Please note this may not be the same link you use to log on for your normal vendor DocuShare folder.

This link should take you to the “~Sample Database – EARN & Work Ready” DocuShare folder.

Payment documentation for all sample database performance cases must be provided via DocuShare. Payment documentation must be uploaded to DocuShare within the established time frames set by BPE.

Thank you for your time and cooperation, if you have any questions or concerns about the Required

Performance Documentation for Validation Reviews of Placement and Retention benchmarks, please

contact Kerry Bacon at (717) 787-1699, email kbacon@pa.gov or Tom Ritko at (717)787-9011

tritko@pa.gov