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NC Innovations Individual/Family Directed Supports

Employer of Record Handbook Supplement Revised July 1, 2014

Cardinal Innovations Healthcare Solutions

NC Innovations Health Plan 1915 (b)/(c) NC Innovations Waiver 1915 (c)

Individual and Family Directed Supports Option: Employer of Record Model

NC Innovations Individual/Family Directed Supports Revised 7/1/2014 Cardinal Innovations Employer of Record Handbook

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Table of Contents 1. Getting Started in the Employer of Record Model Page 5 2. Preparing to Hire Employees Page 9 3. Screening and Interviewing Applicants Page 12 4. Reference and Background Checks Page 14 5. Completing the Hiring Process Page 17 6. Training Employees Page 19 7. Implementing Services and Managing Employees Page 21 8. Risk and Emergency Planning Page 28 9. Managing the Individual and Family Directed Services Budget 0

10. Service Documentation Page 33 12. Quality Assurance in the Employer of Record Model Page 38 Appendix A: Materials in the Employer of Record Notebook Page 41 Appendix B: Materials for Individual/Family Direction: Employer of Record Box Page 42 Appendix C: Employee Qualifications and Training Checklist Page 44 Appendix D: Documentation Forms Page 46 Appendix E: Back-Up Staffing Incident Reporting Form Page 50 Appendix F: Employer of Record Expenditure Coverage Chart Page 52 Appendix G: Employer of Record Bonus Report Page 56 Appendix H Employer of Record Checklist for Individual/Family Supports Page 58 Appendix I Release of Information to Cardinal Innovations Page 60 Appendix J Employment of Relative/Legal Guardian Page 61 Appendix K Request for Out of State Travel Page 63


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Appendix L Health/Safety Justification for Personal Care or Respite in Provider’s Home Page 64 Appendix M Staff Competencies Page 66 Appendix N Workers’ Compensation Information Page 68 Appendix O Employer of Record Task List Page 69 Appendix P Job Application for Prospective Employers Page 71 Appendix Q Employee Support Agreement Page 73 Appendix R Incident Reporting Page 77 Appendix S Documentation Task Lists for Employers of Record Page 84


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1. Getting Started in the Employer of Record Model The Employer of Record is the individual that is recorded by and registered with federal and state government agencies as the employer for legal purposes. The information in this Chapter describes how the Employer of Record prepares to self-direct services. Review of Initial Steps Prior to Employer of Record Model Approval Prior to approval by Utilization Management, the Employer of Record has:

Completed the Orientation to Individual/Family Supports

Attended Introductory Training on Individual and Family Directed Supports provided by a Community Guide

Completed the Employer of Record Assessment with the Care Coordinator

Appointed a representative if one is mandated (required) or desired. The representative must have completed the same Introductory Training as the Employer of Record

Chosen a Model of Individual and Family Directed Supports (Employer of Record)

Completed the Employer of Record Agreement with the Care Coordinator. If the employer has appointed a representative, the agreement indicates the duties the representative will perform on behalf of the employer.

Worked with the Care Coordinator to update the Individual Support Plan to include the Employer of Record Model, including adding Financial Support Services and Community Guide Services needed for start-up of the Employer of Record Model

Upon approval by Utilization Management, the Employer of Record receives notice of Individual Support Plan Approval from the Care Coordinator.

Representative Role If an employer has appointed a representative, the Individual/Family Agreement defines the functions that the representative may perform on behalf of the Employer of Record. The Care Coordinator is informed if the Employer of Record needs to appoint a different representative, remove a representative, or change the function of the representative. The Employer of Record requests that the Care Coordinator provide a copy of the Representative Appointment and Employer of Record Agreement to the Financial Support Agency and the Community Guide Agency.

Information that the Employer of Record Should Have When Starting to Self-Direct Services The Employer of Record should have the following information at the time they are approved to begin self-directing services:

Orientation Booklet (provided by Care Coordinator)

Orientation Fact Sheets (provided by Care Coordinator)

NC Innovations Individual/Family Guide (provided by Access or Care Coordinator)

Employer Handbook (provided by Community Guide)

Copies of Training Power Point Slide (provided by Community Guide)

Copy of the Training Certificate (provided by Community Guide)

Copy of Employer of Record Assessment (provided by Care Coordinator)

Copy of Employer of Record Agreement (provided by Care Coordinator)

Copies of Representative Appointment Forms, if a representative has been appointed (provided by Care Coordinator)


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Copies of Service Definitions with Qualifications of NC Innovations Services the Employer of Record is self-directing (provided by Care Coordinator)

Copies of the approved Individual Support Plan and Budget (provided by Care Coordinator)

Auto-Calculator (provided by the Community Guide; Community Guide obtains from Financial Support Services Provider)

If the Employer of Record needs one of these documents, the employer should ask the Care Coordinator or Community Guide for a copy of the document. Meeting with Community Guide after Utilization Management Approval When an employer is approved for participation in the Employer of Record Model, the Community Guide contacts the Employer of Record to set up an initial meeting. The meeting is typically held in the home of the individual participating in NC Innovations but can be held at another location, depending on the needs and preferences of the Employer of Record. The meeting is held at a time that is convenient for the Employer of Record. At the meeting, the Community Guide:

Explains the start-up process for the Employer of Record Model

Provides the Employer of Record with the Employer of Record Handbook Supplement

Provides the Employer of Record Training Notebook to the Employer.

Provides the Employer of Record Lock Box, including forms needed by the Employer

Explains that additional forms may be obtained from the Community Guide

Inquires if the Employer of Record has received a start-up letter from the Financial Support Agency that includes a form to complete and return to the agency. If this form has not been received by the Employer of Record, the Community Guide follows up with the Care Coordinator or Financial Support Agency to make sure that the form has been mailed to the Employer of Record.

Assists the Employer of Record in completing the form with start-up information needed by the Financial Support Agency.

Assists the Employer of Record in determining the number of Direct Service Professionals (also known as employees, workers) to be hired by the employer. This information is needed in preparation for start-up meeting with Financial Support Agency. With several employees, there are more choices in scheduling and more options for back up in emergencies. Changing employees is easier with several employees.

Assists the Employer of Record in completing a draft of the Auto Calculator used to determine potential employee wages, benefits and funds available for other expenditures in preparation for the start-up meeting with Financial Support Agency. Additional information about the Auto-Calculator is located in Chapter 9.

The Care Coordinator also develops/reviews short-range goals developed to address Community Guide long-range outcomes in the Individual Support Plan. The Employer of Record signs these goals.

Appendix A of this supplement lists the Contents of the Training Notebook. Appendix B lists the Contents of the Lock Box. Employers may reorganize the information if they so desire. Initial Meeting with Financial Support Services Agency Field Representative The Financial Support Agency sends a letter to the Employer of Record once the agency has received an authorization to provide Financial Support Services on behalf of the NC Innovations participant. This authorization is sent electronically to the agency when the Individual Support Plan is approved.


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The letter includes a form for the Employer of Record to complete and return to the Financial Support Agency. The form contains basic information that the Financial Support Agency needs to pre-fill forms that the Employer of Record will sign at the Initial Meeting with a Field Representative. By having the Field Representative pre-populate the forms with this information, the meeting can be conducted in a shorter amount of time and the documents are readable with the correct information. One important item is Previous EIN. If the employer has ever had an Employee Identification Number (EIN), it is important that this information be provided to enable the Financial Support Agency to accurately complete the work they will do on the employer’s behalf. Also included with the letter will be an information release for the Financial Support Agency to communicate with the individual’s Community Guide. When the completed form is returned by the Employer of Record, the Field Service Representative contacts the Employer of Record to set up the Initial Meeting. This is also known as the Kick off Meeting. The Community Guide is also invited to attend the meeting. The meeting is usually held in the home of the Employer of Record. The purpose of the meeting is to explain how the Financial Support Agency will provide services on behalf of the Employer of Record. In addition important paperwork is completed at the meeting. The paper-work completed and signed at the Financial Support Start-Up Meeting allows the state and federal government to keep track of whether laws are being followed and that employment taxes are paid correctly. This includes information needed to obtain an Employer Identification Number (EIN) on behalf of the Employer of Record, information needed to obtain Workers’ Compensation Insurance on behalf of the Employer of Record, and completion of the Financial Support Agreement with the Financial Support Agency. The Field Representative provides information and materials that the Employer of Record will find helpful in hiring employees, completing employee payroll reports and service billing. The process for hiring an employee is also reviewed, including the Background Check Authorization Form and Sample Employee Packet. The Final Version of the Auto-Calculator is completed at the meeting. The Employer of Record signs a printed copy of the Auto-Calculator and gives it to the Field Representative. If the employer or Community Guide do not have access to a printer, the Community Guide arranges for a copy of the Auto-Calculator to be printed, signed by the Employer of Record, and returned to the Financial Support Agency after the meeting. While the Auto-Calculator can be updated (changed) at any time, it is important that it be kept current and that a copy of the most recently completed Auto-Calculator be sent to the Financial Support Agency. The Community Guide also sends a copy of completed Auto-Calculators to the Cardinal Innovations Finance Department. The Field Representative answers any questions that the Employer of Record may have about the forms being signed. Information is provided at that meeting about how to contact the Financial Support Agency if the Employer of Record has additional questions. Copies or originals of documents are available by request to a Financial Support Services Customer Service Representative once everything has been processed. The Financial Support Agency determines which documents are returned as originals or copies, based on the content and purpose of the document.

Reminder: Employer Identification Numbers (EIN) Employer Identification Numbers are requested in the name of the Employer of Record. Employer Identification Numbers are not requested in trade or business names. If the Employer of Record has previously had an Employer Identification Number in a trade or business

name, the Financial Support Agency will work with the appropriate agency to change the name on the Employer Identification Number to the Employer of Record’s name.

Post Financial Support Agency Start-Up Meeting Activities After the Start-Up Meeting, the Financial Support Agency completes a number of tasks on behalf of the Employer of Record. This includes obtaining the Employer Identification Number (EIN) and Workers’ Compensation Insurance on


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behalf of the Employer of Record. The Financial Support Agency notifies the employer of the receipt of the EIN, and sends a copy of the Workers’ Compensation Insurance Policy with the effective date of the Policy. While the Employer of Record is free to interview prospective employees at any point, no job can be offered to a prospective employee until the Financial Support Agency confirms that Workers’ Compensation Insurance has been obtained and a criminal background check is obtained by the Financial Support Agency on the prospective employee. Criminal background checks will not be completed prior to the effective date of the Workers’ Compensation Insurance Policy.

Reminder: Individual and Family Directed Services, the Financial Support Agency and Personal Income Taxes

The Financial Support Agency does not advise Employers of Record or assist in any way with the Employer’s personal income taxes.

Employers of Record should consult an accountant or tax advisor for information related to personal taxes.

Ordering Employer of Record Supplies Employer of Record supplies are requested through the Financial Support Agency by using the Financial Support Request Form. The Community Guide assists the Employer of Record in completing the form and updating the Auto-Calculator as needed. Initially the Employer of Record requests/receives Start-Up Supplies. These are:

1 Box of Gloves

1 CPR Mask

1 First Aid Kit The type of gloves, mask and kit the Employer of Record receives is standardized, as recommended by the Financial Support Agency and approved by Cardinal Innovations Healthcare Solutions. These items are paid out of the Individual Budget, and the Care Coordinator includes them in the Individual Support Plan and Individual Budget. If an Employer of Record wants a different type of gloves, mask and/or First Aid Kit or additional supplies, the employer budgets these items in the Auto-Calculator and indicates the request in the Auto-Calculator Section of the Request Form. For employee training or items included in the Auto-Calculator Section of the form, the Employer of Record completes the Vendor Section of the form. Additional purchasing information may be included by attaching copies of pages from a catalog or narrative information on additional pages. The Form is signed and dated. The Request Form is mailed, faxed or attached to an e-mail and sent to the Financial Support Agency. Once the Employer of Record receives an item, the packing invoice is mailed, faxed or attached to an e-mail and sent to GT Financial. It is very important that this be done so the vendor can be paid. If the item requested is included in the Individual Budget, the authorized Cardinal Innovations Financial Support Services Code is billed to Cardinal Innovations by the Financial Support Agency. If the item is included in the Service Rate Section of the Auto-Calculator, the item is paid out of the Individual and Family Directed Budget (Individual and Family Directed Services provided and billed). (See Appendix F for further detail of Employer Expenditures.)


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2. Preparing to Hire Employees

The NC Innovations Waiver has rules about providing services to individuals participating in the Waiver. Additionally State regulations must be followed. While the Employer of Record may be eager to begin self-directing services, it is important to remember that the completion of Financial Support start-up activities does not mean that employees may be immediately hired. The Employer of Record should also remember that if there is a delay in hiring employees, the Care Coordinator must be immediately notified so that the Individual Support Plan can be updated. The Community Guide can teach and assist the Employer of Record in all aspects of this process. Employee Qualifications A Direct Service Professional (employee) is a person hired by the Employer of Record to provide services to the waiver participant. The direct service employee cannot be:

The minor participant’s parent or step-parent, or participant’s spouse

The Employer of Record

The Representative or anyone with Power of Attorney Status for the Individual or Employer

Anyone employed by Cardinal Innovations, a Community Guide, or Financial Support Agency

A relative of an individual 18 years or older living in the home of the participant who has not been approved by Cardinal Innovations.

If an Employer of Record considers hiring a relative as the direct service employee, this should be carefully considered. If the relative lives in the home of the Individual, the NC Innovations Relative as Provider Policy must be followed. (See Appendix J for additional information.) At a minimum employee qualifications must include the General Requirements for all NC Innovations Waiver Providers, service specific requirements, and any qualifications specified in the ISP. (See the Cardinal Innovations Web Site and the Checklist in Appendix C.)

Reminder: Hiring Friends and Family In hiring a family member or friend, the following should be considered:

Pros May be easier to find someone May be a more dependable relationship May be more flexible with work schedule

Cons May be harder to give criticism or to fire, if necessary May have trouble adjusting to new Employer/employee relationship May want to decide work schedules for themselves

Questions to consider prior to hiring a relative or family member:

1. Is this about the individual’s needs or about supplementing a family member’s income? 2. As an adult is it appropriate to have mom and dad with the individual throughout the day? 3. If a family member supports an individual from birth onwards into adulthood, does the

individual learn to adapt to different people and increase independence? 4. If an individual with a disability is always supported by a family member, what happens when

that caregiver ages/dies? 5. Can a family member be a barrier to increased community integration or friendship

development?


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Job Descriptions Before employees are hired, they should understand all aspects of the job, work hours, salary, daily tasks, and needs of the individual. An essential part of getting the employer-employee relationship off to the right start is clear expectations. The job description is a way to make sure that there is clear communication between an employer and employee. A good way to begin writing a job description is to decide what the employees need to do. Checklists should be used to develop the job descriptions that are consistent with the goals and supports listed in the Individual Support Plan (ISP). It may also be helpful to make a more detailed checklist for each task listed on the job description. Employees can use the checklists as guidelines for carrying out tasks correctly. These lists will also be useful in developing strategies for goals/outcomes. The information in the job description does not need to be permanent, and can be changed if the individual’s needs change. Sample job descriptions can be found in Employment Tips and Resources. Employee Guidelines There are some employee habits and behaviors that can be annoying. To address this ahead of time, guidelines that the employee will be expected to follow should be developed. These are not included in the job description but should be shared with applicants. If an applicant has problems with the guidelines, this could present problems if they are hired. Some employers choose to identify guidelines after the employee has started work as situations arise. If this is done, the Employer of Record should remember that it is important for the employee to know exactly what the guidelines are and why they are there. Sample Employee Guidelines can be found in Employment Tips and Resources. Locating and Contacting Potential Employees Finding employees may be as simple as the Employer of Record and Representative telling family and friends that they are looking for someone to hire. Current employees may also know of individuals who are looking for work. When potential applicants are encountered that are not sure that they want the job, it is important to “sell” them on the merits of direct service work. The Employer of Record should be realistic but upbeat, focusing on the rewards without minimizing the challenges. Also, it is important to discuss what makes working in a self-directed employment environment more appealing than working for an agency. Some of the ways to advertise for employees include:

Community newsletters advertisements

Posting flyers

Advertisements in newspapers and local publications

Word of mouth and networking

Reminder: Places Potential Employees Can Be Found

Churches, synagogues mosques, and other places of worship

Faith-based and other human service agencies

Disability organizations and rehabilitation agencies

Supermarkets, shopping centers, Laundromats, and other stores that allow posting of flyers

Community organizations that serve special populations including Senior Centers

Neighborhood associations

Cultural centers

Health clinics

Unemployment offices (public)

Libraries

Schools and local colleges with GED, nursing, social work, or other human service programs, particularly those with student employment offices


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Private Employment Agencies The Employer of Record should be cautious before considering the use of a private employment agency. These agencies will likely charge a fee to either the Employer of Record or any employee that is successfully hired. Before using an employment agency that charges a fee, the Employer of Record must discuss this with a Community Guide, as the Individual and Family Directed Budget will likely not contain enough funds for the fee to be paid by the Employer of Record. Employers of Record are reminded that they may not be reimbursed for expenditures in the hiring process. Authorized expenditures are paid by the Financial Support Agency directly to the vendor. Paid Advertisements Advertisements can be paid out of the Individual and Family Directed Supports Budget if pre-arranged with the Financial Support Agency and budgeted in the Auto-Calculator. The newspaper charges by the word or line, so ads should be brief with only essential information. Advertising in neighborhood newspapers is cheaper than major city newspapers, and are good to target potential employees. Developing Advertisements and Flyers Successful advertisements or flyers must be clear about the kind of support that is needed; concise in the wording, i.e. short and to the point; and specific about what the employee will be expected to do. The following is a list of suggestions for developing advertisements or flyers:

Read other ads for ideas.

Include the basics of the job including hours, duties, name of the position, and how to reach the Employer of Record. Employers of Record should be careful in disclosing information about the contact person for the ad.

Other things that are important to the Individual can also be listed such as smoking preference but do not overload the ad with information.

Be positive in describing the job. Sample advertisements are located in Employment Tips and Resources.


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3. Screening and Interviewing Applicants After advertising for possible employees, the Employer of Record should be prepared to receive responses at any time. A folder should be started that contains the application, forms, and notes made during the application process. The following is a suggested screening/interviewing process. Employers of Record are free to develop their own interviewing processes. The Community Guide can train and assist Employers of Record in all aspects of screening and interviewing applicants. Screening Applicants Many of the responses from ads or flyers will be by telephone. The Employer of Record must be prepared to “pre-interview” applicants when they call. The conversation will be useful in helping to decide if they have the necessary skills and qualifications, and if the Employer of Record is comfortable with them. Personal information about the individual (name, address, etc.) is not shared during the telephone interview. Only questions directly related to the job should be asked. Preparing a “script” of what will be said will be helpful. When beginning a telephone interview, it is important to give a brief description of the position, amount of hours that the job requires the amount of pay and any benefits being provided. Sample telephone screening questions are located in Employment Tips and Resources.

At the conclusion of all telephone interviews, the Employer of Record reviews notes made, and decides which of the applicants that they would like to interview in person. These areas should be considered in deciding which applicants to interview:

Qualifications, experience, and ability to carry out assigned tasks

Availability

The feeling about the applicant’s answers to questions, including if the individual is likely to enjoy spending time with the applicant

The Personal Interview Once applicants are selected to be interviewed, they are called and face-to-face interviews are arranged. When applicants are contacted, they should be reminded to come prepared to complete an application form. The safest way to interview someone that is not well known to the Employer of Record is to have a friend or family member present for the interview if it is held in the home; or have the interview in a public place (library, community center, etc.). If the meeting is at a restaurant, the Employer of Record should be clear on who is paying for the meal so there are no misunderstandings. Meals cannot be reimbursed from the Individual and Family Directed Supports Budget. The interview should be held at a time and place where interruptions are not likely. It is very important that the interview be non-discriminatory. It is important to be well prepared for the interview. Items that should be available for the interview include a blank application, job description, and background/reference check release forms. The Job Application that is used in the Employer of Record Model is located in Appendix P. The Community Guide provides additional copies of the form as needed. The applicant should be greeted pleasantly, and helped to feel comfortable. The individual’s support needs should be described. The job description is shared with the applicant after the application is completed. The Employer of Record can review the application while the applicant reviews the job description.


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It is important to remember that there are some questions that may be discriminatory to ask. Issues related to arrests, about children (number, names, ages, childcare arrangements), marital status, questions about disabilities or physical conditions which do not relate to the applicant’s fitness to perform the job, questions concerning pregnancy and future child-bearing plans, direct or indirect questions that indicate an applicant’s ancestry, national origin, race or color, questions about age (except to ask if the person is of legal age to work), and any question that if answered, would reveal religious affiliation, denomination, or holidays observed should be avoided. Only questions that directly apply to the job requirements should be asked. The work schedule, pay method, pay rate, any benefits, leave plan, and method of evaluating employees are described. The applicant should also be given an opportunity to ask questions. At the conclusion of the interview, the applicant should be thanked for coming and for their interest in the position and told they will be contacted as soon as a hiring decision is made.

Reminder: Evaluating Applicants The Employer of Record evaluates each applicant on experience, the application, answers given during the interview, availability to work the days and hours needed, and general attitude. The evaluation determines the most promising applicant(s) to select to conduct reference and background checks. The following are areas that should be considered during this process:

Were questions answered completely?

Did the applicant maintain eye contact and pay attention during the interview?

Did the applicant consistently hesitate or stumble with their answers?

Did the applicant seem interested in all aspects of the job, or just the pay and work hours?

Can the applicant perform the needed tasks?

Is the applicant available when needed?

Does the applicant have a solid work history?

Is the applicant positive, eager, and willing to learn?

Would the individual be comfortable receiving support from the applicant? Contacting Non-Selected Applicants The Employer of Record contacts the applicants who were not selected for the position to let them know that a hiring decision has been made. They should be thanked for their interest and asked if their names can be kept on file for future reference. Most applicants will accept the decision to hire another applicant without question, but some might want to know why they were not chosen. A simple answer to this question is that while the applicant’s experience and qualifications were impressive, the employee hired seemed better suited to the individual’s overall needs. There is no obligation to offer any further explanation.


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4. Reference and Background Checks

Reference and background checks are valuable tools in the hiring process, and must be completed prior to employees providing NC Innovations Services. Sample Reference Check Questions and Release Forms are included in Employment Tips and Resources.

Information Needed for Required Waiver Background Checks It is recommended that at least two references for each applicant under serious consideration for employment be checked. Employment references usually provide valuable information but personal references may also be obtained. Former employers should be contacted, paying attention to length of employment at each job. Contacting the applicant’s previous employers for the previous five years of work history may help in verifying that an applicant has resided in North Carolina for five years, and assist in determining the type of criminal record check needed. Some employers will not discuss an applicant without having received a copy of a signed reference release form. Required Waiver Background Checks and Employee Information Prior to requesting the background checks, the Employer contacts the applicant and obtains:

Age verification (copy of driver’s license, other form of verification if not transporting the participant)

Automobile liability insurance if transporting the individual in their personal vehicle (copy of information is sent directly to the Employer of Record)

Copy of High School and/or College Diplomas (transcripts are sent directly to the Employer of Record)

Confirmation of the residency status of the applicant and how long the applicant has resided in North Carolina (number of consecutive years). This allows the Financial Support Agency to perform the correct Background Check, state or both state/national. (See additional information on this page for further information on Criminal Background Checks.)

Copy of the applicant’s job application

Signed consent for background check provided by the Financial Support Agency Required Waiver Background Checks When an applicant is being considered for employment, the Employer submits the age verification and signed consent for the background check and request that the Financial Support Agency obtain required background checks. Required background checks are:

If transporting a waiver participant, driving record check

Criminal record background check

Health Registry Check

Health and Human Services-Office of Inspector General List of Excluded Individuals and Entities database

Verification that the applicant is at least 18 years old

Reminder: Employer of Record Responsibilities The Employer of Record must obtain copies of and keep copies of the documents that verify the prospective employee’s educational and other qualifications such as the prospective employee’s high school diploma or GED as indicated in the service definition qualification requirements. If the prospective employee is expected to transport the individual in the employee’s automobile, the Employer of Record obtains documentation that the employee has a reasonable amount of automobile liability insurance.


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Criminal Background Checks North Carolina law requires a criminal background check on all potential unlicensed employees who have direct access to individuals with developmental disabilities. The law requires that for those potential employees who live in North Carolina less than five consecutive years, a national criminal record check must be obtained. For those prospective employees who have lived in North Carolina for more than five years, only a state criminal record check is required. The employment application has a question that addresses this issue. References should also be checked for the previous five years. If the applicant provides inaccurate information about residency and the Employer of Record discovers this at a later time, this would be grounds for dismissal. If the applicant currently lives in another state, the applicant is subject to the national criminal record check.

Reminder: Hiring Employees Who Have Not Lived in North Carolina for five consecutive years The Employer of Record must clearly identify that the prospective employee has not lived in

North Carolina for five consecutive years when requesting background checks from the Financial Support Agency.

For prospective employees who have lived in North Carolina for five consecutive years, a national criminal record check is obtained. For those prospective employees who have lived in North Carolina for more than five checks, only a state criminal record check is required.

The Employer of Record must obtain Background Checks from the Financial Support Agency. The Employer of Record may not obtain them from or through another source.

The Financial Support Agency returns the results of the background check to the Employer of Record. The Employer of Record carefully reviews the results of the Background Check to determine if any reported convictions present a health and safety risk to the individual, regardless of the Employer of Record’s relationship or knowledge of the prospective employee. The Employer may not hire an applicant whose criminal record check or Health Care Registry check poses a potential health or safety risk to the individual. Guidance and questions about potential issues around criminal background checks are to be discussed with the Community Guide. Should specific information be disclosed to an employee of Cardinal Innovations or a Provider Agency under contract with Cardinal Innovations that indicates that an employee has been hired who has criminal record that presents a potential to the safety or well-being of the individual being supported, the employee or Agency will report this to the Quality Management Department. A “hit” on either the state or federal background check is defined as a relevant offense, meaning a county, state, or federal criminal history of conviction or pending indictment of a crime, whether misdemeanor or felony, that bears upon an individual’s ability to have responsibility for the safety and well-being of an aged or physically disabled person or a person needing mental health, developmental disabilities, or substance abuse services. These crimes include:

Counterfeiting and Issuing Monetary Substitutes

Endangering Executive and Legislative Officers

Rape and Other Sex Offenses

Assaults, kidnapping, or abduction Malicious Injury or Damage by Use of Explosive or Incendiary Device or Material

Burglary and Other Housebreakings

Arson and Other Burnings

Larceny, robbery, or embezzlement

False Pretenses and Cheats

Obtaining Property of Services by False or Fraudulent Use of Credit Device or Other Means


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Financial Transaction and Crimes Act

Frauds or forgery

Offenses Against Public Morality and Decency Prostitution

Perjury

Bribery or misconduct in public office

Offenses Against the Public Peace

Riots and Civil Disorders

Protection of Minors

Protection of the Family

Public Intoxication

Computer Related Crimes

Possession or sale of drugs and alcohol related offenses The Employer of Record is responsible for keeping Personnel Records that meet NC Innovations requirements. Quality Management will review Employee Personnel Records during the Annual Audit of the Employer of Record. Records are also subject to audit by other State and Federal Agencies. The Community Guide trains Employers of Record in setting up Employee Personnel Records. The Employer of Record maintains the criminal record check information in the applicant’s file, separate from other personnel information about the applicant. Specific information about an applicant’s criminal record check is not sent to Cardinal Innovations or disclosed to anyone conducting monitoring or an audit. Employer of Record New Hire Packets will not be processed, nor will the employee be paid for work performed prior to the request of the Background Check from the Financial Support Agency for the applicant and the receipt and review of that Background Check results by the Employer of Record. Health and Human Services-Office of Inspector General List of Excluded Individuals and Entities Database The Health and Human Services-Office of Inspector General List of Excluded Individuals and Entities Database is a database of individuals and entities excluded from participation in the Medicaid and Medicare Programs. If a prospective employee appears on this list, the Employer may not offer a position to or hire the applicant because NC Innovations cannot be billed if the service is provided by an applicant excluded from participating in the Medicaid Program. Concerns and questions about this database are to be discussed with the Community Guide.

Reminder: Hiring Employees A job offer may not be made to an applicant prior to requesting a background check from the Financial

Support Agency. A job offer may not be made to an applicant prior to receiving and reviewing the background check from

the Financial Support Agency. Background checks may not be obtained from any agency or other way except through the approved

process that is the responsibility of the Financial Support Agency. New Hire Packages will not be distributed to Employers by the Financial Support Agency until the Employer

of Record has received and reviewed the results of the Background Checks.


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5. Completing the Hiring Process

A final hiring decision is made after considering all the information gathered. The following steps are suggested in making the final hiring decision:

Review the application. Is the applicant qualified? Do they have the necessary experience? Are there any unexplained gaps in their work history?

Re-read the notes taken during the interview process. Was the applicant attentive, positive, knowledgeable, and eager?

Review the notes about the employment references. What did the applicant’s past employers say about them? Were they trustworthy and competent? Did they get along well with others?

Review the notes about personal references. How long has the person known the applicant? How did that person describe the applicant’s attitude and best qualities?

Review background checks and determine if there are any concerns with those. Background checks must be considered in the context of the individual’s health and safety. The applicant’s driver’s license should be current and overall driving record should be considered. A person whose background check presents a health and safety risk to the individual cannot be hired.

The hiring process may result in finding that none of the applicants are suitable. The search for the right person continues until the right employee is found.

Offering the Position to the Applicant The Employer of Record contacts the selected applicant, and offers the position to the applicant. The starting salary, the pay schedule, the work schedule, training that must be completed, and the work start dates are discussed. The role of the Financial Support Agency is also described. If the applicant accepts the position, the Employer of Record contacts the Financial Support Agency and requests a Hire Packet. A New Hire Packet will not be sent to the Employer of Record until the Employer Identification Number (EIN) and Workers’ Compensation Policy are in place and background checks are received and reviewed by the Employer of Record. Completing the Hire Packet The Employer welcomes any applicant who accepts a position, and confirms the training schedule and first day of work. A time is set for completion of the Hire Packet. The Employer makes sure that the Hire Packet is completed, and that all forms are signed. The Employer also makes sure that a copy of the individual’s social security card is included for the Financial Support Agency’s files. The New Hire Packet is not submitted until a copy of the Social Security Card is obtained to be submitted with the New Hire Packet. The Employer of Record and employee also develop an Employee Support Agreement that is signed by both parties. The Employee Support Agreement includes the employee’s supervision plan. The supervision plan must be updated annually. Employee Support Agreements are retained in the Employer of Record’s Personnel Files. These are not sent to the Financial Support Agency. The Employee Support Agreement is located in Appendix Q. The Employer also arranges or provides any initial training for the employee. (See Chapter 6 for information about training employees.) Role of the Financial Support Agency The employee cannot be paid until the Financial Support Agency receives the completed Hire Packet, including a copy of the employee’s social security card. Forms that are mailed must be postmarked five days prior to the employee’s


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anticipated work start date. The Financial Support Agency contacts the Employer to confirm that forms have been received and that the employee can begin work. Should the forms that the Financial Support Agency needs to put the employee on the payroll be received after the employee begins work, there could be a delay in issuing the employee’s first paycheck and/or there could be penalties for late filings of taxes and other required withholdings. Penalties for late filings because the Employer of Record did not return the forms to the Financial Support Agency on time will be deducted from the Individual and Family Directed (Self-Directed) Budget. This could mean that the Employer of Record would need to make adjustments to the Auto-Calculator. Hepatitis B Vaccinations for New Employees Employers of Record offer employees the option to receive Hepatitis B vaccination series. The Employer shares a notice about the vaccination series with the employee. The employee accepts or declines the offer. A sample notice is located in Employment Tips and Resources. If the employee declines the offer, the new employee signs declination form. If the employee declines, the employee has the right to change their decision at a later date. If the new employee accepts the offer, the Employer of Record arranges for the vaccination. Payment is requested from and made by the Financial Support Agency using the Financial Support Request Form. Information about the completion of this form is located in Chapter 1, page 8.


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6. Training Employees The Employer of Record is responsible for arranging for or training employees. The amount of training will depend on the skills needed to perform the job, and the employee’s experience. At a minimum, employees must meet requirements specified in the NC Innovations Service Definitions and in the Individual Support Plan (ISP). It is suggested that Employers of Record write down Individual’s routines or create training manual before starting to train an employee. Training resources are located in Employment Tips and Resources. Community Guides are helpful in providing information about training resources for Employers of Record. The Community Guide assists the Employer of Record in locating training curriculums or companies that offer training for employees.

Initial Training During the hiring process, information is gathered about the employee’s qualifications. After the applicant accepts the position, the Employer of Record develops a training/supervision plan for the employee as part of the Employee Support Agreement. The Employer of Record arranges or provides any initial training for the employee. Training to be paid by the Financial Support Agency must be pre-arranged with the Financial Support Agency by submitting the Purchase Request Form. The employee may be paid for time spent attending training; however, NC Innovations Services are not billed since the employee is not providing a service to the individual. The employee gives a copy of the training certificate received at the completion of the training to the Employer of Record who maintains copies in the employee’s personnel file. (See Appendix C for Employee Qualifications and Training Checklist.)

Reminder: Initial Training of Employees In order to pay an employee for time spent in training or in classes, the employee must be hired by the Employer of Record. This means that the Employee Start-Up Package is completed correctly, submitted, and received/processed by the Financial Support Agency. The training must be included in the Auto-Calculator unless covered under Employer Expenditures in the Individual Support Plan. After the employee is hired, paid training time is recorded on the employee’s time sheet. The training time is recorded as non-billable to NC Innovations because the Employee is not providing a NC Innovations Service. Request for payment for employee training is submitted to the Financial Support Agency by using the Financial Support Request Form. Information about the completion of this form is located in Chapter 1, page 8

The Employer of Record should also make clear any expectations for service provision to the employee. Locations of items that the employee will be using should be specified. It may be important for the employee to understand why a task should be performed a particular way. The importance of the work schedule should be stressed. The employee should be shown how to complete their time and billing form. On-Going Training Some training for employees may be required to be repeated on a particular timeline (for example annually). It is also possible that an employee may require additional training after they have been working with the individual for some time. The employee may develop a bad habit or forget something that they have already been told. The individual may have a new need that requires additional training. An Employer of Record may request payment for additional formal training for an employee by submitting the Purchase Request Form to the Financial Support Agency. The Financial Support Agency will pay the registration fee for the training as requested on the Financial Support Request Form. Information about the completion of this form is located in Chapter 1, page 8. The Auto-Calculator should also include the cost of the on-going training. Travel expenses for training and conferences for the employee are not reimbursable.


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Documentation of Training Both initial and ongoing training must be documented and filed in the employee’s personnel record. It is also critical that the supervision plan in the Employee Support Agreement is followed, and that supervision be provided and documented as specified in the Agreement. (See Employment Tips and Resources for sample Forms.) The Quality Management staff will review employee training records at the time of the Annual Employer of Record Audit. Community Guides train Employers of Record in setting up/maintaining training files for employees.


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7. Implementing Services and Managing Employees

After employees are hired and trained, the Employer of Record implements the Individual Support Plan (ISP). There will be successes and challenges as employees provide services as written in the ISP. While the Financial Support Agency and Community Guide are available to assist the Employer of Record in completing many employment tasks, there are still a number of responsibilities that must be met by the Employer of Record to assure that the ISP is implemented as written. Additional information and tools can be found in the Employment Tips and Resources. Scheduling Employees If there is only one employee, scheduling is simple. However, because of the hours of services needed by an individual and the need to plan for back-up staffing, there likely will be more than one employee, and scheduling is more difficult. Scheduling takes time as does dividing tasks among employees. The schedule should be posted in a place that all will see it. Ultimately the decision about scheduling is made by the Employer of Record but relationships with employees will be better if they feel that their needs are considered when the schedule is made. Employees need to know how much notice will be given when the schedule is changed, as well as when the schedule might need to change on short notice. The Employer of Record should inform employees what will happen if they arrive late or do not come to work. It is equally important that employees not be asked to stay late without notice. Employers and employees must respect each other’s time. Employers of Record schedule employees so that employees are available to deliver the number of service hours specified in the Individual Support Plan. It is very important for the Employer of Record to remember that services must be provided as written in the Individual Support Plan. If more services are provided than approved in the ISP, the Financial Support Agency will not be able to process the billing for the extra hours. This means that the revenue needed to pay the employee’s paycheck was not counted in the Auto-Calculator, and the budget could be overspent. If fewer services are provided than approved, the Employer of Record documents the reason, and could need to complete a Back-Up Staffing Incident Report. (See Appendix E for an explanation of the Back-Up Staffing Incident Report.) If fewer services are provided than approved, the individual’s health and safety could be at risk. In following the ISP and scheduling services, the Employer of Record must be aware of how services are authorized (approved) for an individual participating in the Employer of Record Model. When services are authorized per week, the week is defined as Sunday – Saturday. If an individual is to receive an amount of a service per week and does not receive the total hours of service for that week, the service cannot be rescheduled for the following week. Community Guides are helpful in explain how services are authorized. Handling Conflicts and Issues Because Employers of Record deal with some very personal issues, they need good communication skills. Employees need to be trained, praised and at times, corrected. Problems and misunderstandings are more likely to occur if people do not talk to each other and know where they stand. Employers and employees may react to conflict in a different way. Some are passive, and are scared to speak up for their own needs. Others are aggressive, and may lash out at someone over small issues. The best approach is to be assertive. Being assertive is being polite but insistent on what is needed. When conversations are being held about important issues, reviewing the Employee Support Agreement with the employee may be helpful. Evaluating Employees To insure that the best care is being provided to the individual, employees should be evaluated regularly. If employees are new or if there are problems with an employee, evaluations should be scheduled more frequently. Evaluations should be conducted at least annually. A prepared evaluation form should be used for formal reviews. The form should have similar items as the employee’s job description. The employee should be allowed to give


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feedback, and to document their comments. These are attached to the evaluation. Sample evaluation forms are located in Employment Tips and Resources. Some employees need more time to perform well. If feedback and evaluations do not improve performance, a written warning may be given that things need to improve by a certain date. A copy is kept in the employee’s file. If the written warning does not work, then it may be necessary to issue a second warning with a copy placed in the employee’s file. After the second warning, it should be clear that things need to improve or the employee may be terminated (fired).

Reminder: General Supervision Tips Avoid stereotyping employees based on age, race, or gender. Be ready to train, and provide on-going training when things change. Communicate openly and directly with employees. Work directions should be clear. Technical

language and terms should be explained. Employees should be encouraged to ask questions. Assume that employees want to do a good job. Praise good performance and initiative. Treating employees with respect builds good working

relationships. Be consistent. Monitor the work of the employees. If they are not doing tasks as trained, additional training

may be needed. Deal with problems. Issues should be addressed early and tactfully. When dealing with

problems, the Employer of Record should focus on the problems. Lead by example, and show respect and courtesy to employees. Employers if Record should

avoid talking about the employee to another employee. Supervising employees includes but is not limited to observing employees delivering services,

reviewing service documentation, and face-to-face meeting with the employee. All supervision is documented, provided as described in the Employee Supervision Plan and

maintained by the Employer of Record.

Dismissing Employees An Employer of Record has the right to terminate employees with or without cause. If there is a serious problem with an employee, the solution to the problem could be to terminate (fire) the employee immediately. Examples of serious situations are:

Hurting the individual or abusing the individual in any way

Drinking or using street drugs on the job, or coming to work drunk or drugged

Stealing from the individual

Violating confidentiality If an employee threatens the Employer of Record, the local law enforcement office may need to be contacted, and the employee may be fired over the telephone. The employee should be told that arrangements will be made to pay them any wages that are owed. In cases of abuse to the individual, the Care Coordinator, the Department of Social Services Protective Services Unit, and the Quality Management Department must be notified. If the problem is not serious, the Employer of Record may want to discuss the problem with the Community Guide who can offer advice about solving the problem. If the problem is still unresolved, a change in employees may be necessary. The Employer of Record is responsible for telling the employee that he/she is fired. The employee may be terminated by phone or letter but doing it in person is more respectful. It the employee is concerned that there will


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be problems with the employee when the subject of firing comes up, a third party may be asked to be present during the conversation. The conversation should be direct so that there are no misunderstandings but it is not necessary to go into great detail with the employee. If plenty of corrective feedback and regular evaluations have been given, the employee should know what the problems are. Depending on the situation, the employee may be given two weeks’ notice. This will give the employee the opportunity to start looking for a new job and the Employer of Record will have time to start looking for a new employee. There may be a need to use the emergency back-up plan while looking for a replacement. If the emergency back-up plan costs more than regular services, the Individual and Family Directed Supports Budget (auto-calculator) may need to be adjusted. The Employer of Record contacts the Community Guide should the Employer of Record need help adjusting the auto-calculator. Some grounds for termination include:

The employee’s work is not good enough.

The employee does not learn fast enough to meet the individual’s needs.

The employee is late or fails to show up too many times.

The employee’s personal habits bother the individual.

The employee fails to pay attention to the instructions of the Employer of Record.

The individual and the employee are having too many disagreements.

The individual is not comfortable with the employee.

The employee has a schedule that is not flexible enough for the individual.

The employee violates the employment conditions, seriously or often.

Reminder: Suggested Steps for Terminating an Employee Set a date for the termination, have the backup system ready to go, have someone else

present. Have the documentation and Employee Support Agreement out at the time. Make a list of anything the employee may have such as keys to the individual’s home and ask

for their immediate return. Let the employee know that their services are no longer needed. Suggested methods of

communicating the termination are: “I’m sorry, but I do not feel you are appropriate for this job.” or “I won’t need your services anymore.” If an explanation is requested, refer them to the discussions and the Agreement. Do not argue with the employee.

Have the employee sign the last time sheet and complete any documentation that is not finished. Tell the employee when they can expect to receive their last paycheck. Turn the time sheet and other paperwork in immediately to the Financial Support Agency so that the paycheck can be issued.

If the employee becomes angry or offensive, ask them to leave immediately and call the police if they refuse to leave.

Continue to maintain confidentiality related to employee issues, including the termination. Analyze what went wrong to avoid similar situations in the future.

It is extremely important that the Employer of Record document all events leading up to termination of an employee in the event an employee decides to file for unemployment benefits, and to prevent the Individual and Family Directed Budget from being charged an increased rate for unemployment taxes. The documentation will help defend actions in a hearing with the Employment Security Commission, a complaint with the Equal Employment Opportunity Commission (EEOC), or in a wrongful discrimination lawsuit. The Employer of Record is responsible for responding to inquiries from the Employment Security Commission should a terminated employee file for unemployment benefits.


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The Fair Labor Standards Act The Fair Labor Standards Act (FLSA) establishes minimum wage, overtime pay, record keeping, and child labor standards affecting full-time and part-time workers. Employers are required to follow the provisions of the FLSA. Covered employees are entitled to at least minimum wage, and overtime pay at a rate of not less than one and one-half times their regular rate of pay after 40 hours of week in a workweek. While FLSA does set basic minimum wage and overtime pay standards and regulates the employment of minors, there are a number of employment practices that FLSA does not regulate. These include:

There is no federal requirement to pay overtime or premium pay for time worked on weekends or holidays, or if more than the usual number of hours is worked on a single day.

There is no requirement to pay vacation, holiday, severance, or sick pay.

There is no requirement to pay for meal or rest periods, holidays off, or vacations.

There is no requirement for pay raises or benefits.

There are no regulations about discharge notices, reason for discharge, or immediate payment of final wages to terminated employees.

More information can be obtained from the Federal Department of Labor at: www.dol.gov

Investigators stationed across the U.S carry out enforcement of FLSA. They conduct investigations and gather data on wages, hours, and other employment conditions or practices, in order to determine compliance with the law. Where violations are found, they also may recommend changes in employment practices to bring an employer into compliance. It is a violation to fire or in any manner discriminate against an employee for filing a complaint or for participating in a legal proceeding under FLSA. Violations can result in criminal prosecution and/or fines. Employers who willfully or repeatedly violate the minimum wage or overtime pay requirements are subject to civil money penalties. If the Employer has more than 15 employees, there may be other employment related laws that the Employer of Record must follow. These include:

Title VII of the Civil Rights Act of 1964, 42 U.S.C. §§ 2000e, et.seq. (applies to employers with 15+ employees)

Age Discrimination in Employment Act, 29 U.S.C. §§ 621, et.seq. (applies to employers with 20+ employees)

The Americans with Disabilities Act, 42 U.S.C. §§ 12101, et.seq. (applies to employers with 15+ employees)

The Family and Medical Leave Act, 29 U.S.C. §§ 2601, et.seq. (applies to employers with 50 or more employees working 20 or more workweeks per year)

The Community Guide will provide the Employer additional information about these laws as needed. Employer Record Keeping The Employer of Record is provided a Training Notebook and a portable file box that can be locked when the Employer begins to participate in the Employer of Record Model of Individual and Family Directed Supports by the Community Guide. The Training Notebook contains this Handbook Supplement and other resources that the Employer of Record will find useful in self-directing services. The Employer of Record will want to add the Orientation Materials and Employer Handbook to the Notebook that were previously distributed to the Employer by the Care Coordinator and Community Guide. (See Appendix A for Materials in the Employer of Record Notebook.) The file box includes forms and other materials that are used in employer record keeping. The Community Guide trains Employers on the forms and answers questions about the forms and record keeping responsibilities. (See Appendix B for a list of the contents of the Employer Lock Box.)

http://www.dol.gov/


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Additional copies of forms included in the box are provided by the Community Guide. The Community Guide only provides copies of the forms in the box and does not customize the forms for the Employer of Record. Forms are also available in electronic form on the Individual and Family Directed Supports web site. The Community Guide assists the Employer of Record in accessing the web site and provides the password for the site to the Employer of Record. A separate file should be maintained on each employee. Copies of important documents, such as the application, schedules, job duties, time sheets, evaluations, and Employee Support Agreement are maintained in the file. Information about employees is confidential and should be kept in a secure location. Employers of Record must not release information about an employee without the written permission of that employee. Records are subject to review by the Care Coordinator, Quality Consultant, and/or State or Federal governments. Actual results of criminal record checks are maintained separately and should not be released to a third party. (See Appendix I for a copy of a Release Form that is used to release employee information to Cardinal Innovations.) Time and Billing Forms Employees complete the Time and Billing Form provided by the Financial Support Agency and are submitted by the Employer of Record as indicated on the schedule provided by the Agency. Copies of the employee’s Time and Billing Forms are kept by the Employer of Record. The form is signed both by the employee and Employer of Record. Time sheets that are incomplete or that have inaccurate information should not be signed. For example, should the employee record hours worked on a day off, this is pointed out to the employee. The form would be corrected by the employee prior to the Employer of Record signing it. The Financial Support Agency provides the Employer of Record with a method of confirming receipt of Time and Billing Forms. Employers of Record are strongly advised to confirm receipt of Time and Billing Forms by the Employer of Record by a method suggested by the Financial Support Agency. Employee pay could be delayed if Time and Billing Forms are not received by the Financial Support Agency. The Financial Support Agency pays the employee based on information on the time sheet. The Financial Support Agency contacts the Finance Department if NC Innovations Services are not billable for the time reported on the Time and Billing Form. Should hours reported on the employee’s time sheet not be billable to NC Innovations, this could mean less money in the Individual and Family Directed Budget in the future and could result in termination from the Employer of Record Model if the Individual and Family Directed Budget is overspent. The Financial Support Agency reviews time and billing forms as they are submitted. The Agency has a policy that is followed when errors are discovered on time and billing forms. There are instances when the time and billing forms are returned to the Employer of Record for correction. If time sheets are submitted or resubmitted after the deadline established by the Financial Support Agency, employees are not paid until the next scheduled pay date.

Reminder: Employer Record Keeping

The Employer of Record may choose to complete documents electronically, The Financial Support Agency has policies and a form that must be completed and signed if the time and billing form is to be completed and submitted electronically by e-mail attachment.

Employers of Record are not reimbursed for computers, software, printer cartridges, paper, and/or similar items except when the Individual is the Employer and is allowed to receive a specific item or items according to a NC Innovations service definition.

The Community Guide Agency and/or Cardinal Innovations will not print or reimburse for printing of documents that the Employer chooses to customize.

If an Employer of Record chooses to submit forms to the Financial Support Agency via mail, the Employer should request self-addressed stamped envelopes from the Agency.


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Direct Deposit of Employee Paychecks Employee paychecks are typically deposited in the employee’s bank account. As part of the New Hire Packet, the employee completes paperwork to authorize the employee’s check to be deposited in a bank account that includes the employee’s name. Paychecks will not be deposited in third party bank accounts. Should the employee not have a bank account, the Financial Support Agency will issue the employee’s pay in the form of a Pay Card at the employee’s mailing address. Employee paychecks are never given to the Employer of Record for distribution. The Financial Support Agency requires documentation that the employee’s name is included on the bank account where payment of wages is requested. This is usually done by providing the Financial Support Agency with a copy of a voided check that lists the employee’s name on the account. If the employee is unable to provide the Financial Support Agency with a voided check, the employee may provide a statement from the bank (on bank letterhead) that confirms that the employee’s name is on the account. If this information is not provided to the Financial Support Agency, the employee’s pay will be issued in the form of a Pay Card. Taxes Employers of Record need to be aware of responsibilities that they have regarding taxes. The Financial Support Agency withholds taxes as required by law from the employee’s pay. The Financial Support Agency provides written information and answers questions about tax withholdings.

Reminder: Correspondence from the Internal Revenue Service, NC Department of Revenue or other Agency

Should an Employer of Record receive a correspondence from the Internal Revenue Service, NC Department of Revenue, or other Agency about tax or other withholdings related to the Employer of Record Model, the correspondence should immediately be forwarded to the Financial Support Agency, and followed up with a telephone call to the Financial Support Agency to confirm receipt of the correspondence.

Any delay in reporting of such correspondence to the Financial Support Agency could result in monetary penalties to the Employer of Record.

The Financial Support Agency needs information in the New Employee Hire Packet, in order to withhold and pay the proper taxes on behalf of the Employer of Record. Employment Taxes that the Financial Support Agency will withhold on behalf of the Employer of Record are:

Income Taxes: Federal income taxes are usually paid on employee income. Ordinarily, employers are required to do income tax withholding. Publication 15 from the Internal Revenue Services, Circular E Employers Tax Guide, includes information regarding withholding and payment of federal taxes. There is an exception that may apply to certain relatives providing services to the individual. The Financial Support Services gathers information from the employee to determine if this exception should be applied. The telephone book has the number and location of the nearest IRS office or branch. Information can also be found at http://www.irs.gov/ State income taxes are also withheld by the Financial Support Agency. Information about North Carolina state income taxes can be found at http://www.dor.state.nc.us/index.html

Social Security and Medicare (FICA) Taxes: Social Security and Medicare (FICA) Taxes set aside living and medical expense monies for employees to use when they retire. Federal regulations require employers to withhold and pay Social Security and Medicare taxes.

Federal Unemployment Tax (FUTA): The Federal Unemployment Tax (FUTA) compensates workers who lose their jobs. Employers of Record must file federal unemployment taxes (FUTA) on behalf of employees. Employers receive a credit for taxes paid toward state unemployment taxes.

http://www.dor.state.nc.us/index.html


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North Carolina Unemployment Tax (SUTA): The State Unemployment Tax (SUTA) compensates workers who lose their jobs. State Unemployment Taxes work very much like Federal Unemployment Taxes. Employers with stable employment records receive credit for this in reduced tax rates after a qualifying period. The experience rate includes the number of employees who are terminated from the Employer who file for and receive SUTA benefits.

The Financial Support Agency files taxes electronically in aggregate on behalf of all Employers of Record. It is not possible for the Agency to provide each Employer a copy of the actual filing since it includes names of other Employers. However, the Financial Support Agency provides Employers of Record with notifications of taxes paid on behalf of the Employer of Record as part of the Employer of Record Monthly Report. Cardinal Innovations audits the Financial Support Agency annually. Included in this audit is a review of taxes paid on behalf of Employers of Record. As previously stated it is extremely important that the Employer provide the Financial Support Agency any correspondence from the Internal Revenue Service, NC Department of Revenue, or other Agency about tax or other withholdings related to the Employer of Record Model. Receipt of this correspondence does not mean that the Financial Support Agency has not paid taxes on behalf of the Employer of Record. It could mean; however, that the taxes have not been properly credited to the correct account. The Financial Support Agency would follow up to make sure that the taxes or other expenditures are properly credited.

Reminder: Unemployment Taxes

If an employee quits or is dismissed from employment, Employers of Record should respond to all inquiries about the dismissal from the NC Employment Security Commission.

The Employer of Record’s Unemployment Tax Rate could be higher if former employees receive unemployment benefits.

Community Guides can provide information and assistance if there is an inquiry from the NC Employment Security Commission.

It is important to use the current Auto-Calculator provide to the Employers of Record (through their Community Guides) by the Financial Support Agency so that the correct FUTA/SUTA rates are used.

Monthly Employer of Record Report Each Employer receives a Monthly Report completed by the Financial Support Agency that shows the revenues to the account (billing of NC Innovations services to Cardinal Innovations), and expenditures (payments made that include employee pay, employer taxes, purchases made on behalf of the Employer) The Financial Support Agency provides each Employer with a companion to the report that explains the format of the Report. The report is in the same format as the billing and time reports. Both have color coded numbering. The monthly report includes a payroll register and notifications of taxes paid. The Monthly Report is sent to the Employer with copies to the Finance Department, Care Coordinator, and Community Guide. All parties review the Monthly Report for accuracy/problems. Unresolved concerns about the Report are reported to Finance by the Care Coordinator.


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8. Risk and Emergency Planning The Care Coordinator shares the results of the Risk/Support Needs Assessment completed prior to the development of the Individual Support Plan (ISP) with the Employer of Record. Each identified risk is addressed in the Individual Support Plan, if needed. Employees must be trained to implement risk strategies that are specifically related to the individual’s needs. Emergency plans are also developed for weather and other environmental emergencies. Examples of emergency plans that should be developed include:

Power outages

Severe weather conditions such as tornados, hurricanes, floods, and snow/ice storms, including emergency water and food supply location

Situations that would require evacuation including emergency evacuation routes, shelter locations, and medications, supplies, and important papers to take in case of evacuation

Back-Up Staffing For an individual who participates in the Employer of Record Model of Individual and Family Directed Supports, the ISP includes a back-up staffing plan. The Employer Handbook identifies ways that the Employer of Record can identify back-up staffing. It is important to remember that back-up staffing does not include the use of a provider agency, including the back-up staffing agency, on a routine basis. The Employer of Record should hire enough employees so that back-up staff is usually available when the regularly scheduled employee is sick, takes vacation or is otherwise unavailable. For individuals who choose the Employer of Record Model, Cardinal Innovations contracts with back-up staffing agencies that can help with staffing needs, beyond the planned back-up that each Individual Support Plan includes. There is a single back-up staffing agency for each Cardinal Innovations Region, and the regional back-up staffing agency is the only agency that is authorized as a back-up staffing agency for Cardinal Innovations Employers of Record. Contact information for the Back-Up Staffing Agency is provided to Employers of Record by the Community Guide. The use of the back-up Staffing Agency is included in the ISP for individuals participating in the Employer of Record Model for the purpose of unplanned, emergency staffing needs when the routine back-up staffing plan is not operational. The Auto-Calculator will need to be adjusted if the back-up staffing agency provides services because the back-up staffing agency bills Cardinal Innovations directly for self-directed services rather than billing though the Financial Support Agency. The Community Guide assists the Employer of Record in adjusting the Auto-Calculator. Employers of Record must remember to adjust the Individual and Family Directed Service Budget (auto-calculator) if over-time pay is authorized to meet unexpected back-up staffing needs. Use of over-time pay for employees, on a regular basis, will likely result in the over spending of the Individual and Family Directed Services Budget. This could result in termination from Individual and Family Directed Supports. Review of Back-up and Emergency Plans The Employer of Record (or Representative), reviews Back-Up and Emergency Plans every three months to make sure they still work. The plan for review or testing the plans should be included in the ISP, and a note should be made when they are reviewed or tested. For example if family or friends are listed as back-up supports, and if these individuals move, change jobs, have new family responsibilities, or develop health problems, they may not be able to provide back-up services for the individual. Contact should also be maintained with paid back-up employees on a


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regular basis to make sure they are still available. The Employer of Record may want to give the back-up employees a few hours of work periodically to keep a relationship with them. The Individual and Family Directed Supports Budget and Auto-Calculator should be reviewed to make sure there are enough funds to use the current emergency plan.

Care Coordinators monitor Back-Up and Emergency Plans. Quality Assurance Specialists review/monitor Back-Up and Emergency Plans during the annual review process and through follow-up of Incident Reports. Primary Crisis Response If the Employer of Record is self-directing In-Home Intensive, In-Home Skill Building, and/or Personal Care Services, the Employer of Record must choose a Primary Crisis Response Agency. The Back-Up Staffing Agency may also be chosen as the Primary Crisis Response Agency by the Employer of Record. The Employer of Record is free to choose any other Primary Crisis Response Provider within the Cardinal Innovations Provider Network.


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9. Managing the Individual and Family Directed Services Budget NC Innovations funds are Medicaid dollars that the Employer of Record and Cardinal Innovations must use wisely. Laws and regulations must be followed, and funds must be used to obtain services in the Individual Support Plan (ISP). The Employer of Record must be a careful purchaser of services, and remember to use existing personal and community resources before using NC Innovations and other public funds. The Employer of Record has control over how the Individual and Family Directed Supports Budget is spent within NC Innovations Guidelines. Medicaid payment rates are two parts: the administrative portion and a direct service portion.

The Administrative portion of the rate is used to pay for billing, required staff training, forms, and items to meet other regulations. A portion of the rate is retained to pay for these expenditures.

The direct services portion of the rate that is used to pay costs for staffing and benefits is available to the Employer of Record to negotiate staff salaries and benefits.

Detailed information about the Individual and Family Directed Supports Budget is located in Appendix F. Auto-Calculator An Auto-Calculator developed by Cardinal Innovations assists Employers of Record in managing the Individual and Family Directed Supports Budget. The Auto-Calculator is a computer tool that enables an Employer of Record to manage the Individual and Family Directed Supports Budget. It provides a way for the Employer of Record to estimate revenues from services billed and expenditures such as employee salaries and employment taxes. Community Guides assist Employers of Record in obtaining the Auto-Calculator from by making sure they obtain the customized auto-calculator from the Financial Support Agency that is needed if the Employer of Record has an adjusted SUTA (State Unemployment Tax) Rate. Typically SUTA adjustments occur after the Employer of Record has been established for a period of time so it is important to check back with the Financial Support Agency whenever the Auto-Calculator is updated. The Financial Support Agency sends updated Auto-Calculators to Employers of Record and their Community Guides if there are other changes in the Auto-Calculator. Community Guides train Employers of Record in using the Auto-Calculator. If the Employer of Record does not have access to a computer, the Community Guide brings the Auto-Calculator to the Employer of Record on the Community Guide’s laptop computer. The Community Guide also provides the Finance Department with a copy of the completed Auto-Calculator. The Finance Department reviews, but does not approve, the Auto-Calculator. Finance may be able to identify problems with the completion of the Auto-Calculator. If problems are identified, Finance notifies the individual’s Care Coordinator who notifies the Community Guide. The Finance Department’s ability to identify problems with the Auto-Calculator depends on the information submitted in the Calculator. Additionally after the Auto-Calculator is completed, a print-out of the Auto-Calculator is signed by the Employer of Record and submitted to the Financial Support Agency by mail, fax or e-mail (scanned document with signature of the Employer of Record). The Community Guide assists with this process and may need to print the auto-calculator and bring it to the Employer of Record for signature, if the Employer of Record does not choose to print the Auto-Calculator themself. The Community Guide may also need to submit the signed print-out to the Financial Support Agency on behalf of the Employer of Record. The Auto-Calculator must be updated at a minimum if the following occur:


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Anytime an Individual Support Plan is updated that results in a change in frequency and/or duration of Individual and Family Directed Services

Service revenue is less than projected. For example, the individual is approved in their Individual Support Plan to receive 20 hours of In-Home Skill Building each week. The individual goes on a trip with family and does not receive the 20 hours of In-Home Skill Building. The Community Guide works with the Employer of Record to deduct the 20 hours of In-Home Skill Building from the projected revenue portion of the Auto-Calculator, and make any other adjustments that need to be made as a result of the reduced Individual and Family Directed Budget.

Anytime the Financial Support Agency notifies Employers of Record that the Employment Tax or Workers’ Compensation Insurance rates have increased. If this happens, information will be provided about how to do this, and/or a new Auto-Calculator may be provided to the Employer of Record with implementation instructions.

Annually, no later than the time of the Annual Plan development

Prior to requesting a Bonus for an employee

Prior to granting a pay raise for an employee.

When an employee uses overtime that is not budgeted in the Auto-Calculator. Using over-time on a regular basis will likely result in over spending of the Individual and Family Directed Services Budget. This could result in termination from Individual and Family Directed Supports.

Anytime a new Auto-Calculator is issued by the Financial Support Agency

Use of the Back-Up Staffing Agency that was not previously budged in the Auto-Calculator

Training for employees not covered under Employer of Record Expenses that are listed in the Individual Support Plan that was not previously budged in the Auto-Calculator

Bloodborne Pathogen Gloves/First Aid Supplies in Excess of those covered in Employer Expenses that were not previously budged in the Auto-Calculator

Employment Ads that were not previously budged in the Auto-Calculator

Training materials directly related to the training of a habilitation service (does not include personal items) that were not previously budgeted in the Auto-Calculator

Anytime additional benefits are provided to employees that will have an impact on the Individual and Family Directed Budget.

An updated Auto-Calculator must be submitted to the Finance Department and the Financial Support Agency at the following times:

Prior to the first employee starting work for the Employer of Record

Annually, no later than the end of the first month of the Annual Plan implementation

Prior to requesting a Bonus for an employee

Prior to granting a pay raise for an employee.

Using more than 10 days of Overtime that is not previously budgeted in the Auto-Calculator

Anytime the adjusted Auto-Calculator projects that the Individual and Family Directed Supports Budget will be overspent

Anytime a new Auto-Calculator is issued by the Financial Support Agency. The Community Guide assists the Employer of Record in developing, making adjustments to the Auto-Calculator, and submitting Auto-Calculators to the Finance Department. Utilization Management will mandate Community Guide Services for any Employer of Record who does not understand how to use or submit Auto-Calculators as required. Guidelines for Determining Allowable Expenditures


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There are rules that must be followed for using NC Innovations funds. The most basic rules are that everything purchased must be related to the individual’s needs and that the funds are used for services allowed by the NC Innovations waiver. The following are guidelines for determining allowable expenditures in Individual and Family Directed Supports:

The expense is related to the Individual’s disability needs.

The expense must only be for the waiver participant.

The expense is needed to maintain the health, safety and well-being of the Individual.

The expense is not covered by another funding source.

The expense is directly related to a service in the current ISP.

The expense is the actual cost of the item after all applicable credits, including refunds, rebates, and discounts.

Any service provided out of state must receive prior approval by the Utilization Management Department. The form is located in Appendix K.

The expense is not associated with any room and board charges.

The expense is adequately justified.

Payment is not made directly to the individual, Employer of Record, Representative, or family but to the person or business providing the service, supply, or other item.

The expense is not prohibited under other federal, state, local, and/or Cardinal Innovations laws or regulation.

Reminder: Examples of items that cannot be paid from NC Innovations Funds

Gifts for or loans to workers, family, or friends

Rent or mortgage payments

Payments for someone to be the Representative

Clothing except as specified in the Assistive Technology Definition

Alcoholic beverages and/or tobacco products

Televisions, radios, DVD/VCR Players, MP3 players, game systems

Services that are available without charge from community organizations

Items that are illegal


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10. Service Documentation Employers of Record are required to have employee’s document services following State established criteria. Services must be documented prior to submitting time and billing claims to the Financial Support Agency. The documentation is stored in the individual/family home, and must be maintained in a secure location. The minimum service documentation requirements for services provided through the NC Innovations Waiver are contained in this Chapter and the DMH/DD/SAS Records Management and Documentation Manual 45-2. A Community Guide can provide information about documentation requirements and assist the Employer of Record in locating this document on the DMH/DD/SAS website, or ordering a hard copy of the Manual. The Quality Management Training provides information and answers questions about documentation requirements. Role of the Community Guide A Community Guide or Community Guide Agency provides a start-up lock box containing documentation forms to the Employer of Record. The lock box is a secure place to maintain service documentation. If the Employer of Record wants to use a different format for documentation than the one approved by Cardinal Innovations, the Employer of Record must obtain approval from the Quality Management Department prior to using the form. The Employer of Record must also supply these different forms for employee use. The Community Guide Agency only provides approved Cardinal Innovations forms to the Employer of Record. It is extremely important that the Employer of Record monitor all service documentation by direct service employees. Employer of Record Responsibilities The Employer of Record must maintain the following documentation:

The Individual Support Plan (ISP) and all revisions to the ISP, including long-range outcomes, the Individual Budget and all revisions to the Budget

Short-Range Goals to meet long-range outcomes

Strategies for completion of Outcomes/Goals in the ISP

Any related correspondence from Cardinal Innovations

Required Service documentation Short-Range Goals and Strategies The Employer of Record and/or Representative are responsible for developing and implementing short-range goals and task analyses/strategies for achieving long-range Individual Support Plan outcomes. Community Guides train Employers of Record on development of short-range goals and task analysis/ strategies. Short-range goals are steps taken to achieve the long-range outcomes. They are statements describing a proposed behavior, or what the participant will do. Short-range goals are based on wants/needs of the participant. They are based on the individual’s preferences or needs, not staff convenience or preference. A strategy is a long-term plan of action designed to achieve a particular outcome. Strategies are used to make a problem easier to understand and solve. A strategy is adaptable rather than a rigid set of instructions, for example to assist a participant with behavioral issues. A task analysis is a process for determining in detail the specific behaviors required of staff to assist the individual with the implementation of an outcome. Task analysis includes a detailed description of any unique factors involved in or required for one or more people to perform a given task. For example, a task analysis would be used to assist an individual with a specific daily living skill.


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Short-range goals, strategies and/or task analysis must be in place prior to service delivery. This includes having the signature of the individual and/or legally responsible person for initial plans and all updates prior to implementing the goals. If a signature page is developed for the strategies or task analysis, this signature page could serve as the signed document and therefore each page of the strategies or task analysis would not require a separate signature. Types of Documentation There are two types of documentation that are used in Individual and Family Directed Services: Service Notes and Service Grids. Service Notes For Service Note requirements, the Employer of Record refers to the DMH/DD/SAS Records Management and Documentation Manual 45-2 (chapter 8 & 9). The following NC Innovations Individual and Family Directed Service require a service note, which includes items 1 through 13, under Contents of a Service Note, Chapter 8 of the DMH/DD/SAS Records Management and Documentation Manual 45-2:

Community Guide

Individual Directed Goods and Services (required for service component)

Natural Supports Education

Service Grid For Service Grid requirements, the Employer of Record refers to the DMH/DD/SAS Records Management and Documentation Manual 45-2 (chapter 8 & 9). A service grid should include all elements 1 through 10, under Required Elements of a Service Grid, Chapter 8 of the Record Management and Documentation Manual. A service grid shall be completed daily or per activity to reflect the service provided and may only be used for the following Individual and Family Directed Services:

Community Networking

In-Home Intensive Support Services

In-Home Skill Building

Personal Care Services

Respite Care

Supported Employment Signatures All entries in the service record shall be signed with a full signature. A full signature is to include the credentials, degree or licensure for professional staff or the position of the individual who provided the service for paraprofessional staff. Please refer to the DMH/DD/SAS Records Management and Documentation Manual 45-2 (chapter 9) for signature requirements. Frequency of Service Documentation All NC Innovations services require a daily or per activity service note or grid. The person who provided the service shall write and signed the service note or grid. The service note or grid shall be documented on the day that the service was provided or no later than the next work day. If a service or grid is not documented on the day the service was provided, it shall be considered a “late entry”. The entry shall be noted as a “late entry” and at a minimum the date the documentation was made and the date for which the documentation should have been documented, for example, “Late Entry made on 2/15/12 for 2/14/12.” The late entry must include a dated signature. (See Corrections in the Service Record below for information about late entry timelines for billing purposes.)


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Service notes shall be made at the frequency necessary to indicate significant changes in the individual’s status, needs, or changes in the Individual Support Plan. Corrections in the Service Record Changes or modifications in the original documentation for the purpose of making a correction can be made at any time, when appropriate. Whenever corrections are necessary in the individual’s record, service providers should refer to the procedures as noted in the DMH/DD/SAS Records Management and Documentation Manual 45-2 (chapter 9). However, for quality assurance and reimbursement purposes all necessary documentation or corrections to support billing shall be properly completed within seven (7) working days. Therefore for billing purposes, corrections must be made within the prescribed timeframes. Progress Summary Employers of Record are required to complete progress summaries for habilitation services to reflect the individual’s progress toward the short-range goal and long-range outcomes that have been implemented in the Individual Support Plan for the following services: Community Networking, In-Home Intensive Supports, In-Home Skill Building, and Supported Employment. The Progress Summary shall contain at a minimum:

The individual’s name

Date of the quarterly review an dates that the review covers

The goals reflected in the current Individual Support Plan

Progress towards goals

Recommendations for continuation, revision, or termination of an outcome

Signature of the individual who completed the review. The Progress Summary is completed monthly for the first three months the individual participates in Individual/Family Directed Supports and then quarterly thereafter. The quarterly progress summary is documented within seven (7) working days of the close of the quarterly progress period. If a quarterly progress summary is not documented within seven (7) working days of the close of the service period, it shall be considered a “late entry.” The documentation shall be noted as a “late entry” and includes the date the documentation was made and the date when the documentation should have been entered. For example, “Late Entry made on 4/21/12 for 3/31/12.” The Employer of Record is responsible for using the documentation from employees and writing and signing a note that outlines the individual’s progress during that service period. Specific Service Documentation Community Guide Maintain service notes signed by the individual providing the service that documents the date of the service, the amount of time involved in the service and a description of the activities related to the Long Range goals and short range goals. A daily per event service note should be completed. Community Networking

Maintain service note or grid signed by the individual providing the service that documents the date of the service, the amount of time involved in the service and a description of the activities related to the long-range outcomes and the short-range goals.


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For conferences, classes, and related materials purchased in conjunction with these an invoice will be required.

For Community Networking Transportation that is not part of the provision of a staffed service with an established per trip rate, maintain a record with a signature of a representative providing the transportation.

For Community Networking Transportation that is not part of the provision of a staffed service with a per mile charge, maintain a record that documents the date service was provided, the specific activity that the person is being transported to/from, and the mileage related to the transportation of the person. The person providing transportation shall sign the record.

Individual Directed Goods and Services An invoice from the supplier that shows the date the Good was provided to the Individual, and the cost including related charges (for example, applicable delivery charges) shall be maintained by the Financial Support Agency. Services will require a service note signed by the individual providing the service that documents the date of the service, the amount of time involved in the service and a description of the activities related to the long-range outcomes and the short-range goals. In-Home Intensive Supports Maintain service note documentation signed and dated by the individual providing the service that documents the date of the serve; the amount of time involved in the service, and a description of the activities related to the Long Range goals and short range goals, personal assistance activities, and transportation provided to the person. In-Home Skill Building Maintain service note documentation signed and dated by the individual providing the service that documents the date of the service, the amount of time involved in the service and a description of the activities related to the long-range outcomes and short range goals, and transportation provided to the Individual. A grid may be used to document this service. Natural Supports Education Maintain service note signed by the individual providing the service that documents the date of the service, the amount of time involved in the service and a description of the activities related to the long-range outcomes and the short range goals. For conferences and classes and related materials purchased in conjunction with these an invoice will be required. Personal Care Services Maintain service note documentation signed and dated by the individual providing the service that documents the date of the serve; the amount of time involved in the service, and a description of the activities related to the Long Range goals and short range goals, personal care activities, and transportation provided to the person. Respite Services Documentation shall be documented on a daily basis, and the documentation must contain the following components: Name of the individual, the record number, the service provided, the date of service, duration of service, task performed including comments on any behaviors, which are considered relevant to the individual’s continuity of care, that special instructions were followed, and signature of the individual providing the service (initials if the full signature is included on the page when the use of a grid is used for documenting). A grid may be used to document this service.


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Supported Employment Maintain service note documentation signed and dated by the individual providing the service that documents the date of the service, the amount of time involved in the service and a description of the activities related to the long-range outcomes and short range goals, and transportation provided to the Individual. A grid may be used to document this service. General Records Administration Employers of Record will make service documentation available to the Care Coordinator, Cardinal Innovations staff, DMH/DD/SAS, DMA, and/or CMS to review the documentation to support a claim for NC Innovations services rendered, when requested. Records must be accessible for inspection, and must be brought to a designated location for review when requested by the Quality Management Department, State of North Carolina, and/or Federal Government. How Long Records Must Be Kept Employment related documentation must be kept for at least five years after the employee ends employment with the Employer of Record, and until all outstanding lawsuits, claims, and audits are resolved. Service specific documentation must be maintained by the NC Innovations Employer of Record for 11 years after the date of the last encounter or for minors, 12 years from the 18th birthday. All participant specific documentation must be given to the Quality Management Department if a Participant is terminated from the NC Innovations Waiver or from the Individual and Family Supports Option. Records must be brought to the Quality Management Department within 30 Days of termination


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11. Quality Assurance and the Employer of Record Model The Employer Handbook contains information about Quality Assurance in Individual and Family Directed Supports. This Chapter provides additional information to complement that Chapter related to the implementation of Quality Assurance practices. Problems and Complaints Related to Work with the Financial Support Agency For problems identified related to an Employer of Record’s work with the Financial Support Agency, the following process is followed:

Problem is identified. For any unsigned forms or incorrectly completed forms, or other type of problem, the Financial

Support Agency makes one additional request to the Employer of Record for completion/correction. This includes time sheets and billing forms. If the problem is not corrected, the Community Guide is notified. If there is no Community Guide, the Care Coordinator is notified.

The Community Guide assists the Employer of Record in resolving the issue. If the Financial Support Agency believes that a Procedure should be changed or modified for an

Employer of Record, Finance must be consulted prior to making that change or modification. Both the Financial Support Agency and Community Guide Agency document the problem, with the

Community Guide Agency documenting the outcome of the Community Guide’s intervention with the Employer of Record.

If the same form or type of form is unsigned or incorrectly completed a second time, or other type of problem the Financial Support Agency reports the issue to the Community Guide.

The Care Coordinator is also notified of the problem and that this is the second time the issue has been reported to the Community Guide.

The Community Guide assists the Employer of Record in resolving the issue and notifies the Care Coordinator of the resolution of the issue.

The Financial Support Agency, the Community Guide and the Care Coordinator document the problem, with the Community Guide Agency documenting the outcome of the Community Guide’s intervention with the Employer of Record.

If the same form or type of form is unsigned or incorrectly completed a third time or other type of problem identified a third time, the Financial Support Agency reports the issue to the Community Guide.

The Care Coordinator is also notified of the problem and that this is the third time the issue has been reported to the Community Guide.

The Community Guide assists the Employer of Record in resolving the issue and notifies the Care Coordinator of the resolution of the issue.

The Care Coordinator notifies Quality Management. Quality Management investigates the issue. Depending on the investigation results, Quality Management follows up. Actions may include:

Required Plan of Correction. The Community Guide assists the Employer of Record in developing and implementing the Plan of Correction.

Recommendation for additional training by the Community Guide. Recommendation to Utilization Management for mandated Community Guide Services or

appointment of a mandated Representative.


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Recommendation for change of Individual/Family Directed Services model or return to Provider Directed Services. NC Innovations waiver processes are followed, including consultation with the Division of Medical Assistance.

For complaints by an Employer of Record or Representative, the Financial Support Agency reports all concerns and complaints to the Care Coordinator.

The Care Coordinator responds to the issue, involving the Community Guide, Community Partners, Utilization Management, Medicaid Program Department, and/or Quality Management as needed.

If other Departments receive complaints or identify concerns, Care Coordination is notified. The Care Coordinator follows up with the Employer of Record as needed.

Plans of Correction Plans of correction are helpful when mistakes occur for the first time, are due to misunderstandings, and can be corrected. An example of using a plan of correction to address minor problems might be not submitting time sheets by the deadline for payroll. More serious problems include overspending the budget and not having adequate funds to meet payroll or lack of documentation for services provided by an employee. A plan of correction may be as simple as requiring an Employer of Record to discuss issues with a Community Guide. Or, a plan of correction may be more detailed and prescriptive such as requiring an Employer of Record to spend a certain amount of the budget on staff training. If additional Community Guide services are needed, the Quality Management will involve the Care Coordinator who prepares an Individual Support Plan revision and submitting it to the Utilization Management Department for approval and authorization. A format that can be used in submitting a plan of correction is located in the Employment Tips and Resources. Incident Reports Incident Reports must be completed and submitted to the Quality Management Department as required by State Rule. The procedures for reporting incidents are located in Appendix R. The Back-Up Staffing Incident Reporting Form is completed and submitted to the Quality Management Department any time the Individual does not have paid back-up staff. The Employer of Record, or Representative, as needed, indicates how the Individual’s needs were met in the absence of paid staff. (See Chapter 7 for further information about the Back-Up Staffing Incident Reporting Form, and Appendix E for a copy of the form.) Incident Forms are included in the Employers box that is obtained from the Community Guide or the Community Guide Agency. The Quarterly Incident Report Form is submitted by the Employer of Record to the Quality Management Department. Annual Reviews Cardinal Innovations will also conduct an annual review of services provided under the Individual and Family Directed Supports Option. The Employer of Record is notified of the scheduled review. Annual Reviews may include:

Interviews

Record reviews (both individual and employee records)

Employee interviews

Incident report reviews

Reviews of training and supervision documentation The Employer of Record is provided a copy of the Annual Review Report.


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Appendices


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Appendix A: Materials in the Employer of Record Notebook Orientation Materials (assist participant in placing these materials in the notebook; Care Coordinator responsible for distribution)

Orientation Booklet

Fact Sheet: Community Guide

Fact Sheet: Financial Support Services

Fact Sheet: Agency With Choice

Fact Sheet: Individual Goods and Services Training Materials

Copies of slides in handout form, 3 slides to a page (distributed during Prospective Employer Initial Module Training)

Red Cross Disaster Preparedness Manual Employer Handbooks

Employer Handbook that includes contact list (distributed during Prospective Employer Initial Module Training)

Employer of Record Supplement Employer Tips and Resources (forms in Tips and Resources are available as separate documents on the password protected web site) Quality Documentation Module/Record Keeping Service Rate Coverage Chart Rate Sheets

Cardinal Innovations

Employer of Record


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Appendix B: Materials for Individual/Family Direction: Employer of Record Box I. Portable File Box (has lock and 2 keys)

Key is numbered and taped to the top of box. Each box has two keys. The other key is maintained by the Community Guide Agency

Box contains 28 Hanging Files with 25 File Folders Placed Inside Each Folder. The Hanging Files are labeled as follows:

# Label on File Form Provided By

1 Applicants Information Gathered on Applicants who are not hired

Employer of Record

2 Back-Up Staffing Incident Reports

Back-Up Staffing Incident Reports

5 copies provided by Community Guide

3 Criminal Background Check Request Results

Results of Criminal Background Checks are filed separately and not included in Employee Personnel Files

Provided by Financial Support Agency

4 DHHS Restrictive Intervention Details Report

DHHS Restrictive Intervention Details Report, blank copies. Completed Reports are placed inside file folder


5 DHHS Incident and Death Report

DHHS Incident and Death Report blank copies. Completed Reports are placed inside file folder


6 Individual Clinical Documentation

Completed documentation forms and other clinical information related to individual service provision

Employer of Record

7 Financial Support Agency Correspondence

Information sent to Employer of Record by Financial Support Agency


8 Financial Support Agreement and Purchase Request Forms

Agreement and Forms provided by Financial Support Agency


9 Employer of Record Monthly Reports

Monthly Employer of Record Report


10 Quarterly Incidents Report

Blank Quarterly Incident Reports; completed copies of Quarterly Incident Reports are placed inside file folder

8 copies provided by Community Guide; Completed Forms by Employer of Record

11 Completed Time and Billing Forms

Copies of Time and Billing Forms Employer of Record

12 Workers’ Compensation Insurance Policy

Copies of Policies Facilitated by Financial Support Agency


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# Label on File Form Provided By

13 Blank Label for Employee Personnel File *

Employee Information Employer of Record







17 Confidentiality Statement

Confidentiality Statement in Tips and Resources


18 Criminal Background Check Request Forms

Criminal Background Request/Release Form


19 Documentation Forms Documentation Forms Copies provided by Community Guide

20 Employee Support Agreement

Employee Support Agreement in Tips and Resources


21 Employment Application

Employment Application in Tips and Resources


22 Evaluations Evaluations in Tips and Resources


23 Hepatitis B Notification Notification in Tips and Resources


24 Job Description Developed by Employer of Record

Employer of Record

25 Reference Release Checks

Reference Release Check in Tips and Resources


26 Supervision Log Supervision Log in Tips and Resources


27 Time and Billing Forms Blank Time Sheets and Billing Forms (may submit electronically per Financial Support process)

FS Agency

28 Training Documentation

Obtained by Employer of Record Employer of Record

II. 1 ½ inch 3-ring binder (labeled Emergency Info) (burgundy) III. 1 folder with tangs (labeled Goal Sheets)


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Appendix C: Employee Qualifications and Training Checklist

Employee ________________________________________ Employer ________________________________________ Date _____________________

Requirement Hiring

Requirement Before Work Begins

When Work Starts

On-Going

A copy of a job application signed by the employee with a statement that the it is true/accurate

Initially one time document

Copy of a High School Diploma/GED

x Initially one time document

Documentation that the employee is at least 18


Verification that the employee has not been excluded from participation in Medicaid/Medicare Programs: Question on the application or check the Office of the Inspector General website


Criminal record check that shows no conviction that would present health/safety risk to Individual

x Initially prior to working with consumers Updated as specified in ISP

Healthcare Registry checks with no substantiated findings of abuse or neglect.

x Initially prior to working with consumers

Service Specific Requirements as Specified in NC Innovations Technical Manual

x As required

First Aid x Every three years

CPR x Annually or for a period of time as specified on card/certificate

Orientation to Employer’s Expectations

x Initially upon hire


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Requirement Hiring Requirement

Before Work Begins

When Work Starts

On-Going

Medication Administration if employee is administering medications

x-Before administering medications

Initially upon hire; updated as needed to address medication changes

1. Alternatives to Restrictive Interventions or Positive Behavior Support Training. Ex; NCI Part A; Getting it Right. 2. Restrictive Intervention Training if listed in PCP or Crisis Plan. Ex: NCI Part B; PMAB.

x Annually following an approved curriculum

Service/Documentation x Initially upon hire

Client Rights x Initially upon hire

Confidentiality x Initially upon hire

Blood borne Pathogens x Initially upon hire and annually within 12 months from the initial/last date of Blood borne Pathogens training

Customized Needs of Individual as specified in ISP

X Per Employers preference and Updated as specified in ISP as needs change

Employee Support Agreement x Initially upon hire; updated as needed

Supervision Plan x-Within Employee Support Agreement

Per Employers preference and Updated annually

Documentation of Supervision Consistent with frequency outlined in Supervisor Plan

Evidence of Liability Insurance if transporting consumers

x As needed based on expiration date of insurance policy


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Appendix D: Documentation Forms Goal Sheet Date:

Goal Number

Signature Intervention Key Duration

Key Identifier: 1) Y=Yes, N=No 2) + = completed, - = did not complete 3) I = Independent, VP = Verbal Prompt, PP = Physical Prompt Additional:


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Goal Sheet Date: _______________________

Goal Number

Goal Key Target Date


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Monthly/Quarterly Progress Summary

Instructions For each entry include goal number, key, signature, duration and comment (if needed). If pages are not dated, include date.

Goal Number

Review Date

Justification of continuation/discontinuation of goals Target Date


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Short-Range Goal for Self-Directed Service Note: All Short-Range Goals must relate back to a Long-Range Outcome in the Individual Support Plan (ISP)

Self-Directed Service (* Tip: List the self-directed service this specific goal is for)

Goal Statement (* Tip: Goal statement must be measurable. It should be very clear what skill is being worked on and what criteria will be met in order for it to be achieved)

Start Date for Goal (* Tip: Goal must be developed/in place before any billing occurs for that goal. Date must include month/day/year.)

Target Date for Goal (* Tip: This is the date you anticipate goal will be met/cannot exceed one year from start date or end of plan year, whichever occurs first. Date must include month/day/year.)

Strategies/Interventions/Task Analysis to Meet The Goal (* Tip: This is the intervention the staff member should provide to meet the goal. For supportive services such as Respite, general strategy statements are sufficient. For habilitative/training services such as In Home Skill Building, a more in-depth task analysis is indicated. Attach an additional sheet if needed)

Signature:_____________________________________________ Date: ________________ (Legally Responsible Person) (* Tip: The Legally Responsible Person’s signature must be obtained/dated on or before the start date for the goal)


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Appendix E: Back-Up Staffing Incident Reporting Form

Consumer’s Name: _______________________

Consumer DOB: ________ County of Service Provision: ________

Date of Incident: ___________

Time of Incident:____ __AM __PM

Location where services were scheduled to occur: ___________________ Name of person(s) who discovered issue: _______ Name of Provider Agency: ________________________ Provider Agency Address: ________________________

Contact Number: ____________

Name of Provider to provide staffing: _________________

Contact Number: ____________

____Back-up staffing not available (as applicable) Indicate name of service(s): _______ Indicate the number of hours consumer was without staff: _______ Indicate specific reason back-up staffing was not available: _______ What options were provided to the consumer/legally responsible person? ________ Who was notified of the incident (list names)? _________ How was the consumer’s health and safety ensured? ________ How was time covered? ________ What follow-up was provided to consumer/legally responsible person? _________ What corrective measures will your agency implement to prevent this from occurring in the future? _____ ___Back-up staffing offered but declined by consumer/legally responsible person (as applicable) Indicate name of service(s): _______ Indicate the number of hours consumer was without staff: ______ Indicate reason consumer/legally responsible person declined back-up staffing: ______ Who was notified of the incident? ________ Signature/Credentials of person completing form: ____________________________________ Date: ____________


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Supervisor Action: ____Action Pending ____Action Complete _________________________________________________________________________________ ______________________________________________________________________________________ Signature/Credentials ___________________________________________________________ Date: ____________ Quality Management Action: ___Action Pending ___ Action Complete ________________________________________________________________________ ________________________________________________________________________ Signature/Credentials ______________________________________________________ Date: ____________


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Appendix F: Employer of Record Expenditure Coverage Chart

Monthly Financial Support Individual Maintenance Fee

Financial Support Employer Related

Expenses

Cardinal Innovations Covered Employer

Expenditures

Service Rate *** See Rate Sheet for

Covered Services

NOT Included in Auto-Calculator



Included in Auto- Calculator

Code: T2025U1 Code: T2025U2 N/A Code: See Rate Sheet

Rate: $ 175 per month Rate: Invoice N/A Rate: See Rate Sheet or Invoice as appropriate

Add-On to Base Budget; counts towards Waiver Cost Limit

Add-On to Base Budget; counts towards Waiver Cost Limit

No Charge to Budget/ does not count towards Waiver Cost Limit

Counts towards Individual/Family Directed Budget and Waiver Cost Limit

New Employer Packet One time New Employer Set-Up: $75

Time and Billing Sheets Employee Hourly Wage (at least minimum wage)

Agency Brochure Training for new employees: CPR

Incident Report Forms Employment Taxes

Financial Support Services Agreement and Amendments

Training for new employees: First Aide

Documentation and other forms provided to Employers

Overtime pay

Copies of employee criminal record check forms with return stamped envelopes

Training for new employees: Blood borne Pathogens

Retainer fee for the Back-Up Staffing Agency

Benefits provided to employees: paid vacation or sick leave, holiday pay or differential pay, bonuses, insurance premiums, etc. determined by employer

Stamped Envelope to Return New Employer/Employee Packets

Training for new employees: Medication Administration

Employer of Record training materials and modules

Workers Compensation Insurance

Processing New Employee Hire Packets

Start-Up Supplies: one box of gloves

Notebooks and Manuals Use of Back-Up Staffing Provider Agency: cost is the maximum allowable rate for the service provided by the back-up staffing agency

Payroll set-up Start-Up Supplies: one CPR mask and one first-aid kit

File box with folders to keep individual documentation/ personnel information

Other liability insurance directly related to self-direction (optional; requires invoice)

Payroll processing, quarterly payroll tax filings

Applicant Background Checks

Bloodborne Pathogen Gloves/First Aid Supplies in Excess of those covered in Employer Expenses (requires invoice)


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Monthly Financial Support Individual Maintenance Fee

Financial Support Employer Related

Expenses

Cardinal Innovations Covered Employer

Expenditures

Service Rate *** See Rate Sheet for

Covered Services




Included in Auto- Calculator

Monthly Report to Employer

Employee training not covered under Employer of Record Expenses (requires invoice)

Processing invoices/checks for Goods and Services/other items authorized by Employer

Employment Ads (optional; requires invoice)

Filing claims for services authorized by Employers

Hepatitis B Vaccinations for employees (requires invoice)

Stamped envelopes addressed to Financial Support Agency for use by Employers to return time sheets

Training materials directly related to the training of a habilitation service (does not include personal items; requires invoice )

1 box of standard file folders (not to exceed 100) once folders provided under Employer Expenditures is exhausted (optional; requires invoice)

Gloves after the start-up supply box is exhausted, as needed (requires invoice)

Filing cabinet once initial File Box provided under Employer Expenditures is full (optional; requires invoice)

*Worker’s Compensation Insurance must be in place before training fees are authorized for new employees and/or new employees begin work *Invoices are submitted to Financial Support Agency Payments will not be made for the following (this list is not exhaustive):

Fax Machines

Computers, Printers, and/or Internet Fees

Telephone Fees

Any other item listed as not covered in the Employer Handbook

Printer or copy machine cartridges

Items that are covered under a North Carolina Innovations Service definition


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Understanding the Employer of Record Expenditure Coverage Chart 1. Monthly Financial Support Individual Maintenance Fee Definition: This is the monthly fee paid to the Financial Support Agency to cover the cost of providing Financial Support Services on behalf of Employers of Record. In Provider Directed Services, these expenditures are paid out of the service reimbursement rate.

Financial Support Services Fees are considered an “Add on” to the Individual Base Budget The Care Coordinator includes theses fees in the Individual Support Plan and Individual Budget This fee is not budgeted in the Auto-Calculator This fee does count towards the overall waiver cost limit.

Approval Required: Utilization Management approves one unit of service per month for each individual participating in Individual and Family Directed Services, Employer of Record Model 2. Financial Support Employer Related Expenses Definition: These are basic Employer of Record start-up and required expenses. These expenses are included in the Individual Budget. In Provider Directed Services, these expenditures would be paid out of the service reimbursement rate.

These expenses are not budgeted in the Auto-Calculator. The Employer of Record Financial Support Services Fees are an “Add on” to the Individual Base Budget.

The Care Coordinator includes these in the Individual Support Plan and Individual Budget. These expenses require approval by Utilization Management. This fee does count towards the overall waiver cost limit.

Approval Required: Utilization Management approves these expenses, as needed. 3. Cardinal Innovations Covered Employer Expenditures Definition: These are expenses that are paid for out of the administrative portion of the service rate. These expenses are not billed to an NC Innovations service. The Community Guide Agency provides these materials to the Employer of Record. In Provider Directed Services, these expenditures are paid out of the service reimbursement rate.

These expenditures are not budgeted in the Auto-Calculator These expenditures do not count towards the Waiver Cost Limit.

Approval Required: None 4. Service Rate A. Individual and Family Directed Services Budget Revenues (the money available by Individual and Family Directed Supports billed by the Financial Support Agency) Definition: The hours of service for each service to be self-directed multiplied by the Individual and Family Directed Rate for each service.


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Points to remember:

The Individual and Family Directed Rate is the maximum hourly Medicaid rate on the Cardinal Innovations Employer of Record Fee Schedule for each service.

The Community Guide provides the current Individual and Family Directed Supports Employer of Record Rate Sheet to the Employer of Record.

The service must be provided as approved in the Individual Support Plan and billed to be counted as revenue for the Individual and Family Directed Budget.

The Auto-Calculator is used to assist Employers of Record in budgeting revenues and expenditures. The Community Guide assists the Employer of Record in submitting the Auto-Calculator to Finance at required intervals as described in Chapter 9.

The Community Guide also assists the Employer of Record in signing a print out of the Auto-Calculator and submitting it to the Financial Support Agency.

Employers of Record must document why a service was not provided as written in the Individual Support Plan, and report via the Back-Up Staffing Incident Reporting Form, if needed.

Approval Required: Approval Required: Utilization Management approves the actual Self-Directed (Individual Family Directed) Services. B. Service Rate Expenditures Definition: The expenditures cover the employees’ salaries, benefits, associated taxes, and other expenses needed. The services are included in the Individual and Family Directed Portion of the Individual Budget.

These expenses are included in the Auto-Calculator. Services included are Community Guide Service (only if Self-Directed; do not include if provider directed);

Community Networking; In Home Intensive; In Home Skill Building; Natural Supports Education; Respite, Supported Employment

Approval Required: Utilization Management approves the actual Self-Directed (Individual Family Directed) Services but not the expenses covered under the service rate.


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Appendix G: Cardinal Innovations Healthcare Solutions Procedure: Employer of Record Bonuses If employee bonuses are issued, the funds for paying those bonuses are budgeted in the Auto-Calculator and paid by the Financial Support Agency on behalf of the Employer of Record. When the Employer of Record plans to request that a bonus be issued to an employee, the following process is followed: 1. The Employer of Record reviews the Auto-Calculator to make sure that it is current. The Community Guide participates in the review and updating of the Auto-Calculator. 2. The Review of the Auto-Calculator, at a minimum, ensures that all revenues (units of services billed or planned to be billed) are current. Areas that must be closely reviewed include, but are not limited to:

Service hours: While services are authorized and budgeted at the beginning of the Individual’s Plan Year, services billed could be less than planned. For example if the Individual is sick and does not receive a service, the Auto-Calculator may need to be adjusted.

Overtime pay for employees: If this was not planned, the Auto-Calculator may need to be adjusted.

Use of the Back-Up Staffing Agency: If the Back-Up Staffing Agency has been used, the Auto-Calculator must be adjusted for this because the Back-Up Staffing Agency bills Cardinal Innovations directly rather than being paid by the Financial Support Agency.

3. After reviewing the Auto-Calculator, the Employer of Record includes the amount of the bonus for each employee who is to receive the bonus in the Auto-Calculator, being careful to allow for any potential non-billing of service hours or unanticipated overtime or other unplanned expenditures. 4. The Community Guide submits the Auto-Calculator to the Finance Department on behalf of the Employer of Record. The Auto-Calculator is submitted, allowing at least 30 days prior to the date that the Employer of Record desires for the bonus to be paid so review of the Auto-Calculator by Finance and payment processing by the Financial Support Agency. 6. The Finance Department reviews the Auto-Calculator to the degree that current billing and expenditure information is available. The Finance Department submits the Auto-Calculator to the Financial Support Agency for payment. The Finance Department returns the Auto-Calculator for correction if the Employer of Record has not completed the Auto-Calculator correctly or if the Auto-Calculator indicates that the Individual and Family Budget will be overspent. The Employer of Record may resubmit the bonus request through the Community Guide by correcting the Auto-Calculator. 7. The Employer of Record retains the responsibility for ensuring that all anticipated revenues and expenditures are accurately reflected in the Auto-Calculator and that the Individual and Family Directed Supports Budget is not overspent. 8, The Financial Support Agency processes the request made via the updated Auto-Calculator. If the Financial Support Agency has questions about the request or the amount of funds in the Employer of Record’s account, the Finance Department is contacted. The Finance Department contacts Care Coordination about any issues that require follow-up. Care Coordination contacts the Community Guide Agency working with the Employer of Record as needed.


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9. The Financial Support Agency pays the employee the requested bonus with the next scheduled payroll. Cardinal Innovations is not billed for the amount of the payment because the bonus is paid out of the service funds billed to Cardinal Innovations.


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Appendix H: Employer of Record Checklist: Individual and Family Directed Supports

# Items To Be Completed Date Completed

1 Complete Orientation

2 Inform Care Coordinator of interest in attending training; may need to revise Individual Support Plan to add Community Guide Services to provide Training

3 Attend Individual and Family Directed Services Training and obtain a copy of Training Certificate

4 Make decision to participate in Individual/Family Directed Supports and determine model (Employer of Record or Agency with Choice). Inform Care Coordinator of decisions.

5 Consider if Representative is needed; if needed name Representative, and have prospective Representative attend training, complete Assessments, and sign Agreements

6 Complete Assessments with Care Coordinator

7 Assist Care Coordinator in completing or updating Individual Support Plan to include

Projected Effective Date

Model of Individual/Family Directed Supports

Employee Qualifications beyond required

Involvement of the individual in Individual/Family Supports

Outcomes for Care Coordinator and Financial Support Services

Back-up Staffing Plan

List of emergency plans to be developed by Employer of Record

Services to be self-directed

8 Sign Individual Support Plan and Individual and Family Directed Supports Agreement

9 Obtain copy of approved Individual Support Plan or Revision from Care Coordinator

10 Begin work with Community Guide on new or revised Community Guide goals, training needed to implement Individual and Family Directed Supports, including preliminary work on developing the Auto-Calculator. Community Guide requests auto-calculator from the Financial Support Agency on behalf of the Employer of Record.

11 Decide number of employees needed to deliver services

12 Complete and return information form sent by the Financial Support Agency to pre fill forms in preparation for the start-up or kick off meeting with the Employer of Record and the Community Guide.

13 Participate in meeting with Financial Support Agency and Community Guide to complete forms to set the Employer of Record up with Financial Support Agency (Start Up Package), including developing Financial Support Agreement and obtaining Workers’ Compensation Insurance

14 Finalize Auto-Calculator with assistance of Community Guide and Financial Support Agency. Community Guide submits Auto-Calculator to Finance Department on behalf of the Employer.

15 Sign copy of a print out of the Auto Calculator. Community Guide submits the print out to the Financial Support Agency.

16 Develop short term goals and strategies for long range outcomes in the Individual Support Plan as well as any Emergency Plans needed. Potential Restrictive Interventions are presented to the Cardinal Innovations Client Right’s Committee

17 Financial Support Agency informs Employer of Record that EIN and Workers’ Compensation Insurance has been obtained.


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# Items To Be Completed Date Completed

18 Develop job descriptions and guidelines for employees

19 Recruit (advertise) employees

20 Screen applicants and interview prospective employees

21 Check personal and work references on prospective employees

22 Determine employees that are serious candidates for employment and request Background Checks from Financial Support Agency

23 Review background checks and determine employees that will be hired

24 Offer job to prospective employees

25 Request new employee hire packet from Financial Support Agency

26 Assist employees in completing hire packet and develop an Employee Support Agreement with each employee to include training and supervision plans

27 Return Hire Packet to Financial Support Agency

28 Refer Employees to training and/or train them

29 Develop service documentation forms for employee use

30 Post Emergency contact Numbers

31 Supervise employee, including making sure time and billing are sent to Financial Support Agency

32 Reviews clinical documentation completed by employees

33 Document training that employees receive and supervision of employees, making sure that all parts of Supervision Plan are followed

34 Update Employee Supervision Plan at least annually

35 With Care Coordinator, monitor services provided to the Individual as well as Individual’s health, safety, and well-being

36 Notify Care Coordinator of any needed changes in the Individual Support Plan

37 With Care Coordinator, develop annual Individual Support Plan and Individual Budget

38 Update Auto-Calculator as required or as needed

39 Complete Incident Reports as needed

40 Participate in audits by Quality Management Department, State and Federal government as requested


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Appendix I: Release of Information to Cardinal Innovations

Applicant’s Name_______________________________________ Potential Employee______________________ Position________________ I, ____________________________________ authorize ________________ to release information about me to Cardinal Innovations so that my qualifications can be reviewed to verify that I have met minimum requirements to provide services in the NC Innovations Waiver. I understand that as Lead Agency for the NC Innovations Waiver, Cardinal Innovations will monitor services that are being provided to the individual that I am applying to become a service provider. In addition, my qualifications are subject to review by State and Federal Auditors as well as records I keep, including records of the time I work. Cardinal Innovations and these Auditors are required by law to keep information they review confidential. My Employer will maintain my records for at least five years. The results of my criminal background record check will not be disclosed to Cardinal Innovations, state, or federal auditors. A photocopy of this authorization form shall be as effective and binding as the original. Applicant Signature______________________________ Date__________ Witness Signature______________________________ Date__________


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Appendix J: Employment of Relative/Legal Guardian as Provider

This policy explains how the Employer of Record may apply for approval of certain relatives living in the home of the participant to provide services for the wavier participant.

This policy applies to NC Innovations participants ages 18 and older.

A relative is defined as the individual’s mother, father, step-mother, step-father, sister, brother, aunt, uncle, grandmother or grandfather.

Excluded from providing NC Innovations services are the following relatives: biological or adoptive parents of a minor child, stepparents of a minor child or the spouse of a waiver participant.

The following relatives may provide services (if approved under the conditions of the policy): parents of adult participants who are not the Employer of Record, and other relatives who live in the home of the individual.

The Individual and Family Directed services that relatives or legal guardians may provide are In-Home Intensive Supports, In-Home Skill Building, and Personal Care.

The relative must meet the provider qualifications for the service.

Employers of Record and Managing Employers participating in the Individual Family Directed option may not be employed to provide waiver services.

The ISP contains documentation that the waiver participant is in agreement with the employment of the relative and has been given the opportunity to fully consider all options for employment of non-related staff for waiver service provision.

It is recommended that relatives residing in the home of the recipient provide no more than 40 hours per week of services to the person. If additional hours are requested to be provided by relatives residing in the home of the recipient then justification needs to be provided as to why other providers are not available and assurances of provider choice and that the individual will not be isolated from their community.

The NC Innovations Waiver requires that Cardinal Innovations prior approve any relative as a service provider to make sure the conditions of the Waiver are met. The Community Guide assists the Employer of Record with this process by providing copies of the form, teaches the Employer of Record how to complete the form, and assists the Employer of Record in sending the forms to Cardinal Innovations.

If an Employer of Record intends to hire a relative that was previously approved through employment with a provider agency then the Relative As Provider Application process must still be completed by the Employer of Record and the employee approved by Cardinal Innovations prior to the employee beginning to provide services to the participant under the Employer of Record Model.

The relative or legal guardian will not be reimbursed for any activity that they would ordinarily perform or are responsible to perform.

Services delivered by relatives/legal guardians are monitored monthly. Care Coordinators monitor through on-site monitoring and documentation review to ensure that payment is made only for services rendered and that the services are furnished in the best interest of the individual.

Employers of Record monitor the relative or legal guardian’s provision of the service, on site a minimum of one time per month

Payments are only made for service authorized by Cardinal Innovations in the Individual Support Plan.


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It is mandatory that Employers of Record identify back-up staff for each employee inclusive of Employees under the Relatives/legal guardians as Provider process.

Quality Management monitors employment documentation during on-site reviews or if issues arise. NC Innovations waiver policy is based on Federal requirements.


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Appendix K: Request for Out of State Travel

NC Innovations Waiver Out of State Travel Request Form

Date of Request: ________________ Name of Individual: _________________________________________________ Dates of Travel: From: ____________ To: ________________ Destination: ____________________________________ 1. Natural Supports Traveling with Individual (include relationship to individual): _________________________________________________________________________________ _________________________________________________________________________________ 2. Individual’s Daily Needs: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ 3. Staff Requirements (based on needs above): _________________________________________________________________________________ _________________________________________________________________________________ 4. Why are natural supports unable to meet individual’s needs? _________________________________________________________________________________ _________________________________________________________________________________ 5. What services need to be delivered out of state (must be habilitative service): _________________________________________________________________________________ _________________________________________________________________________________

On what schedule will these services be delivered:

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

If licensed professionals are involved, Medicaid cannot waiver other state licensure laws

Medicaid will not be responsible for room, board, or transportation cost

Provider Agencies must assume all liability for their staff while out of state

Treatment plans must not be changed to increase services while out of state

Respite, based on the defining, would not be an appropriate service since natural supports are present during the travel

By signing below, the Employer of Record agrees with this request and to all above listed conditions: Signature: ___________________________ Date: ______________ Send form to: DD/UM use only: Cardinal Innovations DD/UM Approved 4855 Milestone Avenue Denied Kannapolis, NC 28081 Comments: _______________________________________________ ______________ Reviewer Signature Date

Hou

rs


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Appendix L: Health and Safety Checklist/ Justification for Personal Care/Respite Provided in Direct Service Employee’s Home

Name of Direct Service Employee Location of Service Address City, State, Zip Code Telephone Number at Service Location

Assurance Met Not Met Comments 1. The home is free from any hazards that present a risk to the Participant’s health and safety. Appropriate safety preventive devices are in place to include at a minimum of a smoke detector on each level of the home.

2. Medications, hazardous cleaning supplies, or firearms in the home are kept in a secure (locked) location.

3. Pets that the Participant comes in contact with have up-to-date vaccinations. If the pet presents a risk to the safety of the Participant, the pet must be kept in a secure location, separate from the portions of the home accessed by the Participant.

4. There is an evacuation plan specific to the Participant in the home, and it is tested at least monthly.

5. If the Participant requires adaptive equipment for services and supports provided in the employee’s home, that equipment must be available. Medicaid does not fund duplicate equipment for the purpose of availability in the employee’s home.

6. A criminal background check is performed for any adult who lives in the home, who is present during the time the Participant is receiving services. The results of the background check do not present any safety risk for the Participant.

7. A healthcare registry check is performed for any adult who lives in the home, and who is present during the time the Participant is receiving services. The results of the healthcare registry check do not present any safety risk for the Participant.

The Employer of Record verifies that this information is accurate and has been discussed with the Direct Service

Employee providing Personal Care or Respite in their own home. This checklist is valid for this location only. Services provided are documented in the Individual Support Plan with the Direct Service Employee’s home listed as the

service location.


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Services provided in the direct service employee’s home do not include In-Home Skill Building or In-Home Intensive Supports.

Services provided at this location are based on the documented needs of the Participant, not for the convenience of the employee.

The Individual Support Plan states how the Participant’s needs are better met in the direct service employee’s home. Personal Care/Respite are not billed when the direct service employee is providing direct care to another child or

person. If the direct service employee is providing direct care to another child or person, the Participant’s health and safety must be assured.

The Participant may not clean or perform other household tasks in the direct service employee’s home, including preparing meals for the direct service employee’s family.

Medication administration regulations are followed for any medications that the Participant is assisted in taking. If the Participant has a goal to learn to evacuate the Participant’s private home, that goal must be trained in the

Participant’s home. The Participant and/or Participant’s guardian/family may not be charged for any damage to the Direct Service’s

Employee’s property or any additional charge for the service provided. The issue of liability insurance to cover accidents to/by the Participant is addressed by the Provider Agency.

The NC Innovations Waiver does not pay for room and board costs. The Care Coordinator has access to the service location during hours that services are provided to the Participant for

both announced and unannounced monitoring visits. The Provider Agency will make and document at least one monthly site visit during hours of service provision to make

sure that the services provided are consistent with the Individual Support Plan, and that the environment continues to be healthy and safe for the Participant.

The Provider Agency agrees to immediately notify the Participant’s Care Coordinator if there is any situation that involves the health and safety of the Participant in the Direct Service Employee’s home, including providing the Care Coordinator with a copy of any Incident Report.

___________________________________________ Signature of Direct Service Employee/Date ____________________________________________ _______ _____________________________ Signature of Employer of Record/Date Signature of Participant/Legally Responsible Person/Date

________________________________________ _________________________________ Signature of Provider Agency Signature of Direct Service Representative/Date Employee/Date ________________________________________ _________________________________ Signature of Provider Agency Administrator/Date Signature of Participant/Legally Responsible Person/Date Original Maintained in Agency or Employer Participant File


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Appendix M: Staff Competencies

Staff hired to provide these services prior to the effective of NC Innovations in their Community Operations Center will have six months to meet the designated competences described in this Appendix.

Staff Competencies: Community Guide

Completion of training within one year of date of employment that provides instruction in assisting participants and family members in developing support networks that include natural (unpaid) and other community supports.

Knowledge of and ability to assist the participant in forming and sustaining a full range of relationships with natural and community supports that allows the participant meaningful community integration and inclusion

Ability to provide support to increase the participant’s opportunity to expand valued social relationships and build connections within the individual’s local community

Ability to assist participants in locating and accessing non-Medicaid community supports and resources

Ability to effectively advocate for participants with intellectual and other developmental disabilities and collaborate with legal guardians, family members, service providers, professionals and members of the community on behalf of the participant the community guide is supporting

Ability to assist parents/guardians of participants in Individual Education Plan Meetings , including an understanding of the Individuals with Disabilities Education Act (IDEA)

Knowledge of NC Innovations waiver Goals, Policies and Procedures, including Individual and Family Directed Supports

Understands the role of the Community Guide and the role of the Care Coordinator

Effective interpersonal skills that consistently respect participants and family members and their ability to make choices and take risks

Ability to develop and maintain positive relationships with community agencies, and to guide the participant in making connections in the community

Understands Principles of Self-Determination

Ability to support participants and employers in managing the Participant-directed (Individual and Family Directed) Budget

Ability to train participants, Employers and/or Representatives in Individual and Family Directed Supports

Ability to train and support participants in recommending hiring, managing, and if necessary, recommending firing employees

Ability to train and assist Employers in submission of employee hiring packages

Ability to train and assist Employers in locating resources or developing training for employees

Understands the role of the Agency with Choice, and able to maintain effective working relationships with the Agency with Choice

Ability to assist Employers in developing and/or completing Agreements

Trained or experienced in conflict resolution and/or mediation

Trained in and adherence to NC Client Rights Rules in Community Training, including ability to assist Employers in complying with Client Rights Rules

Trained in Health Insurance and Portability and Accountability Act (HIPAA)

Trained in Cultural Diversity

Ability to work flexible hours to meet the needs of participants/employers


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Staff Competencies Supported Employment

Demonstrates an understanding of the difference between supported employment and traditional vocational services

Demonstrates the ability to identify how support strategies can enhance, or detract from the image of a participant

Demonstrates the rights and responsibilities of participants in supported employment

Demonstrates an understanding of the benefits of integration at the workplace for participants, including maximizing lunch and break times

Demonstrates an understanding of group and individual models of supported employment

Demonstrates the ability to prepare a participant for a job search and maximize participant involvement in that job search

Demonstrates an understanding of legislation and regulations related to supported employment, including the Americans with Disabilities Act, the Rehabilitation Act, Ticket to Work, Individuals with Disabilities Education Act, the Fair Labor Standards Act and other Department of Labor and Internal Revenue Service laws related to employment

Demonstrates the ability to provide prospective employers with information related to employer incentives, including tax and other incentives

Able to appropriately handle employer questions about participant’s disability

Demonstrates the ability to identify and facilitate natural supports within each work site

Demonstrates the ability to assess company culture including architectural, attitudinal and cultural barriers to employment for participants with disabilities

Demonstrates the ability to write accurate job descriptions by identifying the essential and marginal functions of a job

Demonstrates an understanding of job site modifications and accommodations, and can identify resources for those modifications and accommodations

Demonstrates competence in person centered thinking processes

Demonstrates the ability to assess the availability of community transportation and train the participant in using community transportation, as applicable

Understands the impact of participant wages on benefits

Demonstrates the ability to adhere as closely as possible to typical new employee orientation and training procedures

Demonstrates the ability to develop strategies to systematically fade prompts and other forms of assistance

Demonstrates the ability to assist a participant in locating resources and provide other support for developing and operating a micro-enterprise


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Appendix N: Workers’ Compensation Insurance Information

Workers’ Compensation Insurance provides coverage to employees for financial compensation, in particular compensation of loss of wages and sometimes for medical costs, if they are injured or disabled while performing the duties of their job(s). Employers of Record are required to have Workers’ Compensation Insurance. The Financial Support Agency facilitates the application for Workers’ compensation Insurance. The following Frequently Asked Questions provide further information about Workers’ Compensation Insurance: Why do I Need Workers’ Compensation Insurance? You as Employer of Record are responsible for any injuries that may occur while your employees are working. That includes attending training and providing services outside of the home, including after scheduled work hours, if they are performing duties for you as an employer. Having this coverage relieves you of financial liability which would put your home or personal assets at risk. What happens if I terminate from the Employer of Record Model? If you terminate from the Employer of Record Model, you need to contact the Financial Support Agency who will complete a “Cancellation Request” on your behalf. Once the signed request is received by the insurance carrier they will complete a final audit. Who do I contact if I have inquires or need assistance with a claim? If you need to report a claim, you contact the Financial Support Agency for assistance. As the Employer of Record am I insured under the Workers’ Compensation Policy? No, this coverage is only for your employees. If you designate a Representative, the Representative is not covered.


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Appendix O: Employer of Record Task List

MONTHLY TASKS

Employee Supervision

Observe work of employee

Review employee’s documentation (time sheets, service documentation)

Meet with employee and document the supervision

Monthly Expenditure Report Review Monthly Expenditure Report

Time Sheets /Billing Tickets Review and submit Employee Time Sheets and Billing Tickets to Financial Support Agency

QUARTERLY TASKS

Quarterly Progress Summaries

Due by the 7th working day after close of quarter

Required for In Home Intensive, In Home Skill Building, Personal Care, Supported Employment, Community Networking

Emergency Plans Review Emergency Plans and revise as needed

Document review of Emergency Plans

Back-Up Staffing Plan

Review/test the Back-Up Staffing Plan (e.g. make contact with individuals listed, whether paid staff or natural supports, to ensure that they are still available)

If Back-Up Staffing Plan needs to be revised, notify Care Coordinator

Document the review/testing of Back-Up Staffing Plan

ONGOING TASKS

Short-Range Goals for Each

Service

Develop and/or revise short-range goals as needed

All short-range goals must link back to a Long Range Outcome in the ISP and all required elements must be included.

Service Documentation

Ensure that employees are documenting service delivery on the date of the service.

Ensure that all required elements of service documentation are included.

Employee Instruction/Training

Ensure that employees know goals/strategies and that they have access to Emergency Plans, Emergency Numbers, short-range goals and interventions/strategies, Behavior Support Plan if applicable, Crisis Plan if applicable

Ensure that employees receive required/needed training and that this training is documented

Service Delivery/ Documentation of Service

Deviations

Ensure that services are delivered as outlined in the ISP (e.g. number of service units/hours per week)

Document Service Deviations, as applicable (any instance in which service is not delivered at frequency/intensity outlined in ISP)

Incident Reports Submit Incident Reports to Cardinal Innovations Healthcare Solutions as required


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ONGOING TASKS

Employment of Relative/Guardian Living In Same Home as Participant

The Employer of Record cannot furnish a service that is self-directed. If a relative/guardian living in the same home as participant is employed, all requirements related to Employment of Relative/Guardian must be followed.

Delivery of Personal Care or Respite in Worker’s Home

Ensure that a completed "Health & Safety Checklist/Agreement for Personal Care or Respite provided in the Direct Service Employee's Home" is on file if Personal Care or Respite is being provided in the employee’s home

Complete and document monthly site visits to the employee’s home while service is being delivered.


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Appendix P: Job Application for Prospective Employees Date of Application

Name (as it appears on your Social Security Card)

Mailing Address: Street or P. O. Box

City State/Zip Code

Street Address (if different)

City State/Zip Code

Telephone Number Alternative Telephone Number

Are you at least 18 years old? Yes____ No____

State/Month Moved to North Carolina Have you lived in North Carolina continuously during the past five years?

Date Available for Work Days and Hours Available for Work

Type of Work Interested In (check all that apply): ___ Full Time ___ Part Time ___ Backup employee (substitute)

I understand that CPR and First Aid Certifications are a condition of employment. ___Yes ___No

Are you certified in CPR? Yes ___ No ___ Expires on ________

Are you certified in First Aid? Yes ___ No ___ Expires on _________

Have you ever been convicted of a crime, plead guilty, or no contest to a crime, or received deferred adjudication for any offense? Yes___ No___ If so, please explain on back of this form. (A criminal background check must be verified before an offer for employment is made.)

Do you have a valid North Carolina Driver’s License? Yes___ No____

Have you ever been excluded from participation in the Medicaid or Medicare Programs? Yes___ No___

Education: List all diplomas/GED and degrees and name of school, college, or university that you received them. Use additional pages if you need additional space

High School

College/University

List all the jobs you have had beginning with the most recent. Use the back additional pages if you need additional space

Employer Address

Position Dates Employed

Supervisor Telephone Number

Description of Work Duties

Reason for Leaving


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Employment Application Page Two Employer Address




Reason for Leaving

Employer Address




Reason for Leaving

May I contact your current Employer Yes____ No____

List two personal references (other than former Employers) Name and Telephone Number Address

Name and Telephone Number Address

By signing This application I am verifying that the information provided is true and correct to the best of my knowledge. I also acknowledge that a Background Check is required and that some convictions prevent employment. I also acknowledge that if I am hired, I must have and maintain current certification in CPR and First Aid. Signature _____________________________________________ Date __________


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Appendix Q: Employee Support Agreement Employee _____________________________________________________________ Employer of Record ______________________________________________________ Date of Agreement_________________

The Employee agrees to: 1. Perform the duties in this Agreement and any attachments to this Agreement. 2. Maintain required documentation, and agrees that all matters regarding the Individual or matters discussed

with my Employer are confidential. Information will not be disclosed to other persons without authorization from my Employer.

3. Complete all necessary paperwork to secure payroll deductions from my pay. This includes keeping a time and billing forms that must be signed by the Employer and employee, and incident and accident reports. Submission of false information on timesheets, clinical documentation, or other reports could result in criminal prosecution.

4. All records are the property of the Employer of Record and must be returned to the Employer of Record at the time that the employment relationship ends. Records will not be taken from the work site unless authorized by the Employer of Record.

5. To notify ___________________ or their designee, __________________ of any medical emergency or illness. The employee will notify one of them before taking the Individual to the physician, except in case of an emergency.

6. To participate in any meetings requested by the Employer. 7. The employee acknowledges receipt of the employee’s job description and employee guidelines, and agrees

to abide by all rules. The Employee agrees to comply with all policies and procedures of the federal and state Department of Health and Human Services related to the provision of Medicaid Services. These policies can be changed by the state or federal government at any time, including reimbursement rates for services that could change employment or salary terms.

8. The first 30 days of employment are a trial period to determine if the relationship is working for both parties. I understands that this is an employment “at will relationship”, which can be terminated by either party, at any time. I agree to give 10 days written notice to my Employer if this Agreement is to be terminated. My Employer will immediately terminate this agreement and employment if I habitually neglect duties or if my actions present a threat to the health or welfare of the Individual. My Employer may give me 10 days written notice of termination unless this it is determined to be a health and safety situation which will result in immediate termination.

9. I understand that a Financial Support Agency will process my paycheck. Only my Employer has the authority to authorize my paycheck. If I am overpaid, I must reimburse the Financial Support Agency for the overpayment.

10. The first 30 days of employment are a trial basis and that employment may not continue after this time period.

11. As compensation for services rendered, I will receive a salary of $______ per hour as gross wages, which shall be paid_____________ (frequency). Payment of wages will be made _________days after the close of the pay period. The Financial Support Service provider will withhold and remit the appropriate federal and state required taxes. Other deductions include: FICA, FUTA, SUTA, Workers Compensation and __________________. A W-2 statement for the previous calendar year will be supplied to the employee no


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later than January 31. 12. I will be paid time and a half for any hours worked over 40 per week. The time is calculated from hours

worked from Sunday thru Saturday. My Employer or their representative must specifically authorize overtime pay.

13. No gifts may be made or accepted from the individual supported, the family of that individual, or the individual’s guardian or Representative.

14. Performance reviews will be given once each ______. 15. I agree to reimbursement of ____ per mile when asked to use my personal vehicle to perform job duties as

directed by my Employer. I agree to keep an accurate record of mileage incurred, and to abide by all traffic and driving-related laws of the State of North Carolina, including proper use of seat belts at all time. I will provide adequate insurance on my vehicle. (If the Employer supplies a vehicle, the Employer will provide adequate auto insurance for vehicle to be used; furthermore, the Employer will provide proof of such insurance on the vehicle.) I must maintain a NC Driver’s License to keep my job. Travel from home to work and back again or to other assignments not related to work for Employer will not be reimbursed. I understand that meals or admission tickets will not be reimbursed.

16. I recognize that employment is conditional on my Employer’s participation in NC Innovations Waiver, Individual and Family Supports Option. If the Employer no longer participates in the Option, I may no longer be employed.

17. My Employer has authorized _______________________ to act on all supervisory matters.

The Employer of Record agrees to the following: 1. Keep all information about my employee confidential, and to release it only upon the consent of my

employee. 2. Pay the employee (through the Financial Support Agency) the salary and benefits described in this

Agreement. 3. Provide or arrange required and appropriate training to/for the employee. 4. Evaluate the performance of the employee, and provide appropriate feedback to assure that the Individual

being supported receives quality services.

If there are disputes about this Agreement, they must be addressed by the Employer of Record. A complaint may also be filed by the Employee with Cardinal Innovations Healthcare Solutions. However, Cardinal Innovations Healthcare Solutions is not the Employer. We agree to the terms of this agreement. Employer of Record’s Signature______________________________________________________ Date___________________________ Employee’s Signature______________________________________________________________ Date___________________________ Representative’s Signature, if applicable_______________________________________________ Date____________________________


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Attachment A:

Employee Schedule:

Start Date: __________, 20__. Days/Hours of Employment: The employee shall work the following schedule: Friday _____ to _____ Tuesday _____ to _____ Saturday _____ to _____ Wednesday _____ to _____ Sunday _____ to _____ Thursday _____ to _____ Monday _____ to _____ Total hours week ________ Absences/Tardiness: In the event the employee is unable to work at a scheduled time due to illness or other legitimate reason, employee shall give Employer _____ hours advance notice. In case of an emergency or tardiness, employee shall notify Employer as soon as possible. Scheduled Holidays that I will not be expected to work: _____________________________________________________________________ _____________________________________________________________________ Vacation Days With Pay: _________ Vacation Days Without Pay: ______ Sick Days With Pay: _____________ Holiday Days With Pay: ________ Holiday Pay Rate: (specify holidays): ______________________________________


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Attachment B:

Employee Training and Supervision Plan

Training that must be completed before the employee provides services to the individual the individual is supporting:

CRP

First Aid

Blood borne Pathogens Other training that must be completed with expected completion date: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ The above training will be arranged by the Employer of Record at no cost to the employee. The employee will be paid during the actual hours of training attendance (minus any time off for lunch). The employee will not be paid mileage for driving to the training, as this will be the employee’s assigned work site for the day. Failure to attend training will be grounds for dismissal. A training certificate must be returned to the Employer of Record to verify attendance. Other training may be required by the Employer of Record to keep CPR and First Aid certifications current, or as needed in order for the employee to perform job duties. The plan for supervising the employee is:

Observing the work of the employee at least monthly

Reviewing the Time and Billing Forms completed by the employee

Reviewing the employee’s documentation at least monthly

Meeting with the employee at least monthly

Documenting the supervision in the Supervision Log in the employee’s file.

cc: Employer Employee


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Appendix R: Cardinal Innovations Healthcare Solutions Incident Reporting The North Carolina Administrative Code requires Cardinal Innovations Healthcare Solutions to receive, review, and follow-up on reports of Level II and Level III Incidents that occur in provider agencies. This includes Incidents that occur in services provided under the Individual and Family Supports Option. Incidents are reviewed to ensure that appropriate preventions and interventions are put in place for Individual’s in relation to serious occurrences.

Definitions (all definitions are based on NC Administrative Code definitions) Incident: Any happening which is not consistent with the routine operation of a facility or service or the routine care of an Individual and that is likely to lead to adverse effects upon an Individual. Level 1 Incident: Any Incident that does not meet the requirements to be classified as a level II or Level III Incident. Level 2 Incident: An Incident that results in an Individuals health or safety or a threat to the health and safety of others due to the Individual’s behavior. Level 3 Incident: Any Incident that results in death or permanent physical or psychological impairment to an Individual; a death or permanent physical or psychological impairment caused by an Individual; or a threat to public

safety caused by an Individual. Restrictive Interventions: Restrictive Intervention: Report any restrictive intervention that is:

a. used in an unplanned, emergency situation (i.e. not part of the individual’s service plan) b. planned, but administered improperly or without proper authorization by staff without proper training or for

longer than the authorized time c. planned but resulting in discomfort, complaint, or injury requiring treatment by a licensed health professional

Please note the following:

a. Type(s) of intervention: If more than one intervention is used number in order of use b. Appropriate administration: Answer “Yes” if the restrictive intervention is administered by a person without

current training certification for more than the authorized time and/or in an unauthorized manner c. Discomfort, complaint or injury: If the individual requires treatment beyond first aid by a licensed health

professional due to discomfort, complaint or injury or if anyone alleges abuse of the individual answer “Yes”.

Level I Incidents These Incidents are documented within the Employer of Record’s forms, procedures and timelines. Employers of Record or Representatives must have a form to record Level I Incidents on file that includes directions for reporting and timelines for reporting. These reports must be kept on file, and give to the Quality Management Department if the Employer is no longer participating in the Individual or Family Supports Option. If a Level I Incident occurs, the Employer or Representative must:

Attend to the health and safety of the Individual

Analyze the causes of the Incidents

Correct issues/processes that contributed to the Incident

Review Incidents to identify/develop preventive measures for similar Incidents

Keep records about the analysis, corrective action, and preventive measures taken.


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Complete the Quarterly Incident Report and submit it to the Quality Management Department by the following dates: January-March: due to Quality Management on April 10th April-June: due to Quality Management on July 10th July-September: due to Quality Management on October 10th October-December: due to Quality Management on January 10th

Level II Incidents Level II Incidents must be documented on the State’s mandated form which outlines specific types of Incidents that meet this level. If a Level II Incident occurs, the Employer of Record or Representative must:

Report to law enforcement agencies, as needed

Submit the State Mandated Incident Reporting Form to the Quality Management Department within 72 hours of occurrence

If the Incident Report involves restrictive intervention, information concerning the Restrictive Intervention is included in the State Mandated Incident Reporting Form.


Keep records about the analysis, corrective action, and preventive measures taken. Copies of these records are submitted to the Quality Management Department Quarterly.

Level III Incidents Level III Incidents must be documented on the State’s mandated form which outlines specific types of Incidents that meet this level. If a Level III Incident occurs, the Employer of Record or Representative must within 24 hours:

Notify the Quality Management Department who will notify the State

If the Representative is reporting, the Employer of Record must be notified

Notify law enforcement authorities

Secure the Participant’s record immediately following the Incident

Make a copy of the Participant’s record

Send a copy of the record to the Quality Management Department

The Employer of Record or Representative must also

Submit the State Mandated Incident Reporting Form to the Quality Management Department within 72 hours of occurrence. If a death occurs that is the result of a suicide, accident, homicide, or other violence, the Quality Management Department will notify the State.

If a death occurs within 72 hours of seclusion or restraint, the Quality Management Department will be notified immediately. The Quality Management Department will make an immediate report to the State.


Keep records about the analysis, corrective action, and preventive measures taken. Copies of these records are submitted to the Quality Management Department Quarterly.

Follow Up/Review of an Incident or Patterns of Incidents A follow-up review with the Employer and/or Representative may occur if, after receiving information and clarification from an Employer or Representative regarding an Incident or patterns of Incidents, there are issues related to:

Failure to provide appropriate protections to an Individual that places them in a situation of endangerment to their health and safety

Failure of the provider to detect patterns of Incidents

Failure to provide appropriate responses to an Incident or patterns of Incidents


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Failure to report Incidents within given timeframes, reporting requirements or timelines

Failure of the Employer or Representative to submit appropriate documentation related to the Incident; follow up to the Incident; or administrative actions taken within given timelines.

Follow-up can include interviews with the Employer, Representative, Participant, direct service employee, and/or other family members who may have knowledge of the incident. These individuals may be asked to submit a written statement or sign a statement that has their answers to questions asked. The home, vehicle, or medication storage may be reviewed as well as the Individual’s record. Administrative files, including billing records, may also be reviewed. The Employer of Record and Representative, if applicable, will receive a written report of the Quality Management Incident Review. The report will include required actions of the Employer and Representative including other agencies that must be notified, plans of correction required, and date the plans of corrections are due to the Quality Management Department. Serious Incidents, patterns of Incidents, or failure to take correction action may result referral to the Utilization Management Department with a recommendation to terminate Individual and Family Directed Supports. Termination from Individual and Family Directed Supports will result in the individual returning to the Provider Directed Supports Option.

Level 1 Quarterly Incident Reporting Providers must use this form to summarize in aggregate numbers Level 1 Incidents for the reporting quarter to the host area authority for each quarter in the state fiscal year. This form is only for Level 1 Incidents. Aggregate information on Level 1 incidents must be reported to Cardinal Innovations Healthcare Solutions) according to guidelines provided by the North Carolina Department of Health and Human Services and as set forth in 10A NCAC 27G .0600. Level 1 incidents are events that in isolated numbers do not significantly threaten the health or safety of an individual, but that could indicate systematic problems if they occur frequently. For further explanation please consult the DHHS Incident and Death Response System manual available at the Division's web site (http://www.dhhs.state.nc.us/mhddsas/manuals/index.htm). Even if there are no Level 1 incidents of the types to be reported during the quarter, providers should still submit this form to Cardinal Innovations Healthcare Solutions indicating 0 incidents. This will allow the host LME to distinguish between no incidents and a failure to report by a provider. This report should be emailed, faxed or mailed to: Host Community Operations Center Contact Person Quality Management Community Operations Center Cardinal Innovations Healthcare Solutions - 704 721-7000 Alamance Caswell- 336 513-4222 Five County- 252 430-1330 OPC-919 913-4000 Mecklenburg 980-938-4100

When to File: The quarterly summary of complaints is to be done every three months and submitted no later than 20 days after the end of the quarter. The Quality Management Department should be consulted for Cardinal Innovations Healthcare Solutions quarterly report deadlines. (See Quarterly Report document attached.)


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QM11-Quarterly Incident Report

State Fiscal Year and Quarter of this Report: SFY11-12 4th Qtr (Apr, May, Jun)

Provider Name and Site Information – Submit one form for each site in the catchment

Provider Name: Site Name:

Site Physical Address (Street & City):

Site County:

Provider Identification Number:

[Use National Provider Identifier (NPI), otherwise in preferred order (from top down on the list to the right) -- MH License Number, Medicaid Enrollment Number, IPRS Attending Number, LME Assigned Number, or Provider Tax ID]

Check which type of Provider Identification Number was provided:

National Provider Identifier MH License Number Medicaid Enrollment Number IPRS Attending Number LME Assigned Number Provider Tax ID

Section 1 - Summary of Level 1 Incidents

Number of

Incident Reports1

Unduplicated Count of

Consumers Involved2

Highest Number of Incidents for One

Consumer3

Restrictive Interventions [A Level 1 incident is any planned use of a restrictive intervention administered appropriately and without discomfort, complaint, or injury.]

Total Unduplicated Count4

Seclusion

Isolated Time-Out

Restraint

Medication Errors [A Level 1 incident is any error that a physician or pharmacist has determined does not threaten the consumer’s health or safety. Providers of periodic services should report errors for consumers who self-administer medications as soon as learning of the incident.]

Wrong Dosage Administered

Wrong Medication Administered

Wrong Administrative Technique

Wrong Time (over 1 hour from prescribed time)

Wrong Person Given Medication

Missed Dose of Prescribed Medication

Refused Dose of Prescribed


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Medication

Dose Preparation Error

Loss or Spillage of Medication

Other Medication Errors

Other Incidents [All searches/seizures are classified as a Level 1 incident.]

Any Search of Consumer/Living Area or Seizure of Consumer’s Property

Footnotes Referenced Above In Section 1:

1. A count of the number of incident reports completed during the quarter for the type of incident indicated.

2. Provide an unduplicated count of the consumers for which an incident report was completed during the quarter for the type of incident indicated. For example, if one consumer had multiple incidents during the quarter of the type indicated, that consumer should be counted only once.

3. Identify the individual consumer with the highest number of incidents during the quarter for the type indicated and report this number as the highest number of incidents for one consumer. For example, if 30 medication errors out of a total of 35 during the quarter were attributed to one consumer, the highest number for one consumer would be 30. If 35 consumers each had one medication error during the quarter, the highest number for one consumer would be one.

4. For total unduplicated count, count each incident report only once regardless of the number of different types of restrictive interventions that may be listed on an individual report. For each type of restrictive intervention listed (seclusion, isolated time-out, or restraint), count each incident reported on the incident report. It is possible that the sum of each type of incident may exceed the total unduplicated count if more than one type of restrictive intervention is reported on a single incident report.

Section 2 - Summary of Level 2 and 3 Incidents

This section provides a summary of the number of Level 2 and Level 3 Incident Reports that were completed and submitted to the host LME during the quarter.

Number of

Incident Reports

Unduplicated Count of

Consumers Involved

Highest Number of Incidents for One Consumer

Number of Level 2 Incident Reports

Number of Level 3 Incident Reports

If no Level 2 or Level 3 Incident Reports were submitted, did any Level 2 or Level 3 incident occur and go unreported?

Yes No

Section 3 - How the Provider is Analyzing Trends and Using Incident Report Data

Provide a brief description of patterns or trends identified through data analysis, strategies developed to address identified problems or opportunities for improvement, actions taken, evaluation of the results of actions taken, and/or next steps being planned. The information provided below should address quality improvement efforts related to all types of incidents (Level 1, 2, and 3) and should not be limited to the Level 1 incidents reported on this form. This section will expand as needed.


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Description

Analysis (Trends, patterns)

Strategies Developed

Actions Taken

Evaluation of Results of Actions

Taken

Next Steps

Print Name of Person Completing Report for Provider: Title: Date: Phone: Email:


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Instructions

Requirement to Submit the Report:

* A Level 1 incident is any occurrence that is not consistent with the routine operation of a facility or service or the routine care of a client and that is likely to lead to adverse effects upon a client and does not meet the definition of a Level 2 or 3 incident. For further explanation, please refer to the DHHS Incident and Death Response System Manual, a copy of which also may be found on the above referenced web site.

Even if there are no Level 1 incidents of the types to be reported during the quarter, providers are still required to submit this form to the host LME indicating “0” incidents. This will allow the host LME to distinguish between no incidents and a failure to report by a provider.

When to Submit the Report:

The quarterly summary and analysis of incidents is to be done every three months and submitted no later than 10 days after the end of the quarter. The following table describes the months covered and the due dates for each quarterly report.

Report Months Covered Due Date

First Quarter July, August, September October 10

Second Quarter October, November, December January 10

Third Quarter January, February, March April 10

Fourth Quarter April, May, June July 10

Where and How to Submit the Report:

This report should be emailed, faxed or mailed to the Incident Report Coordinator at your Host LME. Contact information for each LME is listed alphabetically by LME and by county on the Local Contact LME Listing page of the Division’s website at: http://www.ncdhhs.gov/mhddsas/lmedirectory.htm

Cardinal Innovations Healthcare Solutions 4855 Milestone Avenue Kannapolis, NC 28081

Attention: QM Quarterly Reports Desk Email: [email protected]

Phone Number: 704.939.7700 (Ask for QM Quarterly Reports Desk) Fax Number: 704.939.7906

Questions:

Questions about this quarterly report should be directed to the Incident Report Coordinator

http://www.ncdhhs.gov/mhddsas/lmedirectory.htm

mailto:[email protected]


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Appendix S: Documentation Task List for Employers of Record

Type Document Requirement

Plan Current ISP/Updates to ISP/ Individual Budget

Employer of Record must maintain a copy of Annual ISP, any ISP Updates since start of Annual Plan, and Individual Budget

Plan Short Range Goals in place for each service self-directed, relate back to long range outcome in ISP, and include all required elements

Short Range Goal (s) must be in place BEFORE service is delivered. Each short-range goal must tie back to a long range outcome in the ISP and all required elements must be included.

Required elements include measurable goal statement strategies/interventions/task analysis to meet the goal target date including month/day/year signature of LRP

Plan Target dates for short-range goals have not expired

Goals cannot be run after the target date. Emplyers cannot bill for running expired goals.

Plan Direct Care Worker/Employee has access to copy of short-range goals and task analysis/strategies

The employee/worker must know specifically what the goals are and the established strategies/task analysis to achieve the goals.

The employee must have access to a copy of the short-range goals.

Plan Behavior Support Plan If the individual has a Behavior Support Plan, the Employer of Record must have a copy and a copy must be accessible to employees

Plan Crisis Plan If the individual has a Crisis Plan, the Employer of Record must have a copy and a copy must be accessible to employees

Service Services documented using service note or service grid, as applicable to service.

A service note or grid must be completed for each service delivered.

A service grid is allowed only for self-directed Community Networking, In Home Intensive, In Home Skill Building, Personal Care, Respite, and Supported Employment and. All other self-directed services require a service note

Service Service documentation completed on day of service or on next work day and includes all required elements (see to right)

Service documentation must be completed on the day of service or no later than the next work day. Service documentation not completed on the date of service is considered a "late entry".

Service Notes: name of individual receiving service, Medicaid ID#, Name of Service, month/day/year of service, purpose of service (tied to specific short-range goal), description of intervention/support provided, duration, effectiveness of the intervention, full signature and degree or position

Modified Service Note (allowed for Respite only): name of individual, Medicaid ID#, month/day/year of service, name of service, duration, tasks performed, full signature with degree or position


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Type Document Requirement

Service Grid: name of individual receiving service, Medicaid ID#, month/day/year of service, goal addressed, number or letter as specified in appropriate key which reflects the intervention/ activities/tasks performed, number or letter as specified in the appropriate key which reflects the assessment of progress toward goal, duration, initials of individual providing service, corresponding full signature in signature log section of grid

Service Progress Summary completed quarterly for each habilitative service self-directed

Employer of Record must complete progress summary for any self-directed habilitative service (Community Networking, In Home Intensive, In Home Skill Building, Personal Care, Supported Employment)

Summary must be completed within 7 working days of the close of the quarterly progress period

Progress Summary must contain, at a minimum, the participant's name, date of the summary and dates the summary covers, the current short-range goal(s), progress toward goals, recommendations for continuation/revision/termination of short-range goal and the signature of individual who completed the review (either the Employer of Record or Representative)

Service Billing Ticket/Sheet completed for each pay period and submitted to Financial Support Agency

Employer of Record must submit Billing Form to the Financial Support Agency along with the employee timesheet(s). The timesheets document employee hours and result in paycheck. The Billing Ticket is used by the Financial Support Agency to generate claims to Cardinal Innovations for the services so that the Financial Support Agency can be paid for services delivered.


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Notes: ________________________________________________________________________________________

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