Fillable PARTICIPANT-COMMUNITY SUPPORT WORKER EMPLOYMENT AGREEMENT

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PARTICIPANT-COMMUNITY SUPPORT WORKER EMPLOYMENT AGREEMENT

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IDHW FDCS CSW Agreement Revised 011/09/2015
1
04886
PARTICIPANT-COMMUNITY SUPPORT WORKER
EMPLOYMENT AGREEMENT
This agreement is hereby made between _____________________________, a Participant of
Participant’s Name
the Family-Directed Community Supports (SDCS) Option, a Medicaid Option administered by
the Department of Health and Welfare (Department), and _____________________________,
CSW’s Name
a Community Support Worker (CSW).
The Participant desires to engage CSW for services under the FDCS Option. In exchange, the
CSW desires to be paid for services provided to the Participant. Both parties understand and
agree that payment is made through a fiscal employer agent (FEA), using Medicaid monies and
based on time sheets submitted by the CSW and approved by the Participant.
To these mutual purposes, the parties promise and agree as follows:
1. CSW services are to be provided in accordance with the Participant’s FDCS Support and
Spending Plan, and the Consumer Directed Community Supports rules, outlined in IDAPA
16.03.13, “Consumer-Directed Services.”
2. It is mutually understood that CSW is the employee of the Participant, and that the
Participant directs, controls and approves the CSW’s work.
3. The CSW is hired to assist the Participant and assumes no legal liability for the Participant’s
conduct.
4. The CSW promises that he/she meets the following minimum qualifications to be a CSW, as
outlined in Section 136 of IDAPA 16.03.13, “Consumer-Directed Services.”
5. The parties mutually agree that CSW is an employee of the Participant and is not an
employee of the FDCS Option or the Fiscal Employer Agent (FEA), and agree that the CSW is
not entitled to nor will make claim for any employee benefits from the FDCS Option or the FEA,
including but not limited to, worker’s compensation, disability, life or health insurance.
6. The CSW agrees to notify the Participant immediately in the event he/she is unable to
provide the agreed services due to sickness, injury or personal emergency. The CSW must
obtain the Participant's written approval in advance for any pre-planned absence.
7. The Participant shall train the CSW on the duties and responsibilities of the CSW and shall
be responsible for approving the accuracy of CSW’s time records.
IDHW FDCS CSW Agreement Revised 11/09/2015
2
04887
8. The CSW agrees to provide services in a safe, courteous and professional manner. The
CSW acknowledges that any physical, sexual or mental abuse or neglect of the Participant by
the CSW will result in the immediate termination of this Agreement and a report being made
according to the requirements in Section 39-5303, Idaho Code.
9. The CSW agrees to report any observed physical, sexual or mental abuse, exploitation or
neglect of Participant to adult protection authorities immediately.
10. The CSW understands and agrees that they cannot provide or bill for services until:
an authorized Support and Spending Plan has been submitted to the FEA,
the signed Employment Agreement has been submitted to the FEA
the signed Medicaid-CSW Agreement has been submitted to the FEA
11. The CSW understands and agrees that no payment for services will be made until both the
CSW and the Participant have signed the appropriate time sheets, acknowledging their
accuracy, and have submitted them to the FEA.
12. It is mutually understood that Medicaid funding can only pay for services rendered. Under
the FDCS option, the CSW will not receive payment for any vacation time, holiday time,
overtime or sick time. Medicaid will not pay wages at an hourly amount in excess of this
agreement.
☐ Please check this box if the employer is requiring the Community Support Worker to
specifically document activities that support billable time in writing in a manner agreed
upon between the employer and the Community Support Worker.
More than forty (40) hours per week of paid work are allowed only if the CSW meets the criteria
for employees that are exempted from overtime pay and minimum wage requirements as per
the Fair Labor Standards Act.
The participant must obtain and follow guidance from the Idaho Department of Labor and
Commerce to determine if the CSW is exempt from these requirements. It is the responsibility
of the participant to ensure that the CSW is exempt if the participant requires the CSW to work
more than forty (40) hours per week.
The CSW will be paid only for the specific services authorized as per the Support and Spending
Plan.
The signing of this Employment Agreement by the participant and the CSW signifies that the
parties acknowledge that the criteria for exemption from overtime and minimum wage
requirements will be met prior to scheduling work hours in excess of forty (40) hours per week
or agreeing to wages less than minimum wage standards.
IDHW FDCS CSW Agreement Revised 011/09/2015
3
04888
13. Terms and conditions of work. Effective Date: ___________________.
COLUMN A B C D E
Service needed
Type of Support
only one box per row
Number of
hours per
year OR
Number of
miles/year
Wage
per hour
OR
Wage
per mile
Annual
Cost
Personal PSS Emotional ESS
Job JSS Skilled Nursing SNS
Transportation
TSS (hourly)
Relationship RSS
Learning LSS Transportation Mileage
Reimbursement (MR)
X
=
$
Sub-
Total
Personal PSS Emotional ESS
Job JSS Skilled Nursing SNS
Transportation
TSS (hourly)
Relationship RSS
Learning LSS
Transportation Mileage
Reimbursement (MR)
Code for
second rate of
pay/hour
_____ Fill in code
X
=
$
Sub-
Total
Personal PSS Emotional ESS
Job JSS Skilled Nursing SNS
Transportation
TSS (hourly)
Relationship RSS
Learning LSS Transportation Mileage
Reimbursement (MR)
Code for
second rate of
pay/hour
_____ Fill in code
Code for third
rate of pay/hour
_____ Fill in code
X
=
$
Sub-
Total
Personal PSS Emotional ESS
Job JSS Skilled Nursing SNS
Transportation
TSS (hourly)
Relationship RSS
Learning LSS Transportation Mileage
Reimbursement (MR)
Code for
second rate of
pay/hour
_____ Fill in code
Code for third
rate of pay/hour
_____ Fill in code
X
=
$
Sub-
Total
Personal PSS Emotional ESS
Job JSS Skilled Nursing SNS
Transportation
TSS (hourly)
Relationship RSS
Learning LSS Transportation Mileage
Reimbursement (MR)
Code for
second rate of
pay/hour
_____ Fill in code
Code for third
rate of pay/hour
_____ Fill in code
X
=
$
Sub-
Total
Personal PSS Emotional ESS
Job JSS Skilled Nursing SNS
Transportation
TSS (hourly)
Relationship RSS
Learning LSS Transportation Mileage
Reimbursement (MR)
Code for
second rate of
pay/hour
_____ Fill in code
Code for third
rate of pay/hour
_____ Fill in code
X
=
$
Sub-
Total
Total Cost of Agreement:
$
IDHW FDCS CSW Agreement Revised 11/09/2015
4
04889
14. The CSW must meet the following specific qualifications in order to provide the following
services including attaching copy of certification/licensure, if applicable, as outlined in IDAPA
16.03.13 Subsections 120.05 and 110.03:
Age Criteria for CSWs (applies to Non-Waiver and Waiver eligible participants):
Minimum age of in-home worker, with adult caretaker present: 16
Minimum age of community support, skill building or behavior management: 18
Minimum age to transport into community: 18
☐ The CSW meets the above age criteria.
15. The CSW agrees to take all actions necessary to become Participant’s employee, and to
maintain the employment relationship by submitting necessary documents to the FEA, including:
Completion of W-4, I-9 and other IRS required forms
A copy of this agreement
Time sheets approved by Participant recording hours worked.
Completion of a criminal history check, including clearance in accordance with IDAPA
16.05.06, "Rules Governing Mandatory Criminal History Checks”
o Unless the Criminal History Background Check is Waived, the CSW has applied for a
Criminal History Background Check through the Department of Health and Welfare.
The CSW will list the Department as the agency/employer, using identification
number 1710.
☐ The CSW gives permission to the fiscal employer agent to notify the Participant (Employer) of
the results of the Criminal History Background Check. _________________________________
CSW Signature
☐ I am waiving the Criminal History Check requirement. I have completed the attached Waiver of
Liability form. I understand that even if CHC is waived the CSW cannot receive Medicaid dollars if
he is on a federal or state Medicaid exclusion list. ___________________________________
Parent or Legal Guardian Signature
The provisions of this agreement represent the entirety of the agreement between the parties. It
may be amended only in writing with both parties consenting by their signatures. It is mutually
understood that this is employment at will. Either party may terminate the employment relationship
without cause upon two weeks notice. This agreement may be terminated at any time by the
Participant due to unsatisfactory CSW performance.
PARTICIPANT Date
LEGAL GUARDIAN (IF APPLICABLE) Date
CSW Date
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PARTICIPANT-COMMUNITY SUPPORT WORKER EMPLOYMENT AGREEMENT

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Completed 31 August 2021

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