STATE OF CALIFORNIA − HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SOC 2255 (11/15)
PAGE 1 OF 7
PROVIDER NAME: PROVIDER NUMBER:
PROVIDER REQUIREMENTS:
State law (Welfare and Institutions Code section 12300.4) limits providers in the IHSS and Waiver Personal Care
Services (WPCS) programs to working a maximum weekly number of hours providing IHSS and WPCS. A
provider who works for multiple recipients is limited to providing 66 hours per workweek.
The maximum weekly workweek does not include travel time as described in Part B of this form. The workweek
starts on Sunday at 12:00 a.m. (midnight) and ends at 11:59 p.m. on the following Saturday.
Recipients are authorized services on a monthly basis and, based on state law, are limited to receiving a set
amount of those services on a weekly basis. You will get a notice telling you how many authorized service hours
each of your recipients gets weekly and monthly. You may never work more than a recipients monthly authorized
hours for that recipient. However, you may work more than a recipient’s weekly authorized hours in certain
circumstances. A recipient may adjust his or her weekly authorized hours, but he/she must get approval from the
county if the adjustment will result in either a provider working more overtime hours in the month than the provider
would normally work or working over 40 hours in any workweek for him/her (when, he/she is authorized to receive
40 hours or less in services in a workweek).
It is your responsibility as a provider to:
Make sure that the total combined hours you work providing authorized services for all the recipients you
work for in one workweek do not total more than the 66 hours in a workweek.
Make sure that the hours you work providing services to any one of your recipients are not more than that
recipient’s weekly authorized hours, unless the hours are correctly adjusted.
PART A. WORKWEEK SCHEDULE
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
PROVIDER WORKWEEK & TRAVEL TIME AGREEMENT
(To be completed by a provider who provides authorized services to multiple recipients)
PROVIDER NUMBER ______________________
STATE OF CALIFORNIA − HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SOC 2255 (11/15)
PAGE 2 OF 7
Make sure that if one of your recipients adjusts their weekly authorized hours to have you work more than the
usual authorized amount, that you work less hours in a previous or later week to make sure you are not working
more than his/her authorized monthly hours or working more overtime in the month than you normally would.
If you submit a timesheet in which you violate the workweek schedule in any of the following ways, you will receive
a violation:
You work more than 40 hours in a workweek without county approval for a recipient if he/she is authorized 40
hours or less in a workweek;
You work more hours for a recipient than he/she is authorized in a workweek, without county approval and it
causes you to work more overtime hours in the month than you normally would;
You work for multiple recipients and work more than the 66 hours in a workweek;
You claim more than seven hours of travel time (see Part B of this agreement).
If you violate the workweek schedule in any of the ways described above, you will receive the following:
You and your recipient(s) will get a notice of the violation with appeal rights information.
Your recipient(s) and you will get a notice of the violation, and you will have a choice to
complete a one-time training about the workweek and travel time limits. If you choose to
complete the training, you will avoid a second violation
If you choose not to complete the training within 14 calendar days of the date of the notice,
you will be sent a notice of your second violation with the appeal rights information.
You and your recipient(s) will get a notice of the third violation with appeal rights information.
You will be suspended as an IHSS provider with the IHSS program for three months.
You and your recipient(s) will get a notice of the fourth violation with appeal rights information.
You will be terminated as an IHSS provider with the IHSS program for one year.
First Violation
Second Violation
Third Violation
Fourth Violation
PROVIDER NUMBER ______________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
STATE OF CALIFORNIA − HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SOC 2255 (11/15)
PAGE 3 OF 7
INSTRUCTIONS: You must complete the chart below to help you plan your workweek schedule. Your schedule
must include services provided to all recipients you work for and must not be more than 66 hours in one workweek.
You will be notified of each of your recipients’ total maximum weekly hours in the Provider Notification of Recipient
Authorized Hours and Services, (form SOC 2271).
1. In Column A, write the name of each recipient you provide authorized IHSS services for.
2. In Column B, write the case number of each recipient listed in Column A.
3. In Column C, write the address of each recipient listed in Column A.
4. In Column D, write the total number of hours per day (for each day of the week) you work or plan to work providing
authorized IHSS services for each recipient listed in Column A.
5. For Column E, add the total number of hours from each day in Column D that you work or plan to work providing
authorized IHSS services for each recipient listed in Column A and write the total number of hours for the week for
each recipient in Column E.
6. At the bottom of Column E, add the total number of hours you work or plan to work providing authorized IHSS for
all of your recipients each week.
A
Recipient’s Name
B
Recipient
Case #
C
Recipient’s Address
D
Total Number of
Hours I Work
or Plan to Work
E
Total
Hours
Street
Address
Sun.
Mon.
City
Zip
Code
Tues.
Wed.
Thurs.
Fri.
Sat.
TOTAL HOURS I WORK OR PLAN TO WORK PROVIDING AUTHORIZED SERVICES FOR ALL RECIPIENTS:
PROVIDER NUMBER ______________________
0
0
STATE OF CALIFORNIA − HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SOC 2255 (11/15) PAGE 4 OF 7
PART B. TRAVEL TIME
PROVIDER REQUIREMENTS:
If you travel from one recipient’s location to another recipient’s location on the same workday in order to provide
IHSS services to both recipients, you can get paid for that travel time, but that time cannot be more than seven
hours per workweek. These seven hours are in addition to the 66 hours.
To get paid for that travel time, you must travel directly from one recipients location to the other recipients location
without stopping. If you make only a brief stop on your way to the second recipient’s location, such as to fill your
gas tank at a service station, you are still considered to be traveling directly. However, if you stop to conduct
personal business or if you return to your own home, you can only be paid for the time that it would have taken to
travel between the two locations where services are provided without the personal stops.
If your total estimated weekly travel time will be more than seven hours, you will need to adjust your work schedule
so that your travel time is less than seven hours.
Do you plan to travel from a location where you provide authorized services to another location where you
provide authorized services to another recipient on the same day
?
n
YES
n
NO
If you answer NO, you do not need to complete PART B, go directly to PART C.
PART B INSTRUCTIONS: You must complete this section to help you plan the travel time that you can be paid for so
that your total weekly travel time is not more than 7 hours. Because you are traveling, it may be necessary for you to
provide proof of time and mileage.
1. In Column A below, write the name(s) of the recipient(s) you will be traveling from.
2. In Column B below, write the name(s) of the recipient(s) you will be traveling to.
PROVIDER NUMBER ______________________
STATE OF CALIFORNIA − HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SOC 2255 (11/15)
PAGE 5 OF 7
3. In Column C below, write how far (in miles) it takes to travel directly from one recipient’s location to the next
recipient’s location.
4. In Column D below, write how long (in minutes) you estimate it takes to travel directly from one recipient’s location
to the next recipient’s location.
5. In Column E below, write how many days each workweek you plan to travel from one recipient’s location to
another recipient’s location on the same day?
6. In Column F, multiply the amount of time you estimate it takes to travel directly from one recipient’s location to the
next recipient’s location (Column D) by the number of days you will travel between recipients’ locations each
workweek (Column E) to indicate your total travel time between the two recipients’ locations (Column A and B).
7. Add up the total of all the time listed on the lines in Column F and write the total at the bottom of Column F.
PROVIDER NUMBER ______________________
STATE OF CALIFORNIA − HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SOC 2255 (11/15) PAGE 6 OF 7
ABCDEF
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
Distance
Between
Recipients’
Locations
(in miles)
Estimated
Travel Time
Between
Recipients’
Locations
(in minutes)
Number of Days
You Will Travel
Between
Recipients’
Locations Each
Workweek
Total Estimated
Travel Time
Between
Recipients’
Locations Each
Workweek
(Col. D x Col. E)
Names of the Recipients You Will Be
Traveling Between
How will you travel between recipients’ locations?
n
CAR*
n
PUBLIC TRANSIT
n
OTHER Specify: _________________________________________
TOTAL ESTIMATED TRAVEL TIME EACH WORKWEEK:
From
To
* If you will be driving yourself to travel between recipients, you must have a valid California driver’s license
and proof of insurance, and your vehicle must have current registration. If you do not have a valid California
driver’s license, proof of insurance, or current vehicle registration, you are not legally allowed to drive your
vehicle for the purpose of providing IHSS. You must choose a different form of transportation, such as
public transit. If you have chosen to drive yourself and there is a negative change to the status of your legal
right to drive your vehicle (i.e., your California driver’s license, auto insurance, or vehicle registration
expires or is no longer valid), you must inform the county and select a different form of transportation. If
you fail to inform the county of this change in status, you will be considered in violation of IHSS program
requirements and may be terminated.
PART B. TRAVEL TIME
PROVIDER NUMBER ______________________
0
0
0
0
0
STATE OF CALIFORNIA − HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SOC 2255 (11/15) PAGE 7 OF 7
I declare that I have read and understood the requirements as stated in this document and I agree to comply
with these requirements. I further declare that all of the information I have provided on this form is true and
correct to the best of knowledge. I agree to notify the county within 10 calendar days if any of the information I
have provided in this Provider Workweek and Travel time Agreement changes, and depending on what information
has changed, I may be required to complete a new SOC 2255.
PROVIDER SIGNATURE:
PROVIDER’S PRINTED NAME:
DATE:
WORKER NAME:
SOURCE USED TO VERIFY TRAVEL TIME:
DATE:
ESTIMATED TRAVEL TIME REVIEWED:
YES
n
NO
n
PART C. PROVIDER AGREEMENT
FOR COUNTY USE ONLY
NOTES:
PROVIDER NUMBER ______________________
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