Fillable SOC846 In­Home Supportive Services (IHSS) Program Provider Enrollment Agreement

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SOC846 In­Home Supportive Services (IHSS) Program Provider Enrollment Agreement

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
PROVIDER ENROLLMENT AGREEMENT
PROVIDER NUMBER
PROVIDER NAME (FIRST, MIDDLE, LAST)
1. I attended the required provider enrollment orientation for IHSS providers and I
understand and agree to the following:
• I was given information about being a provider in the IHSS program.
• I was informed of my responsibilities as an IHSS provider.
• I was informed of the consequences of committing fraud in the IHSS program.
•I was given the Medi-Cal toll-free telephone fraud hotline number, 1-800-822-6222
and web site, http://www.dhcs.ca.gov/individuals/Pages/StopMedi-CalFraud.aspx
for reporting suspected fraud or abuse in the IHSS program.
2. I understand the following:
• The only hours I am allowed to report on my timesheet are the hours I worked
providing authorized services for the recipient.
• By signing my timesheet I am saying that the information I reported on it is true
and correct.
• I must submit my timesheet (signed by both my recipient and me) within two
weeks after the end of each pay period. If I submit my timesheet on time, and it
is properly completed, I will get paid within 10 days of the day it is received at
the timesheet processing facility. If I do not submit my timesheet within two
weeks after the end of the pay period, my pay will be delayed.
• If I am convicted of fraudulently reporting information on my timesheet, in
addition to any program or criminal penalties, I may be required to pay back any
overpayment I received and to pay civil penalties of at least $500, and not more
than $1,000, for each act of fraud.
3. I received information regarding the maximum weekly hour and travel time
requirements. This information included the following topics:
Overtime Pay
• Beginning February 1, 2016, IHSS providers will get paid overtime (one and a
half times the regular pay rate) when they work more than 40 hours in a workweek.
The workweek begins at 12:00 a.m. (midnight) on Sunday and ends at 11:59 p.m.
on the following Saturday.
SOC 846 (11/15)
PAGE 1 OF 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PROVIDER NUMBER
What Does My Recipient’s “Authorized Weekly Hours” Mean?
My recipient’s authorized weekly hours mean his/her monthly authorized hours divided
by four. For example, if my recipient is authorized to receive 125 hours of service
monthly, my recipient’s authorized weekly hours are 125 ÷ 4 = 31 hours, 15 minutes.
Maximum Weekly Hours
The maximum weekly hours amount is a guideline that tells me the highest number of
hours I can work in a workweek so my recipient can budget his/her service hours in the
month to ensure all his/her monthly service hours are received.
• If I work for just one recipient, the maximum hours that I may work in a workweek
is my recipient’s monthly authorized hours divided by 4. However, since most
months are slightly longer than 4 weeks, I will work with my recipient to spread
his/her hours throughout the month to make sure he/she has enough hours of
service at the end of the month.
For example: There are 31 days in the month of December. If I work for just
one recipient, and she receives 100 monthly authorized hours, my maximum
weekly hours are 25 hours (100 monthly authorized hours divided by 4). How-
ever, since December is actually 4½ weeks, my recipient would need to decide
how many hours to take away from each of the first four weeks in order to
have enough hours left for the last few days at the end of the month. My
recipient could, for example, set up a schedule for me to work 22 hours in each
of the first four weeks of December, which would leave her with 12 authorized
service hours left over for the final few days of the month (22 X 4 = 88 hours;
88 hours + 12 hours = 100 hours).
• If I work for just one recipient and he or she has other providers
, my recipient
must make a work schedule for me and the other providers to determine how
many hours each of us will work. My recipient may divide his/her total authorized
hours among his/her providers as he/she sees fit.
• If I work for more than one recipient, the maximum number of hours that I may
claim in a workweek for all of the time I work for all my recipients combined is
66 hours. Each of my recipients must make a work schedule for me to
determine how many hours I will be working for each of them so I can
make sure that I do not work more than 66 hours per workweek.
Changing the Number of Hours I Work Each Week: What My Recipients Can and
Cannot Do
Switching hours
• If my recipient has one or more other providers, I may “switch” some of my hours
with another provider in a particular workweek in order to ensure that the recipient
SOC 846 (11/15)
PAGE 2 OF 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PROVIDER NUMBER
receives all the hours to which he or she is entitled for the week. This means
that another one of the recipient’s providers may work any of my hours while I
work any of his/her hours for the particular week. As long as no provider works
more than my recipient’s weekly authorized hours, this will not cause a violation
even if the other provider usually works overtime and I usually don’t (so for this
one week, I will have overtime).
If I am asked to work more than my maximum weekly hours:
• If I work for more than one recipient, my recipients cannot
ask me to work more
than my 66 maximum weekly hours. If a recipient wants me to work more hours
and doing so would put me over 66 hours, he/she will have to get another IHSS
provider to work those additional hours.
• If I work for only one recipient, my recipient can ask me to work more than my
maximum weekly hours. In that case, I would have to make sure to balance out
these additional hours by working fewer hours in another week of the month in
order to avoid exceeding my recipient’s monthly authorized hours.
If I am asked to work more than my recipient’s authorized weekly hours:
• A recipient can authorize me to work more than his/her weekly authorized hours
without asking the county for approval as long as the authorization does not
cause me to work:
o More than 40 hours for him/her in a workweek when he/she is authorized 40
hours or less in a workweek; or
o More overtime hours in the month than I normally would, based on the total
overtime I work for all of my recipients.
• If my recipient gets county approval, he/she can
authorize me to work more than
his/her weekly authorized hours even if it does not meet the above criteria. My
recipient may ask for county approval either before or after I work the extra hours.
Limit on Travel Time
• Also beginning February 1, 2016, the maximum amount of time I will be allowed
to travel during a workweek is seven hours. Travel time means the time I spend
on the same workday traveling directly from one location where I provide authorized
services for a recipient to another location where I provide authorized services
for a different recipient.
• Travel time will not
be counted as part of the maximum weekly hours I can work
in a workweek.
• Travel time that occurs after I have worked more than 40 hours in a workweek
will be paid at the overtime rate of time and a half.
SOC 846 (11/15)
PAGE 3 OF 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PROVIDER NUMBER
Violations for Going Over Workweek & Travel Time Limits
• Beginning May 1, 2016, if I submit a timesheet reporting hours that go over the
maximum weekly hours or travel time limits, I will get a violation.
• Each time I do any of the following, I will get a violation:
- I work more than 40 hours in a workweek for a recipient without the recipient
getting approval from the county (when the recipient is authorized to receive
40 hours or less per workweek); or
- I work more hours than my recipient is authorized to receive in a workweek
without getting approval by the county, and this causes me to work more
overtime hours in the month than I normally would; or
- I work for multiple recipients and I work more than 66 hours in a workweek; or
- I claim more than seven hours travel time in a workweek.
• If I get more than one violation during a particular month, it will only count as
one violation.
For each violation I receive, there will be a consequence:
First Violation
• My recipient(s) and I will get a notice of the violation with
appeal rights information.
Second Violation
• My recipient(s) and I will get a notice of the second violation
with appeal rights information, and I will have the choice of
completing a one-time training about the workweek and
travel time limits. If I choose to complete this training, I will
avoid getting a second violation. However, if I choose not to
complete the training within 14 calendar days of the date of
my notice, I will get a second violation.
Third Violation
• My recipient(s) and I will get a notice of the third violation
with appeal rights information.
• I will be suspended as a provider with the IHSS program for
three months.
Fourth Violation
• My recipient(s) and I will get a notice of the fourth violation
with appeal rights information.
• I will be terminated
as a provider with the IHSS program for
one year.
SOC 846 (11/15)
PAGE 4 OF 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PROVIDER NUMBER
• Once I have received a violation, the violation will remain on my record. However,
after one year, if I do not receive another violation, the number of violations I
have received will be reduced by one. As long as I do not receive any additional
violations, each year after the last violation, my number of violations will be
reduced by one.
• If I receive a fourth violation and I am terminated as a provider for one year,
when the year is up and I apply again to be an IHSS provider, my violations
count will be reset to zero.
• If I am terminated as an IHSS provider because I get multiple violations, I can
reapply to be an IHSS provider when the one year termination ends and I will
have to complete all of the provider enrollment requirements again, including the
criminal background check, the provider orientation, and completing all required
forms before I can be reinstated.
4. I understand that I am required to complete the Employment and Eligibility
Verification form (Form I-9), which is kept on file by the recipient. That form
states that I have the legal right to work in the United States.
5. I understand that I have the option to submit an Employee’s Withholding
Allowance Certification (Form W-4) to request federal income tax withholding
and/or California Employee’s Withholding Allowance Certification (Form DE 4)
to request state income tax withholding from my wages. I understand that if I do
not submit Form W-4 and/or DE 4, federal and state income taxes will not be
withheld from my wages.
6. I understand that authorized IHSS services cannot be performed when the
recipient is away from his/her home unless my recipient gets approval for such
services from his/her social worker.
7. I understand that, in the future, I will receive the IHSS Program Notification Of
Recipient Authorized Hours and Services and Maximum Weekly Hours (SOC
2271), that names my recipient(s) and the services I am authorized to perform for
each recipient to whom I provide services.
8. I will cooperate with state or county staff to provide requested information related
to the evaluation of a recipient’s IHSS case.
SOC 846 (11/15)
PAGE 5 OF 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PROVIDER NUMBER
I UNDERSTAND THE IHSS PROGRAM RULES EXPLAINED AT THE PROVIDER
ORIENTATION OR INFORMATION GIVEN TO ME BY THE COUNTY IHSS OFFICE.
I ACCEPT THE RESPONSIBILITY TO FOLLOW THE INFORMATION PROVIDED
BY THE COUNTY. I UNDERSTAND THAT MY FAILURE TO FOLLOW THE
REQUIREMENTS PROVIDED TO ME MAY RESULT IN MY TERMINATION AS AN
IHSS PROVIDER.
IHSS PROVIDER’S SIGNATURE
DATE
PROVIDER NAME (FIRST MIDDLE LAST)
SOC 846 (11/15)
PAGE 6 OF 6
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SOC846 InHome Supportive Services (IHSS) Program Provider Enrollment Agreement

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Completed 9 April 2020

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