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Consumer Directed Service Agency (CDSA)
Compliance Monitoring Guide
DADS Form 1722 and Instructions
DADS Form 1722
Demographic Information
1.1. Consumer and EmployerConsumer and Employer
2. CDSA Provider Agency2. CDSA Provider Agency
3.3. Monitor,Monitor, Review Date, Review Review Date, Review
Period, Review TypePeriod, Review TypeContract Monitoring Guide - Page 1
STANDARD 1 Orientation and Service AgreementOrientation and Service Agreement1. ORIENTATION
• Face-to-Face by CDSA Representative• Consumer’s Residence• Employer and Designated Responsible party
(if applicable) must attend• Documented (DADS Form 1736, Documentation of
Employer Orientation)
2. Service Agreement• CDSA and Employer (DADS Form 1735)• Documents Incorporated in Agreement
Contract Monitoring Guide - Page 1
STANDARD 1 Orientation and Service AgreementOrientation and Service Agreement
2. The following documents are incorporated in the Service Agreement by Reference
a) Form 1726, Relationship Definitions in Consumer Directed Services
b) Form 1733, Employer and Employee Exemption from Nursing License for Certain Services
c) Form 1736, Documentation of Employer Orientation
d) Form 1738, Rules Acknowledgement
Contract Monitoring Guide - Page 1
STANDARD 2 Budget DevelopmentBudget Development
1. Employer/DRP and CDSA Participationa) Budget must be developed using the DADS CDS
Budget Workbookb) Budget must be “VALIDVALID”
2. Each Service Plana) Must be current. Revisions with changes to the
Consumer’s Service Plan affecting CDS servicesb) Must have a CDS Budget for each service category
delivered through CDS
3. Approved by CDSA / Acknowledged by the Employer/DRP
Contract Monitoring Guide - Page 1
Definitions / ClarificationCONSUMER - Individual
receiving program services and participating in Consumer Directed Services (CDS)
MINOR - Individual UNDER the age of 18
ADULT - Individual OVER the age of 18
DESIGNATED RESPONSIBLE PARTY – Willing adult that agrees to assist the Employer with responsibilities for CDS
PARENT – Natural, Legal, Adopted, Step-Parent, Foster Parent, Court Appointed Guardian
SPOUSE –Married with Formalities (Legal) or Married without Formalities (Common Law) Texas Family Code
STANDARD 3 Employer and Employer-Agent RegistrationEmployer and Employer-Agent Registration
EMPLOYEREMPLOYERCONSUMER – Age 18 or more; Does NOT have a court appointed guardian
PARENT – of a minor-aged Consumer (Consumer is under 18 years of age)
CONSUMER – Consumer, under 18 years of age, but has been
(1) Emancipated by the court OR
(2) Is legally married
GUARDIAN – Court Appointed Guardian, regardless of the Consumer’s age
Contract Monitoring Guide - Page 2
POWER OF ATTORNEY = Designated Responsible Party
Designated Responsible Party (DRP) is NOT the Employer.
STANDARD 3 Employer and Employer-Agent RegistrationEmployer and Employer-Agent Registration
FEDERAL GOVERNMENT
INTERNAL REVENUE SERVICE (IRS)
Employer: Employer Identification Number (EIN)
CDSA: Employer Appointment of Agent (Employer-Agent)
STATE GOVERNMENT
TEXAS WORKFORCE COMMISSION (TWC)
Employer: Employer TWC Account Number
CDSA: Authorization to Represent Employing Unit (“Employer’)
Contract Monitoring Guide - Page 2
STANDARD 4 CDSA Responsibilities, Federal and State AgenciesCDSA Responsibilities, Federal and State Agencies
1. WITHHOLDINGS
2. DEPOSITS
EMPLOYEE EMPLOYEE CONTRIBUTIONS:CONTRIBUTIONS:
Income Tax
Social Security Tax
Medicare Tax
Voluntary Benefits
Garnishments
Wage Attachments
Optional Benefits
EMPLOYER EMPLOYER CONTRIBUTIONS:CONTRIBUTIONS:
Match:
Social Security Tax
Medicare Tax
Total Amount:
Unemployment Tax
Total Amount or Share:
Benefits
Contract Monitoring Guide - Page 2
STANDARD 4 CDSA Responsibilities, Federal and State AgenciesCDSA Responsibilities, Federal and State Agencies
3. Workers’ Compensation and Employee Work-Related Injuries
a) Texas Workers’ Compensation Commission (TWCC)
b) Liability Insurance – Homeowner/Renter
4. Deductionsa) Garnishments – Court Ordered (Child Support)
b) Wage Attachments – Government Agency Directive (Guaranteed Student Loan Payment)
c) Optional Deductions – Insurance Premiums, 401K,
Contract Monitoring Guide - Page 2
STANDARD 4 CDSA Responsibilities, Federal and State AgenciesCDSA Responsibilities, Federal and State Agencies
5. Annual Tax-Related Forms - a) IRS Form W-2, Wage and Tax Statement;
b) IRS Form W-3, Transmittal of WAGE and Tax Statements;
c) IRS Form 1099-MISC, Miscellaneous Income
TAX REPORTING ANNUALLY: Calendar Year, January 1 – December 31
CDSA DUE DATES:
To Employee: W-2 by January 31
To IRS and Employer: W-3, with copy of Form(s) W-2 by the last day of February
To Contractor: 1099MISC by January 31
To IRS and Employer: 1099MISC by the last day of February
Contract Monitoring Guide - Page 2
STANDARD 4 CDSA Responsibilities, Federal and State AgenciesCDSA Responsibilities, Federal and State Agencies
Records Records – Federal and State Agencies– Federal and State Agencies
Contract Monitoring Guide - Page 2
6. Provide Copy or Original of Employer-Related Forms and Reports to Employer
7. Retain Copy or Original of Employer-Related Forms and Employer-Agent Forms and Reports
STANDARD 5 CDSA Responsibilities, Payroll and CDSA Responsibilities, Payroll and
Accounts PayableAccounts Payable
1. Payroll Payments – Based on complete, accurate, Employer-approved Timesheets
2. Payroll Distribution – Two times each calendar monthly in accordance with posted payday schedule.
3. Invoice Payments –
4. Receipt Payments –
a.) Based on complete, accurate, Employer-approved invoice or receipt
b.) Distribute payment within 30 DADS’ workdays of receipt by the CDSA of the acceptable invoice or receipt
Contract Monitoring Guide - Page 3
STANDARD 6 CDSA Responsibilities, Payroll Status CDSA Responsibilities, Payroll Status
Monitoring and ReportingMonitoring and Reporting
1. Account Balances – Each Service Area; Ongoing Balances; Based on All Transactions; Complete and Accurate Records
Provide Summaries at Least Quarterly:
2. To Employer
3. To Consumer’s Case Manager
Contract Monitoring Guide - Page 3
STANDARD 7 CDSA Responsibilities, Ongoing TrainingCDSA Responsibilities, Ongoing Training
Ongoing Training – Training, Support, Assistance by CDSA
Based on – • Employer/DRP Documentation, Performance, and
Compliance;
• Budget Compliance
• Employee and Contractor Documentation
Contract Monitoring Guide - Page 4
STANDARD 8 CDSA Responsibilities, CDSA Responsibilities,
Criminal Conviction History CheckCriminal Conviction History Check
Contract Monitoring Guide - Page 4
1. Report obtained: From the Texas Department of Public Safety
(DPS), Before applicant was hired, or contractor
retained, and Before service delivery by the individual
2. Employer Notification by CDSA before individual was hired/retained by the Employer (if check was conducted by the CDSA)
STANDARD 8 - CDSA Responsibilities, CDSA Responsibilities, Criminal Conviction History CheckCriminal Conviction History Check
Contract Monitoring Guide - Page 4
3. Copy of Report on File at CDSA: Report from the Texas Department of Public Safety CDSA must not make payment to an individual
barred from employment based on Criminal Conviction History Check
(Note as a Financial Error if Applicable)
4. Offers of Employment / Retain Contractor -
Individuals barred from employment by Chapter 250, Health and Safety Code, must not deliver services or receive payment for services.
STANDARD 9 CDSA Responsibilities, ComplaintsCDSA Responsibilities, Complaints
Contract Monitoring Guide - Page 5
1. CDSA
(a) maintains a log of all complaints and
(b) makes records and resolution of complaints accessible to DADS Staff
Contracting Requirements:Contracting Requirements: §§ 49.17(d)(3) Complaint 49.17(d)(3) Complaint ProceduresProcedures
STANDARD 9 CDSA Responsibilities, ComplaintsCDSA Responsibilities, Complaints
Contract Monitoring Guide - Page 5
2. Each complaint received from any source must be:
(a) Documented, and (b) Resolved
Contracting Requirements: § 49.17(d)(3) Complaint Procedures
3. Based on documentation, did CDSA: (a) Investigate and resolve each complaint in
5 DADS’ workdays? (b) Provide written complaint procedures
initially and at least annually thereafter?
CASE REVIEW SUMMARY
Contract Monitoring Guide - Page 1
Transfer results of Case ReviewCase Review to Form 3853, Provider Agency Evaluation Summary.
Standard Met Not Met N/A Standard Met Not Met N/A
Standard 1 Standard 5
Standard 2 Standard 6
Standard 3 Standard 7
Standard 4 Standard 8
TOTAL:
DADS Form 3853, Provider Agency Evaluation Summary
Texas Department of Aging and Disability Services
Contract/Program ComplianceProvider Agency Evaluation Summary
Form 3853September 2001
Region No.
Type of Review Review
PeriodDate
Other
Reason for Review
Provider Agency Name Vendor No.
Routine Monitoring Complaint
A B C D ESTANDARDS NUMBER MET NUMBER NOT MET NUMBER N/A TOTAL (A + B) % MET
TOTALS
DADS Form 1722, Compliance Monitoring Guide
Consumer Name
Sue Smith Medicaid No.
123456789 Consumer's Region/Catchment Area
07
Address
125 East Blue Bird Avenue City
Austin ZIP Code
78795 Telephone No.
(512) 123-4567
Employer Name (Verify employer status – see form instructions.)
James Smith
Employer Relationship to Consumer
Consumer Parent of Minor X Guardian
Consumer's Date of Birth
01/25/1965 Consumer's Age
39 Guardian
X Yes No
Designated Responsible Party
Yes X No
Agreement Signed by Employer/CDSA (Date)
May 15, 2005
Demographic Information
CONSUMERCONSUMER = INDIVIDUAL RECEIVING SERVICES
EMPLOYEREMPLOYER = Consumer, Parent of Minor, or Court Appointed Guardian
DADS Form 1722, Compliance Monitoring Guide
Demographic Information
CDSA =CDSA = CONUSMER DIRECTED SERVICE AGENCY (CDSA)
MONITORMONITOR = DADS CONTRACT MANAGER/MONITOR
REVIEWREVIEW = REVIEW PERIOD AND TYPE
CDSA Provider CDSA Vendor No. CDSA Location
ACB CDSA 100100456 Austin Name of Monitor Date of Review Review Period
Amy Brown 12/05/05 From: May 1, 2005 To: July 31, 2005 Type of Review
X Formal Administrative Other:
DADS Form 1722, Compliance Monitoring Guide
STANDARD 2 – Budget Development YES NO Review each item in Standard 2 regardless of when the activity occurred within or outside of the review period. Response to each item must be yes or no.
1. Did the CDSA assist the employer in budget development for each service area authorized for CDS, including use of DADS CDS Budget Workbook and related worksheets? ……………………………………………………………………………………. X
2. Is the budget calculated based on each service plan in effect during the review period? …………………........................................................................................................ X
3. Have the employer and CDSA agreed (signed and dated) with each service budget?. X
Reference: 40 TAC §41.103(1)-(3) If any item is marked NO, Standard 2 is NOT MET. Standard 2 is: ......................................... X MET NOT MET
Monitoring Guide - Page 1
DADS Form 1722, Compliance Monitoring Guide
Monitoring Guide – Page 2
STANDARD 3 – Employer and Employer-Agent Registration YES NO N/A
Did the CDSA ensure that (1) the employer and (2) the employer-agent (CDSA) are registered within required time frames established by CDS rules and IRS and TWC regulations? If a registration has not yet been required, or is not required for this employer, mark the item as N/A.
1. Employer Registration: a. Federal: IRS – Employer Identification Number (EIN) X X Form SS-4 – Date Signed: May 15, 2005 , or Other verification, if acquired through telephone or electronic registration: Date EIN: 987654321 b. State: TWC – Employer Registration X X Form C-1 – Date Signed: May 16, 2005 , or Other verification, if acquired through electronic registration:
Date: TWA ID/Account No.: 01-98432 2. Employer-Agent Registration:
a. X Federal: IRS – Employer Appointment of Agent (Written Authorization to Represent Employing Unit) X
Form 2678 – Date Signed: May 15, 2005 b. State: TWC – Written Authorization to Represent Unit in its Relations with Texas Workforce Commission X X Form C-42 – Date Signed:
May 16, 2005
(notarized or completed per current TWC instructions)
Reference: 40 TAC §41.103(4)(A)-(B) If any item is marked NO, Standard 3 is NOT MET. Standard 3 is: .......................................X MET NOT MET N/A
DADS Form 1722, Compliance Monitoring Guide
Monitoring Guide – Page 4
STANDARD 7 – CDSA Responsibilities, Ongoing Training YES NO N/A
Did the CDSA conduct the following activity as required and/or indicated by need:
Did the CDSA provide ongoing training pertaining to the CDSA's responsibilities/employment and employer-related issues?……………… X
Note: Refer to each standard in this and other monitoring activities to determine if employer was non-compliant (adhering to budgets, time sheets, credentialing of employees and providers, providing required documents to the CDSA within established timeframes, etc.). Did the CDSA document that additional training was provided to the employer? Mark this standard as Not Met if the CDSA did not provide ongoing training to the employer related to any problem or non-compliance. Reference: 40 TAC §41.103(2), (3), (4)(L)-(M) If any item is marked NO, Standard 7 is NOT MET. Standard 7 is: ……… MET X NOT MET N/A
Notes/Comments: The CDSA did not document that ongoing training was provided to the Employer for:
1. Timesheets submitted after posted CDSA due dates on 3 occasions; (May 30; June 16, July 1)
2. One Employee did not sign his timesheet on or after the last date of service documented for 2 pay periods (May 31 and June 15) ;
3. The CDSA did not document that the Employer had been notified that the consumer’s CDS Budget for attendant services had exceeded the program authorized number of hours for 3 consecutive pay periods (May 30, June 15, June 30)
DADS Form 1722, Compliance Monitoring Guide
Monitoring Guide – Page 1
Standard Met Not Met N/A Standard Met
Not Met N/A
Standard 1 X Standard 5 X
Standard 2 X Standard 6 X
Standard 3 X Standard 7 X
Standard 4 X Standard 8 X TOTAL: 7 1 0
Case Review Summary:
Transfer results of case review to Form 3853,
Provider Agency Evaluation Summary.
DADS Form 3853, Provider Agency Evaluation Summary
ABOVE COMPLIANCE–Your agency is performing at or above 90%, which is the minimum compliance level. Please review the “Findings” section (below), if appropriate, for areas of concern.
BELOW COMPLIANCE–Your agency is
performing BELOW 90%, which is the minimum
compliance level. The major reasons for
noncompliance of standards are noted in the
“Findings” section (below).
CDSA Compliance Monitoring
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