Innovations Waiver - Relative/Guardian as Direct Service Employee

Innovations Waiver - Relative/Guardian as Direct Service Employee

This document is to be completed by a (PIHP) Network Provider or Agency or Employer of Record as a part of their certification of compliance with the Innovations Relative/Legal Guardian as a Direct Service Employee Policy. The North Carolina Division of Medical Assistance (NC DMA) has defined a relative as the NC Innovations beneficiary's mother, father, step-mother, step-father, sister, brother, aunt, uncle, grandmother, grandfather, adoptive parent, or any other relative related by blood or marriage that lives in the home of the adult member.

Please note that when an individual moves from their natural home and into the home of a relative that is not their parent then this may be considered an AFL situation and RDSE would not apply. RDSE only applies to an individual residing in their natural home.

Beneficiary Name*

Beneficiary DOB*

Beneficiary's County of Residence*

Select

RDSE Status*

If you've recently changed provider agencies, you will also count as "New".

Select

Relative/Guardian Name*

Relationship to waiver recipient*

The North Carolina Division of Medical Assistance (NC DMA) has defined a relative as the NC Innovations beneficiary's mother, father, step-mother, step-father, sister, brother, aunt, uncle, grandmother, grandfather, adoptive parent, or any other relative related by blood or marriage that lives in the home of the adult member.

Select

Other Relationship Description*

Guardianship Status*

*Court Appointed Guardian

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Is the guardian able to provide services as defined in HB 543?*

Select

Does this Relative or Legal Guardian live in the same home as the member?*

Select

Will the Relative or Legal Guardian be providing Primary or Back-up services?*

Select

Who will provide required Back-Up Staffing?*

Provider/Employer of Record*

Provider's/Employer of Record's Address*

Provider's/Employer of Record's Phone Number*

Phone

Provider/Employer of Record's Email Address*

Prospective RDSE start date*

*Date Relative/Guardian will begin providing services as RDSE

Proposed Service(s)*

*Some of these may end on 02/29/2024.

Select

Proposed Hours per Week*

Effective Date*

*Plan Start Date

End Date*

*Plan End Date

The NC Innovations Waiver requires that justification be provided as to why there is no other qualified employee to provide Community Living and Support, assurances of provider choice, and that the individual will not be isolated from their community.

As the qualified provider, I am attesting that no other qualified direct support employee (who is not a relative or legal guardian) is available to provide the service.*

Provide employment-based justification as it relates to exceptional medical and/or exceptional behavioral needs.*

Explain how you plan to assure provider choice for the member.*

Explain how you plan to protect the member from isolation from the community. For example: What is the plan to introduce additional staff to provide some of the services that are needed by the member?*

Annual Recertification

Month and Year that the Relative/Legal Guardian was hired by your agency.*

A qualified provider who is not a Relative or Legal Guardian is not available to provide the service.

Prior Agency Employment*

Select

Previous Agency*

Does your agency employ other staff to provide services to this member?*

Select

Other Services Provided*

Signatures below certify that all information on the form is true and accurate.

The prospective employee understands that the Provider Agency/Employer of Record will monitor the service that a relative or legal guardian provides each month on-site, at a minimum of one time per month.
The prospective employee understands that a Care Coordinator will monitor the relative/legal guardian's provision of services on-site, at a minimum of one time per month.
The prospective employee will provide Community Living and Support. payments are only made for service in the Individual Support Plan authorized by the Utilization Management Department.
The relative or legal guardian must meet the provider qualification for the service. The provider certifies that there is documented training for the specific medical task by a professional appropriately qualified in the task or equipment and that the employee receives nursing supervision to carry out this function as specified by the NC Nursing Practice Act. Provider will train all staff, including parents/guardians, who are providing medical tasks.

Employee attests that the information documented on this form is accurate and that they are in full compliance with four bulleted statements at the end of the form.*

Employee (Full Name)*

Provider/Employer of Record representative attests that the employee is in compliance with all of the following statements and that all of the information completed on this form is accurate.*

Provider Agency Qualified Professional, Employers of Record, Managing Employers (Full Name)*

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