02 A. Louisiana Self-Direction Option for OCDD Waivers Employer Attestation Form

Prototype- Louisiana Self-Direction Option for OCDD Waivers Employer Attestation Form

For questions, please contact Morning Sun Financial Services at 1-844-450-5444
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Louisiana Self-Direction Option for OCDD Waivers Employer Attestation Form

For questions, please contact Morning Sun Financial Services at 1-844-450-5444
Instructions
Employer Legal Name*

Legal First NameLegal Middle NameLegal Last Name
Employer Email*
example@example.com
Participant Legal Name*

Legal First NameLegal Last Name
HIDE- Participant Legal Name

Legal First NameLegal Last Name
HIDE- FEA Vendor Name
Do the Employer and Participant share an address?*

YesNo
Employer Address*

Street Address

Apartment or Unit Number

CityState

Zip Code
Enter the shared address*

Street Address

Apartment or Unit Number

CityState

Zip Code
Employer Attestations & Initials
As the Self-Direction Employer for the Participant, I am attesting to all of the following must initial by each section):
I declare that I am at least 21 years of age, live in Louisiana and in close proximity to the participant to be able to carry out all responsibilities. *

Clear
I understand I must adhere to the health and welfare safeguards identified by the team (the beneficiary, the Support Coordinator, family, any professionals involved and anyone the beneficiary wants involved in their life), including the application of a comprehensive monitoring strategy and risk assessment. *

Clear
I understand all services must be documented in service notes, which describes the services rendered and progress towards the beneficiary’s personal outcomes in the plan of care. I understand I must see that the Direct Support Professional (DSP) does this for each shift worked. *

Clear
I understand the Electronic Visit Verification (EVV) system must be used when the DSP starts and ends the established work shift and that if the schedule changes from what is in the Plan of Care daily schedule, it must be documented as to why the change occurred. *

Clear
I understand the beneficiary’s Rights and Responsibilities and I will ensure that these rights are respected. *

Clear
I understand critical incidents must be reported within 24 hours to the beneficiary’s support coordinator/support coordination agency and any emergency room visits and/or hospitalizations must be reported as soon as possible but within the 24-hour period. Some examples of critical incidents are emergency room visits, evacuations, and hospitalizations. *

Clear
I understand service hours shall be capped at 40 hours per week, Sunday to Saturday, for services delivered by family members living in the home and any hours over this time must not be billed to Medicaid. *

Clear
I understand services must be provided with the beneficiary present. A DSP cannot leave a beneficiary at home while they run errands nor can they run personal errands while “on the clock” working with the beneficiary. *

Clear
I understand DSPs cannot work another job at the same time they are caring for the beneficiary and billing Medicaid nor can they care for other children or adults while caring for the beneficiary and billing Medicaid. *

Clear
I agree to notify the Department of Children and Family Services/Adult Protective Services/Elderly Protective Services or LAW ENFORCEMENT immediately should any form of abuse or neglect occur. *

Clear
I understand I am to read the most up to date Self-Direction employer’s handbook and to understand the provisions in it. If there is something I don’t understand I am to ask questions until I do understand. *

Clear
I understand that, as an employer, my DSPs should not be asked to do any activities that are not directly for the beneficiary, on the plan of care and should not be subjected to harassment in any form, verbal, sexual or other. If problems occur, it is my job to address them immediately. *

Clear
I understand that I am responsible for reviewing each payroll report to make sure employees are being paid the correct rate for the correct number of hours worked, and there is enough hours in the account to continue receiving paid services for the reminder of the coordinator. I understand I should contact the Fiscal Employer Agent if I do not receive payroll reports. *

Clear
I understand that I am responsible for approving all time worked by each DSP and that all activities delivered by the DSP meet the requirements outlined in this attestation form. *

Clear
I understand that I must ensure employee background checks and required screenings are conducted prior to the employee working and at intervals as required in Appendix H of the OCDD Self-Direction Handbook. *

Clear
I understand that if all rules and regulations of the Self-Direction waiver option are not followed, the beneficiary may be asked to leave Self-Direction and choose a provider agency. *

Clear
I understand that the HCBS Waiver program is funded by State and Federal dollars and at any time without advanced notice I may be asked to turn over DSP notes and/or records to the OCDD Monitoring Unit, Louisiana Department of Health’s Program Integrity, the Louisiana Legislative Auditor, the United States Department of Justice, and/or the United States Office of the Inspector General’s Office. *

Clear
Signatures

I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
Signing this document is an attestation that, to the best of my knowledge, the information on this form is true and accurate and I understand the responsibilities of working under the HCBS waiver program. I understand that falsifying or omitting information may result in an investigation by Medicaid Program Integrity and/or the Louisiana Attorney General’s Office or any other state or federal agency with oversight of home and community based services and/or Medicaid funds resulting in jail time and/or a recoupment of paid claims.
Employer Signature*

Clear
Date of Signature*

MonthDayYear
Date
Should be Empty:

Prototype- Louisiana Self-Direction Option for OCDD Waivers Employer Attestation Form

Louisiana Self-Direction Option for OCDD Waivers Employer Attestation Form

Employer Attestations & Initials

Signatures