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					                 Service Contract Review Summary Report - DSPD SFY 2011 - FOCUS Form
                                                    'Rate Based Contracts - Open Ended'
Form Content Updated 10/1/2011
Sample Size: ____________[5% minimum or at least two files]


Division: Division of Services for People With Disabilities                                                Review Date:
Reviewer(s):                                                                                                    (1)            (2)
Provider Name:                            Prov #                                          Contract #(s):
Review Location(s):                                                                     Service Type(s):
Compliance Ratings: Y = Yes; N = No; N/A = Not Applicable                                                  ID.RC & ABI
                                         CONTRACT MONITORING PLAN
   Program Requirements/Scope of Work                               Compliance? (Yes / No / N/A)                    Comments
1) Documentation/client record                                Yes     No      N/A     Major _______        4. Long Form
requirements (Q4)                                                                     Significant ______
                                                                                      Minor ______
2) Staff Training, Competency & Tracking (Q5)                 Yes     No      N/A     Major _______        5. Long Form
                                                                                      Significant ______
                                                                                      Minor ______
3) Staff requirements; annual updates (Q6)                    Yes     No      N/A     Major _______        6. Long Form
                                                                                      Significant ______
                                                                                      Minor ______
          Rate Based Contracts                                      Compliance? (Yes / No / N/A)                    Comments
4) Case management/worker                                     Yes     No     N/A      Major _______        14. Long Form

verification of billings prior to                                                     Significant ______
fund disbursement? (Q10)                                                              Minor ______

5) Onsite reconciliation of billings                          Yes     No      N/A     Major _______        15. Long Form
with client service records? (Q11)                                                    Significant ______
                                                                                      Minor ______
6) Billings have attached lists of clients                    Yes     No      N/A     Major _______
receiving billed service? (Q12)                                                       Significant ______
                                                                                      Minor ______
7) Onsite reconciliation of billed                            Yes     No      N/A     Major _______
hours with provider time records? (Q13)                                               Significant ______
                                                                                      Minor ______
8) Staff hours provided agree with                            Yes     No     N/A      Major _______        16. Long Form
client worksheets? LUR Current? (Q14)                                                 Significant ______
                                                                                      Minor ______
           Client Fund Management                                   Compliance? (Yes / No / N/A)                    Comments
9) Client funds have been managed                             Yes     No     N/A      Major _______        17. Long Form

appropriately by the Provider? (Q15)                                                  Significant ______
                                                                                      Minor ______
   Federal Assurances & Standard Terms                              Compliance? (Yes / No / N/A)                    Comments
10) Compliance with Federal Employment
Eligibility Verification (I-9) & BCI from OL,
DHS & DSPD Code of Conduct, Indemnity
Requirements, Fraud training, and                             Yes     No      N/A     Major _______        19. Long Form
 Emergency Mgt & Business                                                             Significant ______
 Continuation Plan on file (Q16)                                                      Minor ______
Service Contract Review Summary Report- DSPD SFY 2011- FOCUS Form
                                       Rate Based Contracts- Open Ended


Date of Last Review     ____________________________
FY10 Follow-up Findings

1)


2)


3)




Synopsis of Current Review:
Sample Description:

Client Files:

Staff Training Files:

Staff Personnel Files:

Billing Files:

Labor Usage Report & Tool:

Protective Payee Files:

Federal Assurances:

Licensing Issues:


Support Coordination Issues:


Federal Assurances & Standard Terms:
The Division no longer requires signed copy of the entire Contractor Annual Certification Statement.
We do verify various elements related to personnel, provider insurance, and protective payee.
The Contractor is still responsible for full contract compliance.



Contract Monitor Signature/ Date                                                Contract Monitor (Please Print)
Service Contract Review Summary Report - DSPD SFY Form SVR Review
           'Rate Based Contracts - Open Ended'
Form Content Updated 10/1/2010
Sample Size: ____________


Division: Division of Services for People With Disabilities                                Review Date:
Reviewer(s):                                                                                                 (1)       (2)
Provider Name:                                                                          Contract #(s):
Provider #
Review Location(s):                                                                Service Type(s):      RHS RHI/CLS DSG/DSW
Compliance Ratings: Y = Yes; N = No; N/A = Not Applicable                                                HHS,PPS    SED

Issues to Consider in Reporting DIRECT (dir) Hours Provided:
                                                         Compliance? (Yes / No / N/A)             Comments
     No Sick/Vac/Hol included (16 DAYS IN RATE)         Yes     No      N/A      Major _______
                                                                                 Significant ______
                                                                                 Minor ______
            No 'qualifications' Training Included       Yes     No      N/A      Major _______
                                                                                 Significant ______
                                                                                 Minor ______
          No Professional Consultant hours included     Yes     No      N/A      Major _______
                                                                                 Significant ______
                                                                                 Minor ______
          Hourly Supports not included & ties to 520's  Yes     No      N/A      Major _______
                                                                                 Significant ______
                                                                                 Minor ______
      Contracted hours ties to IBWS net Absentee Factor Yes     No      N/A      Major _______
Providers are not supposed to SUBTRACT hours from the
                                                                                 Significant ______
contracted part of the SVR when a client is absent from a residential
                                                                                              Minor ______
program UNLESS the client has exceeded his or her absentee factor.
               Net Direct hours ties to Payroll                         Yes   No     N/A      Major _______
Paid hours less:S/V/H & training =net hours available for DIR                                 Significant ______
HHS/PPS = Advisor Hours only                                                                  Minor ______
          Site ties to DIR Mgt controls                                 Yes   No     N/A      Major _______
Could this be equal to how 520s' print out?                                                   Significant ______
Provider adequately seperates DAY from RESIDENTIAL?                                           Minor ______
                      Timecard signatures                               Yes   No     N/A      Major _______
                                                                                              Significant ______
                                                                                              Minor ______
        Electronic timecards tied to payroll (run parallel)             Yes   No     N/A      Major _______
                                                                                              Significant ______
                                                                                              Minor ______
           Supervision Hours included in DIR?*                          Yes   No     N/A      Major _______
                                                                                              Significant ______
                                                                                              Minor ______
               Support Staff included in DIR?*                          Yes   No     N/A      Major _______
                                                                                              Significant ______
      *=Estimated Indirect hrs; approved & documented                                         Minor ______
* Properly trained Indirect or Admin staff doing certain DIRECT
support activities MAY be allowed per adequate documentation after
DSPD approval.
               Private Pay & other non-DSPD Adj                         Yes   No     N/A      Major _______
                                                                                              Significant ______
                                                                                              Minor ______
Review Summary:
DEPARTMENT OF HUMAN SERVICES
DIVISION OF SERVICES FOR PEOPLE WITH DISABILITIES
                     (name goes here) PROVIDER STAFF VERIFICATION DETAIL REPORT
                   COMMUNITY LIVING AND/OR DAY SERVICES HOURS REPORT DETAIL
           (Contracted Hours from Client Budget IBWS vs. Provided Hours - Direct Support Staff Payroll)

                                                         QUARTER 1
       Reporting Period From:          July (date)          TO     September (date)
First Payroll period beginning:
    Last payroll period ending:
           Payroll periods are:                          (weekly, bi-weekly, bi-monthly, monthly)
   Individual preparing report:
                        Phone:

                                                             Contracted
 PROGRAM SETTING (Cost            Includes: NAME OR            Hours       Provided                        Percent
        Center                         ADDRESS                 (IBWS)       Hours        Type of Service   Variance
Home 'A'                       Individual 'A-1'                      200          180   RHS                  -10.00%
                               Individual 'A-2'                      630          680   RHI                    7.94%
                               Individual 'A-3'                      300          330   CLS                   10.00%
                               Individual 'A-4'                      500          460   Community Living      -8.00%
                               Individual 'A-5'                      400          390   Community Living      -2.50%
     Home 'A' Totals & Count               5                      2,030        2,040    Community Living       0.49%
Home 'B'                       Individual 'B-1'                      200          210   Community Living       5.00%
                               Individual 'B-2'                      400          390   Community Living      -2.50%
                               Individual 'B-3'                      500          540   Community Living       8.00%
                               Individual 'B-4'                      600          580   Community Living      -3.33%
     Home 'B' Totals & Count               4                      1,700        1,720    Community Living       1.18%
HOST Home 'C'                  Individual 'C-1'                       12           14   HHS                   16.67%
HOST Home ''d"                 Individual 'C-2'                       40           27   HHS                  -32.50%
HOST Home 'J'                  Individual 'C-3'                       15           18   PPS                   20.00%
   Host Home Totals & Count                3                         67           59    Community Living     -11.94%
HHS/PPS SVR is for provider "advisor hours" in daily rate.

DAY program must be reported separate from the RESIDENTIAL program
       Loc 'A'              Individual 'a-2'              400         425 DSG/SED/DSW                          6.25%
       Loc 'A'              Individual 'b-3'              600         580 DAY                                 -3.33%
   DAY Loc A Totals & Count            13              1,000       1,005 DAY Sum                               0.50%

        Loc 'B'              Individual 'c-2'                        400          470 DSG/SED/DSW            17.50%
        Loc 'B'              Individual 'c-3'                        600          620 DAY                     3.33%
    DAY Loc B Totals & Count            17                        1,000        1,090 DAY Sum                  9.00%

Example Contracted DAY: 2.2 hours per day x (20 day+17 day+22 day) = 129.8 direct hours in this quarter
Expected DAY includes 6 hours + 3/4 hour before & after day staff coverage = 7.5 hours paid in the rate.

SVR Issues to Consider in Reporting DIRECT Hours Provided:
                                                       No
                                                  Professional                        Contracted hours
                                                   Consultant              Hourly       ties to Client    Net Direct
No S/V/H included (must net                          hours               hours ties   Budget IBWS net     hours ties
  16 days in the rate first) No Training Included   included              to 520's    Absentee Factor     to Payroll

                                                         *=Estimated
                                                         Indirect hrs;   Private Pay HHS/PPS is for
Supervision Hours included          Support Staff        approved &      & other non- provider "advisor  Timecard
         in DIR?*                 included in DIR?*      documented       DSPD Adj hours" in daily rate. signatures
* Properly trained Indirect or Admin staff doing certain DIRECT support activities MAY be allowed per adequate documentation.
 Hours
Variance
      (20)
       50
       30
      (40)
      (10)
       10
       10
      (10)
       40
      (20)
       20
        2
      (13)
        3
       (8)




       25
      (20)
        5

       70
       20
       90
              Site ties to
               DIR Mgt
                controls

                Electronic
             timecards tied
             to payroll (run
                 parallel)
uate documentation.
DIVISION OF SERVICES FOR PEOPLE WITH DISABILITIES GUIDELINES FOR COMPLETING THE PROVIDER STAFFING VERIFICATION
REPORTS (SVR) - REVIEW OF STAFF HOURS IN COMMUNITY LIVING AND DAY SERVICES

OBJECTIVE: The main purposes of the SVR are to identify health and safety concerns due to on-going shortage in contracted services and to attest/verify
the provider’s system for reporting/monitoring average daily services billed. The Division, using sampling processes noted below, monitors within the provider
labor reporting system by comparing the average daily hours of support expected/contracted per quarter, as generated on the persons individualized budget
worksheet (IBWS), to the actual service hours delivered by the service provider.

PROCESS: Residential Habilitation and Day Service providers will provide the Division a company wide SVR using existing payroll information (time cards
and staffing schedules) to document actual support hours delivered by site during the period sampled. This SVR is normally one quarter from the previous four
quarters. This includes those providers who bill for RHI, RHS/CLS, HHS, PPS, SED, and DSG/DSW.

To enhance the process of reviewing by the Division, individual samples are grouped into meaningful sample reports -- common address settings (cost
centers). Groupings should be as small as possible and directly relate to direct supervision staffing patterns and payroll accounting processes already in place.
The Division will process random based 5% to 10% samples of a provider’s census (or two files minimum). DAY sites are reviewed uniquely from
RESIDENTIAL sites. HHS/PPS is for advisor hours only. Providers should have time cards, staff schedules or other supportive documentation available to
verify information submitted for Provider Staff Verification Report Forms. Once client sample groupings have been made, providers will confirm with the
Division each person in the sample group and confirm the total quarterly hours of service expected/contracted (from the Division’s individualized budget
worksheet-prepared by the support coordinator). Total hours required are calculated by adding the expected/contracted hours of each member of the sample
group at a site. This total will then be compared to the total service hours delivered (from provider payroll records). A sample report is attached for reference.


The definition for direct hours of service will be consistent with wording used on the individualized worksheets. For example, day supports will be the staff
time used to support an individual in a day setting or in the community. Community living supports will be the staff time used to support an individual in a
residential setting when sleeping, getting up, dressing, bathing, making meals, washing clothes, learning things and helping on the weekend.
Documented Staff time used helping a person achieve the goals of their person centered support plan are countable direct service hours. These direct service
hours, defined as “face to face” may include documented indirect hours for specific individuals that support those individuals with approved services. The
process of reporting allowed indirect hours must be prior approved and supported by annual time study or actual time tracking. Direct care staff and on
occasion, qualified supervisory staff or administrative staff may deliver these hours. Administrative and supervision hours, staff training, sick/vacation/holiday
pay must be “adjusted out” of paid hours to compare accurately service hours provided to those expected/contracted. Reported hours are properly adjusted for
any absentee factor used on IBWS.


Contract analysts in each region will visit providers to audit the service hours reported. They will look for consistency in hours reported with time cards and/or
other source documentation. They will also review the service or monthly file notes to validate the service was provided on the days they were reported. They
may suggest IBWS adjustments to develop greater correlation between Individual Budget worksheets and required/delivered services.

                                                                SFY-Q1:
                                        SAMPLE REPORTING PERIODS:                         July 1 thru September 30
                                                                SFY Q2:                   October 1 thru December 31
                                                                SFY Q3:                   January 1 thru March 31
                                                                SFY Q4:                   April 1 thru June 30

These annual Sample reports are routine, therefore, please submit them to the Division Auditor and with a copy to the region director. Exact dates may be
“adjusted” to provider’s closest 13 week payroll period for the quarter.
Sample quarterly SVR may be submitted to Clair Abee at cabee@utah.gov or 801-538-4279 FAX. An electronic copy per e-mail is preferred.

For State Fiscal Year 2011 review process, the Division will attest/verify only the reporting period October 1 2009 thru December 31 2009 already collected
from providers. No additional reports will be requested until SFY 2012.

Blank report form, guideline and audit tool are available from Mr. Abee or from the Division’s web page: http://www.dspd.utah.gov/contracttools.htm
DSPD Quality and Audit staff is available to respond to any questions you may have related to this process.

                                        State Office-required copy to:
DHS/DSPD
Clair Abee
195 North 1950 West
Salt Lake City, Utah 84116
801-538-4680
FAX: 801-538-4279
cabee@utah.gov

Regions Director:                                    Region Contract Analysts:
   Douglas Maughan, Director                         Pam Madsen (C)          pmadsen@utah.gov
   150 East Center Street, Suite 5100                Dirk Murdock (C)        dirkmurdock@utah.gov
   Provo, Utah 84606                                 Jessica Hooper (C)      jessicahooper@utah.gov
   801-374-7005                                      Cara Ross (N)           cross@utah.gov
   FAX: 801-374-7638                                 Steve Brown (N)         stevebrown@utah.gov
dwmaughan@utah.gov                                   Sue Chandler (S)        stchandler@utah.gov
                                                     Jay Karlinsey (S)       jkarlin@utah.gov
UTAH DEPARTMENT OF HUMAN SERVICES
DIVISION OF SERVICES FOR PEOPLE WITH DISABILITIES

  DSPD SFY 11 'SERVICE CONTRACT REVIEW SUMMARY REPORT' REFERENCE TOOL - SHORT FORM

1) Assessment requirements (Support Coordinator File)         (Non-Fiscal*)
        a) Verify 'Form 817 or 817b' (Waiver Level of Care Determination) is complete and updated annually by
        a Qualified Mental Retardation Professional (QMRP).

        b) Verify that the, 'Signature of Client & Choice', is signed and checked.

2) Clients match program description. (Support Coordinator File)                 (Non-Fiscal*)
         a) Ensure that a copy of the '1056' or 'Individual Budget Worksheet' is on file.

        b) Verify that a current, 'Individual Service Plan', is on file.

3) Treatment and service requirements (Provider Site)             (Non-Fiscal*)
        a) Ensure that a copy of the '1056' with related 'Individual Budget Worksheet' was given to the Provider.

        b) Verify that a current, 'Provider Action Plan', is on file.

        c) Verify that, Type of Service, agrees with ISP.

4) Documentation/client record requirements -FACE SHEET (Provider Site)                               (Non-Fiscal*)
        a) Ensure that the client record includes the client's name, address, phone number, birth date,
        ID number, and Medicaid number. The name, address, phone number of the following people:
        1. Sponsor or owner of facility providing services; 2. Support Coordinator; 3. Primary Care Physician;
         and 4. Legal representative/Guardian or emergency contacts (how to contact); 5. Identify any
        responsible 3rd party or Medical Insurance; 6. Client identification photo; 7. Date of last update

        b) Verify that a record of all medical and/or dental examinations performed, a record of all
        medications (Logs) are on site.

        c) Verify that a record of all surgeries, immunizations, illnesses, chronic complaints, and
        significant changes in health is on file; verify the presence of an authorization for any
        emergency medical treatment needed.

        d) Verify that the Provider has a process for Incident Reporting (What triggers a report?).
        Verify that Support Coordinator is receiving copies of reports.
                           first aid and/or referral to medical personnel,
                           medication errors, accidents or injuries,
                           behavioral or other incidents such as property damage

        e) Verify that client records are locked and secured. Confirm records confidentiality,
        maintenance, retention, destruction, and audit access is per contract.




                                                         F. 1 - 4
UTAH DEPARTMENT OF HUMAN SERVICES
DIVISION OF SERVICES FOR PEOPLE WITH DISABILITIES

  DSPD SFY 11 'SERVICE CONTRACT REVIEW SUMMARY REPORT' REFERENCE TOOL - SHORT FORM

5) Staff Training & Tracking (Provider Site)                  (Non-Fiscal*)
         a) Verify provider has a system to document in employee records required training and competency;
          sample at least one full-year staff.

         b) Ensure that copies of educational transcripts, licenses, and Degrees (if transcripts and
         degrees are used by the contractor to prove competency). Staff with "equivalent service
         experience" must have supporting documentation in staff file.

         c) Ensure that Emergency Procedures, e.g. when to call emergency 911 number, incident
         reporting, when to call a doctor or hospital and orientation about seizure disorders
         are posted, visible or easily ascertained.

6) Staff requirements (Provider Site) (Non-Fiscal*)             (Non-Fiscal*)
          a) Application (including name, address, and telephone number)

         b) References (2) and documentation of reference verification

         c) BCI release forms from Office of Licensing per State requirements (annually)

         d) All staff must have a signed DHS & DSPD Code of Conduct on file; updated annually.
                             found at: http://www.dspd.utah.gov/codeofconduct.htm
         e) All staff must have a negative screen for tuberculosis, or have a chest x-ray that is negative
         if a previous test indicated a positive result. (on file); test must be updated when staff has exposure
          or symptoms

         f) Staff involved in food preparation or supporting clients with food preparation shall have
         a current Food Handler's Permit from the County Health Department.

         g) On at least an annual basis verify the driver's license, driving record, and personal auto insurance
         coverage of staff that transport clients (personal or private vehicles).

7) Client outcomes are included in all client files (Provider Site)               (Non-Fiscal*)
         Verify that client outcomes are in their file.

8) Data for client outcomes has been collected (Provider Site)                    (Non-Fiscal*)
         (i.e. outcomes based on assessment data, progress reports, etc).
         Ensure that client monthly progress reports are in their file.

9) Methods or system in place to prevent abuse, neglect, or exploitation (Provider Site)          (Non-Fiscal*)
        a) Ensure that an Agency Human Rights Plan is on file.

         b) Ensure that an Agency Human Rights Committee is established, meets & documents activities.

         c) Ensure documentation signed by the Person and/or Representative that a copy of the grievance
         procedure was given, read and explained to the Person and/or Representative.

         d) Verify client Human Rights documentation, guardianship, Client List of Rights,
         and other pertinent legal documents




                                                        F. 2 - 4
UTAH DEPARTMENT OF HUMAN SERVICES
DIVISION OF SERVICES FOR PEOPLE WITH DISABILITIES
  DSPD SFY 11 'SERVICE CONTRACT REVIEW SUMMARY REPORT' REFERENCE TOOL - SHORT FORM

10) Case management/worker verification of billings prior to fund disbursement (Region Office)              (Fiscal**)
     a) Verify payment documents or authorizations (520, 295, 1032, 1056, Budget Worksheets, etc.)
     are signed by appropriate Provider and DSPD personnel (Support Coordinator, Admin Prog Mgr,
     Contract Analyst, etc.)
     (Document with audit work papers and/or schedules)

      b) Verify clients on payment documents for eligibility, services, and dollar authorizations with USSDS
      records and reconcile to corresponding ISP and/or adjustments.
      DOH PAYBACK ISSUE IF NOT RECONCILABLE
      (Document with audit work papers and/or schedules)

      c) Verify payment documents have attached Provider client attendance logs and that they reconcile.
      (Document with audit work papers and/or schedules)

      d) Review the Division Admin Prog Mgr review logs (USTEPS & activities) to verify they support a process
      of sufficient Supervisory samples from all SCE & Division staff client files to verify required provider
      monthly summaries are timely, complete and effective for supporting monthly billings.
      DOH PAYBACK ISSUE IF MONTHLY SUMMARIES NOT COMPLETE AND TIMELY.
      Ref Contract section 19b - Contract Required Monthly Reports.
      (Document with audit work papers and/or schedules)

      e) Verify Process for Supervisory notification to Region Director of providers unable to provide
       summaries timely, complete and effective for supporting monthly billings.
      (Document with audit work papers and/or schedules)

11) Onsite reconciliation of billings with client service records (Provider Site)           (Fiscal**)
     a) Reconcile client service records to payment documents for unit of measure, rate and
      dollar accuracy. (Document with audit work papers and/or schedules)

      b) Reconcile client service records to payment documents for correct eligibility and service codes.
      (Document with audit work papers and/or schedules)

12) Billings have attached lists of clients receiving billed services (Provider Site)          (Fiscal**)
      a) Reconcile client service records to payment documents for attendance accuracy.
      (Document with audit work papers and/or schedules)

      b) Reconcile client records to payment documents for services not requiring
      attendance logs (medical equipment, cash payments, etc.)
      (Document with audit work papers and/or schedules)

13) Onsite reconciliation of billed hours with provider time records (Provider Site)           (Fiscal**)
     a) Reconcile hourly payment documents to Provider timesheets or personnel records
     for authorized client direct service hours provided by employees.
     (Document with audit work papers and/or schedules)

      b) Verify Provider timesheets or personnel records have authorized employee and supervisor signatures.




                                                      F. 3 - 4
UTAH DEPARTMENT OF HUMAN SERVICES
DIVISION OF SERVICES FOR PEOPLE WITH DISABILITIES

DSPD SFY 11 'SERVICE CONTRACT REVIEW SUMMARY REPORT' REFERENCE TOOL - SHORT FORM

14) Staff hours provided agree with client worksheets; SVR Current. (Provider Sites) (Fiscal**)
       a) Reconcile client worksheets to client records, payment documents and Provider timesheets
       or personnel records for authorized direct service hours.
       (Document with audit work papers and/or schedules)

       b) Reconcile client worksheets to client records, payment documents and Provider timesheets
       or personnel records for authorized staff service hours. Estimates of such indirect hours on behalf of
       specific clients may be allowed in Labor Usage Reports when pre-approved and supported by client-
       based time study (updated at least annually) or other similar methodology.
       (Document with audit work papers and/or schedules) Audit SVR for FY10 Q2 - Oct 09 to Dec 09

       c) Reconcile client worksheets to client records, payment documents and Provider timesheets
       or personnel records for authorized professional/consultant service hours.
       (Document with audit work papers and/or schedules)

       d) Verify Provider timesheets or personnel records have authorized employee and supervisor signatures.

       e) Reconcile Provider payroll timesheets with electronic timecard system reporting of direct labor.
       Results from Parallel-run-tests of electronic payroll and manual pay timecard systems are to be
       reconciled prior to Division use.
       (Document with audit work papers and/or schedules)

       f) Verify Provider Staff Verification Report system of reporting direct labor & reports are current.
       (Document with SVR audit tool, work papers and/or schedules)

15) Client funds have been managed appropriately by the Provider (Provider Site)                (Fiscal**)
        Verify that clients with the Provider as their representative payees or have had their personal funds
        restricted by the Provider Human Rights Committee are having their personal funds properly managed.
        (Collect a copy of client names and Complete Representative Payee Form for each client who fits this
         description) Validate a sample with DSPD staff for (monthly) reports received timely per contract.
        Validate provider administrative review monthly & quarterly per contract.

16) Provider is complying with Federal Employment Eligibility Verification (Sec 2-H) (Provider Site)     (Non-Fiscal*)
       Ensure that there is a signed copy of the I-9 'Employment Eligibility Verification' and annual BCI- all staff;
       AND Provider is current on Conflict of Interest, annual DHS & DSPD Code of Conduct, and

       Indemnity Requirements (Contractor Annual Certification Statement Sec 3 H). That it has and that it will
       continue to maintain in good standing throughout the life of this contract, policies of liability and property
       damage insurance that comply with the specific terms and policy limits outlined in this contract, including
       worker's compensation insurance that complies with the requirements of the Utah Workers Compensation
       Act (U.C.A. 34A-2-1 et seq.). Provider has Emergency Management & Business Continuation Plan on
       file.Provider has policy & training related to abuse reporting, anti-fraud, and records security & control.
       (Document with audit work papers and/or schedules) Provider is no longer expected to submit annual
       signature of Certifictions Statement to DSPD Contract unit.

17) Were possible violations of licensing requirements identified that required (Provider Site)            (Non-Fiscal*)
notification of the Office of Licensing?
        a) Verify that if there are violations of licensing requirements you document date of notification
        to the Office of Licensing and who was contacted.

        b) Complete 'Certification Checklist for Community Living Supports - 3 or less' form where applicable.
        Validate annual self-inspection of licenced child care site for PPS or host home site for HHS.
* Non-Fiscal - This requirement should be completed using the most recent data available.
** Fiscal - This requirement should be completed using data from the previous Fiscal Year
           or in the case of a Rep Payee the most current last 12 months.


                                                           F. 4 - 4
                                           SFY 11 DSPD INDIVIDUAL CHECK-OFF FORM
                                       (To be used with DSPD Contract Reference Tool - Short Form)

                 CONSUMER INFORMATION                                                             PROVIDER INFORMATION
NAME:                                                                       AGENCY NAME:
ADDRESS:                                                                    CONTRACT # (S):            (1)           (2)        (3)
CLIENT ID NUMBER:                                                           ADDRESS:

                                                            REVIEWER INFORMATION
NAME:                                                                       DATE OF REVIEW:
TITLE:                        REG:                                          SUPPORT COORDINATOR:

                                                           CP II GR (Contract Part II General Requirement #
                                   DSPD SHORT FORM REQUIREMENT (Non-Fiscal)                                                         COMPLIANCE
1) Assessment requirements (Support Coordinator File)      (Non-Fiscal*)      Rule R539-1-2
       a) Verify 'Form 817 or 817b' (Waiver Level of Care Determination) is complete and updated annually by                        YES   NO   N/A
       a Qualified Mental Retardation Professional (QMRP).      5% sample

         b) Verify that the, 'Signature of Client & Choice', is signed and checked.                                                 YES   NO   N/A

2) Clients match program description. (Support Coordinator File) (Non-Fiscal*)                         CP II GR #8
        a) Ensure that a copy of the '1056' or 'Individual Budget Worksheet' is on file.                                            YES   NO   N/A

         b) Verify that a current, 'Individual Service Plan', is on file.                                                           YES   NO   N/A

3) Treatment and service requirements (Provider Site)          (Non-Fiscal*)    CP II GR #8, #9
        a) Ensure that a copy of the '1056' or 'Individual Budget Worksheet' was given to the Provider.                             YES   NO   N/A

         b) Verify that a current, 'Provider Action Plan', is on file.                                                              YES   NO   N/A

         c) Verify that, Type of Service, agrees with ISP.                                                                          YES   NO   N/A

4) Documentation/client record requirements -FACE SHEET (Provider Site)                  (Non-Fiscal*)               C P II GR #9
         a) Ensure that the client record includes the client's name, address, phone number, birth date,                            YES   NO   N/A
         ID number, and Medicaid number. The name, address, phone number of the following people:
         1. Sponsor or owner of facility providing services; 2. Support Coordinator; 3. Primary Care Physician;
          and 4. Legal representative/Guardian or emergency contacts (how to contact); 5. Identify any
         responsible 3rd party or Medical Insurance; 6. Client identification photo; 7. Date of last update

         b) Verify that a record of all medical and/or dental examinations performed, a record of all                               YES   NO   N/A
         medications (Logs) are on site.

         c) Verify that a record of all surgeries, immunizations, illnesses, chronic complaints, and                                YES   NO   N/A
         significant changes in health is on file; verify the presence of an authorization for any
         emergency medical treatment needed.

         d) Verify that the Provider has a process for Incident Reporting (What triggers a report?).                                YES   NO   N/A
         Verify that Support Coordinator is receiving copies of reports.                       GR #16
                             first aid and/or referral to medical personnel,
                             medication errors, accidents or injuries,
                             behavioral or other incidents such as property damage

         e) Verify that client records are locked and secured. Confirm records confidentiality,                                     YES   NO   N/A
         maintenance, retention, destruction, and auddit access is per contract.               GR #10




                                                                         NF. 1 - 2
                                           SFY 11 DSPD INDIVIDUAL CHECK-OFF FORM
                                       (To be used with DSPD Contract Reference Tool - Short Form)

                                   DSPD SHORT FORM REQUIREMENT (Non-Fiscal)                                                        COMPLIANCE
5) Staff Training & Tracking (Provider Site)                 (Non-Fiscal*)              CP II GR #6
      a) Verify provider has a system to document in employee records required training and competency;                           YES   NO   N/A
      sample at least one full-year staff.                                                                        R 539-6-3

     b) Ensure that copies of educational transcripts, licenses, and Degrees (if transcripts and                                  YES   NO   N/A
     degrees are used by the contractor to prove competency). Staff with "equivalent service                        GR #9
     experience" must have supporting documentation in staff file.

     c) Ensure that Emergency Procedures, e.g. when to call emergency 911 number, incident                                        YES   NO   N/A
     reporting, when to call a doctor or hospital and orientation about seizure disorders
     are posted, visible or easily ascertained.                     R539

6) Staff requirements (Provider Site) (Non-Fiscal*)           R 539-6                        C P II GR #3, #7, #9
      a) Application (including name, address, and telephone number)                GR#9                                          YES   NO   N/A

     b) References (2) and documentation of reference verification                  GR #9                                         YES   NO   N/A

     c) BCI release forms from Office of Licencing per State requirements (annual)
                                                                            GR #9                                                 YES   NO   N/A

     d) All staff must have a signed DHS & DSPD Code of Conduct on file; updated annually.                        GR #7           YES   NO   N/A
                                                                                                                  R 539-6-8
     e) All staff must have a negative screen for tuberculosis, or have a chest x-ray that is negative                            YES   NO   N/A
     if a previous test indicated a positive result. (on file); test must be updated when staff has exposure
      or symptoms                                                                            R539-6-1             GR #3

     f) Staff involved in food preparation or supporting clients with food preparation shall have                                 YES   NO   N/A
     a current Food Handler's Permit from the County Health Department.                     R539-6-1              GR #3

     g) On at least an annual basis verify the driver's license, driving record, and personal auto insurance                      YES   NO   N/A
     coverage of staff that transport clients (personal or private vehicles).                   GR #1 #3

7) Client outcomes are included in all client files (Provider Site) (Non-Fiscal*)            R 539-5-1
      Verify that client outcomes are in their file.                                                                              YES   NO   N/A

8) Data for client outcomes has been collected (Provider Site)                               R 539-5-1
     Ensure that client monthly progress reports are in their file.                                                               YES   NO   N/A

9) Methods or system in place to prevent abuse, neglect, or exploitation (Provider Site) (Non-Fiscal*) C P II GR #21
     a) Ensure that an Agency Human Rights Plan is on file.                                                                       YES   NO   N/A

     b) Ensure that an Agency Human Rights Committee is established, meets & documents activities.                R 539-2-3       YES   NO   N/A

     c) Ensure documentation signed by the Person and/or Representative that a copy of the grievance                              YES   NO   N/A
     procedure was given, read and explained to the Person and/or Representative.    R 539-5-3

     d) Verify client Human Rights documentation, guardianship, Client List of Rights,                                            YES   NO   N/A
     and other pertinent legal documents                                               R 539-2-1

16) Provider is complying with Federal Employment Eligibility Verification (Sec 2-H) (Provider Site)
                                                                                             (Non-Fiscal*)        (Non-Fiscal*)
     Ensure that there is a signed copy of the I-9 'Employment Eligibility Verification' and annual BCI-                          YES   NO   N/A
     all staff; AND Provider is current on Conflict of Interest, annual DHS & DSPD Code of Conduct, and
     Indemnity Requirements (Contractor Annual Certification Statement Sec 3 H). That it has and that it
     will continue to maintain in good standing throughout the life of this contract, policies of liability and
     property damage insurance that comply with the specific terms and policy limits outlined in this
     contract, including worker's compensation insurance that complies with the requirements of the Utah
     Workers Compensation Act (U.C.A. 34A-2-1 et seq.). Provider has Emergency Management &
     Business Continuation Plan on file.Provider has policy & training related to abuse reporting, anti-
     fraud, and records security & control.
     (Document with audit work papers and/or schedules) Provider is no longer expected to submit
     annual signature of Certifictions Statement to DSPD Contract unit.                                           C P VII Sect B Table 3

17) Were possible violations of licensing requirements identified that required (Provider Site)                   (Non-Fiscal*)
     notification of the Office of Licensing?                     R 539-6-7
     a) Verify that if there are violations of licensing requirements you document date of notification                           YES   NO   N/A
     to the Office of Licensing and who was contacted.

     b) Complete 'Certification Checklist for Community Living Supports - 3 or less' form where applicable.                       YES   NO   N/A
     Validate annual inspection of licenced child care site for PPS or host home site for HHS.

                                                                      NF. 2 - 2
                                       SFY 11 DSPD INDIVIDUAL CHECK-OFF FORM
                                  (To be used with DSPD Contract Reference Tool - Short Form)
                                 DSPD SHORT FORM REQUIREMENT (Fiscal)                                                 COMPLIANCE
10) Case management/worker verification of billings prior to fund disbursement (Region Office)    (Fiscal**)
       a) Verify payment documents or authorizations (520, 295, 1032, 1056, Budget Worksheets, etc.)                 YES    NO   N/A
       are signed by appropriate Provider and DSPD personnel (Support Coordinator, Admin Prog Mgr,
       Contract Analyst, etc.)
       (Document with audit work papers and/or schedules)

       b) Verify clients on payment documents for eligibility, services, and dollar authorizations with USSDS        YES    NO   N/A
       records and reconcile to corresponding ISP and/or adjustments.
       DOH PAYBACK ISSUE IF NOT RECONCILABLE
       (Document with audit work papers and/or schedules)

       c) Verify payment documents have attached Provider client attendance logs and that they reconcile.            YES    NO   N/A
       (Document with audit work papers and/or schedules)     CP IV #3

       d) Review the Division Admin Prog Mgr review logs (USTEPS & activities) to verify they support a              YES    NO   N/A
       process of sufficient Supervisory samples from all SCE & Division staff client files to verify required
       provider monthly summaries are timely, complete and effective for supporting monthly billings.
       DOH PAYBACK ISSUE IF MONTHLY SUMMARIES NOT COMPLETE AND TIMELY.
       Ref Contract section 19b - Contract Required Monthly Reports.
       (Document with audit work papers and/or schedules)

       e) Verify Process for Supervisory notification to Region Director of providers unable to provide              YES    NO   N/A
        summaries timely, complete and effective for supporting monthly billings.
       (Document with audit work papers and/or schedules)

11) Onsite reconciliation of billings with client service records (Provider Site)       (Fiscal**)
       a) Reconcile client service records to payment documents for unit of measure, rate and dollar accuracy.       YES    NO   N/A
       (Document with audit work papers and/or schedules)

       b) Reconcile client service records to payment documents for correct eligibility and service codes.           YES    NO   N/A
       (Document with audit work papers and/or schedules)

12) Billings have attached lists of clients receiving billed services (Provider Site)   (Fiscal**)
         a) Reconcile client service records to payment documents for attendance accuracy.                           YES    NO   N/A
         (Document with audit work papers and/or schedules)

       b) Reconcile client records to payment documents for services not requiring                                   YES    NO   N/A
       attendance logs (medical equipment, cash payments, etc.)
       (Document with audit work papers and/or schedules)

13) Onsite reconciliation of billed hours with provider time records (Provider Site) (Fiscal**)           CP II GR #13
       a) Reconcile hourly payment documents to Provider timesheets or personnel records                              YES   NO   N/A
       for authorized client direct service hours provided by employees.
       (Document with audit work papers and/or schedules)

       b) Verify Provider timesheets or personnel records have authorized employee and supervisor signatures.        YES    NO   N/A

14) Staff hours provided agree with client worksheets; SVR Current. (Provider Sites) (Fiscal**)     CP II GR #5 and #13
        a) Reconcile client worksheets to client records, payment documents and Provider timesheets             YES NO           N/A
        or personnel records for authorized direct service hours.
        (Document with audit work papers and/or schedules)

       b) Reconcile client worksheets to client records, payment documents and Provider timesheets                   YES    NO   N/A
       or personnel records for authorized staff service hours. Estimates of such indirect hours on behalf of
       specific clients may be allowed in Staff Verification Reports when pre-approved and supported by client-
       based time study (updated at least annually) or other similar methodology.
       (Document with audit work papers and/or schedules)

       c) Reconcile client worksheets to client records, payment documents and Provider timesheets                   YES    NO   N/A
       or personnel records for authorized professional/consultant service hours.
       (Document with audit work papers and/or schedules)

       d) Verify Provider timesheets or personnel records have authorized employee and supervisor signatures.        YES    NO   N/A

       e) Reconcile Provider payroll timesheets with electronic timecard system reporting of direct labor.           YES    NO   N/A
       Results from Parallel-run-tests of electronic payroll and manual pay timecard systems are to be
       reconciled prior to Division use.
       (Document with audit work papers and/or schedules)

       f) Verify Provider Staff Verification Report system of reporting direct labor & reports are current.          YES    NO   N/A
       (Document with SVR audit tool, work papers and/or schedules)

15) Client funds have been managed appropriately by the Provider (Provider Site)            (Fiscal**)    CP II GR #20
        Verify that clients with the Provider as their representative payees or have had their personal funds         YES   NO   N/A
        restricted by the Provider Human Rights Committee are having their personal funds properly managed.
        (Collect a copy of client names and Complete Representative Payee Form for each client who fits this
         description) Validate a sample with DSPD staff for (monthly) reports received timely per contract.
        Validate provider administrative review monthly & quarterly per contract.

                                                                                                                                       FIS F-1-1
  SFY 11 DSPD PROTECTIVE (REPRESENTATIVE) PAYEE/PERSONAL FUNDS INDIVIDUAL RECORD REVIEW FORM

       CONSUMER INFORMATION                               PROVIDER INFORMATION
NAME:                                             AGENCY NAME:
ADDRESS:                                          CONTRACT NUMBER (S):
CLIENT ID NUMBER:
MONTHLY BENEFIT AMOUNT:                                  AGENCY RELATIONSHIP TO CONSUMER - CHECK ONE
TYPE OF BENEFIT:                                  INDIVIDUAL REPRESENTATIVE PAYEE
                                                  ORGANIZATIONAL REPRESENTATIVE PAYEE
          REVIEWER INFORMATION                    OTHER (specify)
NAME:
TITLE:            REG:                                        LIVING ARRANGEMENTS
SUPPORT COORDINATOR:                              HOME (# living in home)
DATE OF REVIEW:                                   APARTMENT (# living in apartment)
REVIEW PERIOD:                                    OTHER (specify)

     NOTE: This is a unique and billable service in new waiver. Ref F06 State Legislation changes.
        DHS/DSPD CONTRACT REPRESENTATIVE PAYEE REQUIREMENT CP II GR #20                                     COMPLIANCE
1) Verify that there is a Provider Human Rights Committee authorization or a DHS/DSPD form 1-3,             YES   NO   N/A
Voluntary Financial Agreement', signed by the client/Representative.     R539-5-3

2) Verify that Provider Staff reviews financial records with client on a monthly basis and that             YES   NO   N/A
the Provider maintains documentation of these reviews in the client's file.
( Review one month from each quarter for the most recent previous 12 months )

3) Verify that an accurate record of all funds deposited with the Provider for use by the client is         YES   NO   N/A
on file.
( Review Provider Bank Reconciliations for accuracy for one month from each quarter
( for the most recent previous 12 months )

4) Verify that purchases over 20 dollars per item are substantiated by receipts signed by the client        YES   NO   N/A
and professional staff.
( Review one month from each quarter for the most recent previous 12 months )

5) Verify that multiple items purchased over 20 dollars shall be verified with receipts, cancelled          YES   NO   N/A
checks or monthly bank statements.
( Review one month from each quarter for the most recent previous 12 months )

6) Verify that a record of the client's petty cash funds is on file. The amount of cash maintained in the   YES   NO   N/A
client's petty cash account shall not exceed 50 dollars without Provider administrative approval.
Records shall be kept of all deposits and withdrawals to the petty cash account.
( Reconcile Bank Statement to Provider client records for one month from each quarter
( for the most recent previous 12 months )

7) Verify that a quarterly administrative review of monthly financial documentation, bank statements,       YES   NO   N/A
receipts and purchases shall be conducted by the Provider for a random sample of clients
and that these are documented.

8) Verify that an inventory is kept of client belongings with a purchase price of 50 dollars or more or     YES   NO   N/A
items of significance. Form should reflect additions and deletions made.

9) Ensure that a Protective payees monthly statement is forwarded within 45 days to the                     YES   NO   N/A
Support Coordinator.




                                                       REP F. 1 - 1
                                CERTIFICATION CHECKLIST                                               Form 5-9CC (6/03)
                         DSPD COMMUNITY LIVING SUPPORT (3 or less)

Provider Name:                                   Region:                                          Provider ID#:
Location Name:                                   Date:                                            Site #:
Site Address:                                    Surveyor:
                                                 Site Contact Phone:
City:                                                                                             Site Expires:
Zip Code:


                                       BEST PRACTICE                                                              Rule 539-6-7
                           (Recommended for each living structure)                                                 Comments
SLEEPING
1. No more than two (2) persons are housed in a single bedroom.
2. A minimum of sixty (60) square feet per consumer is provided in a multiple occupant
    bedroom. Storage space/closets not included.
3. A minimum of one hundred (100) square feet per individual is provided in a single
    occupant bedroom. Storage space/closets not included.
4. Sleeping areas have a source of natural light, and are ventilated by mechanical means or
   equipped with a window that opens and has a screen.
5. Beds are solidly constructed (no portable beds). Each individual has his/her own bed.
6. There are at least two working outlets, or one outlet and one permanently installed
    light fixture.
BATHROOMS
1. Bathroom mirrors are at convenient heights and other furnishings or equipment necessary
   to meet the consumer’s basic hygienic needs is installed appropriately.
GENERAL
1. Stove must have at least 2 of the burners and the oven working. The range and oven must
   have all of the knobs and handles intact.
2. The refrigerator must have a freezer compartment that shuts securely. The refrigerator
   must have all of the handles and a kick plate secure and intact.
3. Furnishings are sufficient, comfortable, clean and in good repair.
4. There is sufficient storage space for the clothing and personal belongings of each person.
   All outside storage units must have some kind of working lock.
5. Window coverings assure privacy and are in good repair.
                                       LIFE AND SAFETY                                          YES     NO              Comments
                 (These must be marked yes or a certificate will not be issued)
SLEEPING
1. Bedroom exit windows must open, lock, & have a screen. The window is situated so that
    a person could safely exit. Evacuation plans are practiced.
BATHROOMS
1. Bathrooms meet a minimum of one (1) toilet, one (1) lavatory, and one (1) tub/shower.
2. Toilets and baths/showers allow for individual privacy unless the persons require
     assistance.
3. Bathroom mirrors are secured to the walls.
4. Toilet is clean and has some kind of lid or cover over the tank.
5. A permanently installed washbasin and tub/shower are clean and provide hot and
   cold running water.
6. There is at least one permanently installed light fixture that is operating and all other
    sockets are filled.
7. There is a window that opens, locks, and has a screen or a ventilation fan that is in
    proper working order.


                                                                     (FRONT)
                                      LIFE AND SAFETY                                              YES   NO   Comments
                 (These must be marked yes or a certificate will not be issued)
GENERAL
1. Interior and exterior of residence are in good repair. Floors cannot have loose carpet or
   large holes in the floor covering. Ceilings and walls cannot have large cracks or holes, no
   severe bulging or large amounts of loose or falling surface area. Doorknobs cannot turn
   from inside when locked, unless the turning results in the door unlocking and opening.
   Roof must not leak.
2. Kitchen area and counters are clean and in good repair. The sink has hot and cold
   running water.
3. The Apartment/Home has an approved and working carbon monoxide monitor on each
    level of the unit.
4. Apartment/Home has an approved fire extinguisher and a working smoke detector on
    each level of the unit. If the smoke detector is electrical, there must be a backup that has
   a working battery in case of an electrical failure.
5. All windows are in good repair and have screens and locks.
6. Coverings are on all electric outlets. Extension cords are used appropriately. In each
    room there are two working outlets, or one outlet and one permanently installed light
    fixture that is operating and all other sockets are filled.
7. Heating systems are operative and can maintain at least 68 degrees temperature. Cooling
    system is operative. Furnace area is clean and not used for storage. Hot water
    temperature is no greater than 120 DEGREES FAHRENHEIT. If there are no
    controls and the consumer has the proper training, this can be approved by a
    Region Director.
8. First Aid Kit / Supplies are available. A minimum kit should have the appropriate needs
   for the individuals in the home. A complete list of an ideal First Aid Kit is available.
9. Stairways and handrails are provided, if necessary, and are safely maintained. There
    must be a handrail wherever there are four or more steps, or steps that are over 30 inches
    in height.
10. Evacuation Plan for Fire / Natural Disasters is placed in view within the home. Fire Drills
     are held and documented.
11. Potentially hazardous substances are stored in a safe and secure manner. No large piles
     of trash, debris, or garbage inside or outside the home. A lid must be on all outside
     garbage cans, or both lids must be on any dumpster.
12. No serious pollution inside or outside the unit such as exhaust fumes. There must not
      be any signs of infestation such as rats, mice, roaches, spiders, mice droppings etc.
13. Plumbing and pipes must be in good condition. For any sink in the home there cannot
      be any leaks of the pipes that are inside the structure of the house.



     SIGNATURE OF APPLICANT                                DATE
        (PROVIDER STAFF)


     SIGNATURE OF SURVEYOR                                 DATE

PROVIDER COMMENTS:




                                                                       (BACK)
Suggested Emergency Management & Business Continuity Plan Contents:
Provider is complying with : (Provider Site)
      Provider is current on Emergency Management & Business Continuity Plan
      (Sec 3-G)

     That all services are being and will continue to be performed in conformity with the
     requirements of this Contract by qualified personnel in accordance with generally
     recognized standards. That it has a "business continuity plan" that will allow it to continue
     to operate critical functions or processes during or following an emergency and protect the
     health and safety of clients receiving services through the CONTRACTOR.

     Suggested Content of Emergency & Continuity Plan: (Anyone remember the Millennium Bug??)
     Organizational, approval, and notification plan(s) - person responsible and backup - communication
     info (phone, cell #, fax #, address)
     Functional Process - person responsible and backup - communication info (phone, cell #, fax #, address)
     Timely Site-by-site confirmation of status and needs to those in control
                Information systems
                             Personnel/Human Resource (HR) & Payroll backup
                                            Emergency call-in pool (former staff and capable friends in
                                            community); next shift call-in
                                            Staff relief & rotation plan
                             Accounts Receivable (AR) backup
                             Accounts Payable (AP) backup
                             30 to 90 day cash reserves and access plan
                             Asset inventory and insurance valuations; agent contacts
                                            vehicle & fuel protection & control
                             Supply Inventory (site recovery & emergency stash)
                                            Food, water, blankets, cleaning
                             Medical Supply and pharmacy inventory (site recovery & emergency stash)
                             Emergency resource listing (hospital, pharmacy, grocery, State offices)
                Records protection and recovery
                             Staff files
                             Client files
                                            protective payee checkbooks, petty cash control
                             Medication files
                             Vested party notification of status & location
                Immediate & Ongoing Process Assurance
                             physical treatment of injuries & triage
                             Medications, feeding, water, blankets
                             physical movement to temp quarters or stay put criteria and 1st & 2nd choice options
                             Utility safety check
                             site and building safety check
                Levels of Plan
                             Emergency: 1 to 24 hours
                             Emergency: 1 to 3 days (72 hours)
                             Continuity: Bigger Problems!
                Training and Plan Maintenance
                             File plan with DSPD at least once per contract; as updated
  6-Aug-07

                                                                             Please use the WORD version of this form on web!

Division of Services for People with Disabilities
Provider Business Continuity and
Disaster Preparedness Plan Template
Please Check Provider Services: 24 hr Residential ___ Day Supports ___ Supported Employment ___ Sup


(DSPD Providers may use the following template as a “Best Practice” Business Continuity and Disaster Preparedne
elements that must be contained in the providers Business Continuity and Disaster Preparedness Plan which is req
Providers may use this template as a guide in the development of their plan or may develop their own format as lon
preferred that the provider have a Plan that is in an electronic format that can be easily updated annually or when ch
may be forwarded to Steve Wrigley, DSPD Emergency Manager, at swrigley@utah.gov . Steve will see that a copy


Department / Division Contract Requirements:
EMERGENCY MANAGEMENT AND BUSINESS CONTINUITY PLAN: The Contractor shall use qualified personnel to pe
Contract and generally recognized standards. The Contractor’s performance shall not be excused by force majeure. The Contra
processes of its business operations essential for providing the services required in this Contract. The Contractor also represent
continuity plan that will allow the Contractor to continue to operate those critical functions or processes during or following an
emergency management and business continuity plan addresses at least the following areas as they pertain to the services Contr
alternate living arrangements, including arrangements for isolation or quarantine; 3. Vital supplies, including food, water, cloth
necessities, etc.; 4. Communications (with Contractor staff, the appropriate government agency, and clients’ families); 5. Trans
In addition, the Contractor represents that it provides at least annual training for its staff on its emergency management and bus
may rely upon this and the other representations of the Contractor in this paragraph.
The Contractor shall evaluate its emergency management and business continuity plan at least annually, and shall modify the plan as appropriate. The Contra
request.


Department of Human Services Appendix C “Federal Assurances and Standard Terms and Conditions” section 3G states: “Emer


(**) PROVIDER INFORMATION:
Provider Name:

Provider Main Office Address:
City:                                                                        State:

Main Office Telephone Number / Backup Number:

The following natural and man-made disasters could impact our business.
 
 
 
 
(**) EMERGENCY PLANNING TEAM
The following individual’s will participate on our emergency planning and crisis management team.
Name                                                 Location / Office
     
     
     
     
     

OUR CRITICAL OPERATIONS
The following is a prioritized list of our critical operations, staff and procedures needed to recover from a

Operation                                                                   Staff in Charge




Suggested Business Continuity Planning Outline For All Providers:

INFORMATION SYSTEMS BACKUP:
Indicated how you will address the following Personnel / Human Resources & Payroll areas:
  Emergency call-in pool
  Accounts receivable backup
  Accounts payable backup
  30 to 90 day cash reserves and access plan
  Assess inventory and insurance
  Supply inventory – food, water, blankets, etc.
  Medical supplies and medication inventory

CYBER SECURITY
To protect our computer hardware, we will:

To protect our computer software, we will:

If our computers are destroyed, we will use back-up computers at the following location:
RECORDS BACK-UP
(Insert name) is responsible for backing up our critical records including payroll and accounting systems.
Back-up records including a copy of this plan, site maps, insurance policies, bank account records and com
Another set of back-up records is stored at the following off-site location:

If our accounting and payroll records are destroyed, we will provide for continuity in the following ways:

Recovery and maintenance of consumer records:

** To be completed for each Provider Organization:
Emergency Planning Outline For Main Office Sites:
To be completed for each Residential, Supported Living, Day Support, and Supporte

** EVACUATION PLAN FOR (insert address) LOCATION
          (Please type answer after question)
 List circumstances under which evacuation may be required:

 List personnel having the authority to order a partial or total evacuation:

 List established assembly site outside the office site, in the event of an evacuation:

 Our assembly site coordinator & alternate is:

 List staff responsibilities in the even of an evacuation:

 List methods of contacting key persons and staff:

 How will you contact key persons and staff?

 What vital records, and documents need to be part of the evacuation?

 We have developed, copied and posted site evacuation maps.

 We will practice evacuation procedures (insert #) times a year.


** RELOCATON PLAN
 List circumstances under which relocation are necessary?
          o
 List personnel having authority to order relocation.
          o
  Our alternative main office relocation site/s would be located at:
           o
  What system is established to notify staff and key outside resources of your relocation?
           o
  We have made arrangements for transportation to our alternative site through:
           o
  We have a written letter of agreement with our alternative site and have prepared to bring the necessary
           o

Emergency Relocation Summary: (This is optional to complete only if the provider desires)
This is a quick reference to needed relocation information. The summary includes specific relocation sites to be used during a Level I, II, and
* A Level I is defined as a local emergency situation, affecting the main office site. Such an emergency could include a major fire with toxic
* A Level II Emergency is defined as an emergency situation caused by an event that occurs in a community or limited geographic area, com
* A Level III Emergency is defined as a catastrophic emergency that affects a wide area and that requires immediate relocation of the popula
Relocation Plan for Level I Emergency:
             1. Relocation Site:
             2. Relocation Address:
             3. Relocation Phone #:
             4. Relocation Contact:
Relocation Plan for Level II Emergency:
 1. Relocation Site:
 2. Relocation Address:
      3. Relocation Phone #:
      4. Relocation Contact:
Relocation Plan for Level III Emergency:
 1. Relocation Site:
 2. Relocation Address:
      3. Relocation Phone #:
      4. Relocation Contact:

Survival (isolation)
** SHELTER-IN-PLACE PLAN
  List possible circumstances when we will shelter-in-place.

  Which personnel have authority to implement shelter in place procedures?

  List materials and supplies that will need to be stockpiled and their storage location:




  We have talked to co-workers about which emergency supplies, if any, the company will provide in the
 What area of the office site will be utilized for shelter if the building integrity is threatened?

 We will practice shelter procedures (insert #) times a year.

 What are the internal and external communications systems established in the event of the need to shelte

 "Seal the Room" Shelter Location:

  Shelter Manager & Alternate:
a. Responsibilities Include:

Training:
          How will everyone in your program become knowledgeable of the content of your plan and ha
                o
          What is the training schedule that includes content, method, and frequency of training and test
                o

Emergency Planning Provider Site Outline:
To be completed for Each Residential and Day Support Provider Site:

**EVACUATION PLAN FOR (Insert address) LOCATION

 List circumstances under which evacuation may be required.

 List personnel having the authority to order a partial or total evacuation.

 List established assembly site outside the home / facility, in the event of an evacuation.

 Our assembly site coordinator & alternate is:

 List staff responsibilities in the even of an evacuation.

 List methods of contacting key persons and staff

 How will you contact key persons and staff?

 What vital records, documents, and meds needed to be part of the evacuation?

 Are your plans in collaboration with neighbors and community emergency resources?
  We have developed, copied and posted site evacuation maps.

  Our Exits are clearly marked. (For Workshops only)

  We will practice evacuation procedures (insert #) times a year.
  If we must leave the residential or workshop setting quickly, we will:


** RELOCATON PLAN FOR (Insert site address) LOCATION

 List circumstances under which relocation are necessary?
          o
 List personnel having authority to order relocation.
          o
 Our alternative residential and/or day support relocation sites are:
          o
 What staff will accompany the individuals?
          o
 What system is established to notify staff and key outside resources of your relocation?
          o
 We have made arrangements for transportation to our alternative site through
          o
 We have a written letter of agreement with our alternative site and have prepared to bring the necessary
          o
 Individual’s going home or to other locations will be released and accounted for by the following proced
          o
Emergency Relocation Summary: (This is optional to complete if the provider desires)
This is a quick reference to needed relocation information. The summary includes specific relocation sites to be used during a Level I, II, and
* A Level I is defined as a local emergency situation, affecting a single residential or day program site. Such an emergency could include a m
* A Level II Emergency is defined as an emergency situation caused by an event that occurs in a community or limited geographic area, com
* A Level III Emergency is defined as a catastrophic emergency that affects a wide area and that requires immediate relocation of the popula
Relocation Plan for Level I Emergency:
             1. Relocation Site:
             2. Relocation Address:
             3. Relocation Phone #:
Relocation Plan for Level II Emergency:
 1. Relocation Site:
 2. Relocation Address:
 3. Relocation Phone #:
Relocation Plan for Level III Emergency:
 1. Relocation Site:
 2. Relocation Address:
Relocation Phone #: _
Survival (isolation)
** SHELTER-IN-PLACE PLAN FOR (Insert address) LOCATION

 List possible circumstances when we will shelter-in-place.

 Which personnel have authority to implement shelter in place procedures?

 List materials and supplies that will need to be stockpiled and their storage location.


 We have talked to co-workers about which emergency supplies, if any, the company will provide in the

 We have addressed vital supplies including food, water, clothing, first aid supplies, consumer medicatio

 What area of the home / facility will be utilized for shelter if the building integrity is threatened?

 What are the minimum staff requirements to assure consumer health and safety? What is your plan to as

 What are the internal and external communications systems established in the event of the need to shelte

  "Seal the Room" Shelter Location:
  Shelter Manager & Alternate:
a. Responsibilities Include:

** Coordination of Plans
 Who is responsible to coordinate the individual plans, the site plans, and the organization plan with the c
         o
 Who is responsible to coordinate the plan with other providers (i.e. day and residential), Division and th
         o
 Who is responsible to coordinate plans with parents and/or relocation community settings?
         o
 Who is responsible to obtain agreements for outside resources?
         o

** Training:
          How will everyone in your program become knowledgeable of the content of your plan and ha
                o
          What is the training schedule that includes content, method, and frequency of training and test
                 o
(**) To Be Completed for Individuals in Supported Living and Supported Employme

All individuals in Supported Living and Supported Living settings will have a Individual Emergenc

Possible Content for Individual Emergency Preparedness Plan: (These are suggested items to possibly be inclu
 1. Establish a Personal Support Network. (A personal support network is made up of individuals who will check with the i
   a. Help the individual organize a network for their home, workplace, and other place where they spend a lot of time.
   b. Give the network members copies of the individual’s emergency information list.
   c. Arrange with the network to check on the individual immediately after an emergency strikes.
   d. Agree and practice a communications system regarding how to contact each other in an emergency.
   e. Show the network members how to operate and safely move the equipment the individual uses for their disability.
   f. Explain to the network any assistance for personal care the individual may need.
   g. The individual and their network members should always notify each other when they are going out of town and when th
 2. Help the individual develop a Health Card, which contains emergency health information.
 3. Help the individual to maintain at least a 7 to 14 day supply of essential medications. (If not possible, at least a three day su
 4. Help the individual develop an emergency contact list including a number of someone who lives outside of the area.
 5. Help the individual gather necessary emergency documents. (records, social security card, identification cards, bank accou
 6. Help the individual conduct an “Ability Self-Assessment” to evaluate their capabilities, limitations, and needs, as well as th
 7. Help the individual develop a 72-hour emergency kit and obtain necessary supplies to use in the event of an emergency.

To Be Completed for Individuals in 24-Hour Respite in the Home of a Provider:

**EVACUATION PLAN FOR (Insert address) LOCATION

 List established assembly site outside the home in the event of an evacuation.

 What vital records, documents, and meds needed to be part of the evacuation?

 Are your plans in collaboration with neighbors and community emergency resources?

 If we must leave the residential we will:


** RELOCATON PLAN FOR (Insert address) LOCATION

 Our alternative residential relocation sites are located at:
          o
 What system is established to notify provider staff of your relocation?
          o
 Individual’s going home or to other locations will be released and accounted for by the following proced
          o
Survival (isolation)
** SHELTER-IN-PLACE PLAN FOR (Insert address) LOCATION
List materials and supplies that will need to be stockpiled and their storage location.

We have addressed vital supplies including food, water, clothing, first aid supplies, consumer medicatio

What area of the home / facility will be utilized for shelter if the building integrity is threatened?

"Seal the Room" Shelter Location:
D version of this form on web!




_ Supported Employment ___ Supported Living ___ 24-Respite ___


 Continuity and Disaster Preparedness Plan. Those items marked with a (**) are required
ster Preparedness Plan which is required under contract with the Department / Division.
may develop their own format as long as their format contains the required elements. It is
e easily updated annually or when changes occur within their organization. A copy of your plan
utah.gov . Steve will see that a copy of your plan is shared with your local DSPD Office.




ractor shall use qualified personnel to perform all services in conformity with the requirements of this
e excused by force majeure. The Contractor represents that it has identified the critical functions or
 Contract. The Contractor also represents that it has developed an emergency management and business
 ons or processes during or following an emergency. The Contractor further represents that its
reas as they pertain to the services Contractor is providing: 1. Evacuation procedures; 2. Temporary or
tal supplies, including food, water, clothing, first aid supplies, client medications, and other medical
t agency, and clients’ families); 5. Transportation; and, 6. Recovery and maintenance of client records.
f on its emergency management and business continuity plan and it acknowledges that DHS and DHS/

 shall modify the plan as appropriate. The Contractor shall provide DHS or DHS/_______ with a copy of its current plan upon



and Conditions” section 3G states: “Emergency Management and Business Continuity Plan” states: That all services are being and will continue to be performed in conformity with th
nd crisis management team.
            Responsibility




cedures needed to recover from a disaster.

  Staff in Charge




Providers:


rces & Payroll areas:




 lowing location:
  payroll and accounting systems.
cies, bank account records and computer back ups are stored onsite Yes ( ) NO ( ).


continuity in the following ways:




Day Support, and Supported Employment main office location:




 evacuation:
 your relocation?




e prepared to bring the necessary supplies.


 if the provider desires)
ation sites to be used during a Level I, II, and III emergency situation requiring evacuation and relocation of main office staff.
ergency could include a major fire with toxic fumes, significant damage to utilities affecting a local area, a toxic spill or release of hazardous chemicals or biological agents
a community or limited geographic area, comprised of contingent towns, which require relocation outside the affected area. Such an emergency could include a fire, prolon
t requires immediate relocation of the populace of large geographic areas. Public confusion and panic are anticipated. Such an emergency could include a major earthquake




rage location:




 the company will provide in the shelter location and which supplies staff might consider keeping in a portable kit personalized f
ntegrity is threatened?




d in the event of the need to shelter in place?




of the content of your plan and have opportunity to participate in testing it?

and frequency of training and testing?




rovider Site:




of an evacuation.




ency resources?
 your relocation?




e prepared to bring the necessary supplies and support staff.

ounted for by the following procedure.

e provider desires)
ation sites to be used during a Level I, II, and III emergency situation requiring evacuation and relocation of the individuals attending the program site.
 m site. Such an emergency could include a major fire with toxic fumes, significant damage to utilities affecting a local area, a toxic spill or release of hazardous chemicals
a community or limited geographic area, comprised of contingent towns, which require relocation outside the affected area. Such an emergency could include a fire, prolon
t requires immediate relocation of the populace of large geographic areas. Public confusion and panic are anticipated. Such an emergency could include major leakage of r
rage location.


 the company will provide in the shelter location and which supplies individuals might consider keeping in a portable kit persona

aid supplies, consumer medications and other medical necessities.

ng integrity is threatened?

nd safety? What is your plan to assure adequate staff during an emergency? How will you get commitment from direct support st

d in the event of the need to shelter in place?




nd the organization plan with the community emergency plan? (example House Manager)

y and residential), Division and the Department?

community settings?




of the content of your plan and have opportunity to participate in testing it?

and frequency of training and testing?
g and Supported Employment providers:

will have a Individual Emergency Preparedness Plan developed to met their specific needs. Providers will work with the DS

e suggested items to possibly be included in the individual’s Personal Emergency Plan. Provider to include those questions that are appropr
 of individuals who will check with the individual in an emergency to ensure that the individual is okay and give assistance if needed. Identify a minimum
ce where they spend a lot of time.


er in an emergency.
ndividual uses for their disability.

n they are going out of town and when they will return.

ns. (If not possible, at least a three day supply)
one who lives outside of the area.
ty card, identification cards, bank accounts, etc)
ities, limitations, and needs, as well as their surroundings to determine what type of help will be needed in an emergency.
s to use in the event of an emergency.

e Home of a Provider:




ency resources?




ounted for by the following procedure.
rage location.

aid supplies, consumer medications and other medical necessities.

ng integrity is threatened?
continue to be performed in conformity with the requirements of this Contract by qualified personnel in accordance with generally recognized standards. That is has a “business continuity plan
  hazardous chemicals or biological agents that may affect water systems or are expected to be airborne over short distances . Relocation sites may be within a 10-mile radi
 an emergency could include a fire, prolonged power outage; local flooding, or toxic spills. Relocation sites must be outside a 10-mile radius of the administrative site.
mergency could include a major earthquake, or other significant incidents that result in state or national direction to relocate a wide area or region. Evacuation of large num




g in a portable kit personalized for their needs.
ding the program site.
 ic spill or release of hazardous chemicals or biological agents that may affect water systems or are expected to be airborne over short distances . Relocation sites may be w
 an emergency could include a fire, prolonged power outage; local flooding, or toxic spills. Relocation sites must be outside a 10-mile radius of the program site.
mergency could include major leakage of radioactive material due to an incident at a nuclear power plant, or other significant incidents that result in state or national directi
keeping in a portable kit personalized for the needs of the individuals and staff.




mmitment from direct support staff?
Providers will work with the DSPD Support Coordinators to assure that each consumer has an appropriate individual emergency

e those questions that are appropriate.)
stance if needed. Identify a minimum of three people per location where the individual spends a signification part of their week: job, home, volunteer site e
standards. That is has a “business continuity plan” that will allow it to continue to operate critical functions or processes during or following an emergency and protect the health and safety of
 elocation sites may be within a 10-mile radius of the affected administrative site.
 10-mile radius of the administrative site.
wide area or region. Evacuation of large numbers of citizens to relocation sites well beyond the affected area is required .
r short distances . Relocation sites may be within a 10-mile radius of the affected program site.
10-mile radius of the program site.
cidents that result in state or national direction to relocate a wide area or region. Evacuation of large numbers of citizens to relocation sites well beyond the affected area i
appropriate individual emergency plan developed for the specific circumstance of the individual. This plan should be developed


of their week: job, home, volunteer site etc.)
an emergency and protect the health and safety of clients receiving services through the CONTRACTOR.
location sites well beyond the affected area is required .
l. This plan should be developed at the time of placement into the program and reviewed annually. This could be part of the Ann
ally. This could be part of the Annual Person Centered Planning process and could be one of the identified Action Plan items. Ea
e identified Action Plan items. Each individual in Supported Living and Supported Employment needs to assume the primary res
t needs to assume the primary responsibility for his/her care during and emergency. Provider staff will work with the individual
aff will work with the individual and/or their family in development of a Plan. In the event of an emergency, provider staff will a
n emergency, provider staff will attempt to contact individuals in Supported Living settings as quickly as it possible to assess the
quickly as it possible to assess their needs. Supported Employment staff will work with the individual’s employer in the develop
ividual’s employer in the development of a basic emergency plan to be implemented should an emergency occur during the work
emergency occur during the working day.
  20-Aug-07



Division of Services for People with Disabilities
Provider Business Continuity and
Disaster Preparedness Critical Information Sheet

Please Check Provider Services:
24 hr Res. __ Day Supports __ Supported Employment ___ Supported Living ___ 24-Respite ___




EMERGENCY CONTACT INFORMATION
Provider Name:

Provider Main Office Address:
City:

Main Office Telephone Number / Backup Number:
Out of State Emergency Contact Number:

The following person is our primary Emergency Crisis Manager and will serve as the company spokesperson in the event of an emergency

Primary Emergency Contact:

Telephone Number:
Alternative Number / Cellular Number:
E-mail Address:

If the Emergency Crisis Manager is not available the persons below will succeed in management:
Secondary Emergency Contact:
Telephone Number:
Alternative / Cellular Number:
E-mail Address:

If our current main office location is not accessible we will operate from the alternative location listed below:
Business Name:
Address:
City:
Telephone Number:




Provider Disaster Preparedness Critical Information Sheet Continued:

We have Satellite Offices in the following Counties / Cities:

*
Address:
*
Telephone Number:
*
Alternative / Cellular Number:
*
E-mail Address:
*
-----------------------------------------------------------------------------------------------------------------------------------------------------
*
Address:
*
Telephone Number:
*
Alternative / Cellular Number:
*
E-mail Address:
*
(Copy and Paste More Office locations if necessary)

Provider Residential / Day Support Site Locations: (Not necessary for Supported Employment / Supported Living and 24-hour Respite location


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Provider Disaster Preparedness Critical Information Sheet Continued:

Do you have an established EMERGENCY PLANNING TEAM Yes ___ No___

WE PLAN TO COORDINATE WITH THE FOLLOWING PRIVIATE, LOCAL AND STATE AGENCIES:
We have coordinated with the following individuals, organizations, and community / state agencies in the development of our emergency plan.
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COMMUNICATIONS


*
*
In the event of a disaster we will communicate with employees in the following way:
*
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