Independent Contractor Employment Agreement Sample by bzr17786

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									                                     DSPD SFY 2011 SCE Service Contract Review CHECK OFF FORM

                    Provider Information                                                                   Reviewer Information
Agency Name:                                                           Name:
Contract #                                                             Region: (N,S,C,ALL)
Provider ID number:                                                    Date of Review:
Sample Size:
     SOIQ: #90514                                                                                                              Reference         COMPLIANCE
PART I) General Provisions - Section A Contract Description and Specifications
        1. Purpose and Scope of Contract: The contractor represents that it has the financial, managerial, and institutional
        capacity to fully comply with the requirements of this contract.                                                     C-Part I A1-p1     YES   NO   N/A
                           Do you comply?
        2. No imposition of Fees: The Contractor shall not charge clients for any services provided under this
        contract, except as expressly authorized in writing by DHS/DSPD.                                                   C-Part I A9-p3       YES   NO   N/A
                           Do you impose any fees? [If yes, explain.]

PART I) General Provisions - Section B Contractor's Legal Status & Indemnification Responsibilities
       1. Contractor is an Independent Contractor.
       * persons employed by the contractor shall not be deemed employees or agents of DHS/DSPD
       * Contractor is responsible for its own operations and for providing the office, equipment, and other
       supports necessary to provide the services covered by this contract.                                                C-Part I B1-p4       YES   NO   N/A
                            Do you comply?
       2. Contractor must provide Insurance and Indemnification:
       a. Required Insurance (1) maintain adequate protection (2) policies include an endorsement per
       contract
       c. Types of Liability Insurance (a) General Liability (b) Automobile Insurance (c) Professional Liability
       Insurance                                                                                                           C-Part I B2-p4 to9   YES   NO   N/A
                            Do you comply?                          Office of Licensing will verify
       3. Emergency Management and Business Continuity Plan:
       * Use of qualified personnel to perform services * Staff is trained on this EMBC Plans requirements
       and expectations * Plan is evaluated and updated annually - changes or modifications reported to
       DHS/DSPD within 15 days of change.                                                                                  C-Part I B3-p9       YES   NO   N/A
                            Is current EMBC Plan on file with Steve Wrigley?

PART I) General Provisions - Section C Contractor's Compliance with Applicable Laws

        1. Compliance with DHS' and DSPD Provider Codes of Conduct:                                                        C-Part I C8-p11
        a. Provide a current copy of DHS and DSPD Codes of Conduct to each new hire                                        C-Part II P-p5;
        b. Retain in personnel file signed and dated copy of Code signature page.                                          SCS H1 TO H4         YES   NO   N/A
                            Is completed signature page on file? Office of Licensing will verify
        2. Restrictions on Conflict of Interest per contract:
        f. Disclosing Conflicts of Interest to DHS: (1) Self Disclosure and Contractor Review process per                  C-Part I C9-p12
        contract. (3) Contractor's Continuing Duty to Disclose Conflicts of Interest-due each July.                        to18; SCS H5         YES   NO   N/A
                            Is disclosure documentation current? Office of Licensing will verify
                                                                                                                           C-Part I C10-p18
        3. Deficit Reduction Act - Medicaid Fraud and Abuse (detecting and preventing fraud, waste & abuse)                to19                 YES   NO   N/A
                            Anti-fraud training documentation current?
                            Is training included in Employee Handbook?          Office of Licensing will verify
        4. Certify Registration and Use of Employment "Status Verification System" E-Verify per contract.                  C-Part I C11-p19     YES   NO   N/A
                            Do you comply?                         Office of Licensing will verify

PART I) General Provisions - Section D Compliance Monitoring & Record Keeping Responsibilities
       1. Training for Contractor's Staff:                                                                     C-Part I D3-p21                  YES   NO   N/A
                           * Have staff credentials been submitted to
                           DHS/DSPD for USTEPS access?
                           * Recommended-Current Organization Chart on file
                           with DHS/DSPD
       2. Retention of Records per contract: Contractor has a system in place that: confirms client record
       confidentiality, maintenance, retention, destruction, are locked and secured, and provides audit access
       per contract.                                                                                           C-Part I D5-p21                  YES   NO   N/A
                           Has Contractor relocated or destroyed patient
                           records without the prior written consent of
                           DHS/DSPD?

PART I) General Provisions - Section E Subcontracting, Contract Modifications, & Dispute Resolution Procedures
       1. Subcontracts b. Contractor may not subcontract to provide the services in this contract.        C-Part I E1-p24                       YES   NO   N/A
                             Do you comply?
       2. Grievance Procedures for Clients: Contractor shall establish a grievance system and notify each
       client in writing of process.                                                                      C-Part I E5-p25                       YES   NO   N/A
                             Do you have documentation that you comply?




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                                  DSPD SFY 11 SCE Service Contract Review CHECK OFF FORM
Agency Name:                                                                    Contract #
                                                                                                                 Reference         COMPLIANCE
PART II) SCOPE of Work & Special Conditions - General Description
    1. Assist persons with gaining access to services provided under the Medicaid State Plan as well as
    gaining access to Other non-Medicaid based resources.                                                     C-Part II H-p1      YES   NO   N/A
                       Can Contractor document assistance with access
                       to Other non-Medicaid based resources?

PART II) SCOPE of Work & Special Conditions - Contractor Qualifications
    A. Certified by DHS/DSPD as a qualified provider per UCA 62A-5-103.
    B. Enrolled as an approved Medicaid Provider with the Utah Department of Health (DOH)
    Contractor may agree to let DSPD bill Medicaid on its behalf for covered Medicaid services. If so,
    Copy of signed waiver on file.                                                                            C-Part II A,B-p2    YES   NO   N/A
                       Do you comply?

PART II) SCOPE of Work & Special Conditions - Staff Qualifications
                                                                                                              C-Part II B-p2;
                                                                                                              SCS G, SCS I1
     1. Verify that all staff have met ALL qualifications required:                                           to I2               YES   NO   N/A

                         Initial: QMRP, ABISC (per ABI clients on caseload)
                         and DHS/DSPD Certified (or supervised)
                         Annual: BCI current with Office of Licensing and 30
                         hours continuing education (with 10 in ABI area if
                         ABI clients on caseload.

PART II) SCOPE of Work & Special Conditions - Caseload Limitations
    1. Caseload limitation is fourty six (46) with reductions of ten (10) per SC seeking full certification
    supervised. Limitation of three (3) SC supervised by same manager.                                        C-Part II -p3       YES   NO   N/A
                       Do you comply?

PART II) SCOPE of Work & Special Conditions - General Service Requirements
    1. Contractor will comply with the most current version of the DHS/DSPD Support Coordination              C-Part II - p3 to
    Standards as published http://dspd.utah.gov ;Contractor has process in place to stay informed.            5                   YES   NO   N/A
                        Do you comply?
                        How many Contractor staff were reviewed by DHS/DSPD APM per "SCE Contract
                        Compliance Review" tool over the previous 12 months?
                         How many Corrective Action Plan (CAP) requests were required by DHS/DSPD
                         over the previous 12 months?
                        What contract or Standards issues were noted on such CAP requests:
                        Form 1-8 Incident Report
                        Ongoing crisis availability
                        Timely completion of PCSP and Budget updates
                        Monthly USTEPS Documentation
                        Documentation of Behavioral and Medical plan supports
                        Documentation of PBA Protective Payee and emergency loans
                        Documentation of Human Rights and Grievance issues
                        Face-to-face reviews
                        Monitoring appropriate support strategies
                        Monitoring health, welfare, and safety status
                        Timely processing of Provider billings
                        Improper Marketing of SCE services
     2. Quality Monitoring Process: a) Quality Monitoring Process can be externally validated by DSPD.
     b) Quality Monitoring Process includes an agency self-assessment or accreditation process. c)
     Quality Monitoring Process includes established method for responding to concerns identified in the
     SCE Contractor's own quality monitoring and feedback processes. d) Quality Monitoring Process            C-Part III #2 -
     includes an established method for responding to and/or correcting within specified timeframes, any      p1 & C-Part II O
     areas of non compliance per contract monitoring.                                                         - p5                YES   NO   N/A
                        Do you comply?

PART II) SCOPE of Work & Special Conditions - Direct Service Requirements
    1. Representative Payee:
    (6) DHS/DSPD Form 1-3 has been signed; Ensure the person's funds are properly accounted for and
    are used for the benefit of the person.                                                          C-Part II C6,
    (11) Ensure that PBA providers forward representative or protective payee's monthly statement of C11 - p6 to 9;
    activity to the Contractor                                                                       SCS D.3                      YES   NO   N/A
                        Do you comply?
                         Does Contractor track (look for) monthly financial
                         source & use reports by individual on caseload?




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                                DSPD SFY 11 SCE Service Contract Review CHECK OFF FORM
Agency Name:                                                                Contract #
                                                                                                               Reference         COMPLIANCE
     2. Person's Personal Funds:
     (2) Ensure that person's personal funds only go to the provider as follows: (1] Reimbursement to the
     provider for destruction of property by the person IF approved by the team, and allowed by contract,
     (2] Normal room and board charges, (3] Repayment of emergency loan authorized by the person's          C-Part II D2 - p8
     PCPT.                                                                                                  to 9; SCS D.3       YES   NO   N/A
                        Do you comply?
                        Does Contractor document Human Rights review
                        of personal funds restrictions or the approval of
                        emergency fund repayments to providers?
     3. Health & Safety Requirements:
     (3) Contractor monitors for medication errors, mitigation, and reporting.                              C-Part II F3 - p9   YES   NO   N/A
                        Do you comply?
                        Briefly describe monitoring process.
     4. Transportation:
     Contractor monitors that provider(s) provide routine transportation per team judgement.
     Contractor monitors that provider(s) receiving transportation code have provided an actual service.    C-Part II H - p10   YES   NO   N/A
                        Has Contractor allowed provider to direct charge
                        any client for transportation?
                        Briefly describe monitoring process.

PART II) SCOPE of Work & Special Conditions - Limitations
    1. Marketing of Services:
    Contractor may not engage in any form of false, deceptive or misleading advertising; may not offer
    any incentives or inducements, including financial incentives in order to solicit business or induce    C-Part II D -
    individuals to engage their services.                                                                   p11; SCS H7         YES   NO   N/A
                       Do you comply?

     2. Marketing Materials are prior reviewed; written approval by UDOH/DHCF and DHS/DSPD.                 C-Part II E - p12   YES   NO   N/A
                        Contractor has documentation of written approval?
     3. Information Technology and Security of Records:                                                     C-Part II F -
     Ensure that all person's records are secured (per contract).                                           p12; SCS H6         YES   NO   N/A
                        Do you comply?
                        Briefly describe security of person's records not at
                        Contractor's secure location.
     4. Continuous Services
     Contractor will always ensure that the persons they serve are provided with continuous SCE coverage    C-Part II H - p12
     even in the event of planned or unplanned absenses by the Contractor or Contractor staff.              to 13               YES   NO   N/A
                        Do you comply?
                        Provide Plan; key elements include notice to
                        DSPD, to affected providers, phone message, e-
                        mail bounce message, written agreement from
                        qualified workers who cover absense.

PART III) Performance Measures and Client Outcomes
    1. Internal Quality Management:                                                                         C-Part III #2 -
    Contractor has developed, implemented, and maintains an externally validated, internal quality          p1 & C-Part II O
    management system to review all aspects of Contract Part II and mitigates issues noted.                 - p5                YES   NO   N/A
                        Do you comply?
                        How many Contractor staff were reviewed by
                        Contractor review tool over the previous 12
                        months?

Current Review Results:
Administrative Issues:
Total Staff:
Total Caseload:



Program-Service Process Issues:




Follow Up to Previous Review & Results:




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Schedule of Resources and Requirements:

SOIQ Scope and Service and Limitations #90514

SCE - Service Definition for Waiver(s)

Per Contract form dated July 8, 2010:
Contractor Contract Part I - General Requirements
                      Part II - Scope and Definition
                      Part III - Outcomes measures
                      Part IV to IX

SCE Standards          http://dspd.utah.gov   updated 7/1/2010

Admin Program Mgr Monitoring Training Document A
          SCE Contract Compliance Review tool (updated 5/25/2010)
Admin Program Mgr Monitoring Training Document B
          SCE Contract Compliance Review Guide (updated 5/25/2010)

USTEPS Requirements and process training
        Help Manual

Licencing Requirements

								
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