west virginia personal options intellectual/developmental ......august 1, 2012 public partnerships,...

August 1, 2012

Public Partnerships, LLC 601-3 East Brockway Avenue, Suite E Morgantown, WV 26501 Phone: (888) 775-9801 Fax: (877) 567-0071

West Virginia Personal Options Intellectual/Developmental Disabilities Waiver Program

Enrollment Packet Dear Participant: Welcome to Personal Options. The Bureau for Medical Services has contracted with Public Partnerships, LLC (PPL) to help you direct your own services, including the responsibilities of being an employer and purchasing other goods and services. PPL will help you:

• Complete required paperwork; • Develop and manage your self-directed budget; • Recruit, hire, train, supervise, and dismiss employees; • Select and purchase other goods and services.

PPL will perform payroll services on your behalf, including:

• Help you verify the qualifications of employees and other service providers; • Process timesheets and invoices • Issue payment to your employees and other service providers; • Process and pay Federal and State taxes.

Forms to complete and submit to the PPL Resource Consultant during the enrollment visit:

• Enrollment Form – This form explains your rights and responsibilities, and confirms your voluntary participation in Personal Options.

• Emergency Back-Up Plan – This plan is to ensure you have planned for short-term and long-term coverage in the event your employee is unable to show for work.

• Appointment of Representative – Use this form appoint a program representative to assist you. Important - Waiver members who require a guardian or legal representative must designate an alternate program representative if they wish to be a paid employee.

Program Information and Forms to keep and use as needed:

• Notice of Separation of Employment – Use this form to notify PPL when an employee will no longer be working for you and the reason why their employment ended.

• Incident Report – You are required to report unusual situations in your home, such as falls or accidents. You may also use this form to report abuse, neglect or exploitation. You may also call your PPL resource consultant directly to report over the phone.

August 1, 2012

• Grievance Form – PPL is committed to your satisfaction. If you have questions or concerns regarding PPL services, please call your PPL resource consultant. Use this form only if you are dissatisfied with PPL’s response to your concerns.

• Freedom of Choice – Use this form only if you wish to transfer back to the traditional agency service model.

Payroll Forms and Information to keep and use as needed:

• Payroll Schedule – Your employees will submit timesheets and/or invoices every two weeks according to this payroll schedule.

• Timesheet – If your employees are unable to submit an electronic timesheet your employee will use this form to report hours worked. You are responsible for reviewing and signing your employee’s timesheets. Additional copies can be downloaded from the PPL website (listed below).or you can call PPL Customer Service toll free at: (877) 908-1757.

• Timesheet Instructions: Use these instructions to help you and your employee complete the PPL timesheet.

• Direct Support Worker Progress Notes – Your employee will use this form to document any goals that were completed, anything out of the ordinary (such as illness, behaviors, etc.) or any support that required more assistance than usual. This form must be made available to your Service Coordinator as needed.

• Transportation Invoice – If you choose to reimburse your employee for transportation services and they are unable to submit an electronic invoice your employee will use this form to report miles driven. You are responsible for reviewing and signing this form. You or your employee will need to submit this form to PPL at the address or fax number shown on the form.

• Wage Notice and Change Request Form – If you chose to change your employee’s rate, you must fill out this form and submit to your resource consultant. Your resource consultant will help you revise your spending plan to show the employee’s wage change.

For more information: Visit the PPL website at www.publicpartnerships.com to get more information and paperwork. Select “West Virginia” from the drop down menu and enter the following username and password:

Username WVIDD Password PPLWV20 Questions? PPL encourages you to call Customer Service toll free at (877) 908-1757 or email us at [email protected] if you have questions. TTY users please dial toll free at (800) 360-5899. We look forward to serving you. Sincerely, Public Partnerships, LLC Fiscal/Employer Agent and Resource Consultant

August 1, 2012


West Virginia Personal Options

Intellectual/Developmental Disabilities Waiver Program Enrollment Form

Name ________________________________________________________ Address ________________________________________________________ ________________________________________________________ ______________________________________ WV _____________ City Zip Code Phone _________________________________________ Email _________________________________________ Name of Program Representative (if applicable): ________________________________ Representative Phone: ______________________________________ Your Public Partnerships, LLC (PPL) resource consultant is available to help you with the responsibilities of directing your own services. Your resource consultant (RC) is a support and will be there to help you understand and manage your program responsibilities. Your resource consultant will also help you monitor your health and safety through a monthly phone contact and a home visit every six months. The information below covers important program responsibilities: I understand I am responsible for:

• Electing the participant-directed option; • Working with my resource consultant to become oriented and enrolled in the Personal

Options program, enrolling Qualified Support Workers (employees), developing a spending plan for the participant-directed budget, and creating an emergency back-up plan to ensure staffing;

• Revising my spending plan, as needed; • Recruiting, screening, and hiring my employees; • Verifying qualifications of my employees and other service providers; • Providing required and member specific training to my employees; • Determining my employees schedules and how and when my employees should

perform the required tasks; • Supervising my employee’s daily activities; • Notifying my employees 24hrs in advance if services are not needed; • Evaluating my employee’s performance; • Verifying hours worked and services provided by my employees and other providers; • Requesting payment for other goods and services as needed; • Payment of goods and services that exceed my allocated amounts or are not in my

approved spending plan; • Refunding PPL in full in the event of over-payment for goods and services;

August 1, 2012

• Maintaining documentation in a secure location and ensuring employee confidentiality; • Discharging my employees when necessary; • Communicating any problems with services to my PPL resource consultant; • Reporting any suspected fraud to my PPL resource consultant or West Virginia

Medicaid Fraud Unit at 304-558-1858; • Reporting any incidents of abuse, neglect or exploitation to my PPL resource consultant

and/or the Department of Health and Human Services (DHHR) Adult Protective Services or Child Protective Services Hotline at 1-800-352-6513.

• Reporting any suspected illegal activity to my local police department or appropriate authority.

• Notifying my service coordinator of any changes in service needs and any hospitalizations;

• Requesting to transfer to traditional agency services if desired. I understand the following:

• I am a household employer of domestic employees under West Virginia Labor law. • My employees must pass an initial criminal background check before providing services

and every three years thereafter. • My employees must pass an initial screening of the Office of Inspector General

exclusions list and every month thereafter. • My employees must pass a screening of the West Virginia Department of Health and

Human Resources Protective Services Check. • My employees must complete all initial training requirements before providing services

and annually thereafter. • My employee cannot be paid if they have not kept current with all on-going employment

requirements. • Purchases of other goods and services may not exceed $1,000 per year. • I cannot receive Personal Options services while I am in a ICFMR, rehabilitation facility,

or nursing home. • PPL will not pay for services if either my financial and/or medical eligibility for IDD

Waiver services expires. • I am responsible for refunding PPL in full in the event services are approved and paid

and I did not maintain program eligibility, either financial or medical. • I am responsible for refunding PPL in full in the event of over-payment for goods and

services. • I may be removed from Personal Options if I disregard these responsibilities.

I understand I have the right to:

• Appoint a representative to assist me if desired; • File complaints and grievances with PPL and/or APS/IRG Healthcare; • Transfer my participant directed services back traditional agency services if desired.

I agree to:

• Comply with IDD Waiver and Personal Options program requirements; • Permit representatives of BMS, APS and PPL to enter my home as scheduled; • Be present for scheduled appointments.

August 1, 2012

I agree to notify PPL immediately if: • My phone number or address changes; • My employees are no longer employed by me; • I am admitted to a hospital, rehabilitation facility, or nursing home; • I am found medically or financially ineligible for IDD Waiver services; • My employee or representative forces me to continue Personal Options even though I

am not getting needed assistance. Voluntary Consent to Enroll By signing below I certify that I understand and agree with all of the above responsibilities and choose to voluntarily enroll in Personal Options. ____________________________________________________________________ Participant Signature Date ____________________________________________________________________ Representative Signature (Optional) Date ____________________________________________________________________ Witness Name and Signature (Required if signed with mark) Date

October 1, 2011



Qualified Support Worker Back-Up Plan

It is very important that you are prepared in case your Qualified Support Worker (employee) is unable to or does not show for work. The purpose of this back-up plan is to ensure that your needs are met when your worker is absent. You must complete this plan and make it easily accessible in the event your regular worker does not show and you must rely on someone else to assist you.

1. Are you capable of calling 911 in the event of an emergency? YES NO

2. Are family members, roommates, friends or neighbors available to assist you as a “natural support” when a scheduled worker is unavailable? YES NO

3. If YES, please indicate below who you will contact to assist you: Name Relationship Contact Number 1 Contact Number 2

4. If a scheduled worker is running late, are you capable of remaining in your home without assistance for a specified period of time? YES NO

5. If YES, please specify the maximum amount of time that you may wait before a worker

arrives: ________________________________________________________________________

6. If your regular employee is not available to assist you, please describe the specific

tasks/actions that must occur. (Describe urgent needs and types of supports that you must receive.)

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

October 1, 2011

7. Please provide any critical information, such as sensitive medical conditions, strict medication schedules, allergies (food, medical, environmental, etc…) advanced directives, equipment needs, communication barrier, and/or any other information relative to your needs.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Emergency Contact Information

Parent or Relative: ___________________________________________________________ Phone #: _______________________ Alternative Phone #:__________________________ Legal Representative: ________________________________________________________ Phone #: _______________________ Alternative Phone #:_________________________ Resource Consultant: ________________________________________________________ Phone #: _______________________ Alternative Phone #:_________________________ Service Coordinator: _________________________________________________________ Phone #: _______________________ Alternative Phone #:_________________________ Doctor: ___________________________________________________________________ Phone #: _______________________ Alternative Phone #:_________________________

October 1, 2011



Appointment of Representative You may appoint a representative to help you direct your services. Important: An appointed Personal Options representative may not be a paid employee unless approved by the West Virginia Bureau for Medical Services (BMS) Section I (To be completed by participant or legal representative) Name of Participant ______________________________________________ Participant Signature ______________________________________________ Date ______________________________________________ I appoint the below named individual as my representative for Personal Options. My representative will help me with the following. (Please check all that apply) ___ Assist me to complete required paperwork ___ Assist me in developing and revising my Spending Plan ___ Assist me with the responsibilities of being an employer, including approving timesheets ___ Assist me to purchase other goods and services, including submitting payment requests ___ Perform other duties as assigned ___________________________________________ ___________________________________________________________________________ Section II (To be completed by representative) I agree to serve as the representative for the above named participant. I understand and agree to the above responsibilities. I understand that I am not a legal representative and cannot be a paid employee. Name of Representative _____________________________________________________ Address: _____________________________________________________ _____________________________________________________ City State Zip Phone: _________________________________________ Email: _________________________________________ Representative Signature _________________________________________ Date _________________________________________ If Representative is to be a paid employee BMS must approve. BMS Signature _________________________________________ Date: _________________________________________ Section III (To be completed by PPL) Witness Signature _______________________________________________

(Required if participant or representative signs with a mark) Date _______________________________________________

October 1, 2011



Notice of Separation from Employment Use this form to notify PPL when an employee will no longer be working for you. List the date and reason why the employee is no longer employed. This will impact whether the employee is eligible for unemployment benefits. Important: employment is “at-will”.

PARTICIPANT/EMPLOYER Name: _______________________________________________ Address: _______________________________________________ _______________________________________________ Phone: _______________________________________________

EMPLOYEE Name: _______________________________________________ Address: _______________________________________________ _______________________________________________ Phone: _______________________________________________ Last Date of Employment:___________/___________/__________ Employment Status: Part Time ____ Full Time ____ Number of Hours Usually Worked: Per Day ____ Per Week ____ Reason for Separation from Employment: ___ Employee failed to report for work for ___ consecutive days ___ Employee quit with verbal notice ___ Employee quit with written notice ___ Employer no longer had work available for employee at time of separation (lay-off) ___ Employee dismissed (fired) for the following reasons: _______________________ _____________________________________________________________________ Employer Signature: ______________________________ Date: ____________ (Required) Employee Signature: ______________________________ Date: ____________

(Optional) Employer: Please complete, sign and fax or mail this form to PPL as soon as possible even the employee does not sign. PPL will respond to Department of Labor requests for details of separation. If employee applies for unemployment compensation, do you wish to be notified of a hearing? ___ Yes ___ No

October 1, 2011

Intellectual/Developmental Disabilities Waiver Program PERSONAL OPTIONS INCIDENT REPORT

Confidential

Incident Date: __________________Time: _______________a.m./p.m.

Type of Incident: □ Critical □ Simple □ Abuse □ Neglect □ Exploitation

SECTION I – Member Information (completed by person reporting incident) LAST:

FIRST:

ADDRESS: CITY: STATE: ZIP: COUNTY: DOB: GENDER: □ M □ F

SECTION II– Description of Incident (completed & signed by person reporting incident) Describe in detail the reportable incident including other persons involved. Attach additional page(s) if necessary. When was the Resource Consultant Notified? Date: ______________ Time: ______________ Resource Consultant’s Name:__________________________________ Signature of Person Reporting Incident: Date: ______________

If allegation of abuse, neglect or exploitation, incident must be reported to APS at: (800) 352-6513

October 1, 2011



Grievance Form Public Partnerships, LLC (PPL) strives to provide the highest quality service possible. In the event you are dissatisfied with PPL services you may notify your Resource Consultant or complete and submit the grievance form to:

Public Partnerships, LLC 601-3 East Brockway Ave Suite E Morgantown, WV 26501

or by email at: [email protected] PPL grievance process includes two level; (1) Level One – a PPL program manager will review the issues with you and other necessary parties to determine resolution, (2) Level Two – the grievance form and all other information will be forwarded APS Healthcare where a final meeting or decision will be made. Date: ______________________________ Name: __________________________________________________________ Address: __________________________________________________________ __________________________________________________________ Phone: ______________________________ Representative (If applicable) _______________________________________ Phone: _____________________________ Statement of Complaint: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Relief Sought: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

October 1, 2011

LEVEL ONE - Meeting of Resource Consultant and/or Fiscal Management Entity and Member Date of Meeting: ________________________ Individuals Attending Meeting: ________________________________________________ ___________________________________________________________________________ Decision/Action Taken: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Date of Decision: __________________________

___ I am satisfied with the Level One Decision ___ I am not satisfied with the Level One Decision and wish to move to Level Two

LEVEL TWO – Referral of grievance to the APS Healthcare Date of Meeting: ___________________________ Individuals Attending Meeting: ________________________________________________ ___________________________________________________________________________ Date of Decision: _____________________________ Decision/Action Taken: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

WV-BMS-I/DD-2 Freedom of Choice 2011 1 of 1

WEST VIRGINIA I/DD WAIVER FREEDOM OF CHOICE

(Completed annually and as member chooses) M

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Name

________________ ____________ ______________________ _____ First Name Middle Name Last Name Suffix

Birth Date

__ __ / __ __ / __ __ __ __ M M D D Y Y Y Y

Address

___________________________________ ____________________ Address – Street or PO Box Apartment ____________________________ ___ ___ ___ ___ ___ ___ ___ City State Zip Code

Phone (__ __ __ ) __ __ __- __ __ __ __ Area Code Phone Number

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If you qualify for the level of care provided in an Intermediate Care Facility for Persons with Mental Retardation or Developmental Disabilities (ICF/MR) you have the right to choose between receiving services/support in an ICF/MR or your home and/or community. The West Virginia I/DD Waiver Program provides services and support in your home/community. Please initial the option you choose (either the WV I/DD Waiver Program or ICF/MR):

I choose to receive support in my home and community through the WV I/DD (Initial) Waiver Program. I understand the waiver services provided must comply with the

I/DD Waiver Policy Manual. I understand I have the following rights: The right to choose among qualified providers, The right to choose a different provider if I prefer, The right to a fair hearing through the Bureau for Medical Services if I am not given choice.

I choose to receive support in an ICF/MR. (Initial)

SC A

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You have the right to choose among qualified Service Coordination providers in your area. All enrolled providers/agencies that provide Service Coordination in my catchment area have (Initial) been discussed with me.

The provider/agency that I choose to provide my Service Coordination is: ________________________________________________________________________

(Enter the name of chosen Service Coordination Provider/Agency)

Serv

ice

Del

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y M

odel

Cho

ice

All I/DD Waiver services (except Goods and Services) are available through the Traditional model. Person-centered Supports, Goods and Services, Respite Care and Transportation may be accessed through either Traditional or a combination of Traditional and a Participant-directed service delivery model. The service delivery models have been discussed/reviewed with me during my annual (Initial) assessment. I understand that I may make this decision at any time and will notify my Service Coordinator if I wish to access a different model any time throughout the year. I choose to receive supports through the following service delivery model (initial only one):

Traditional - Traditional Services are provided through an agency (The Agency employs/manages my support staff).

Traditional and Agency with Choice - The agency and I (or my representative) co-manage my support staff. The agency provides Financial Management Services (FMS).

Traditional and Personal Options - I (or my representative) am responsible to manage my support staff. WV’s contracted Fiscal/Employment Agent serves as the FMS.

I am unable to choose at this time - I understand that I will automatically default (remain in) to my current service delivery model. If I am a new member, I understand I will default to the Traditional Service Model.

Referral Date of New Service Delivery Model (if applicable) – The date by which I would like a referral to be made to the new service model provider.

_______________________________________ _________________________________________

Member Signature and Date Legal Representative Name, Signature and Date _______________________________________ _________________________________________

ASO Representative Name, Signature and Date SC Agency Representative Name, Signature and Date

Pay Period Start Date Pay Period End Date

Deadline for Timesheets to be Received

by 5:00 PM

(2 days after pay period ends, unless

otherwise specified below)

Check or Direct Deposit

Issued

MONDAY SUNDAY TUESDAY FRIDAY7/6/2015 7/19/2015 7/21/2015 8/7/2015

7/20/2015 8/2/2015 8/4/2015 8/21/2015

8/3/2015 8/16/2015 8/18/2015 9/4/2015

8/17/2015 8/30/2015 9/1/2015 9/18/2015

8/31/2015 9/13/2015 9/15/2015 10/2/2015

9/14/2015 9/27/2015 9/29/2015 10/16/2015

9/28/2015 10/11/2015 10/14/2015 (Wednesday) 10/30/2015

10/12/2015 10/25/2015 10/27/2015 11/13/2015

10/26/2015 11/8/2015 11/10/2015 11/27/2015

11/9/2015 11/22/2015 11/24/2015 12/11/2015

11/23/2015 12/6/2015 12/8/2015 12/25/2015

12/7/2015 12/20/2015 12/22/2015 1/8/2016

12/21/2015 1/3/2016 1/5/2016 1/22/2016

1/4/2016 1/17/2016 1/20/2016 (Wednesday) 2/5/2016

1/18/2016 1/31/2016 2/2/2016 2/19/2016

2/1/2016 2/14/2016 2/17/2016 (Wednesday) 3/4/2016

2/15/2016 2/28/2016 3/1/2016 3/18/2016

2/29/2016 3/13/2016 3/15/2016 4/1/2016

3/14/2016 3/27/2016 3/29/2016 4/15/2016

3/28/2016 4/10/2016 4/12/2016 4/29/2016

4/11/2016 4/24/2016 4/26/2016 5/13/2016

4/25/2016 5/8/2016 5/10/2016 5/27/2016

5/9/2016 5/22/2016 5/24/2016 6/10/2016

5/23/2016 6/5/2016 6/7/2016 6/24/2016

6/6/2016 6/19/2016 6/21/2016 7/8/2016

6/20/2016 7/3/2016 7/6/2016 (Wednesday) 7/22/2016

7/4/2016 7/17/2016 7/19/2016 8/5/2016

7/18/2016 7/31/2016 8/2/2016 8/19/2016

STATEWIDE PAYROLL SCHEDULE

2015 - 2016


INTELLECTUAL/DEVELOPMENTAL DISABILITIES WAIVER PROGRAM

FAX SIGNED TIMESHEETS TO PPL AT 1-877-876-8351

or mail to: PPL, WVPO IDD, 200 Association Dr. Suite 130, Charleston, WV 25311

PUBLIC PARTNERSHIPS, LLC EMPLOYEE TIMESHEET (West Virginia Personal Options I/DD Waiver Program)Participant's ID:

Employee's ID:

MAIL: PUBLIC PARTNERSHIPS, WVPO, 6 Admirals Way Chelsea, MA 02150

WARNING: Falsifying a signature or reporting hours not worked is Medicaid fraud.

Employee Signature:Date (mm/dd/yyyy):

/ /

By signing below, I certify that I have provided the services tothe employer during the times described on this timesheet.

Begin: Monday (mm/dd/yy) / / T i m e IN

:

T i m e OUT

:

Total Hours

:

Week 1

Sat

Mon

Tue

Wed

Thu

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Sun: : :

: : :: : :: : :: : :: : :: : :: : :: : :: : :: : :: : :: : :

End: Sunday (mm/dd/yy) / / T i m e IN

:

T i m e OUT

:

Total Hours

:

Week 2

Sat

Mon

Tue

Wed

Thu

Fri

Sun: : :

: : :: : :: : :: : :: : :: : :: : :: : :: : :: : :: : :: : :

Employer Signature:Date (mm/dd/yyyy):

/ /

By signing below, I certify that "I" received the hours of serviceas reported and the hours do not exceed my monthly plan.

AM/PM

AM PM

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FAX: PPL @ 1-877-876-8351

AM PM AM PM AM PM AM PM

Participant's Name:

Employee's Name:

Service (Fill one)

Person-Centered Support (PCS)

Respite

Y/NTraining Training

Y/N

5980

1

5980

1

October 1, 2011



Intellectual/Developmental Disabilities Waiver Program Timesheet Instructions

If you and your employee are unable to submit timesheets electronically on the PPL Web Portal you will need to complete and submit a paper timesheet. PPL accepts paper timesheets by fax or mail; we do not accept timesheets via email. These instructions are to assist in accurately completing a timesheet prior to submitting to PPL. Please do your part to correctly complete timesheets to insure payment is not delayed. Timesheets are read by a machine IMPORTANT: You will be responsible for informing your employee of their employment start date. PPL cannot pay for services provided before this date. There are 15 required fields that must be completed on the timesheet. These are described below:

1

2

3 4

5

7

11

15

14

8

9

10

12

13

6

October 1, 2011

Required Fields All of the fields pointed out on the timesheet are required and MUST be completed for the timesheet to be paid. The numbering below corresponds with the number pointed out on the timesheet.

1. Participant’s Name: Enter your name as the person receiving services.

2. Employee’s Name: Enter the name of the person providing services.

3. Participant ID: This is the ID that will be used by PPL to identify you (this number is assigned by PPL and will be provided by your resource consultant).

4. Employee ID: This is the ID that will be used by PPL to identify your employee (this number is assigned by PPL and will be provided to you by your resource consultant. You will be responsible for providing this number to your employee).

5. Service Type: Fill in the circle next to the service you are providing. If your employee

provides more than one type of service they will use separate timesheets. For example, a separate timesheet for must be submitted for Person Centered Supports and another for Respite.

6. Pay Period Start Date: This is the start day of the pay period. Your payroll schedule

will list these dates for you.

7. Pay Period End Date: This is the last day of the pay period. Your payroll schedule will list these dates for you.

8. Time In/Time Out: Enter in the time your employee started working and the time they

finished working. Please see the instructions below for entering overnight time and multiple times.

9. AM/PM: Fill in the circle indicating shifts worked in the AM or PM.

10. Total Hours: Enter in the total number of hours and minutes worked. You do not need

to round time to the closest 15 minutes.

11. Training: This is to acknowledge whether or not training was provided during the shift. This field will be completed by indicating “Y” for yes and “N” for no.

12. Date of Employee Signature: This is the date that your employee signs the timesheet.

13. Employee Signature: This is where your employee signs the timesheet.

14. Date of Participant/Employer Signature: This is the date that you or your representative’s signs the timesheet.

15. Participant/Employer Signature: This is where you or your representative’s signs. An

“X” or a mark is accepted as a signature.

October 1, 2011

Here is an example of a correctly completed timesheet:

Special Situations 1. Working Overnight: When your employee works overnight, there are special

instructions for filling in the overnight shift on the timesheet. Your employee must complete one line for services provided before midnight and another line in the next day for services provided after midnight. For example, say your employee worked overnight Thursday night from 8:00 PM to 6:00 AM on Friday morning. Enter the start time as 8:00 PM as seen below. Enter the end time for that day as 11:59 PM. Now, your employee did not finish working at 11:59 PM, they finished working on Thursday at that time. Enter the rest of your employees time on Friday as shown below – 12:00 AM to 6:00 AM.

2. Working multiple times in one day. Many employees work with someone several times in a day. Your employee can enter as many in and out times as they want but must enter each on a new line. For example, say your employee started working at 9:00 AM and stopped at 12:00PM; they left to run an errand, came back at 2:00 PM and stayed until 5:00 PM. Your employee would enter one line for each time they were providing services as shown below. If they came back a third time that evening, your employee would need to move onto another timesheet.

Important Timesheet Information

October 1, 2011

To avoid delays in payment, please use the important information below: Start with a clean copy of the timesheet. Print clearly using a black pen. Mark letters and numbers only inside the

lines and boxes. If you make a mistake start over with a clean timesheet. Do not use military time. Do not reduce the size of the timesheet or use a poor copy. Do not fill in boxes on days you did not work. Do not round-up or round-down hours and minutes worked. Report your

actual time in and time out. PPL will calculate your time worked to the nearest quarter hour.

Submitting Timesheets

If you and your employee are unable to submit timesheets electronically on the PPL Web Portal your employee will need to complete and submit a paper timesheet. In addition to submitting timesheets and invoices electronically PPL also accepts paper timesheets and invoices by fax or mail.

Faxing the timesheet to PPL at 1-877-876-8351. This fax number is for timesheets only.

Mailing the timesheet to PPL, use: Public Partnerships, LLC WVPO IDD 601-3 E. Brockway Avenue Morgantown WV 26501

IMPORTANT POLICY REGARDING PAYMENT: Timesheets/invoices must be submitted by 5:00 p.m. on the Tuesday following the end of the two week payroll period. If there are errors or problems with a timesheet submitted by fax or mail, the employee and participant (or appointed Program Representative) will receive an automated phone call instructing them to contact PPL’s Customer Service Department. Late and inaccurate timesheets and/or invoices will result in a one week delay from the payment date listed on the payroll schedule. If you would like to confirm that your faxed timesheet or invoice has been received you may call Customer Service at 1-877-908-1757 faxing to confirm receipt. Please note that it is best to wait 24-48hrs after faxing as your faxed timesheets are scanned and optically verified by a machine in the order in which it was received.

Obtaining Timesheets You can make copies of the timesheets we give you but make sure they are full size and not tilted or our computer will not read them. You can download and print copies of timesheets online at www.publicpartnerships.com. Select the state of West Virginia and the Intellectual/Developmental Disabilities Waiver Program. The username is: WVIDD. The password is: PPLWV20. You can also contact Customer Service at 1-877-908-1757 and ask them to send you timesheets.

WEST VIRGINIA I/DD WAIVER PERSONAL OPTIONS

DIRECT SUPPORT PROGRESS NOTE (To be used if something out of the ordinary occurs while providing services. This is not to replace or serve as an

equal requirement in documenting regular services.)

Member Name Service Coordinator Agency

Month of Service

Year of Service

Were there any parts of the goal in which the member did especially well or poor? Did anything out of the ordinary occur (such as illness, behaviors, etc.)? Did the member require more support than usual? How did the member respond to support and services provided?

Date

Time AMPM

Employee Initials

Date

Time AM

PMEmployee Initials

Date

Time AM

PMEmployee Initials

Date

Time AM

PMEmployee Initials

Date

Time AM

PMEmployee Initials

Employee Name Employee Signature Employee Name Employee Signature

This form must be made available to your Service Coordinator as needed.

April 5, 2012

Public Partnerships, LLC 601-3 East Brockway Avenue Morgantown, WV 26501 Phone: (888) 775-9801 Fax: (877) 567-0071


Transportation Invoice Instructions: 1. This invoice must be completed and submitted each pay period. Please do not put dates

for more than one pay period on a single invoice. If more space is needed for a single pay period, use additional sheets as needed.

2. Transportation services billed on this invoice will be reimbursed at a rate set by your participant/employer.

3. The participant/employer must review approve and sign the invoice. 4. The invoice must be faxed to 1-877-567-0071; or Mail to: Public Partnerships, LLC, WVPO

IDD, 601-3 E. Brockway Ave., Morgantown, WV 26501

Participant Name: _______________________________ Participant ID#: ____________________ Employee Name: _______________________________ Employee ID#: _____________________Service Code: A0160U3

Date: Starting Destination: Ending Destination: Purpose of Travel: Mileage:

Total Mileage: Signatures: I verify that I have a current valid driver’s license, current vehicle inspection sticker, motor vehicle insurance as required by West Virginia State Law, and that the billing for services provided is accurate and complete.

Employee Signature: _____________________________________ Date: _______________

Participant Signature: _____________________________________ Date: _______________

April 5, 2012

Transportation Documentation Requirements

The transportation invoice requires that you complete the certain fields on the invoice from using the list of pre-defined destination and purpose of travel categories:

1. Starting Destination • Participant’s Home • Employment/Volunteer Site • Facility Day Program • Fitness Center • Public Park • Healthcare Facility • Crisis Respite Site • SFCP Respite Home • I/DD Waiver Provider

• Store • Bank • Post Office • Library • Restaurant • Public Transportation Station • Relative/Friend’s Home • Hotel/Conference Center

2. Ending Destination • Participant’s Home • Employment/Volunteer Site • Facility Day Program • Fitness Center • Public Park • Healthcare Facility • Crisis Respite Site • SFCP Respite Home • I/DD Waiver Provider

• Store • Bank • Post Office • Library • Restaurant • Public Transportation Station • Relative/Friend’s Home • Hotel/Conference Center

3. Purpose of Travel • Career Development • Social Skills Development • Functional Academics Development • Healthcare • Safety • Community Awareness • Communication Skills Development • Decrease Maladaptive Behavior • Shopping

• Exercise

IMPORTANT: These documentation fields are required. If these fields are not completed you will be notified and requested to submit a corrected invoice.


July 1, 2012


Intellectual/Developmental Disabilities Waiver Program Wage Notice and Change Request Form

If you chose to change your employee’s rate, you must fill out this form and submit to your resource consultant. Your resource consultant will help you revise your spending plan to show the employee’s wage change. The maximum rate for transportation is defined by West Virginia Bureau for Medical Services, to find out more information, please contact your resource consultant. Current Hourly Employee Wage: _______________________ Employee Wage Change Request (must begin the 1st of the following month)

_______________________ __________________________ New PCS Employee Wage Effective Date

_______________________ __________________________ New Respite Employee Wage Effective Date

_______________________ __________________________

New Transportation Wage Effective Date

______________________________ ______________________________ ________ Participant Name Participant Signature Date

______________________________ ______________________________ ________ Employee Name Employee Signature Date Reminder: This form must be submitted to your Resource Consultant.

west virginia personal options intellectual/developmental ......august 1, 2012 public partnerships,...

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