Corporate Office:
514 East Main Street
Post Office Box 369
Beulaville, N.C. 28518
Administration: 800-513-4002
Access to Care: 800-913-6109
Kenneth E. Jones, CEO
VERIFICATION OF
RELATIVE/LEGAL GUARDIAN AS DIRECT SUPPORT EMPLOYEE
This document is to be completed by the Network Provider Agency/Agency with
Choice/Employer of Record as a part of their certification of compliance with the
Innovations Relative/Legal Guardian as Provider Policy
Please note that parents, biological or adoptive, and step-parents cannot be employed to provide
services to their minor children under the Innovations waiver. This process only applies to waiver
participants who are 18 years of age or older
Part D Application – Request for Reinstatement
The Part D Application applies to employees that have had their previous Relative/Legal
Guardian as Direct Support Employee approval discontinued for cause. Please complete
one application per employee for whom this process is applicable.
Section I
Date of Submission: Click here to enter text.
Name of Provider Agency QP or Employer of Record: Click
Agency Name: Click
Address: Click
here to enter text.
here to enter text.
here to enter text.
Phone Number(s): Click
here to enter text.
Name of Employee Reinstatement is being requested for: Click here to enter text.
Relationship to Consumer: Mother Father Other: Click
Legal Guardian? ☐Yes
here to enter text.
☐No
Does this Relative or Legal Guardian live in the same home as the waiver participant?
☐Yes ☐No, If no then this process is not applicable for review
Date previous approval was discontinued for cause (dd/mm/yyyy): Click here to enter text.
Managing Behavioral Healthcare for the Citizens of Bladen, Columbus, Duplin, Edgecombe, Greene, Lenoir, Nash, Robeson,
Sampson, Scotland, Wayne, and Wilson Counties
An Equal Opportunity/Affirmative Action Employer
www.eastpointe.net
Reason for discontinuation of previous approval (Attach additional pages if necessary):
Click here to enter text.
Plan of Correction/Training, Supervision, and Monitoring plan (Please describe the steps
the Provider Agency/Agency with Choice/Employer of Record will implement to insure previous
issues that lead to the discontinuation do not occur again. This must include training,
supervision, and monitoring that will be provided should the approval be reinstated. Attach
additional pages if necessary):
Click here to enter text.
Section II (All items in the section must be addressed)
Participant Name: Click here to enter text.
Participant’s Age at Time of Application: Click here to enter text.
Date of Birth (dd/mm/yyyy): Click here to enter text.
Waiver Region that Participant’s Medicaid originates from: Click here to enter text.
Which service (s) will be provided:
☐Community Networking - How many hours requested per week Click here to enter text. or Click here to enter text. per day
☐Day Supports- How many hours requested per week Click here to enter text. or Click here to enter text. per day
☐Personal Care- How many hours requested per week Click here to enter text. or Click here to enter text. per day
☐In-Home Skill Building (Individual) - How many hours requested per week Click here to enter text. or Click here to enter text. per day
☐In-Home Skill Building (Group) - How many hours requested per week Click here to enter text. or Click here to enter text. per day
☐In-Home Intensive Supports- How many hours requested per week Click here to enter text. or Click here to enter text. per day
☐Residential Supports- How many units per week? Click here to enter text.
Will the relative or legal guardian be providing ☐ primary or ☐ back up services?
Who will provide required Back-up Staffing? Click here to enter text.
Managing Behavioral Healthcare for the Citizens of Bladen, Columbus, Duplin, Edgecombe, Greene, Lenoir, Nash, Robeson,
Sampson, Scotland, Wayne, and Wilson Counties
An Equal Opportunity/Affirmative Action Employer
www.eastpointe.net
If the person is the legal guardian what strategies is the Provider Agency/Agency with
Choice/Employer of Record going to employ to ensure that the decisions made by the employee
are in the best interest of the waiver participant?
Click here to enter text.
Section III (All items in the section must be addressed)
PIHP must prior authorize the provision of services by a family member or legal guardian
living in the same household as the waiver participant.
As Provider Agency or Employer of Record, I am verifying the following:
(Please check each item verified and provide additional justification if requested.)
9. The relative or legal guardian must meet the provider qualifications for the service.
Response to a) is required. Response to b) and c) as appropriate to the individual’s
needs.
a) ☐The prospective employee (relative or legal guardian) meets the provider
qualifications for the specific service they are being interviewed/employed to
provide. (To be verified by QM upon on-site review.)
b) ☐If medical tasks are required to meet the individual’s needs, the employee only
performs tasks they are qualified to provide under the NC Nursing Practice Act.
Please detail the tasks: Click here to enter text.
c) ☐The provider certifies that there is documented training for the specific medical
task by a professional appropriately qualified in the task or equipment and that
the employee receives nursing supervision to carry out this function as specified
by the NC Nursing Practice Act.
10. A qualified provider who is not a relative or legal guardian is:
a) ☐Not available to provide the service. Please describe: Click here to enter text.
Number of people interviewed and not hired for the position and the justification for
not hiring each staff person
Total number interviewed: Click here to enter text.
Justification: (Please check all that apply and attach additional sheets if necessary)
☐Did not have necessary skills (# interviewed: Click here to enter text.)
☐Not available at the days/times/places necessary (# interviewed: Click here to enter text.)
☐Difficulty with interpersonal relationships; please explain: (# interviewed: Click here to enter text.)
Click here to enter text.
Managing Behavioral Healthcare for the Citizens of Bladen, Columbus, Duplin, Edgecombe, Greene, Lenoir, Nash, Robeson,
Sampson, Scotland, Wayne, and Wilson Counties
An Equal Opportunity/Affirmative Action Employer
www.eastpointe.net
☐Staff not available due to remote location; please explain: (# interviewed Click here to enter text.)
☐Other; please explain: (# interviewed Click here to enter text.)
OR
b) ☐A qualified provider is only willing to provide the service at an extraordinarily
higher cost than the fee or charge negotiated with the family member or legal
guardian. Please explain: (e.g. specialized nursing training, holds a license in a
field required for the service etc.)
11. ☐The relative or legal guardian is not paid to provide any service that they would
ordinarily perform in the household for an individual of similar age who does not
have a disability.
12. ☐The prospective employee is not the:
 Employer of Record or Managing Employer in an Agency with Choice
model
 Respite Service provider
 The spouse of the waiver participant
Section VI
What is the intended work schedule of the prospective employee? Hours per day/days of the
week etc. Click here to enter text.
NOTE: If the intended work schedule is more than 40hrs per week please fill out the Part
C Application and submit it with this form.
Is there staff currently assigned to deliver services to the waiver participant? If so, how many
and what hours do they work?
Click here to enter text.
Managing Behavioral Healthcare for the Citizens of Bladen, Columbus, Duplin, Edgecombe, Greene, Lenoir, Nash, Robeson,
Sampson, Scotland, Wayne, and Wilson Counties
An Equal Opportunity/Affirmative Action Employer
www.eastpointe.net
What is the plan to introduce additional staff to provide some of the services that are needed by
the waiver participant?
Click here to enter text.
Section V – Signatures
☐The prospective employee understands that the Provider Agency/Agency with
Choice/Employer of Record will monitor the service that a relative or legal guardian provides
each month on-site, at a minimum of one time per month.
☐The prospective employee understands that the PIHP’s Support Coordinator will monitor the
relative/legal guardian’s provision of services on-site, at a minimum of one time per month.
☐The prospective employee will provide Community Networking, Day supports, Personal
Care, In-Home Skill Building (Individual), In-Home Skill Building (Group), In-Home
Intensive Supports, and/or Residential Supports. Payments are only made for service
authorized by the Utilization Management Department in the Individual Support Plan.
☐If reinstatement is granted, the approval shall be conditional for a period of ninety (90) days
or less. Quality Management will monitor the services and documentation provided by the
Relative or Guardian under this policy during the conditional approval period.
☐If reinstatement is granted, failure to resolve all issues that lead to the previous
discontinuation within the conditional approval period will result in revocation of the
reinstatement.
☐Revocation of the reinstatement or any future discontinuation of approval for cause under
this process will result in permanent discontinuation of this parent or guardians approval
under the Relative/Guardian as Direct Support Employee. The Revocation of reinstatement
and permanent discontinuation decisions by PIHP are not appealable.
☐Signature below certifies that I/we have received and read PIHP’s Innovations waiver
Employment of Relative/Legally Responsible Person policy and that all information on the form
is true and accurate. Falsification of this information could result in a Medicaid payback. The
employee understands that communications regarding this submission should be directed to
their Employer of Record or Provider Agency.
______________________________________________________________________
Employee Providing Service Signature, Relationship and Date
______________________________________________________________________
Provider Agency Qualified Professional, Employers of Record, Managing Employers
PRINT NAME, Signature, Title and Date
Managing Behavioral Healthcare for the Citizens of Bladen, Columbus, Duplin, Edgecombe, Greene, Lenoir, Nash, Robeson,
Sampson, Scotland, Wayne, and Wilson Counties
An Equal Opportunity/Affirmative Action Employer
www.eastpointe.net
☐If reinstatement is granted, the Provider Agency/Agency with Choice/Employer of Record
understands they are at full risk for the payback of Medicaid funds associated with services
provided by the Relative/Guardian if the Plan of Correction/Training, Supervision, and
Monitoring plan is not implemented or followed, the requirements under Medicaid service
definition are not met, and/or appropriate and required documentation is not completed.
____________________________________________________________________________
Provider Agency/Agency with Choice CEO or Manager with Authority to make financial
decisions
PRINT NAME, Signature, Title and Date
Optional Comments: Click
here to enter text.
NOTE: If this form is incomplete it will be denied. Only original documents will be accepted (no
copies, faxes or emails please).
Forward Information to: (Address of PIHP)
Click here to enter text.
Date received: Click here to enter text.
Managing Behavioral Healthcare for the Citizens of Bladen, Columbus, Duplin, Edgecombe, Greene, Lenoir, Nash, Robeson,
Sampson, Scotland, Wayne, and Wilson Counties
An Equal Opportunity/Affirmative Action Employer
www.eastpointe.net