Consumer Directed Service
Agency (CDSA)
Compliance Monitoring Guide
DADS Form 1722 and Instructions
DADS Form 1722
Demographic Information
1. Consumer and Employer
2. CDSA Provider Agency
3. Monitor, Review Date, Review
Period, Review Type
Contract Monitoring Guide - Page 1
STANDARD 1
Orientation and Service Agreement
1. ORIENTATION
•
•
•
•
Face-to-Face by CDSA Representative
Consumer’s Residence
Employer and Designated Responsible party
(if applicable) must attend
Documented (DADS Form 1736, Documentation of
Employer Orientation)
2. Service Agreement
• CDSA and Employer (DADS Form 1735)
•
Documents Incorporated in Agreement
Contract Monitoring Guide - Page 1
STANDARD 1 Orientation and Service Agreement
2. The following documents are incorporated in
the Service Agreement by Reference
a) Form 1726, Relationship Definitions in
Consumer Directed Services
b) Form 1733, Employer and Employee
Exemption from Nursing License for
Certain Services
c) Form 1736, Documentation of Employer
Orientation
d) Form 1738, Rules Acknowledgement
Contract Monitoring Guide - Page 1
STANDARD 2
Budget Development
1. Employer/DRP and CDSA Participation
a) Budget must be developed using the DADS CDS
Budget Workbook
b) Budget must be “VALID”
2. Each Service Plan
a) Must be current. Revisions with changes to the
Consumer’s Service Plan affecting CDS services
b) Must have a CDS Budget for each service category
delivered through CDS
3. Approved by CDSA / Acknowledged by
the Employer/DRP
Contract Monitoring Guide - Page 1
Definitions / Clarification
CONSUMER - Individual
receiving program services
and participating in
Consumer Directed Services
(CDS)
MINOR - Individual UNDER
the age of 18
ADULT - Individual OVER
the age of 18
DESIGNATED RESPONSIBLE PARTY – Willing
adult that agrees to assist the Employer with responsibilities for CDS
PARENT – Natural, Legal,
SPOUSE –Married with
Adopted, Step-Parent, Foster
Parent, Court Appointed
Guardian
Formalities (Legal) or Married
without Formalities (Common
Law) Texas Family Code
STANDARD 3
Employer and Employer-Agent Registration
EMPLOYER
CONSUMER – Age 18 or more; Does NOT have a court appointed guardian
PARENT – of a minor-aged Consumer (Consumer is under 18 years of age)
CONSUMER – Consumer, under 18 years of age, but has been
(1) Emancipated by the court OR
(2) Is legally married
GUARDIAN – Court Appointed Guardian, regardless of the Consumer’s age
POWER OF ATTORNEY = Designated Responsible Party
Designated Responsible Party (DRP) is NOT the Employer.
Contract Monitoring Guide - Page 2
STANDARD 3
Employer and Employer-Agent Registration
FEDERAL GOVERNMENT
INTERNAL REVENUE SERVICE (IRS)
 Employer: Employer Identification Number (EIN)
 CDSA: Employer Appointment of Agent (Employer-Agent)
STATE GOVERNMENT
TEXAS WORKFORCE COMMISSION (TWC)
 Employer: Employer TWC Account Number
 CDSA: Authorization to Represent Employing Unit (“Employer’)
Contract Monitoring Guide - Page 2
STANDARD 4
CDSA Responsibilities, Federal and State Agencies
1. WITHHOLDINGS
EMPLOYEE
CONTRIBUTIONS:
2. DEPOSITS
 Income Tax
Social Security Tax
Medicare Tax
Voluntary Benefits
Garnishments
Wage Attachments
Optional Benefits
EMPLOYER
CONTRIBUTIONS:
Match:
Social Security Tax
Medicare Tax
Total Amount:
Unemployment Tax
Total Amount or Share:
Benefits
Contract Monitoring Guide - Page 2
STANDARD 4
CDSA Responsibilities, Federal and State Agencies
3. Workers’ Compensation and Employee
Work-Related Injuries
a) Texas Workers’ Compensation Commission (TWCC)
b) Liability Insurance – Homeowner/Renter
4. Deductions
a) Garnishments – Court Ordered (Child Support)
b) Wage Attachments – Government Agency Directive
(Guaranteed Student Loan Payment)
c) Optional Deductions – Insurance Premiums, 401K,
Contract Monitoring Guide - Page 2
STANDARD 4
CDSA Responsibilities, Federal and State Agencies
5. Annual Tax-Related Forms a) IRS Form W-2, Wage and Tax Statement;
b) IRS Form W-3, Transmittal of WAGE and Tax
Statements;
c) IRS Form 1099-MISC, Miscellaneous Income
TAX REPORTING ANNUALLY: Calendar Year, January 1 – December 31
CDSA DUE DATES:
To Employee: W-2 by January 31
To IRS and Employer: W-3, with copy of Form(s) W-2 by the last day of February
To Contractor: 1099MISC by January 31
To IRS and Employer: 1099MISC by the last day of February
Contract Monitoring Guide - Page 2
STANDARD 4
CDSA Responsibilities, Federal and State Agencies
Records – Federal and State Agencies
6. Provide Copy or Original of EmployerRelated Forms and Reports to
Employer
7. Retain Copy or Original of EmployerRelated Forms and Employer-Agent
Forms and Reports
Contract Monitoring Guide - Page 2
STANDARD 5
CDSA Responsibilities, Payroll and
Accounts Payable
1. Payroll Payments – Based on complete,
accurate, Employer-approved Timesheets
2. Payroll Distribution – Two times each
calendar monthly in accordance with posted
payday schedule.
a.) Based on complete,
3. Invoice Payments –
accurate, Employer-approved
invoice or receipt
4. Receipt Payments –
b.) Distribute payment within
30 DADS’ workdays of receipt
by the CDSA of the acceptable
invoice or receipt
Contract Monitoring Guide - Page 3
STANDARD 6
CDSA Responsibilities, Payroll Status
Monitoring and Reporting
1. Account Balances – Each Service Area;
Ongoing Balances; Based on All Transactions;
Complete and Accurate Records
Provide Summaries at Least Quarterly:
2. To Employer
3. To Consumer’s Case Manager
Contract Monitoring Guide - Page 3
STANDARD 7
CDSA Responsibilities, Ongoing Training
Ongoing Training –
Training, Support, Assistance by CDSA
Based on –
•
Employer/DRP Documentation, Performance, and
Compliance;
•
Budget Compliance
•
Employee and Contractor Documentation
Contract Monitoring Guide - Page 4
STANDARD 8
CDSA Responsibilities,
Criminal Conviction History Check
1.
Report obtained:
 From the Texas Department of Public
Safety (DPS),
 Before applicant was hired, or contractor
retained, and
 Before service delivery by the individual
2. Employer Notification by CDSA before
individual was hired/retained by the Employer
(if check was conducted by the CDSA)
Contract Monitoring Guide - Page 4
STANDARD 8 - CDSA Responsibilities,
Criminal Conviction History Check
3. Copy of Report on File at CDSA:
 Report from the Texas Department of Public Safety
 CDSA must not make payment to an individual
barred from employment based on Criminal
Conviction History Check
(Note as a Financial Error if Applicable)
4. Offers of Employment / Retain Contractor Individuals barred from employment by Chapter 250,
Health and Safety Code, must not deliver services or
receive payment for services.
Contract Monitoring Guide - Page 4
STANDARD 9
CDSA Responsibilities, Complaints
Contracting Requirements:
§ 49.17(d)(3) Complaint Procedures
1. CDSA
(a) maintains a log of all complaints and
(b) makes records and resolution of
complaints accessible to DADS Staff
Contract Monitoring Guide - Page 5
STANDARD 9
CDSA Responsibilities, Complaints
Contracting Requirements: § 49.17(d)(3) Complaint Procedures
2. Each complaint received from any source
must be:
(a) Documented, and
(b) Resolved
3. Based on documentation, did CDSA:
(a) Investigate and resolve each complaint
in 5 DADS’ workdays?
(b) Provide written complaint procedures
initially and at least annually thereafter?
Contract Monitoring Guide - Page 5
CASE REVIEW SUMMARY
Standard
Met
Not Met
N/A
Standard
Standard 1
Standard 5
Standard 2
Standard 6
Standard 3
Standard 7
Standard 4
Standard 8
Met
TOTAL:
Transfer results of Case Review to
Form 3853, Provider Agency
Evaluation Summary.
Contract Monitoring Guide - Page 1
Not Met
N/A
DADS Form 3853,
Provider Agency Evaluation Summary
Contract/Program Compliance
Provider Agency Evaluation Summary
Texas Department
of Aging and
Disability Services
Provider Agency Name
Type of Review
STANDARDS
TOTALS
Vendor No.
Reason for Review
Routine Monitoring
A
NUMBER MET
Form 3853
September 2001
Region No.
Review
Period
Complaint
B
NUMBER NOT MET
Date
Other
C
NUMBER N/A
D
TOTAL (A + B)
E
% MET
DADS Form 1722,
Compliance Monitoring Guide
Demographic Information
CONSUMER = INDIVIDUAL RECEIVING SERVICES
EMPLOYER = Consumer, Parent of Minor, or Court Appointed Guardian
Consumer Name
Medicaid No.
Consumer's Region/Catchment Area
Sue Smith
123456789
07
Address
City
ZIP Code
Telephone No.
125 East Blue Bird Avenue
Austin
78795
(512) 123-4567
Employer Name (Verify employer status – see form instructions.)
James Smith
Consumer
Consumer's Date of Birth Consumer's Age Guardian
01/25/1965
Employer Relationship to Consumer
39
X Yes
No
Parent of Minor
X Guardian
Designated Responsible Party Agreement Signed by
Employer/CDSA (Date)
Yes
X No
May 15, 2005
DADS Form 1722,
Compliance Monitoring Guide
Demographic Information
CDSA = CONUSMER DIRECTED SERVICE AGENCY (CDSA)
MONITOR = DADS CONTRACT MANAGER/MONITOR
REVIEW = REVIEW PERIOD AND TYPE
CDSA Provider
CDSA Vendor No.
CDSA Location
ACB CDSA
100100456
Austin
Name of Monitor
Date of Review
Review Period
Amy Brown
12/05/05
From: May 1, 2005
Type of Review
X
Formal
Administrative
Other:
To: July 31, 2005
DADS Form 1722,
Compliance Monitoring Guide
STANDARD 2 – Budget Development
YES
Review each item in Standard 2 regardless of when the activity occurred within or outside of the review period.
Response to each item must be yes or no.
1. Did the CDSA assist the employer in budget development for each service area
authorized for CDS, including use of DADS CDS Budget Workbook and related
X
worksheets? …………………………………………………………………………………….
2. Is the budget calculated based on each service plan in effect during the review
period? …………………........................................................................................................
X
3. Have the employer and CDSA agreed (signed and dated) with each service budget?.
X
Reference: 40 TAC §41.103(1)-(3)
If any item is marked NO, Standard 2
is NOT MET.
Standard 2 is: ......................................... X MET
Monitoring Guide - Page 1
NO
NOT MET
DADS Form 1722,
Compliance Monitoring Guide
STANDARD 3 – Employer and Employer-Agent Registration
YES
NO
N/A
Did the CDSA ensure that (1) the employer and (2) the employer-agent (CDSA) are registered within
required time frames established by CDS rules and IRS and TWC regulations? If a registration has not
yet been required, or is not required for this employer, mark the item as N/A.
1. Employer Registration:
a. Federal: IRS – Employer Identification Number (EIN)
May 15, 2005
X Form SS-4 – Date Signed:
Other verification, if acquired through telephone or electronic registration:
EIN:
Date
Date:
TWA ID/Account No.:
Employer-Agent Registration:
, or
987654321
b. State: TWC – Employer Registration
May 16, 2005
X Form C-1 – Date Signed:
Other verification, if acquired through electronic registration:
2.
X
X
, or
01-98432
X Federal: IRS – Employer Appointment of Agent (Written Authorization to Represent
a. Employing Unit)
Form 2678 – Date Signed:
May 15, 2005
b. State: TWC – Written Authorization to Represent Unit in its Relations with Texas Workforce Commission
(notarized or
X Form C-42 – Date Signed:
completed per
May 16, 2005
current TWC
instructions)
Reference: 40 TAC §41.103(4)(A)-(B)
If any item is marked NO, Standard 3 is NOT MET.
Standard 3 is: ....................................... X MET
Monitoring Guide – Page 2
X
X
NOT MET
N/A
DADS Form 1722, Compliance Monitoring Guide
STANDARD 7 – CDSA Responsibilities, Ongoing Training
YES
Did the CDSA conduct the following activity as required and/or indicated
by need:
Did the CDSA provide ongoing training pertaining to the CDSA's
responsibilities/employment and employer-related issues?………………
NO
N/A
X
Note: Refer to each standard in this and other monitoring activities to determine if employer was
non-compliant (adhering to budgets, time sheets, credentialing of employees and providers,
providing required documents to the CDSA within established timeframes, etc.). Did the CDSA
document that additional training was provided to the employer? Mark this standard as Not Met
if the CDSA did not provide ongoing training to the employer related to any problem or noncompliance.
Reference: 40 TAC §41.103(2), (3), (4)(L)-(M)
If any item is marked NO, Standard 7 is NOT MET.
Standard 7 is: ………
MET
X NOT MET
N/A
Notes/Comments: The CDSA did not document that ongoing training was provided to the Employer for:
1. Timesheets submitted after posted CDSA due dates on 3 occasions; (May 30; June 16, July 1)
2. One Employee did not sign his timesheet on or after the last date of service documented for 2 pay
periods (May 31 and June 15) ;
3. The CDSA did not document that the Employer had been notified that the consumer’s CDS Budget for
attendant services had exceeded the program authorized number of hours for 3 consecutive pay periods
(May 30, June 15, June 30)
Monitoring Guide – Page 4
DADS Form 1722, Compliance Monitoring Guide
Standard
Standard 1
Standard 2
Standard 3
Standard 4
Met
X
X
X
X
Not
Met
N/A
Standard
Standard 5
Standard 6
Standard 7
Standard 8
TOTAL:
Case Review Summary:
Transfer results of case
review to Form 3853,
Provider Agency
Evaluation Summary.
Monitoring Guide – Page 1
Met
X
Not
Met
N/A
X
X
X
7
1
0
DADS Form 3853,
Provider Agency Evaluation Summary
 ABOVE COMPLIANCE–Your agency is
performing at or above 90%, which is the minimum
compliance level. Please review the “Findings”
section (below), if appropriate, for areas of
concern.
 BELOW COMPLIANCE–Your agency is
performing BELOW 90%, which is the minimum
compliance level. The major reasons for
noncompliance of standards are noted in the
“Findings” section (below).
CDSA
Compliance
Monitoring
Comments
Q&A