Form 3054
Instructions

Primary Home Care Service Delivery Record

08-2009

PURPOSE

  • To certify the actual hours worked by the attendant.
  • To serve as the primary source document of services delivered by the attendant according to DADS authorization.
  • To serve as the primary source document of time worked by the attendant and as a payroll document for the provider agency.

Form 3054 or an alternate form of documentation must be used to document service delivery. The alternate form must include all the required elements to be in compliance with the rules of the Primary Home Care (PHC) Program. DADS approval is not required for alternate forms.

PROCEDURE

When to Prepare

Prepare Form 3054 for each pay period. Example: bi-monthly or monthly. Pay periods must not exceed one calendar month.

Number of Copies

Complete one Form 3054 for each attendant assigned to provide services to each individual receiving services. Complete one Form 3054 for each pay period.

Transmittal

Keep Form 3054 in either the individual or the attendant record.

Form Retention

Keep Form 3054 according to the terms of the Community Services Contract (Provider Agreement).

DETAILED INSTRUCTIONS

One or more Form 3054 may be completed for a month, depending upon the number of pay periods.

A different Form 3054 must be completed for each calendar month.

If the home and community support services agency (HCSSA) fails to complete or correct Form 3054 according to instructions or complete or correct an alternate form, financial errors may result.

Month and Year of Service — Enter the calendar month and year in which services are provided.

Example: An attendant who receives payment twice a month may complete two Form 3054s:

    1. One Form 3054 begins with the first day of the month and ends with the 15th day of the month.
    2. One Form 3054 begins with the 16th day of the month and ends with the last day of the month.

HCSSA - Enter the name of the agency contracted to provide services.

No. – Enter the nine-digit contract number assigned by DADS.

Employee Name/No. — Enter the name of the Community Attendant Services Family Care or Primary Home Care attendant.

Entering the employee number is optional. If the HCSSA assigns employee numbers, the employee number may be entered here. If the HCSSA has more than one contract with DADS, the nine-digit contract number may be entered here to identify the specific service delivery contract.

If more than one employee serves the individual, list employee name(s) — List the names of other attendants if there are multiple attendants assigned to provide services to the individual.

Individual Name — Enter the individual’s name as it appears on Form 2101, Authorization for Community Care Services.

Individual ID No. — Enter the individual’s ID number as it appears on Form 2101.

County — Entering the county is optional. Enter the county in which the individual resides.

Task(s) Assigned — Check all tasks authorized by DADS and assigned by the supervisor.

Note: When multiple attendants provide services to an individual, Form 3054 is completed for each attendant. Each attendant’s task(s) must be reflected on the attendant’s Form 3054.

When an attendant provides services to an individual to prevent a break in service, the attendant’s tasks must be reflected on the attendant’s Form 3054.

Scheduled or Authorized Hours — Enter the hours by day the attendant is scheduled to work in the individual’s home.

Note: When multiple attendants provide services to a individual, a Form 3054 is completed for each attendant. Each attendant’s schedule must be reflected on his Form 3054.

When an attendant provides services to a individual to prevent a break in service, the attendant’s schedule on Form 3054 must match the schedule designated for the previous attendant.

Total Authorized Hours per Week — Enter the weekly total number of hours (Sunday through Saturday) authorized for the attendant. This number must not exceed the weekly total number of hours authorized on Form 2101.

Note: When multiple attendants provide services to an individual, Form 3054 is completed for each attendant. Each attendant’s total authorized hours per week must be reflected on his Form 3054. The combined total hours on Form 3054 for all the attendants must add up to the authorized hours on Form 2101.

When an attendant provides services to an individual to prevent a break in service, the individual’s authorized hours on Form 2101 must be reflected on the attendant's Form 3054. The hours on Form 3054 for the attendant must match the hours authorized on Form 2101.

Time In — This entry is optional. If the HCSSA chooses to use this entry, the HCSSA must not pre-print or pre-enter the Time In portion of Form 3054. The attendant must enter the time (hour and minute) that service delivery begins. Do not round up or down.

Time Out — This entry is optional. If the HCSSA chooses to use this entry, the HCSSA must not pre-print or pre-enter the Time Out portion of Form 3054. The attendant must enter the time (hour and minute) that service delivery ends. Do not round up or down.

Note: The HCSSSA can X out or line through the Time In/Time Out portion of the record of time for those days in which the attendant did not work. However, crossing out or lining through the entire Time In/Time Out portion is considered altering a form. This requires prior approval from state office.

Total Daily Time — This entry is required. The attendant enters the total daily time (hours and minutes) worked. If the attendant does not enter the total daily time, the timekeeper enters the total daily time based on the attendant Time In/Time Out entries. Do not round.

Note: If the total time entered does not match the sum of recorded time in and time out, DADS provides reimbursement based on the lesser amount.

Monthly Total of Hours — The attendant enters the total number of service hours and minutes delivered for the pay period. The timekeeper may enter the monthly total of hours if the attendant entered the total time and/or Time In/Time Out entries.

Note: If the sum of the daily totals of time does not match the monthly total of hours, DADS provides reimbursement based on the lesser amount.

Signature-Employee — The attendant signs the form. An attendant who is unable to complete and sign the form may designate another person to complete and sign the form. The HCSSA must have written documentation of the reason why the attendant is unable to complete and sign the form and the identity of the person authorized to sign the form on behalf of the attendant.

Signature and Date-Timekeeper — You must designate a timekeeper to verify that the hours recorded on Form 3054 were worked and that tasks assigned were provided. The timekeeper may be the supervisor or other designated person.

The timekeeper signs and dates Form 3054 on or after the last workday of the pay period. If a signature stamp is used, the timekeeper must initial the stamped signature. Enter the month, day and year Form 3054 is signed.

Note: Form 3054 must not be pre-signed or pre-dated.

CORRECTIONS TO ENTRIES

Method of Correction — Unless specifically stated below, all entries must be corrected as follows:

Do not use liquid paper/correction fluid. Original entries, corrections and initials must be legible.

Initials for Time Entries —

Task(s) Assigned —

Schedule or Authorized Hours — The supervisor or his designee must initial corrections to the schedule or authorized hours and include the effective date of the change.

Total Authorized Hours per Week — If the correction increases or decreases the number of hours, the supervisor or his designee enters the phrase “change to __________ hours” and the effective date of the change.

Examples

If

Then the change is initialed by

Time In: 8
Time Out: 11   Daily Total 2
Time Out is decreased to 10.

The timekeeper

Time In: 8
Time Out: 11    Daily Total 2
Daily Total is increased to 3.

The attendant

Time In/Time Out and Daily Totals = 58
Monthly Total: 60
Monthly Total is decreased to 58.

The timekeeper

Time In/Time Out and Daily Totals = 62
Monthly Total: 60
Monthly Total is increased to 62.

The attendant

Attachment I