Form 3054
Instructions

Primary Home Care Service Delivery Record

10-2004

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 and to document claims for payment.
  • To serve as the primary source document of time worked by the attendant and as a payroll document for the provider agency.

Form 3054, Primary Home Care Service Delivery Records, 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 (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 client. You must complete one Form 3054 for each pay period.

Transmittal

Keep Form 3054 in either the client or the attendant records.

Form Retention

Keep Form 3054 according to the terms of your contract.

DETAILED INSTRUCTIONS

One or more Form 3054 may be completed for a month, depending on your pay periods.

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

You must obtain prior written approval from the Community Care section if a different timesheet is to be used instead of Form 3054.

If you fail to complete or correct Form 3054 or approved timesheet according to instructions, financial or administrative exceptions 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 beginning with the first day of the month and ending with the 15th day of the month; and
  2. One Form 3054 beginning with the 16th day of the month and ending with the last day of the month.

Employee Name — No. —  Enter the name of the Family Care or Primary Home Care attendant.


Entering the employee number is optional. If you assign employee numbers, the employee's number may be entered here. If you have more than one contract with DADS, the four-digit contract number may be entered here to identify the specific service delivery contract.

Employee Mailing Address —  Enter the attendant’s mailing address.

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

Client Name —  Enter the client name as it appears on Form 2101.

Client Number —  Enter the client number as it appears on Form 2101.

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

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


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

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

Scheduled or Authorized Hours —  Enter the hours by day that you scheduled the attendant to work in the client’s home.


Note: When multiple attendants provide services to a client, 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 client 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 a client, 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 a client to prevent a break in service, the client’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 you choose to use this entry, you must not pre-print or pre-enter the time in portion of Form 3054. The attendant must enter the time in (hour and minute) that service delivery begins. Do not round up or down.

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


Note: You 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, X-ing 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 —  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 or his designee signs the form. The timekeeper may not sign the timesheet for the employee. An attendant who is unable to complete and sign the timesheet may designate a neighbor, friend, or relative to complete and sign the timesheet. You must have written documentation of the reason why the attendant is unable to complete and sign the timesheet and of the person authorized to make the entries for 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, corrections to all entries must be corrected as follows:

  • line through the error,
  • enter the correct entry, and
  • initial the correction.

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

Initials for Time Entries —   

  • If the correction reduces the number of hours recorded, the timekeeper may initial the correction.
  • If the correction increases the number of hours recorded, the attendant must initial the correction.

Task(s) Assigned — 

  • If the correction deletes a task, enter the word “delete,” the effective date of the deletion, and the initials of the person making the change.
  • If the correction adds a task, enter the word “add,” the effective date of the addition, and the initials of the person making the change.

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