Instructions for Support Service Worker Qualification Form

Public Partnerships, LLC
PA ODP Program
7776 S Pointe Pkwy W, Suite 150
Phoenix, AZ 85044
Instructions for Support Service Worker Qualification Form
What is the purpose of this form?
Each SSW that is or will be providing
and reimbursed for services to a
Participant through the VF/EA PDS
model, must be qualified. This form
serves as documentation that that
SSW has been qualified.
How do I complete this form?
Page One (1):
•
•
Fill in the names of the
Participant, Common Law
Employer, and Support Service
Worker at the top of the page.
The SSW and CLE initial the blanks
next to each statement at the
bottom of the page.
Page Two (2):
•
The SSW answers each of the four
questions by checking YES or NO.
Page Three (3):
•
•
•
The SSW submits a valid Driver’s
License or State/Federal ID proving
that the SSW resides in Pennsylvania or a state contiguous to Pennsylvania.
YES or NO is checked off to indicate if Transportation is a component of the service being provided.
If the answer is YES, then fill in the Date of last vehicle inspection and submit copies of a
valid Driver’s License, Automobile Insurance, and Motor Vehicle Registration to PPL.
The SSW and CLE sign and date the bottom of the form.
Who needs to sign?
Both the Support Service Worker and Common Law Employer must sign this form. If the Participant is
acting as their own CLE and require a Guardian or Power of Attorney to sign on their behalf, then
documentation must be provided to PPL that shows proof of the Guardianship or POA.
Instructions for SSW Qualification Form
Support Service Worker (SSW)
Qualification Form
Participant, Common Law Employer, and SSW Information:
Name of Participant:
Name of Common Law Employer:
Name of SSW being qualified:
Purpose of the Qualification Process:
All Support Service Workers should be trained on each of the Participant’s individual needs and how to
properly provide services in a way that supports the Participant’s health, safety, and goals in their
Individual Supports Plan (ISP). It is the responsibility of the Common Law Employer (CLE) to provide this
training to each Support Service Worker, prior to the SSW providing services to the Participant. If
additional services are added to the ISP during the plan year, the CLE will ensure that this SSW is trained
and qualified to provide the new service.
Qualification Verification:
By placing your initials for the following statements, you are confirming that, until the next bi-annual
qualification process, the Support Service Worker will continue to meet the following Medicaid waiver
standards and ODP qualification requirements. Any change in the SSW’s qualifications status will be
reported to Public Partnerships, LLC, by submitting a new Support Service Worker (SSW) Qualification
Form to Public Partnerships, within 5 business days of being notified of the change.
1. The SSW will comply with Department standards related to provider qualifications.
SSW’s Initials: _______
CLE’s Initials: _______
2. The SSW is trained to meet the unique needs of the Participant; which includes, but is
not limited to: communication, mobility, and behavioral needs.
SSW’s Initials: _______
CLE’s Initials: _______
3. The SSW has been trained on the ISP and agrees to carry out ISP responsibilities.
SSW’s Initials: _______
SSW Qualification Form V1.0
CLE’s Initials: _______
Page 1 of 4
Support Service Worker (SSW)
Qualification Form
Qualification Verification (continued):
Each of the FOUR below questions MUST be answered by checking the YES or NO box.
1. Has the SSW has
has continuously lived in the state of PA for the past 2 years?
YES, the SSW has continuously lived in the
state of PA for the past 2 years.
NO, the SSW has not continuously lived in
the state of PA for the past 2 years; the SSW must
submit to FBI fingerprinting.
2. Is the
the Participant the SSW will be providing services to at least 18 years of age?
YES, the Participant is at least 18 years of
age.
NO, the Participant is a minor; the SSW must
mail the Child Abuse History Clearance Check
form found in the SSW Enrollment Packet and
submit to FBI fingerprinting.
3. Is the SSW a legally responsible individual as defined in section CC-2-d of the approved Waiver?
YES, the SSW is a legally responsible
individual as defined in section C-2-d of the
approved Waiver.
NO, the SSW is not a legally responsible
individual.
A legally responsible individual is a person who has a legal obligation under the provisions of law to
care for another person, including parents of minors (natural or adoptive), spouses, and legallyassigned relative caregivers of minor children.
4. Is the SSW a Relative or Legal Guardian of the Participant?
Participant?
YES, the SSW is a Relative or Legal Guardian.
NO, the SSW is not a Relative or Legal
Guardian.
A relative is any of the following who have not been assigned as a legal guardian for the participant:
a parent (natural or adoptive) of an adult, a stepparent of an adult child, grandparent, brother, sister,
half-brother, half-sister, aunt, uncle, niece, nephew, adult child or stepchild of a parent with an
intellectual disability or adult grandchild of a grandparent with an intellectual disability.
A legal guardian is a person who has legal standing to make decisions on behalf of the participant
(e.g., a guardian who has been appointed by the court).
SSW Qualification Form V1.0
Page 2 of 4
Support Service Worker (SSW)
Qualification Form
Valid Driver’s License or State/Federal Issued Identification:
All SSWs must submit a valid driver’s license or state/federal identification or any other documentation
proving the SSW resides in Pennsylvania or a state contiguous to Pennsylvania.
You must submit a
copy with this qualification form.
Transportation:
Will the Support Service Worker provide Transportation as a component of the service being provided?
YES
NO
If YES, the following must be submitted to Public Partnerships, LLC:
1. Automobile insurance certificates for all automobiles owned, leased, and/or hired with
policy numbers and expiration dates.
2. A valid Driver’s License showing state licensed under, license number, and expiration date.
3. A copy of the current state Motor Vehicle Registration.
4. Date of last vehicle inspection:
SSW Attestation:
By signing this form, I do verify, that I have read and/or have had the Individual Support Plan read to me,
and I understand the requirements. I attest that I shall report any change that may affect my
qualification status listed above or in the approved Waivers to my Common Law Employer within 5
business days of the change occurring.
Signature of the SSW or back-up SSW:
Date:
Common Law Employer Attestation:
By signing this form, I do verify, that I have read and/or have had the requirements of the approved
waiver read to me, and I understand these requirements. I verify that I will submit all required SSW
qualification documentation to the VF/EA. I also verify that I am in compliance with the waiver
requirements. I attest that I shall report a change in my SSW’s qualifications status, by submitting a new
Support Service Worker (SSW) Qualification Form to Public Partnerships, LLC within 5 business days of
being notified of the change.
Signature of Common Law Employer:
SSW Qualification Form V1.0
Date:
Page 3 of 4
Support Service Worker (SSW)
Qualification Form
**Use the following information to assist you with the qualification of your SSW**
Criminal Background Checks:
Criminal background checks and child abuse clearances (if the Participant is under 18), must be obtained
for the SSW before they can become initially qualified and “Good to serve.” These clearances are
required for new SSW’s during the initial qualification and are not required during ongoing verification.
The SSW may provide copies of clearances that were obtained within one (1) year prior to applying for
employment. If the SSW does not provide valid clearances, Public Partnerships, LLC (PPL) will pay for,
process, and maintain the results for all required clearances. The Common Law Employer or SSW may
request copies of the results.
PA State CRC
FBI Fingerprinting
All qualified SSWs:
SSWs who have NOT continuously
lived in PA for the past two years:
SSWs providing services to a
Participant who is a minor:
Child Abuse Clearances
Enhanced Home and Community Habilitation or Respite:
If your SSW is bring qualified to provide enhanced services under Home and Community Habilitation or
Respite, as authorized on the ISP:
You must submit a copy of the SSWs certificate/license, four year degree, or transcript.
Enhanced Home & Community Habilitation Procedure Codes
W7061, W7069
Enhanced Respite Procedure Codes
W7251, W7253, W7264, W7266, W8003, W8005, W8013, W8015
Support Broker Services (W7096)
If your SSW is being hired to provide support broker services:
You must submit documentation of training in principles of self-determination, participant
directed services and person centered thinking (if assisting in planning meetings), training in
basic employment law, one year of experience in a management position with human resource
responsibilities, or have a degree in human resources.
SSW Qualification Form V1.0
Page 4 of 4