Form 1732-EMR, Management and Training of Service Provider Addendum

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Documents

Effective Date: 10/2014

Instructions

Updated 1/2015

Purpose

To document training, evaluations, conflict resolution, warnings and other activities that occur in the process of managing, training and supervising service providers in Consumer Directed Services (CDS).

Procedure

When to Prepare

The employer must complete Form 1732:

  • any time an activity is conducted that involves the initial orientation, ongoing training, evaluation or supervision of each service provider; and
  • any time there is an activity, issue or situation that the employer may need to document for future reference, positive or negative, related to the service provider's performance.

The employer must complete Form 1732-EMR within five days of hiring an employee.

Number of Copies

Original and one or two copies.

Transmittal

The employer maintains the original in each service provider's file. The employer gives a copy of the completed form to the service provider. The employer must also send a copy of Form 1732 to the Financial Management Services Agency (FMSA) within 30 calendar days of an initial orientation or an annual evaluation.

Supply Source

This form and the addendum must be printed or downloaded from the Consumer Directed Services Handbook.

Form Retention

The employer (and the FMSA, if applicable) must keep this form and the addendum for five years after termination of the service provider or until the resolution of all outstanding litigation, claims and audits.

Detailed Instructions

Service Provider Name — Enter the name of the employee.

First Day of Work — Enter the date of the service provider's first day on the job.

Annual Evaluation Due Date — Enter the service provider's anniversary date (this is one year from the first day of work). This serves as a reminder to the employer of the date the employer will be required to complete an annual evaluation of the service provider's job performance.

Name of Individual Receiving Services — Enter the name of the participant.

Program — Enter the program name.

Services Delivered — Enter all of the services the service provider delivers.

Name of Consumer Directed Services Employer — Enter the name of the employer.

Complete each section as directed below.

I. Purpose — Check the appropriate box(es) to specify the management and/or supervision activity/activities the employer is documenting.

Initial Orientation — Check this box if this is the first orientation for this service provider.

Ongoing Training — Check this box to indicate if the service provider received ongoing training related to one or more tasks the service provider will perform, or to other employment-related issues.

Evaluation — Check this box to indicate if the employer is documenting an evaluation of the service provider's work performance. Indicate the evaluation period by marking the appropriate time frame (e.g., 30 days after employment, three months after employment, etc.).

The employer must document an evaluation of the employee's performance at least annually (once every 12 months).

Supervision — Check this box if the employer is documenting the supervision of the service provider's work performance.

Verbal Warning — Mark this space if the employer gave a verbal warning to the service provider concerning job performance or job-related issues (e.g., arriving late for work, etc.). Mark the space to indicate how many verbal warnings the service provider has received for the same or a similar issue.

Written Warning — Mark this space if the employer gave a written warning to the service provider. A written warning documents a serious problem that may result in negative consequences for the service provider (e.g., not getting a scheduled bonus or increase in rate of pay, or termination from service). Mark the space to indicate how many written warnings the service provider has received for the same or a similar issue.

Conflict Resolution — Check this box if the employer and service provider met to discuss and resolve a conflict concerning a disagreement, misunderstanding or other employment-related conflict.

The employer must document issues that may result in the service provider’s termination. This documentation is needed if a service provider files a complaint with the Texas Workforce Commission for unemployment benefits or with any other governmental agency for wrongful discharge from employment. The documentation could support the reason the employer terminated the employment and the action(s) taken by the employer to make the service provider aware of the problem(s).

Other — Mark this space to indicate if the employer is conducting an activity not listed above. Enter the type of activity the employer is documenting.

Not all management and supervision activities of service providers are negative. Examples of positive activities that an employer would document as Other may include perfect attendance, improvement in skills, exceptional job performance, documentation of a bonus based on job performance and/or longevity, and other positive actions of the service provider.

II. Documentation of Topics Covered at Initial Orientation or Ongoing Training — The employer documents topics covered during initial orientation and any ongoing training. The initial orientation must include training related to the individual’s condition and the tasks the service provider will perform as well as any required training described in an applicable addendum to Form 1735, Employer and Financial Management Services Agency Service Agreement.*

III. Evaluation/Performance Review — The employer documents any evaluations, performance review, training or conflict resolution provided to the service provider.*

IV. Corrective Action Plan (if applicable) — The employer enters the action taken or to be taken by the employer, service provider or both. If there is to be follow-up, indicate the frequency or dates for follow-up. If no action or follow-up is needed or taken, the employer enters None or N/A.*

V. Service Provider Comments — The service provider writes a response to the employer's comments. If the service provider does not have a response, the service provider enters None in the section.*

* This form field is expandable. You are not limited to the space provided. The box will expand to accommodate up to 2,000 characters. All of the text you enter will show when the form is printed.

Signature of Service Provider — The service provider signs and dates this form to acknowledge and note agreement with the information documented. If the service provider refuses to sign in agreement with the employer's comments or actions, the service provider documents the reason in writing on this form or on the back of the form.

Signature of Employer — The employer signs and dates this form to acknowledge and note agreement with the information documented.

Signature of Witness — The employer may have an adult witness sign and date the form if the service provider refuses to sign this form. The witness does not have to be in the meeting, but the service provider must tell the witness that the service provider refuses to sign. Leave the signature/date line blank or mark it None or N/A if no witness is required.

Date sent to FMSA — The employer must mail or fax a copy of this form to the FMSA within 30 calendar days of hiring a service provider and within 30 calendar days of each annual evaluation.

Date received by FMSA — For each employee, the FMSA must document the date the FMSA received the completed Form 1732 after the initial orientation and after each annual evaluation.

Note: The employer must handle service provider issues confidentially. The employer must not discuss service provider-related problems or concerns with anyone other than the service provider, with the exception of a support advisor, a case manager or other qualified staff. The employer must not discuss problems about any service provider with any other service provider.

If there is a potential problem during a management or supervisory meeting with a service provider, the employer may request that another adult or the designated representative, if applicable, be present at the meeting. This person may be able to help mediate or witness the discussion, especially if the meeting is for a warning, a conflict resolution or a termination of employment.

ADDENDUM INSTRUCTIONS (Form 1732-EMR)

Employee Name — Enter the name of the employee.

Date of Hire — Enter the date the employee started working.

Position — Enter the position the employee has been hired to do.

Employer Name — Enter the name of the employer.

Printed Employee Name — The employee prints his or her name to acknowledge he/she understand the Employee Misconduct Registry (EMR) notification.

Employee Signature and Date — The employee signs and dates this addendum to acknowledge the employer notified him or her of the EMR within five working days.