DSHS Form 07-097 "Individual Provider (Ip) Planned Action Notice Training / Certification" - Washington

What Is DSHS Form 07-097?

This is a legal form that was released by the Washington State Department of Social and Health Services - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2020;
  • The latest edition provided by the Washington State Department of Social and Health Services;
  • Easy to use and ready to print;
  • Available in Somali;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DSHS Form 07-097 by clicking the link below or browse more documents and templates provided by the Washington State Department of Social and Health Services.

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Download DSHS Form 07-097 "Individual Provider (Ip) Planned Action Notice Training / Certification" - Washington

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AGING AND LONG-TERM SERVICES ADMINISTRATION (ALTSA)
DATE OF NOTICE
DEVELOPMENTAL DISABILITIES ADMINISTRATION (DDA0)
Individual Provider (IP) Planned Action Notice
Training / Certification
PROVIDER NAME AND ADDRESS
Planned Action
Washington Administrative Code (WAC) Chapter 388-71 contains training and/or certification requirements necessary to
be eligible to work and be paid by ALTSA or DDA as an Individual Provider (IP) / Long Term Care Worker.
This is to notify you that effective
, the Department of Social and Health Services (DSHS) or the Area Agency on
Aging (AAA) is:
Denying / terminating payment to you as an IP;
Taking steps to terminate your IP Client Service Contract.
___________________________________________________________________________________________
You are not permitted to work as an IP and DSHS will not pay you for any hours worked on or after the effective date
above if you :
Have not completed training within the required timeframe based on information from the Training Partnership.
The required training due is:
Basic Training WAC 388-71-0870 through WAC 388-71-0932;
Continuing Education WAC 388-71-0985 through WAC 388-71-1006.
Have not been certified by the Department of Health (DOH) as a home care aide within the required timeframe.
WAC 388-71-0975, Chapter 246-980 WAC, and RCW 18.88B.021(1)-(2)
No longer have a Home Care Aide or other DOH-issued qualifying credential that is both active and in good
standing. WAC 388-71-0975, Chapter 246-980 WAC, and RCW 18.88B.021(1)-(2)
You may not work for DSHS payment again until you have completed the requirements and are authorized to do so by
DSHS or the Area Agency on Aging (AAA).
This action is being taken per the WAC authorities listed above or under the following rules:
WAC 388-71-0520; WAC 388-71-0523; WAC 388-71-0540; WAC 388-71-0551; WAC 388-71-0836; WAC 388-71-0975
The DSHS client(s) you work for will be notified that if you do not complete the required training/certification by the
deadline, DSHS will not pay for your services on or after the effective date listed above and that he/she will need to find
another provider.
Page 1 of 3
IP PLANNED ACTION NOTICE TRAINING / CERTIFICATION
DSHS 07-097 (REV. 04/2020)
AGING AND LONG-TERM SERVICES ADMINISTRATION (ALTSA)
DATE OF NOTICE
DEVELOPMENTAL DISABILITIES ADMINISTRATION (DDA0)
Individual Provider (IP) Planned Action Notice
Training / Certification
PROVIDER NAME AND ADDRESS
Planned Action
Washington Administrative Code (WAC) Chapter 388-71 contains training and/or certification requirements necessary to
be eligible to work and be paid by ALTSA or DDA as an Individual Provider (IP) / Long Term Care Worker.
This is to notify you that effective
, the Department of Social and Health Services (DSHS) or the Area Agency on
Aging (AAA) is:
Denying / terminating payment to you as an IP;
Taking steps to terminate your IP Client Service Contract.
___________________________________________________________________________________________
You are not permitted to work as an IP and DSHS will not pay you for any hours worked on or after the effective date
above if you :
Have not completed training within the required timeframe based on information from the Training Partnership.
The required training due is:
Basic Training WAC 388-71-0870 through WAC 388-71-0932;
Continuing Education WAC 388-71-0985 through WAC 388-71-1006.
Have not been certified by the Department of Health (DOH) as a home care aide within the required timeframe.
WAC 388-71-0975, Chapter 246-980 WAC, and RCW 18.88B.021(1)-(2)
No longer have a Home Care Aide or other DOH-issued qualifying credential that is both active and in good
standing. WAC 388-71-0975, Chapter 246-980 WAC, and RCW 18.88B.021(1)-(2)
You may not work for DSHS payment again until you have completed the requirements and are authorized to do so by
DSHS or the Area Agency on Aging (AAA).
This action is being taken per the WAC authorities listed above or under the following rules:
WAC 388-71-0520; WAC 388-71-0523; WAC 388-71-0540; WAC 388-71-0551; WAC 388-71-0836; WAC 388-71-0975
The DSHS client(s) you work for will be notified that if you do not complete the required training/certification by the
deadline, DSHS will not pay for your services on or after the effective date listed above and that he/she will need to find
another provider.
Page 1 of 3
IP PLANNED ACTION NOTICE TRAINING / CERTIFICATION
DSHS 07-097 (REV. 04/2020)
Your Appeal Rights
You have a right to an administrative hearing pursuant to WAC 388-71-0561. You may not challenge an action by DOH
that affects your certification. Actions by DOH must be challenged through an appeal to DOH.
You have the following rights:
To receive copies of all information used by ALTSA or DDA in making its decision;
To submit documents into evidence;
To testify at the hearing and to present witnesses to testify on your behalf; and
To cross examine witnesses testifying for the department.
You have 30 calendar days from the effective date on this notice for the Office of Administrative Hearings (OAH) to
receive your request for appeal. To request an administrative hearing, you must send, deliver, or fax a written request to
the OAH. A form for requesting an administrative hearing is included.
Who you may contact for information
NAME
TELEPHONE NUMBER
OFFICE
AGENCY
AAA
DDA
HCS
Copy in Provider File.
Page 2 of 3
IP PLANNED ACTION NOTICE TRAINING / CERTIFICATION
DSHS 07-097 (REV. 04/2020)
AGING AND LONG-TERM SERVICES ADMINISTRATION (ALTSA)
Request for Hearing
Per Chapter 388-526 for DSHS hearing rules
Mail your request to this address:
OR
Fax to this number:
OFFICE OF ADMINISTRATIVE HEARINGS (OAH)
(360) 586-6563
PO BOX 42489
OLYMPIA WA 98504-2489
I am requesting a hearing because I want to challenge the following decision made by Aging and Long Care Support
Administration (ALTSA) or Developmental Disabilities Administration (DDA).
Select one of the following:
ALTSA or DDA is:
Denying / terminating payment to me as an Individual Provider;
Taking steps to terminate my Individual Provider Client Service Contract.
DSHS determined I:
Have not been certified by DOH as a home care aide within the required timeframe;
No longer have a Home Care Aide or other qualifying credential by DOH that is both active and in good standing;
Have not completed required training within the required timeframe based on information from the Training
Partnership.
PRINT YOUR NAME HERE
YOUR TELEPHONE NUMBER
YOUR PROVIDER NUMBER
THE OFFICE YOU RECEIVED THIS NOTICE FROM:
AAA
DDA
HCS
PRINT YOUR ADDRESS
CITY
STATE
ZIP CODE
If you have a representative
I am represented by (if you are going to represent yourself, do not fill in the next two lines):
PRINT YOUR REPRESENTATIVE’S NAME HERE
PRINT YOUR REPRESENTATIVE’S TELEPHONE NUMBER HERE
ADDRESS
CITY
STATE
ZIP CODE
If you have accommodation needs
Do you need an interpreter or other assistance for the hearing?
Yes
No
If yes, what language or assistance do you need?
Page 3 of 3
IP PLANNED ACTION NOTICE TRAINING / CERTIFICATION
DSHS 07-097 (REV. 04/2020)
Page of 3