Form 3848, CBA Documentation of Completion of Purchase
Effective Date: 12/2000
To serve as the primary source document for purchases of approved items or minor home modifications made by the Home and Community Support Services (HCSS) agency for Community Based Alternatives (CBA) participants. This form is used by the HCSS providers for the following CBA services:
- Adaptive Aids
- Minor Home Modifications
When to Prepare
Section I must be completed by the HCSS provider for every adaptive aid except for batteries purchased for adaptive aids, or minor home modification.
Section II must be completed by an inspector upon completion of the minor home modification.
Section III must be completed by the HCSS agency representative after the adaptive aid has been delivered or after the minor home modification has been completed; and the client is called by a HCSS agency representative to assess the client's satisfaction and to identify any need for additional training/orientation hours.
Section IV must be completed after a home visit by the individual who determined if the adaptive aid met the needs of the participant.
Section V must be completed by the HCSS agency upon completion of the form. Section V must be completed and submitted to the case manager before the agency can submit a bill for the item identified in Section I of this form.
Number of Copies
Complete one original for each adaptive aid or minor home modification and one copy of each for the case manager.
The original Form 3848, with all the fields completed, is retained by the provider. A copy is mailed to the CBA case manager within seven DADS workdays of the:
- telephone call to the participant to verify the adaptive aid was delivered or that the minor home modification was completed (as entered in item 3) and participant's satisfaction assessed; or
- home visit by the nurse, therapist, or DME vendor (as entered in item 7) to orient the client on the adaptive aid or the home visit from the inspector (as indicated in Section II) to inspect the minor home modification.
Retain this form according to the terms in the Community Based Alternatives Provider Manual.
This form may be found on the DADS Website.
If Form 3848 is not completed, financial exceptions may result.
SECTION I. ASSESSMENT
1. Participant Name — Enter the participant's name as it appears on page 1 of the participant's Individual Service Plan (ISP) (Form 3671).
2. Type of Purchase — Enter a check in A. for Minor Home Modification or enter a check in B. for Adaptive Aid.
3. Date Completed/Delivered — Enter the correct date the minor home modification is completed or the adaptive aid is delivered. If an inspection is done, enter the date.
4. Participant Address — Enter the participant's address.
Complete the following only on the purchase of adaptive aids:
5. Name of Person Completing Orientation for the Adaptive Aid — Enter the name of the person who oriented the participant on the use and/or fit of the adaptive aid. This person must be the nurse, therapist, or other appropriate HCSS staff that has been involved in the procurement.
6. Title — Enter the title of the person who oriented the participant on the use and/or fit of the adaptive aid.
7. Date of Orientation — Enter the date the participant was oriented to the use and fit of the adaptive aid.
8. Qualifications of Person Completing Orientation — Enter the qualifications of the person who oriented the participant on the use and/or fit of the adaptive aid.
9. Description of Job or Item — Enter the specific description of the minor home modification or adaptive aid.
10. Method of Delivery — For adaptive aids enter the method used to deliver the item(s) to the participant (for example, postal service, United Parcel Service, direct delivery by an HCSS employee, etc).
11. For items costing less than $500 — Completion of this indicates no home visit was done. Enter name of telephone contact and date of contact.
12. For items costing more than $500.00 or when a home visit was made — Enter date of home visit. This item will be completed any time a home visit is made such as for items costing more than $500.00, or when additional training/orientation hours are identified (see Section III, item 3 A.)
SECTION II. MINOR HOME MODIFICATION
Section II is to be completed by the inspector when he makes a visit to inspect every minor home modification.
1. Name of Inspector — Enter the name of the inspector.
2. Qualifications — Enter the qualifications of the inspector (use an attached form if needed).
3. Determination — The inspector identifes the appropriate box by entering a check in:
A. if the modification was completed according to Texas Accessibility Standards (TAS) requirements and no specifications needed,
B. if modification completed according to specifications and TAS requirements, or
C. modification not completed according to TAS and specifications.
A check in C. means the modification was not completed according to TAS and specifications. The inspector completes this section and informs the provider agency of the results of his inspection. The provider cannot bill DADS for the modification until the inspector certifies the completed modification meets the specifications and the TAS requirements.
4. Comments — The inspector should enter any pertinent comments in this section or provide comments on an attachment.
Signature of Inspector — The inspector must sign and date when the inspection is done.
SECTION III. PARTICIPANT SATISFACTION
The HCSS agency representative that calls the participant to assess his level of satisfaction after the adaptive aid has been delivered or the minor home modification has been completed must complete this section. If the participant is not able to communicate with the agency representative, then the agency representative will speak with the responsible party. Participant satisfaction may not be assessed by the individual making the home modification inspection unless the inspector is an HCSS employee.
1. Name of Responsible Party (if applicable) — The HCSS agency representative enters the name of the responsible party if the responsible party was the one whom the orientation was provided to over the phone or if the participant could not communicate over the phone.
2. Satisfaction — The HCSS agency representative enters a check in:
A. if the participant or responsible party verbalizes that the participant is satisfied with the home modification or adaptive aid, or
B. if the participant or responsible party verbalizes that the participant is not satisfied with the home modification or adaptive aid.
Reason/Comments — Enter reason for dissatisfaction and any pertinent comments on the back of this form.
3. Training/Orientation — The HCSS agency staff contact the participant within 10 DADS work days of delivery to verify that the adaptive aid meets their needs, that orientation was provided to the participant in the use of the adaptive aid, and to document completion of purchase and satisfaction of the participant on this form. (If a visit was made by a DME supplier, the agency will complete items 3a and 3b after calling the client/responsible party in follow up to the DME's supplier's visit.) The HCSS agency representative enters a check in:
A. if additional training/orientation hours are needed, or
B. if no additional training/orientation hours needed.
Signature of Agency Representative — The HCSS agency representative signs and dates this after completing fields 1-3 above.
4. Participant Satisfaction Assessment Upon Home Visit — (If a home visit is necessary to assess participant satisfaction.) The nurse or therapist assists the participant or responsible party in identifying satisfaction or dissatisfaction by entering a check in:
A. if satisfied after the home visit, or
B. if not satisfied. (If not satisfied, provide comments for the dissatisfaction on the back of the form.)
Signature of Nurse or Therapist and Date — Self-explanatory.
Signature of Participant/Responsible Party — Responsible party signs if the participant is unable to sign.
SECTION IV. ADAPTIVE AID (Nurse/therapist documentation of the adaptive aid meeting the participants' needs.)
1. Nurse/Therapist Determination — (This section is COMPLETED ONLY if additional orientation/training hour(s) are identified in Section III, item 3a, or if the client/responsible party stated they were not satisfied with the adaptive aid/medical supply as identified in Section III, item 2b.) If conducting a home visit the nurse or therapist enters a check in:
A. if the item meets the documented needs of the participant or
B. if the item does not meet the needs of the participant.
If box (B) is checked, the nurse or therapist must explain why the item does not meet the individual's needs and write recommendations on how the needs can be met. Comments may be made on the back or a sheet of plain bond can be attached.
2. Name of Nurse/Therapist — Legibly print the name of the nurse or therapist and title.
Signature — The person who determined if the adaptive aid met the needs of the participant must sign and date the form.
SECTION V. HCSS AGENCY CERTIFICATION
The HCSS agency representative must complete this section once the rest of the form has been completed.
Name of HCSS Agency Representative — Enter the name of the HCSS agency representative completing this section of the form. Signature of an HCSS agency representative certifies the form is accurately completed. If the participant is not satisfied with the adaptive aid or the completed minor home modification, there is documentation available to substantiate prior agreement to purchase the adaptive aid or the minor home modification.
Name of Agency — Enter the name of the HCSS agency.
Vendor Number — Enter the nine-digit CBA vendor number.
Signature of HCSS Agency Representative — The HCSS agency representative completing this section of the form must sign and date it.
Date Sent to Case Manager — This is the date the form is sent to the case manager.