Texas Department of Aging and Disability Services
Home and Community-based Services Handbook
Effective: January 12, 2015
Waiver Survey and Certification
14100 Waiver Survey and Certification Overview
Waiver Survey and Certification (WS&C) is a unit of Regulatory Services at the Department of Aging and Disability Services (DADS). WS&C conducts certification reviews for the Home and Community-based Services (HCS) and Texas Home Living (TxHmL) waiver programs, and conducts residential reviews for foster/companion care and three- and four-person group homes in the HCS program. WS&C also reviews complaints and deaths in the HCS and TxHmL waiver programs and follows up on abuse, neglect and exploitation (ANE) allegations related to individuals served in the HCS and TxHmL waiver programs and in intermediate care facilities for persons with intellectual disability (ICFs/ID).
14200 Home and Community-based Services Certification Reviews
In accordance with Title 40, Texas Administrative Code (TAC), Chapter 9, Subchapter D, §9.171(a), all HCS program providers must be in continuous compliance with the HCS Program certification principles. (See §§9.172-174 and §§9.177-179.)
In accordance with 40 TAC, Chapter 9, Subchapter D, §9.171(e), WS&C may conduct announced or unannounced reviews of HCS program providers at any time to ensure compliance with the HCS program certification principles.
14210 Types of Certification Reviews
A prospective provider for the HCS Program must complete an application packet and attend provider applicant training to obtain a contract with DADS. If the applicant passes a competency exam at the end of the training, DADS provisionally certifies the contract.
Once an individual has chosen to enroll in a provider's HCS contract, the program provider will receive an enrollment letter from DADS Program Enrollment.
WS&C conducts an initial review within 120 days after a program provider receives the first individual in its contract. During the initial review, the WS&C review team will determine the program provider's compliance with the HCS certification principles.
An HCS program provider's certification must be renewed annually prior to the expiration of the current certification period.
A concurrent review is conducted if principles of noncompliance were cited during the previous review visit and not corrected prior to the exit conference. This review may be in conjunction with an annual certification or intermittent review. The provider must be in compliance with the previously cited principles by the end of the current certification period in order to be re-certified. If principles cited during the previous review remain in noncompliance at the time of the exit conference of the following review, the program provider must submit a corrective action plan with supporting evidence that these principles have been corrected.
Level I Sanctions Review
A follow-up review to Level I sanctions is conducted if between 10% and 20% of the principles cited during the previous review (annual or intermittent) remain in noncompliance. This review will be conducted within 30 to 45 days from the date of the previous review's exit conference.
If the program provider fails to correct all principles of noncompliance remaining from the previous review, this will result in Level I vendor hold. WS&C will conduct a second on-site review within 30 to 45 days from the effective date of vendor hold.
If the program provider fails to correct all principles of noncompliance, WS&C will recommend denial of certification and termination of contract.
Level II Sanctions Review
A follow-up review to Level II sanctions (vendor hold) is conducted if 20% or more of the principles cited during the previous review (annual or intermittent) remain in noncompliance.
The program provider must complete corrective action within 30 calendar days after the review exit conference. WS&C will conduct a second on-site review within 30 to 45 days after the required correction date.
If the program provider fails to correct all principles of noncompliance, WS&C will recommend denial of certification and termination of contract.
In accordance with 40 TAC, Chapter 9, Subchapter D, §9.185(g), if WS&C determines that a program provider's failure to comply with one or more of the certification principles is of a serious or pervasive nature, WS&C may, at its discretion, take any action described in this section against the program provider.
Serious or pervasive failure to comply includes conditions that have potentially dangerous consequences for individuals served by the program provider or conditions that affect a majority of individuals served by the program provider.
Intermittent reviews are conducted at the discretion of WS&C and are usually based on:
- follow up to abuse, neglect or exploitation allegations; or
14220 Overview of the Home and Community-based Services Certification Review Process
HCS program providers will generally be contacted 17-21 days before a certification review by the review facilitator, unless there is cause for WS&C to conduct an unannounced review of the program. WS&C can and may conduct unannounced certification reviews or on-site visits at anytime.
When the review facilitator contacts the HCS program provider to notify it of an upcoming certification review, the facilitator will fax a copy of the Provider Information Request form to the program provider.
The facilitator will also fax Form 8576, Individual Profile Information, to the HCS program provider with a requested date for the information to be completed and returned to the review facilitator.
At the beginning of every certification review, the WS&C review team will conduct an entrance conference with the program provider and any program staff who are present. The WS&C review facilitator will explain the review process and summarize the tentative review schedule.
The review team will review a sample of 10% or more of the individuals in the HCS program provider's contract. The team uses standardized checklists to ensure that all principles are reviewed for compliance. These checklists can be found at www.dads.state.tx.us/providers/HCS/certificationreviews.html.
Certification review activities include, but are not limited to:
- talking with individuals, family members, LARs and staff;
- visiting homes and day habilitation sites;
- reviewing individuals' records (including medical records);
- reviewing personnel and staff training records;
- reviewing financial records of the individuals for which the program provider handles finances;
- reviewing complaint information, satisfaction surveys and Consumer Advocacy Meeting minutes;
- reviewing information regarding any deaths, discharges (permanent or temporary over 90 days) and allegations of abuse, neglect and exploitation;
- reviewing fire drills and emergency evacuation plans, as well as four-person home approvals and fire marshal inspections for four-person homes; and
- reviewing critical incident data, restraints and restrictive behavior support plans.
As a part of WS&C reviews, reviewers note any issues related to service coordination and forward these notations to DADS Contract Accountability and Oversight (CAO) for follow up. HCS program providers may view notations related to their programs in the C-97 screen of the CARE system.
The review team will hold a final debriefing at the end of the review. The program provider is allowed to submit evidence of corrections prior to the exit conference in order to attempt to clear citations. The review team may determine that specific citations may not be corrected if one or more individuals' health, safety or welfare has been jeopardized as a result of the provider's non-compliance.
Note: If the review team determines any of the individuals enrolled in the program are in imminent danger due to a hazard that threatens their health, safety or welfare, the program provider is expected to eliminate this hazard before the end of the review exit conference. If the hazard cannot be eliminated, DADS will deny certification and, in conjunction with the Local Authority, will immediately coordinate development of alternative services for all individuals enrolled in the program provider's contract.
14230 Corrective Action Plan
If a program provider's certification principles are less than 10% out of compliance at the end of the exit conference, Form 8581, Corrective Action Plan, must be submitted for each HCS principle that is found out of compliance at the end of the review. The corrective action plan (CAP) is a written plan that establishes a process by which the program will prevent reoccurrence of the issues that resulted in the principle being found out of compliance. This plan (Form 8581) must be submitted to DADS WS&C for approval. A copy of the corrective action plan will be given to the provider during the review.
DADS must receive the CAP no later than 14 calendar days following the program provider's receipt of the review report. The time line for the provider's completion of the CAP must not exceed 90 calendar days from the date of the exit conference.
If the CAP is submitted by the due date, and is approved, the provider will be certified.
If the CAP is submitted by the due date but is inadequate, the facilitator will notify the program provider and offer detailed information as to why the CAP is inadequate. If the facilitator is unable to assist the program provider to reach compliance within two months of the review exit, written notification that its contract may be terminated will be sent to the program provider if an approvable CAP is not received within seven days of receipt of the letter.
14240 Home and Community-based Services Review Checklists
Go to www.dads.state.tx.us/providers/HCS/certificationreviews.html to view checklists and reports used by DADS during the certification review process.
14300 Texas Home Living Certification Reviews
In accordance with 40 TAC, Chapter 9, Subchapter N, §9.576(a), all TxHmL program providers must be in continuous compliance with the TxHmL Program certification principles. See §§9.578-9.580.
Per 40 TAC, Chapter 9, Subchapter N, §9.576(e), WS&C may conduct announced or unannounced reviews of TxHml program providers at any time ensure compliance with the TxHmL program certification principles.
14400 Residential Reviews
Effective Sept. 1, 2009, the 81st Texas Legislature, Regular Session, required DADS to conduct annual unannounced inspections of HCS three- and four-person residences. In addition, the legislature funded annual inspections of HCS foster/companion care residences. In accordance with 40 TAC, Chapter 9, Subchapter D, §9.171(h), DADS WS&C conducts annual unannounced visits to each residence in which foster/companion care, Residential Support Services or Supervised Living is provided to verify that these residences offer environments that comply with the Form 3609, Waiver Survey and Certification Residential Checklist.
14410 Residential Reviews Policy and Procedures
Upon arrival at the residence, a residential reviewer will introduce himself to the foster/companion care provider or the group home staff and explain the reason for the visit. The residential reviewer will offer the person who greets them a business card. Residential reviewers will be wearing a DADS identification badge. The residential reviewer is supplied with letters written in languages other than English to use as an introduction if arriving at a residence in which no one speaks English and the residential reviewer is unable to speak the language of the people living in the residence. The letter notes that if a person is available who can interpret for the foster/companion care provider or the group home staff, the staff can call them to assist with the residential visit. Each residential reviewer will have a copy of the Letter of Authorization signed by the assistant commissioner for Regulatory Services and the director of Survey Operations. This letter explains the legislative mandates that require WS&C to conduct residential reviews and notes that each residential staff should have been informed by their HCS program provider of the residential reviews that are being conducted.
See Information Letter #2009-99 at: www.dads.state.tx.us/providers/communications/2009/letters/IL2009-99.pdf
Residential reviewers should briefly explain the residential review process before they begin looking at a home.
Residential reviewers use Form 3609, Waiver Survey and Certification Residential Checklist, to conduct each residential visit. Each item on the checklist should be marked yes, no or n/a (not applicable). Some of the checklist items require talking with the residential staff or the foster/companion care provider to assess their knowledge and to confirm training.
Residential reviewers may take a digital photographs to serve as verifiable evidence (when beneficial and appropriate) to support the findings of a situation that warrants correction.
Residential reviewers give each foster/companion care provider or residential staff a pre-addressed, postage paid postcard with a brief feedback questionnaire on it. The feedback is anonymous. Feedback from the foster/companion care providers and residential staff is requested so that WS&C can improve the residential review process by addressing any issues that might arise during a residential review.
If the Address in CARE is Invalid
If the residential reviewer arrives at a home that is no longer associated with the HCS Program, or cannot find the address provided for a location code in CARE, the residential reviewer will fill out Form 3609 noting the incorrect address. A letter notifying the provider of the inaccuracy in CARE will be sent to the HCS program provider's CEO.
If No One is Home
If a residential reviewer finds no one at home after three attempts to visit the home, the reviewer contacts the program provider to find out when the residential staff or foster/companion care provider is most likely to be home.
If the Residential Reviewer Is Not Allowed to Access the Home
If a residential reviewer is not allowed access to a group home or a foster/companion care home, the residential reviewer will notify the program provider for resolution. It is the program provider's responsibility to ensure that regular or contracted employees cooperate with the residential review process.
14411 Residential Review Results
No Evidence of Correction Needed
If a residence has no items marked “fail” on the Residential Review Checklist, no follow-up action is taken by Waiver Survey and Certification (WS&C).
Evidence of Correction Needed
If a residence has any items marked “fail” on the Residential Review Checklist, the program provider must (unless immediate action is required as described below) submit evidence of correction for every item marked “fail.” Evidence of correction must be received by DADS at the address listed on the residential visit report within a time period determined by DADS.
Evidence of correction may be mailed, emailed or faxed to DADS using Form 1573, Residential Review Evidence of Correction. If the evidence of correction is not approved by DADS, DADS requires the program provider to submit additional information as directed by DADS.
Significant Risk Identified
A significant risk is an act or failure to act by the program provider that could have a major adverse effect on the health, safety or welfare of one or more individuals, including emotional or physical harm, or death. If DADS determines that an item marked “fail” on the Residential Review Checklist results in a significant risk, DADS requires the program provider to take one of the following actions:
- Immediate Action – An intervention or correction that must be taken while the residential reviewer is onsite; or
- Prompt Action – An intervention or correction that must be taken within 48 hours after the conclusion of the residential review.
Significant Risk Requiring Immediate Action – If DADS concludes that the significant risk requires immediate action, such as movement of one or more of the individuals from the residence, the residential reviewer will not leave the residence until the program provider has taken immediate action and the significant risk is removed.
Significant Risk Requiring Prompt Action – If DADS concludes that the significant risk requires prompt action, the residential reviewer will call the persons identified in the Client Assignment and Registration (CARE) screen C70 as the “program provider contract contacts” (the HCS provider or a representative of the HCS provider) and inform such persons of the following:
- The significant risk identified requiring prompt action; and
- The date, as determined by DADS, by which the program provider must submit evidence of correction to DADS that prompt action has been taken and the significant risk removed.
14500 Death Reviews
Note: See also Section 17000, Critical Incident and Death Reporting.
In accordance with 40 TAC, Chapter 9, Subchapter D, §9.178(w), HCS program providers must report the death of an individual in their HCS program to DADS and the service coordinator by the end of the next business day following the death or the program provider's learning of the death. Reports to DADS are made via telephone or email to the WS&C risk assessment coordinators (RACs). The RACs collect specific information regarding the death from the program provider and may request additional records, depending on the conditions existing at the time of death. The Death Review Group (DRG), which is made up of the WS&C RACs and a WS&C registered nurse, meets routinely to review the circumstances surrounding each death. Additional regulatory follow up, including an intermittent review, may be scheduled to evaluate the program provider's compliance with HCS or TxHmL certification principles as the result of the DRG review.
14510 Death Review Policy and Procedures
Risk assessment coordinators collect the following information:
- Date of death
- Provider contract number
- Person reporting the death
- Individual's CARE identification number
- Cause of death
- State of individual's health prior to the death
- Whether autopsy was ordered
- Date of autopsy
- Place of death
- Residential type
If the provider reports the death is the result of a behavioral incident, the abuse and neglect coordinators will also collect applicable information listed below.
- Whether restraints were in place
- Whether or not the death was witnessed and by whom
- Whether law enforcement was called
- Critical incidents which may have contributed to the death
- Level of supervision required by the Individual Service Plan (ISP) and actual supervision at the time of death
If abuse or neglect is suspected in relation to the death of the individual, the risk assessment coordinator will immediately contact the Department of Family and Protective Services (DFPS).
Requests for Additional Information
The following records may be requested by the risk assessment coordinator for specified time frames, depending on the conditions existing at the time of death.
- Most recent ISP and interim interdisciplinary team meetings since last ISP
- Nursing notes
- Medication administration records
- Most recent physical exam
- Current physician's orders
- Medical consultations
- Physician order for hospice services
- Most recent therapy evaluations (physical therapy, occupational therapy, speech, dietary, audiology, etc.)
- Critical incident reports
- Current psychological assessment
- Current behavior management plan
- Behavioral data (including documentation of restraints)
- Evidence of special needs training specific to individual, including attendance roster/signature sheet
- Case management notes
- Residential notes
- Any other records deemed necessary to complete review
Click here to view a sample of the letter sent by WS&C to HCS program providers requesting additional information.
If any circumstances surrounding the death are suspicious, WS&C may take further actions, including, but not limited to, referral to local police departments and DFPS, completion of an intermittent certification review or referral to DADS to pursue contract actions. The WS&C assistant unit manager is informed immediately of suspicious circumstances surrounding a death or if other issues of concern are noted.
Risk assessment coordinators may conduct a desk review based on the information received from the provider, requested records and/or the information received from DPRS.
The WS&C assistant unit manager or program manager(s) may authorize an on-site visit based on the circumstances of the death, information obtained from a desk review or information obtained from DFPS. If the review team determines that the provider is in non-compliance with one or more of the HCS program certification principles during an on-site visit, an intermittent review will be opened.
14600 Abuse, Neglect and Exploitation Follow Up
WS&C receives investigative reports from DFPS related to allegations of abuse, neglect or exploitation of individuals who receive HCS, TxHmL or ICF/ID program services. The reports are reviewed by WS&C risk assessment coordinators to determine whether regulatory follow-up is required. Additional documentation may be requested from the program provider to verify that the program provider managed the allegation of abuse, neglect and exploitation according to program standards. In addition, on-site follow up may be scheduled.
14610 Abuse, Neglect and Exploitation Policy and Procedures
DFPS is required to send final DFPS reports to DADS Consumer Rights and Services within 30 days. Consumer Rights and Services then forwards the final reports to WS&C.
The final DFPS report is reviewed by risk assessment coordinators to determine what actions are to be taken by WS&C. Actions to be taken are determined by:
- the severity of the allegation;
- the disposition of the allegation;
- the concerns/recommendations of the DFPS investigator; and
- indicators of non-compliance noted by the risk assessment coordinators during the review of the final report narrative.
DFPS sends a final report to the program provider, unless the administrator is the alleged perpetrator. The program provider has 14 calendar days from the receipt of the investigation findings to notify WS&C of its response to the findings. This notification can be completed by submitting Form AN1A, which is included in the final DFPS report sent to the provider. However, the provider does not always receive the Form AN1A; therefore, WS&C accepts notification from the provider by other means.
When WS&C receives the DFPS intake report from Consumer Rights and Services, it is reviewed by the risk assessment coordinators to determine what actions are to be taken by WS&C. Actions to be taken are determined by:
- the severity of the allegation;
- whether the individual or the alleged perpetrator has been involved in multiple prior allegations; and
- whether the program provider has had multiple recent intakes or investigations.
One of the following actions is taken by WS&C:
- Desk review – A desk review is conducted if there is low risk to the individual(s). The determination of low risk is made if the allegation does not pose a risk to the health or safety of the individual(s) served.
- On-site visit – On-site visits are conducted if it is determined that significant risk exists for one or more individuals. Abuse and neglect coordinators review the allegation with the WS&C assistant manager or designee prior to scheduling an on-site visit.
- Form letter submission – A form letter is submitted to the program provider in response to DFPS concerns. The letter reminds the provider that the program principles require the provider to cooperate with DFPS investigations. See sample here.
If the program provider review is occurring at the time the DFPS intake report is reviewed or a review is scheduled in the near future, the risk assessment coordinator may contact DFPS to determine whether WS&C actions would impede the DFPS investigation. If supported by DFPS, the risk assessment coordinators will share information from the intake report with the review facilitator. The review team will conduct an on-site visit to identify whether the program provider is in non-compliance with HCS program certification principles.
If no citations are given as a result of the on-site visit, a report is completed by the facilitator and submitted to the risk assessment coordinators within 21 days of the on-site visit.
14700 Additional Monitoring Related to Risk Factors
Each quarter, WS&C risk assessment coordinators compile a report of risk factors for all HCS and TxHmL waiver contracts. This risk factor report includes:
- number of confirmed abuse/neglect/exploitation allegations entered into the abuse/neglect database that meet or exceed 10% of the program provider's census;
- number of complaints entered into the complaint database; and
- number of deaths of individuals entered into the death database.
The risk assessment coordinators assess the circumstances related to the identified contracts reflected in this report for two consecutive quarters. If they identify patterns or trends that indicate a possible increased risk to the health, safety or welfare of the individuals in this contract, follow-up actions are taken.
DADS Consumer Rights and Services refers complaints to the WS&C risk assessment coordinators when the complaint is related to non-compliance with the HCS or TxHmL certification principles. The reports are reviewed by the coordinators and appropriate follow-up actions are identified and completed.
14810 Complaints Policy and Procedures
If WS&C staff receive a complaint by telephone, the person making the complaint should be immediately referred to Consumer Rights and Services at 512-438-9858.
Consumer Rights and Services tries to resolve the complaint with the complainant and the program provider. If the complaint cannot be resolved and it impacts the HCS principles, Consumer Rights and Services will refer it to WS&C. The complaint is received by the risk assessment coordinators, who review it to determine what actions are to be taken by WS&C. The actions are determined by:
- severity of the complaint; and
- number and severity of other complaints received about that contract.
Actions to be taken by WS&C are:
- Enter the complaint into the complaint database.
- Desk Review – A desk review is conducted if there is low risk to the individual(s). The determination of low risk is made if the complaint did not involve issues that relate to the health or safety of the individual(s) served or if initial contact with the program provider indicates the situation has been satisfactorily resolved.
- On-Site Visit – This determination is made if there may be significant risk to the individual(s). On-site visits are conducted if it is determined that significant risk exists for one or more individuals. Risk assessment coordinators review the complaint with the WS&C manager or designee prior to scheduling an on-site visit.
If the program provider review is occurring at the time a complaint is received or a review is scheduled in the near future, the complaint may be shared with the review facilitator for follow up during the regularly scheduled review. If an on-site visit is needed immediately and a review team is available in the area, the facilitator may be contacted and requested to complete the on-site visit while in the area.
If no citations are given as a result of the on-site visit, a report is completed by the facilitator and submitted to the risk assessment coordinators within 21 days of the on-site visit. The risk assessment coordinators will enter the results into the complaint database.
If citations are identified at the time of the on-site visit, an intermittent review is conducted. A review report is completed instead of an on-site visit and report.
Complaint resolutions are entered into the complaint database and filed by the legal entity name and contract number. These reports are kept on file for seven years.
14900 Four-Person Home Approvals
Home and Community-based Services (HCS) providers must request and obtain approval of all four-person residences from DADS. Waiver Survey and Certification (WS&C) Residential Review coordinators are responsible for reviewing and approving all four-person home requests in accordance with 40 TAC, Chapter 9, Subchapter D, §9.188.
14910 Four-Person Home Approval Policy and Procedures
To obtain approval of a four-person residence, the program provider must complete the following steps:
- For a new home, enter information into the Client Assignment and Registration System (CARE) Screen C25 Provider Location Type Modification (two screens).
- Header Screen (first screen) – Enter the Component Code, Location Code, "A" for Add and press enter.
- Data Entry Screen (second screen) – Cursor will be blinking at Location Type; enter "4"; cursor will move to the next line; enter the effective date. The cursor then moves to "Ready to Add?" Enter "Y" and press enter.
- Establish location in CARE Screen C24 Provider Location (for new homes only). Refer to the User's Guide for data entry questions: http://www2.mhmr.state.tx.us/655/cis/training/WaiverGuide.html (Note: The CARE User's Guide is only available for those with access to the CARE system.)
- Send a letter to:
Department of Aging and Disability Services
WS&C Residential Review Coordinators, Mail Code E-248
P.O. Box 149030
Austin, TX 78714-9030
Include the following information:
- Current date;
- Name of the agency;
- Contact person and area code and phone number;
- Component code and contract number;
- Location code for the home;
- Address and county of the residence (including the ZIP code);
- Certification from the program provider that the program provider intends to provide residential support to one or more individuals who will live in the residence; and
- Written certification from the program provider that the residence to be approved is not the residence of any person except a person permitted to live in the residence, as described in 40 TAC, Chapter 9, Subchapter D, §9.153(20), relating to definitions.
- the local fire safety authority having jurisdiction in the location of the residence as being in compliance with the applicable portions of the National Fire Protection Association (NFPA) 101: Life Safety Code, as determined by the local fire safety authority;
- the local fire safety authority having jurisdiction in the location of the residence as being in compliance with the applicable portions of the International Fire Code (IFC), as determined by the local fire safety authority; or
- the Texas State Fire Marshal’s Office as being in compliance with the applicable portions of the Life Safety Code, as determined by the Texas State Fire Marshal’s Office; or
- the Department of Aging and Disability Services (DADS) as being in compliance with the portions of the Life Safety Code applicable to small residential board and care facilities and most recently adopted by the Texas Fire Marshal’s Office.
The program provider may ask the local fire authority to complete Form 5606, Life Safety Code Certification, to verify the inspection, if needed.
If the local fire authority refuses to inspect the home, the program provider must ask the State Fire Marshal to inspect the home. If both the local fire authority and the State Fire Marshal refuse to inspect the home, a request may be made to DADS to complete the inspection. Program providers must use Form 5604, HCS Program Provider Request for Life Safety Inspection, to request the inspection.
After initial full approval of a four-person home, the program provider is required to maintain annual fire marshal certifications required by 40 TAC §9.178(e)(1)(A) in order to maintain DADS approval of the home. The certifications must remain current and the provider must adhere to the requirements outlined in 40 TAC §9.178(e)(1)(A).
The HCS program provider can check CARE screen C84 to see if the home has been approved.
For questions, contact DADS Regulatory Services, Waiver Survey and Certification, at 512-438-4163 or email firstname.lastname@example.org.