Texas Department of Aging and Disability Services
Home and Community-based Services Handbook
Effective: November 6, 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 residential reviews for host home/companion care and three- and four-person 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.
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 §§9.177-180.)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
Waiver Survey and Certification (WS&C) conducts on-site certification reviews of HCS program providers, at least annually, to evaluate evidence of the program provider’s compliance with certification principles.
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.
After a program provider has obtained a provisional contract, WS&C conducts an initial on-site certification review within 120 days after the date DADS approves the enrollment or transfer of the first individual to received HCS Program services from the provider under the provisional contract.
An HCS program provider's certification period is for no more than 365 calendar days and 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.
30 Day Follow-Up Review, Vendor Hold and Denial of Certification
If WS&C determines at the end of a review that a program provider is in noncompliance with one or more of the certification principles that results in a condition of a serious nature, WS&C will require the program provider to complete corrective action within 30 calendar days after the date of the review exit conference. An onside follow-up review will be conducted after the 30-day period to determine if the program provider completed the corrective action.
If the program provider fails to correct all principles of noncompliance remaining from the 30-day follow-up review, WS&C will recommend a vendor hold be imposed.
If a vendor hold is imposed for a program provider with a provisional contract, DADS will initiate termination of the program provider's contract in accordance with Texas Administrative Code (TAC) §49.534, Termination of Contract by DADS.
If a vendor hold is imposed for a program provider with a standard contract, WS&C will conduct a follow-up review to determine if the program provider completed the corrective action required to release the vendor hold. If the program provider completed the corrective action, DADS will release the vendor hold. If the program provider has not completed the corrective action, WS&C will recommend denial of certification and termination of contract.
See 40 TAC, Chapter 9, Subchapter D, §9.185, Program Provider Compliance and Corrective Action.
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 before a certification review by the review facilitator, unless there is cause for Waiver Survey and Certification (WS&C) to conduct an unannounced review of the program. WS&C can and may conduct unannounced certification reviews or on-site visits at any time.
When the review facilitator contacts the HCS program provider to notify the provider 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, Legally Authorized Representatives (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.
WS&C conducts an exit conference at the end of all on-site reviews, at a time and location determined by WS&C. WS&C gives the program provider a written preliminary review report at the exit conference.
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.
If a program provider disagrees with any of the findings in the preliminary review report, the program provider may request that DADS conduct an informal review of those findings.
To request an informal review of any of the findings in the preliminary review report, the program provider must submit a completed Form 3610, Informal Review Request, to DADS, as instructed on the form. DADS must receive the completed form within seven calendar days after the date of the review exit conference. If DADS receives a timely request for an informal review, DADS will notify the program provider in writing of the results of the informal review within 10 calendar days of receipt of the request and send the program provider a final review report within 21 calendar days after the date of the review exit conference.
If a program provider does not request an informal review, WS&C will send the program provider a final review report within 21 calendar days after the date of the review exit conference.
14230 Corrective Action Plan
The program provider must submit Form 8581, Corrective Action Plan, for each HCS principle that is found out of compliance at the end of the review and is determined to be non-serious in nature. 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 Waiver Survey and Certification (WS&C) for approval. A copy of the CAP 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.
If the program provider does not submit a CAP as required, or DADS does not approve the CAP, DADS will either impose a vendor hold against the program provider until the program provider submits a corrective action plan approved by DADS or deny or terminate certification of the program provider.
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 onside; 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. Form 8493, Notification to DADS Regarding a Death in HCS, TxHmL and DBMD Programs, must be faxed to 512-438-4148, Waiver Survey and Certification (WS&C). The risk assessment coordinators (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, RAC RNs and RAC manager, 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 Texas Home Living 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 and component code
- Person reporting the death, including contact telephone, email address and fax number
- Individual's Client Assignment and Registration (CARE) System identification number
- Type of setting ─ HCS, Texas Home Living (TxHmL) or Deaf Blind with Multiple Disabilities (DBMD)
- Cause of death
- Date provider notified of death
- Admission date to the provider
- Dates of hospitalizations in the last three months (if applicable)
- Dates of hospice (if applicable)
- If the Department of Family and Protective Services (DFPS) was notified
- Types of residence (Family Care, 3-Person, 4-Person, Own Home or Family Home)
- Place of death
- Type of death (expected, unexpected, or accident)
- Description of events surrounding the death
- Whether autopsy was ordered
- If abuse or neglect is suspected in relation to the death of the individual, the risk assessment coordinator will immediately contact 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 person directed plan and implementation plan(s)
- Any training regarding the individual’s special needs provided to service providers
- Last two months of medication administration records
- Most current nursing assessment
- Last three months of nursing notes, physician orders and lab work
- Last three weeks of Residential Support Services, Supported Home Living, Community Support or Foster/Companion Care notes
- Last week of day habilitation notes
- State supported living center transition notes (if applicable)
- Hospice notes (if applicable)
- RN/LVN names/signature sample key
Additional documents may be requested after the initial review by the DADS Waiver Survey and Certification (WS&C) risk assessment coordinator nurse.
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 DFPS.
The WS&C risk assessment manager 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
The final Department of Family and Protective Services (DFPS) report is reviewed by risk assessment coordinators to determine what actions are to be taken by DADS Waiver Survey and Certification (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 and the secondary designee are 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 by submitting Form 8494, Notification to DADS Regarding a Death in HCS, TxHmL and DBMD Programs, by fax to 512-438-4148. Form 8494 should include:
- the provider name;
- contract number;
- component code;
- date submitted to DADS;
- who submitted the form, as well as area code and phone number and fax;
- DFPS case number;
- date the DFPS report was received;
- Client Assignment and Registration (CARE) System ID number;
- date of allegation;
- type of allegation;
- disposition of allegation;
- concurrence with the disposition;
- what actions were taken by the provider; and
- if the provider will be requesting a methodological review or a review of the finding.
The provider is responsible for attaching documentation when submitting Form 8494 to include a response for how the provider handled any confirmed allegations or DFPS concerns or recommendations.
When deemed serious, WS&C receives the DFPS intake report from Consumer Rights and Services, and 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.
14700 Additional Monitoring Related to Risk Factors
Each quarter, Waiver Survey and Certification (WS&C) risk assessment coordinators compile a report of risk factors for all HCS and Texas Home Living (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 quarters in the last calendar year. 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 Waiver Survey and Certification (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.
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.