PURPOSE

To document the Corrective Action Plan (CAP) developed by the employer or designated representative (DR) at the request of a case manager/service coordinator, a Consumer Directed Services Agency (CDSA), a service planning team or a Department of Aging and Disability Services (DADS) representative.

PROCEDURE

When to Prepare

At the request, in writing, from a case manager/service coordinator, a CDSA, a service planning team or a DADS representative to submit a corrective action plan, the employer or DR completes this form.

Note: An employer or DR may request assistance in the development or implementation of a corrective action plan. Refer to 40 TAC §41.221 and §41.319 for corrective action plan rules.

Number of Copies

Original and at least two copies.

Transmittal

The employer or DR keeps the signed original in the file for the individual receiving services through the CDS option. A copy is sent to the person, agency or service planning team requesting the corrective action plan. A copy must be sent to the case manager/service coordinator. Other service planning team members receive copies as applicable.

Form Retention

The employer or DR, the case manager/service coordinator, and the CDSA keep this form while in effect and for five years thereafter.

DETAILED INSTRUCTIONS

Name of Individual —  Enter the name of the individual receiving services.

Program —  Enter the program name.

Employer —  Enter the employer's name. If the individual receiving services is the employer, enter the individual's name again.

Designated Representative —  Enter the designated representative's name if applicable.

Support Advisor —  Enter the support advisor's name if applicable.

Corrective Action Plan Requested by —  Enter the name of the person who requested the corrective action plan.

Position — Enter the position of the person who requested the corrective action plan.

Agency —  Enter the name of the agency of the person who requested the corrective action plan.

Date of Request —  Enter the date of the written request.

Due Date —  Enter the corrective action plan due date, which is 10 calendar days after the date of the request.

Reason(s) for Requested Corrective Actions: —  State the reason(s) a corrective action plan is being requested.

Corrective Action Plan —  State how the employer or DR will correct the problem.

Specific Action(s) to be Taken —  Enter the specific action to be taken to implement the corrective action plan.

Responsible Person —  Enter the name of the person responsible for each action.

Due Date —  Enter the date the action must be completed.

Plan Approval —  An individual's service planning team must approve the corrective action plan.

Completion of Corrective Action Plan —  Whomever requested the corrective action plan signs and enters information indicating the due date, if the due date was/was not met, corrective actions were/were not completed and any comments.