11-2002
To provide Texas Works advisors with a method for reviewing D&A/GLA facilities.
Advisors complete Form H1845 when conducting a six-month review of D&A/GLA facilities.
The advisor completes one original and two copies.
Provide one copy each to the local Office Supervisor and Program Manager in charge of the D&A/GLA facility. Retain the original in the facility case file.
The form is maintained in the facility case file for 5 years from the date of review.
Date of Visit — Enter the date of the facility review.
Conducted By — Enter the name of the person conducting the facility review.
Facility Name — Enter the name of the D&A/GLA facility being reviewed.
Authorized Representative (AR) — Enter the name of the facility AR.
Facility Address — Enter the physical address of the D&A/GLA facility being reviewed.
Type of Facility — Enter either D&A or GLA.
Number of Residents — Enter the number of residents currently residing at the facility if this is a GLA facility. Leave blank if the facility reviewed is a D&A facility.
GLA Proof of Certification — Enter the name of the state agency that certified this facility if this is a GLA facility. Leave blank if the facility reviewed is a D&A facility.
Authorization — Enter the authorization source of the D&A as either United States Department of Agriculture (USDA) (to accept food stamp benefits) or licensed by Texas Commission on Alcohol and Drug Abuse (TCADA). Leave blank if the facility review is a GLA facility.
Valid — Enter "Yes" or "No" for valid authorization or license. Leave blank if the facility reviewed is a GLA facility.
General Instructions — Using the most recent Form H1852, List of Resident Participants in the Food Stamp Benefits Program, and current HHSC records, randomly select 6 clients who are reportedly currently residing at the facility.
Review No. — Enter the review number, 1-6.
Case Name — Enter the name of a client to be reviewed.
Case Number — Enter the client's D&A/GLA Food Stamp case number.
Admission Date — Enter the date the client entered the facility as shown on facility records.
Is client currently a resident — Check "Yes" or "No" as verified by personal contact or by current facility records.
Resident Verification — Check "In Person" or "Facility Records" to document how the previous question was verified.
Discharge Date — If the client is no longer a resident of the facility, verify the date of discharge per facility records and enter this date.
Form H1019 Date — If the client is no longer a resident of the facility, check office records and enter the date Form H1019, Report of Change/Aviso de Cambio, was received by the local office. If Form H1019 has not been received, enter none.
Former Resident — Check this box if the client no longer resides at the facility. Complete Part III - Former Facility Residents.
General Instructions — Using Form H1852, submitted by the facility, randomly select 6 clients who have reportedly moved since the last D&A/GLA facility review. Include any "current residents" no longer residing in the facility as part of the 6.
Review No. — Enter the review number, 1-6.
Case Name — Enter the former case name being reviewed.
Case Number — Enter the client's D&A/GLA Food Stamp case number.
Admission Date — Enter the date the client entered the facility, based on facility records.
Discharge Date — Enter the date the client was discharged from D&A/GLA, per facility records.
Form H1019 Date — Enter the date Form H1019 was received in the local office reporting the client was no longer a resident.
Form H1852 Listed Months — List the months this client was reported active on Form H1852, beginning with the first month after the month of admission.
EBT Transactions — Using the Administrative Terminal (AT), obtain a printout of all account activity for this Food Stamp case beginning with the month of discharge through the month the AR was removed from the account.
Was the client's Food Stamp account accessed after the date of discharge — Check "Yes" or "No;" based on the AT account activity report for this case.
Review No. — Enter the review number of a former resident whose account was accessed after the date of discharge.
Date Accessed — Using the AT account activity report, enter the first date after the discharge date this account was accessed by the facility.
Time Accessed — Using the AT account activity report, enter the time the account was accessed after the resident moved.
Amount Used — Using the AT account activity report, enter the amount of benefits used for this transaction.
Additional Documentation — Document a summary of findings for this account. Include any discrepancies identified during this review. Attach additional pages if necessary.
Summary of Review — Document a summary of all findings for this review.
Date this review provided to supervisor — Enter the date a copy of this report was provided to the local office supervisor in charge of the D&A/GLA facility.
Date this review provided to Program Manager — Enter the date a copy of this report was provided to the Program Manager in charge of the D&A/GLA facility.
Negative findings in this review — Check "Yes" or "No."
Date Escalated to State Office — Enter the date the Program Manager sent the negative findings of this report to State Office.
By Whom — Enter the name of the Program Manager notifying State Office.