PURPOSE

To serve as the primary document to record findings of contract compliance monitoring of Primary Home Care (PHC), Family Care (FC) and Community Attendant (CA) services providers.

PROCEDURE

When to Prepare

DADS staff who conduct the monitoring complete Form 3858 when reviewing a case.

Number of Copies

Complete one original.

Transmittal

DADS staff will retain the original for DADS records. If requested, a copy of the form is given to the provider agency only after the monitoring results have been finalized.

Form Retention

Keep form according to the terms of the contract.

Supply Source

This form must be printed from the forms website at:
http://www.dads.state.tx.us/forms/providers.asp

DETAILED INSTRUCTIONS

Client Name — Enter the client's name as it appears on Form 2101, Authorization for Community Care Services.

Medicaid No. — Enter the Medicaid recipient number as it appears on Form 2101.

Date of Review — Enter the date the review is being conducted for this client file in month/day/year format.

Review Period — Enter the month(s) and year(s) being reviewed in month/year format.

Review Type — Mark the appropriate box for the type of review being conducted: Formal or Follow-Up.

Service — Mark the appropriate box for the type of service being reviewed.

Status — Mark the appropriate box for the priority level from Item 10, Form 2101:

Vendor No. — Enter the vendor number of the provider agency being reviewed.

Agency Name — Enter the name of the provider agency reviewed.

Monitor — Enter the name of the DADS staff member who conducted the review for this client file.

Region — Enter the number of the region to which the provider agency is assigned.

Services in the Primary Home Care Program must be delivered under the Personal Assistance Services (PAS) category of license.

Standard Summary (Optional) — At the bottom of Page 1, staff may enter the overall compliance for Standards 1 – 7 as: M = MET, NM = NOT MET or N/A = Not Applicable (N/A).

Contract staff must make copies of any deficient standards and maintain with their monitoring records.

Standard 1, Pre-Initiation Activities — Apply Standard 1 to cases in which pre-initiation activities were due or completed during the review period. Review all cases in which the 14th day from the referral date (Item 1, Form 2101, Authorization for Community Care Services), the 14th day from the agency receipt date or the negotiated date falls in the review period, regardless of when the pre-initiation activities were completed. However, for routine referrals, review only one month before the review period to determine whether the pre-initiation activities were done within 14 calendar days of the referral date (Item 1 on Form 2101) or agency receipt date.

This standard also applies to any transfer cases in the review sample, where applicable. A transfer can be a client transferring from one provider agency to another, or from one program to another. Transfers are negotiated with case managers and will be reviewed as negotiated, when applicable. Not all items will be applicable to transfers. For example, the receiving agency would not need to obtain a practitioner's statement for a PHC client transferring from one provider agency to another; however, a practitioner statement would be needed if the client was transferring from Family Care to Primary Home Care for the first time.

This standard is not applicable for Integrated Care Management (ICM) clients that entered services 2/1/2008-3/31/2009.

Standard 1 — Monitoring Protocol

• Item a. 1. and 2. – The provider agency may combine the evaluation and service plan into a single document, but each item must be clearly identified.
• Item a. 1. – The provider agency must conduct an evaluation as outlined in TAC §47.45(a)(1). The evaluation must be a single document that includes the person's self-report of the date(s) and reason(s) for any hospitalization within the last three months, and the assistance needed for the person to achieve activities of daily living. If during the evaluation the agency determines that the client exhibits reckless behavior that results in imminent danger to the health and safety of the client, the agency must convene an IDT meeting as outlined in §47.49 to discuss barriers to service delivery.
• Item a. 2. A. – Determine the date the service plan was signed. Determine the date services were initiated. The service plan must be signed on or before services began.
• Item a. 2. B. – Determine the location of service delivery.
• Item a. 2. C. – Determine if the service schedule is variable or fixed.
• Item a. 3. – For PHC or CA services, the provider agency must obtain a practitioner's statement, which is a document that includes a statement signed by a practitioner verifying that the client has a current medical need for assistance with personal care tasks and other activities of daily living; and certification that the provider agency verified with the U.S. Centers for Medicare and Medicaid Services that the practitioner is not excluded from participation in Medicare or Medicaid. Review for documentation of written or oral practitioner's statement date.
• Item b. – Determine the date all pre-initiation activities were completed to see if done by the specified time frames. Determine the referral date found on Item 1 of Form 2101, or the date the provider agency received Form 2101, whichever of the two dates is later. If the agency failed to stamp the receipt date on the form, use the referral date to determine timeliness. For negotiated referrals, determine the negotiated date. If these time frames are met, mark Items 1. A. – C. N/A. If the time frames are not met, continue to Items 1. A. – C.
• Item b. 1. – Determine the documentation date for failure to complete the pre-initiation activities. This must be documented within 14 days of the referral date or within 14 days after the provider agency received Form 2101 (whichever of the two dates is later) or, for negotiated referrals, the provider has until prior to close of business on the day services were negotiated to begin, or the next work day if the negotiated start date falls on a weekend.
• Item b. 1. A. – C. – Determine the date of documentation. Determine the reason for the delay, which must be beyond the control of the provider agency. Determine from documentation either the date the provider agency anticipates it will complete the pre-initiation activities or the specific reason why the provider agency cannot anticipate a completion date, and a description of the agency's ongoing efforts to complete the pre-initiation activities.

For each Item a. through b.:

• mark Yes, No, N/A or skip an item as instructed on the form; and
• review all Items a. – b. as instructed on the form, even if one item causes the overall standard to be NOT MET. This is to ensure compliance with all rules within this standard.

Standard 1  — Mark the overall standard as MET, NOT MET or N/A, as appropriate.

Standard 2, Service Initiation — Apply Standard 2 to cases in which services should have been initiated or were initiated during the review period. Review all cases in which the service initiation due date (7th or 14th day, as applicable) falls in the review period, regardless of when services were initiated. Review only one month before the review period, however, to determine whether services were initiated timely or the reason for delay was documented.

This standard also applies to any transfer cases in the review sample, where applicable. A transfer can be a client transferring from one provider agency to another, or from one program to another. Transfers are negotiated with case managers and will be reviewed as negotiated, when applicable. Not all items will be applicable to transfers. For example, the receiving agency would not need to obtain a practitioner's statement for a PHC client transferring from one provider agency to another; however, a practitioner statement would be needed if the client was transferring from Family Care to Primary Home Care for the first time.

Standard 2 — Monitoring Protocol

• Item a. – For FC services, determine the referral date found on Item 1 of Form 2101 or the date the provider agency received Form 2101, whichever of the two dates is later. If the agency failed to stamp the receipt date on the form, use the referral date to determine timeliness. For negotiated referrals, determine the negotiated date. Determine the service initiation date by reviewing the service delivery documentation.
• Item b. – For PHC or CA services, determine the practitioner's statement date. The practitioner's statement date is the later of the following: the practitioner's signature date on the practitioner's statement or the date the provider agency receives the practitioner's statement. If the provider agency fails to stamp the receipt date on the form, the date of the practitioner's signature will be used to determine the practitioner's statement date, or the date of the practitioner's oral statement obtained for a negotiated referral. The provider agency must document the practitioner's oral statement date on the practitioner's written statement required in §47.47(c )(2). For negotiated referrals, determine the negotiated date. Determine the service initiation date by reviewing the service delivery documentation.
• Item c. – For ICM/PHC clients entering services 2/1/08-3/31/09, determine if services were initiated within seven days of the effective date of ISP or the date the provider agency received the ISP, whichever of the two is later. If the agency failed to stamp the receipt of the form, use the effective date to determine timeliness. For negotiated referrals, determine the negotiated date.
  
  For clients entering services on or after 7/1/09, verify that services were initiated within seven days after the provider agency's receipt of the DADS authorization form.
• Item d. 1. – 3. — Determine if the provider agency documented any failure to initiate services by the specified time frames. For FC: Determine the referral date found on Item 1 of Form 2101 or the date the provider agency received Form 2101, whichever of the two dates is later. If the agency failed to stamp the receipt date on the form, use the referral date to determine timeliness. For negotiated referrals, determine the negotiated date. For PHC or CA: Delays must be documented within seven days of the practitioner's statement date or, for negotiated referrals, on the negotiated date. Determine the practitioner's statement date. From the documentation, determine the reason for the delay, which must be beyond the control of the provider agency and not caused directly by the provider agency. Determine either the date the provider agency anticipates it will initiate services or specific reasons why the provider agency cannot anticipate a service initiation date, and provide a description of the agency's ongoing efforts to initiate services.
  
  For clients entering services on or after 7/1/09, verify that delays were documented within seven days after the provider agency's receipt of the DADS authorization form.
• Item e. – Determine the date services were initiated. Determine the date written notice of service initiation was sent to the case manager. Determine the date the practitioner's statement date was sent to the case manager or regional nurse, as applicable. Use the signature date of the written notice (which can be Form 2101, 2067 or whatever the agency used as written notice) to measure compliance.
• Item f. – Not Applicable to Family Care Services. If this is not a retroactive case, mark Item e. N/A. If this is a retroactive case, determine the date the provider agency made a referral to DADS. Determine the date services were initiated by reviewing the service delivery documentation. Services must not begin before the agency completes the pre-initiation activities and processes intake referral.
• Item f. 1. – Determine the practitioner's statement date.
• Item f. 2. – Determine the service plan date.
• Item f. 3. – Determine the date the agency verified and documented that the person was not receiving services from another provider agency.
• Item f. 4. – Determine the date all pre-initiation activities were completed. Review Item 4. A. to determine if an intake referral was made to the DADS office on the date all pre-initiation activities were completed. Review Item 4. B. only to ensure that services were not initiated before the date the provider agency completed all pre-initiation activities and called in the intake referral.
• Item f. 5. – The written request must include the following: a copy of the service plan, a copy of Practitioner's Statement of Medical Need form, name of the provider agency, the contact information for the person being referred, the date services were initiated, the tasks to be provided to the person and the weekly hours and cost per hour that was charged to the person, if applicable.

For each Item a. through f.:

• mark Yes, No, N/A or skip an item as instructed on the form; and
• review all Items a. – f. as instructed on the form, even if one item causes the overall standard to be NOT MET. This is to ensure compliance with all rules within this standard.

Standard 2 — Mark the overall standard as MET, NOT MET or N/A, as appropriate.

Standard 3, Supervisory Visits — Apply Standard 3 to all cases in the review sample. Review before the review period, if needed, to determine whether the required time frames were met.

Item a. — The supervisory visit must be done on or before the last day of the month the visit is due. The assigned supervisor sets the visit frequency for PHC/FC/CA clients. The assigned supervisor may or may not be an RN.

Use the following to determine if Item a. is applicable:

Was a visit completed during the review period? If the answer is Yes, then always review Item a. The contract manager must follow these steps to determine if Item a. is MET or NOT MET:

• Determine the date of the previous supervisory visit (look as far back as necessary to find the previous supervisory visit).
• Determine the visit frequency indicated on the previous supervisory visit.
• Determine the due date for the next supervisory visit (based on the previous supervisory visit and the visit frequency).
• Determine if the supervisory visit completed during review period was completed on or before the due date for the next visit.

If the supervisory visit was completed on or before the due date for the next supervisory visit, mark Item a. Yes. If the supervisory visit was not completed on or before the due date for the next supervisory visit, mark Item a. No.

Was a visit completed during the review period? If the answer is No, then review Item a. only if applicable. The contract manager must follow these steps to determine if Item a. is N/A or NOT MET.

• Determine the date of the previous supervisory visit (look as far back as necessary to find the previous supervisory visit).
• Determine the visit frequency indicated on the previous supervisory visit.
• Determine the due date for the next supervisory visit (based on the previous supervisory visit and the visit frequency).
• Determine if the due date for the next supervisory visit is on or before the last day of the review period.

If the due date for the next supervisory visit is on or before the last day of the review period, mark Item a. No (regardless of how far the due date is before the review period). If the due date for the next supervisory visit is after the last day of the review period, mark Item a. N/A. The provider agency still has time after the review period to complete the supervisory visit before the due date.

Standard 3 — Monitoring Protocol

• The supervisor establishes the frequency of supervisory visits to be conducted at least annually.
• Review Item a. for supervisory visits that were completed during the review period; for supervisory visits with a due date during the review period; and for supervisory visits with a due date before the review period that were not completed by the end of the review period (Example: Review period is March, April and May. The supervisory visit was due in February and was still not completed by May). The supervisory visit can be done on or before the last day of the month that it is due.
• Item a. – Determine the date of the previous supervisory visit, the frequency that was set at the previous supervisory visit, when the next supervisory visit is due and the date the supervisory visit was conducted.
• Items 1. A. – E. are reviewed even if the supervisory visit is done untimely to determine if all elements are documented as required. If the untimely visit was not done at all, mark Items 1. A. – E. N/A.

For each item in a.:

• mark Yes, No or N/A, as appropriate; and
• review all items in a. as instructed on the form, even if one item causes the overall standard to be NOT MET. This is to ensure compliance with all rules within this standard.

Standard 3 — Mark the overall standard as MET, NOT MET or N/A, as appropriate.

Standard 4, Attendant Orientation — Apply Standard 4 to all cases in the review sample.

Item a. — An attendant must receive orientation in person in the client's home or other location where services are delivered. The client must be present when the attendant receives orientation in person. An attendant may receive orientation by telephone or in the provider agency office at the discretion of the supervisor, as outlined in §47.25. Orientation is not required for supervisors who are acting as attendants.

Standard 4 — Monitoring Protocol

• Read for both initial and ongoing cases that had any attendants that were new to the client during the review period. The method of orientation must be conducted as outlined in §47.25(b).
• Item a. – Determine the date the attendant(s) were oriented and date they began providing services to the client.

For Item a., mark Yes, No or N/A, as appropriate.

Standard 4 — Mark the overall standard as MET, NOT MET or N/A, as appropriate.

Standard 5, Service Plan Changes — Apply Standard 5 to all cases in the review sample where a service plan change occurred. If there were no service plan changes in the review period, mark all items in this standard N/A. If ICM/PHC service plan occurred prior to 7/1/2009, mark Item a. and b. N/A and continue to Item c.

Standard 5 — Monitoring Protocol

• Item a. – The notification to the case manager/service coordinator must include the date the provider agency learned of the need for the change, the reason for the change, the type of change that includes the number of hours and a signature and date of the provider agency representative.
• Item b. – For any service plan changes, determine the authorization date from Item 4. of Form 2101 or within five days after the date the provider agency received Form 2101, whichever of the two dates is later. If the agency failed to stamp the receipt date on the form, use the authorization date. Determine the implementation date by reviewing any service plan updates and service delivery documentation. Review the date of schedule/service plan changes rather than only looking at the time delivered on the day of implementation.
• Item c. – For ICM/PHC service plan changes, determine the effective date from the ISP or within seven days after the date the provider agency received the ISP, whichever of the two dates is later. If the agency failed to stamp the receipt date on the ISP, use the effective date. Determine the implementation date by reviewing any service plan updates and service delivery documentation. Review the date of schedule/service plan changes
• Item d. – For any delays, the documentation must include the reason for failure to timely implement the service plan change and the new implementation date.

For each Item a. through d.:

• mark Yes, No, N/A or skip an item as instructed on the form; and
• review all Items a. – d. as instructed on the form, even if one item causes the overall standard to be NOT MET. This is to ensure compliance with all rules within this standard.

Standard 5 — Mark the overall standard as MET, NOT MET or N/A, as appropriate.

Standard 6, Annual Reauthorization — This standard only applies to Community Attendant (CA) Services. Apply Standard 6 to all CA cases in the review sample for any cases for which the provider agency received an annual reauthorization from the case manager. Review all cases in which the 14th day from the referral date (Item 1, Form 2101, Authorization for Community Care Services) or the 14th day from the agency receipt date falls in the review period. Review only one month before the review period.

Standard 6 – Monitoring Protocol

Determine the referral date found on Item 1 of Form 2101 or the date the provider agency received Form 2101, whichever of the two dates is later. If the agency failed to stamp the receipt date on the form, use the referral date to determine timeliness.

For Item a, mark Yes, No or N/A, as appropriate.

Standard 6 — Mark the overall standard as MET, NOT MET or N/A, as appropriate.

Standard 7, Service Interruptions — Apply Standard 7 to all cases in the review sample for the entire review period. Review the month before the review period, if needed, to determine whether a service interruption occurred during the review period.

If ICM and service interruption occurred prior to 7/1/09, mark Standard 7 N/A and skip to Standard 8.

Item a. — Review Item a. for all priority and non-priority clients. If Item a. is marked No, and any instance of a service interruption during the entire review period does not have a reason documented or the reason documented is not valid, Standard 4 is NOT MET.

Standard 7 – Monitoring Protocol

• Item a. – Review the service delivery documentation to determine if there is a service interruption. Mark Item a. Yes if the priority client received all services according to the service plan, or if there were no service interruptions that exceeded 14 consecutive days for non-priority clients (no entries are required for Item a. (1)-(4)). For any instances of a service interruption during the entire review period that does not have a reason documented or the reason documented is not valid, Standard 7 is marked as NOT MET.
• For a Fixed Schedule: A service interruption begins on the first day services are scheduled but not delivered.
• For a Variable Service Schedule: For a priority client, the service interruption begins the Sunday following the week the client did not receive all the weekly hours on a service plan approved by the client. For a non-priority client, the service interruption begins the Sunday following the week the client did not receive any services on a service plan approved by the client.
• Priority clients – A service interruption occurs any time the client does not receive all services according to the service plan. Any instance of a service interruption must have the reason for the interruption documented.
• Non-priority clients – Each instance of service interruption that exceeds 14 consecutive days must have the reason for the interruption documented.
• Item b. – For any service interruptions, determine the date the interruption began. Determine the date documentation of service interruption is due. Determine the date of the documentation for any service interruptions.
• Item c. – If applicable, a provider agency must request an IDT meeting under §47.71(a)(7) if the client or someone in the client's home exhibits reckless behavior that may result in imminent danger to the health and safety of the client, the attendant or another person (or under 47.71(b)). See TAC rules for detailed list of optional suspensions. Determine the date services were suspended or the date issues were identified by the provider agency. Determine the date the IDT meeting was convened.
• Item c. 1. – Determine the implementation date or the date the case was referred back to the case manager. Within two work days after the IDT meeting, the provider agency must implement the recommendations of the IDT or, for initial cases, refer the case back to the case manager or, for ongoing cases, send a notice of discharge to the client specifying the effective date of discharge.

For each Item a. through c.:

• mark Yes, No, N/A or skip an item as instructed on the form; and
• review all Items a. – c. as instructed on the form, even if one item causes the overall standard to be NOT MET. This is to ensure compliance with all rules within this standard.

Standard 7 — Mark the overall standard as MET, NOT MET or N/A, as appropriate.

Standard 8, Complaints — Complete Standard 8 only once for each provider agency. Do not figure into the overall percentage.

Item a. – Mark this as NOT MET if there is no complaint log.

Item b. – If this item is marked No, do not review Item c.; mark ItemS c. 1. and c. 2. N/A.

Item c. – Mark Standard 8 NOT MET if Item c. 1. or c. 2. is marked No for any complaints received from a sample or non-sample client during the review period.

Standard 8 – Monitoring Protocol

• The provider agency is no longer required to submit complaint findings to DADS within 30 days of receipt of the complaint; however, it must make review of complaints accessible to DADS staff.
• Items c. 1. and 2. – Mark either c. 1. or c. 2. No for any complaint that is listed on the complaint log from a sample or a non-sample client during the review period that is not completed timely.
• Item c. 1. – The provider agency must investigate and resolve complaints as required by HCSSA licensure rules. The provider agency is required to document receipt of the complaint, initiate an investigation within 10 calendar days of receipt of the complaint and complete the investigation within 30 calendar days after the agency received the complaint, unless the agency documented reasonable cause for delay.
• Item c. 2. – The provider agency's complaint procedures must be provided to the client or client's representative no later than the time services begin, and no more than 12 months between each notification. The complaint procedures can be provided on or before the last day of the month the notification is due. Example: If the notification was provided to a client on October 15, 2003, they must be provided to the client no later than October 31, 2004.
• Do not include the findings for Standard 8 in determining the compliance level for the provider agency. Report Standard 8 findings separately in the findings section of Form 3853, Provider Agency Evaluation Summary.
• Request that the provider agency develop a corrective action plan if compliance with Standard 8 is not met.

Standard 8 — Mark overall standard as MET or NOT MET, as appropriate.