Division of Aging Services
State Review Guide
for
Home Modification and Repair Service
Program
Guidelines and Requirements
for HCBS - Section 314
PSA/County: Site:
Reviewer: Date:
Revised March 30, 2005
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Georgia DHS Division of Aging Services HCBS Section 314 Revised June 2002
Home Modification and Repair Review Guide Page 2 of 24
Review Guide Purpose and Scope:
This guide is designed to assist the Area Agencies on Aging in measuring the compliance and
performance of subcontractors for HCBS Home Modification and Repair Services.
Area Agencies shall contract with only qualified and/or licensed providers for the provision of
a Home Modification and Repair Service Program. An Area Agency providing these services
directly shall be accountable to the same rules, regulations and compliance requirements and
subject to being monitored by the Division of Aging Services using this review guide.
Abbreviations and Acronyms (Peculiar to this guide/Service/Program):
AAA Area Agency on Aging
ADL Activities of Daily Living
AIMS Aging Information Management System
CBA County Based Agency
DON-R Determination of Need - Revised
DAS Division of Aging Services
DHS Department of Human Services
FN Footnote
IADL Instrumental Activities of Daily Living
UCM Uniform Cost Methodology
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Home Modification and Repair Review Guide Page 3 of 24
Review Guide – Manual Section 314 – Home Modification and Repair Service
Items to be Completed Prior to On-Site Review
It will be necessary for the monitor to complete the following tasks and review guide items before making the
on-site visit. Items are identified with an asterisk (*) in the review guide.
Review
Item # Guide # Action Required Purpose Completed
Review Previous To become familiar with past
Yes ________
1. All Items Monitoring Report. performance of the provider and/or site. No ________
Review Contract To become familiar with contracted
Yes ________
2. 1. Documents. services to be performed by the service No ________
provider and any subcontractor for the
provider.
Review Contract To verify the number of units
Yes ________
3. 2. Documents and/or HCBS contracted, provided to date this No ________
– Program Performance program year, and to become familiar
Report for Provider. with funding.
Review HCBS – Missing To determine the number of
Yes ________
4. 18.A and Data Elements Report by unduplicated clients in AIMS for the No ________
18.B Individual Service and provider and to determine the number of
the chart in Review client files to be reviewed.
Guide Item #18.
(a) Review instructions The checksheet and Excel spreadsheet (a)
5. 4, 5, 6, 7, for filling out client file for Part II is included to assist the Yes ________
8, 9, 10, checksheets for Part II of monitor in evaluating a provider’s No ________
11, 13, 14, the Excel spreadsheet. maintenance of client files. The client
16, 18.D, file reviews shall be conducted in
(b)
and 18.E (b)Conduct client file accordance with referenced items in the Yes ________
review and complete a review guide. No ________
checksheet for each
client file reviewed. NOTE: Part II of the checksheet will
capture client information and the Excel
(c)Enter totals from the spreadsheet for Part II will reveal (c)
checksheets into the overall compliance rates; however, Yes ________
No ________
Excel spreadsheet for information entered on each client in
each client. Part II of the checksheet will have to be
calculated separately in order to answer
(d)Transfer the some of the review guide questions.
(d)
information from the Yes ________
Excel spreadsheet into No ________
the respective items in
the review guide.
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Home Modification and Repair Review Guide Page 4 of 24
Instructions to Complete the Client File Checksheet and
Part II of the Attached Excel Spreadsheet (File: Home Mod & Repair Chksheet.xls)
NOTE: The client file checksheet and attached Excel spreadsheet are included for the monitor’s
convenience only and the use of these documents is not required to complete the review guide.
1. Determine the number of clients in AIMS for the service provider.
2. Determine the number of client files to be reviewed.
3. Request files from service provider.
4. Review client files for items listed on checksheet. Note findings on copies of the checksheet using
codes below. Checksheet may be adapted to include additional items of information in the review.
5. Adjust the number of lines in the attached Excel spreadsheet to accommodate the number of client files
reviewed.
6. Total the number of marks in the “yes”, “no”, and “N/A” columns on the checksheet.
7. Enter the number of data elements reviewed into the attached Excel spreadsheet. (Same number review
items for each client.)
8. Enter column totals for each client into the attached Excel spreadsheet from checksheet.
9. Enter overall compliance/non-compliance rates/percentages in the appropriate spaces in the review
guide. (N/A column total is excluded from the calculation of the “yes” and “no” percentages.)
Codes for reviewing information client files for service provider performance:
Yes - Information is in compliance.
No - Information is NOT in compliance.
N/A - Information requested is not applicable to this particular client.
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Home Modification and Repair Review Guide Page 5 of 24
Client File Checksheet
NOTE: The client file checksheet and attached Excel spreadsheet (File: Home Mod & Repair
Chksheet.xls) are included for the monitor’s convenience as a suggested form to check a service provider’s
maintenance of client files. The use of these documents is not required to complete the review guide.
Client Name:___________________________________________________ Client I.D. #:________________
(Last) (First) (Middle)
Provider:_______________________________ _ Reviewer’s Name:_______________________________
File #_____of _____ (number) of files to be reviewed.
Item # Data Elements Yes No N/A Comments
1. AAA Referral
2. Client Information / CRF
3. Client Notification / Service
Status
4. Allowable Services
5. Ownership of Property
6. Rental Property Work
Approvals
7. Properly Executed Service
Agreement
8. Work Plan
9. Completed Work Affidavit
10. Written Warranty
11. On-Site Evaluation of
Residence
12.
13.
14.
Total
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Home Modification and Repair Review Guide Page 6 of 24
Section Compliance Yes/ No/ N/A
Number Cited Section 314 – Home Modification and Repair Services Comments
Scope, Definitions and Service Activities. (1)
*1. 314.2
Yes ______ No ______ N/A______
(Contract and
314.7
(1)________ The AAA has executed a contract with the provider agency specifically for Comments:
Documents)
the provision of the services listed below.
OR
__________ The AAA provides the services listed below.
List service(s) provided:
Monitor – review contract prior to on-site review to become familiar with contracted
services.
(2)Does AAA/provider subcontract for any portion of the services to be provided under (2)
this contract? Yes ______ No ______ N/A______
Comments:
YES __________ NO __________
If “yes” to (2), list service(s):
Provider: If “yes” to (2), provider has provided the AAA with a copy of the
subcontract(s).
YES __________ NO __________ N/A __________
Provider: If “yes” to (2), provider monitors its subcontractor(s) at least annually.
YES _______/DATE __________________ NO __________ N/A __________
AAA: If “yes” to (2), AAA monitors its subcontractor(s) at least annually.
YES_______/DATE __________________ NO __________ N/A __________
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Home Modification and Repair Review Guide Page 7 of 24
Section Compliance Yes/ No/ N/A
Number Cited Section 314 – Home Modification and Repair Services Comments
314.2 Scope and Definitions and Service Activities.
and Yes ______ No ______ N/A______
*2.
314.7
(Contract Monitor – Review AAA contract prior to on-site review to become familiar with Comments:
Documents
and AIMS
contracted services, funding, and the number of units to be provided.
Report)
Monitor – Review the HCBS – Program Performance Report for Provider to verify that
the number of units provided is in line with the percent of the program year passed.
Month: ____________________ __________% of Program Year Passed
Contracted Units: ________ Units Provided: __________ ________% of Units Provided
Units provided annualized for the entire year: ______________# of units __________%
Administrative requirements Yes ______ No ______ N/A______
3. 208.12.c.1
and Comments:
314.10.b
All services provided to a client shall be based on a written service agreement entered
into with the client or the client’s responsible party.
Note: A service agreement is required for services involving construction for home
improvements and not applicable (N/A) for installation of “simple safety and
mobility devices”.
Monitor – Obtain a copy of the provider’s service agreement, if applicable, and review
to verify that the following items at a minimum are addressed:
208.12.c.1.a Date provider made initial contact with the client Yes ________ No _________
208.12.c.1.B Date of referral Yes ________ No _________
208.12.c.1.C Description of services/activities needed Yes ________ No _________
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Home Modification and Repair Review Guide Page 8 of 24
Section Compliance Yes/ No/ N/A
Number Cited Section 314 – Home Modification and Repair Services Comments
Description of services; expected days, times,
208.12.c.1.d
Frequency and duration of visits, service begin
date. Yes ________ No _________
208.12.c.1.e Applicable charges, billing and payment Yes ________ No _________
208.12.c.1.g Client’s/family’s opportunity to contribute Yes ________ No _________
208.12.c.1.h Client’s acknowledgement of “Client’s Rights
and Responsibilities” notification Yes ________ No _________
208.12.c.1.i
Provider’s telephone number Yes ________ No _________
208.12.c.1.j
Telephone numbers for Area Agency on
Aging and Division of Aging Services Yes ________ No _________
208.12.c.1k
Notation/check-off of attached written authorization,
from client or responsible party for access to client’s
personal funds and/or for the use client’s motor
vehicle when applicable. Yes ________ No _________
208.12.c.1.L;
208.12.c.1.L.
2;
Spaces for signature and date of client/responsible
and party and provider upon agreement or refusal or
208.12.c.1.L. cancellation; and space to note reason(s) for refusal
3
and/or cancellation Yes ________ No _________
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Home Modification and Repair Review Guide Page 9 of 24
Section Compliance Yes/ No/ N/A
Number Cited Section 314 – Home Modification and Repair Services Comments
Access to Services Yes ______ No ______ N/A______
*4. 314.4
All clients receiving services paid for “in full” or “in part” under this contract were Comments:
screened by the AAA or Community Based Agency (CBA).
Monitor – Information to complete this item is captured on the client file checksheets
completed during review of the random sample of client files.
# of files reviewed: __________ # of Yes: ___________ # of No: ___________
Access to Services Yes ______ No ______ N/A______
*5. 314.4
Assessment staff/case manager or the provider is providing the client a “notice of service Comments:
status” once the face-to-face assessment has been completed.
Monitor – Information to complete this item is captured on the client file checksheets
completed during review of the random sample of client files.
# of files reviewed: __________ # of Yes: ___________ # of No: ___________
314.7.a; Service Activities Yes ______ No ______ N/A______
*6. 314.7.b;
314.7.c; Comments:
314.7.d;
The provider is performing allowable services/activities such as (a)structural,
314.7.e; (b)accessibility modification, (c)electrical, (d)plumbing, (e)weatherization, (f)safety and
314.7.f; security modification, (g)housing counseling, and (h)home and exterior maintenance.
314.7.g;
and
314.7.h
Non-Allowed Services
314.9.a;
314.9.b; The provider is not performing non-allowed services or non-reimbursable
314.9.c; services/activities which include (a)major repairs of houses and/or furnishings;
and (b)construction, repair or maintenance of outbuildings; (c)installation, repair or
314.9.d
maintenance of nonessential appliances; and (d)beautification of property or activities
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Home Modification and Repair Review Guide Page 10 of 24
Section Compliance Yes/ No/ N/A
Number Cited Section 314 – Home Modification and Repair Services Comments
which are strictly for cosmetic purposes.
Monitor – Review random sample of client files to determine that only allowable
services are being performed. Information to complete this item is captured on the
client file checksheets completed during review of the random sample of client files.
# of files reviewed: __________ # of Yes: ___________ # of No: ___________
Repair of Rental Property Yes ______ No ______ N/A______
*7. 314.8
Documentation of whether the client owns or rents the property to be repaired. Comments:
Monitor – Review random sample of client files for documentation for ownership or
rental of property to be repaired.
Number of files reviewed: __________
Number of Property Owners: _________ Number of Rental Properties: ________
Repair of Rental Property Yes ______ No ______ N/A______
*8. 314.8
For every rental property repaired identified above, assessment staff/case manager Comments:
or provider has the following documented in the client’s file:
(If no rental properties were repaired, mark “N/A” and skip Items 1 – 4 below.)
(1)Prior written approval from the AAA to
perform the repairs. # of Yes ______ # of No ______
(2)Signed agreement from the landlord or entity
controlling the property authorizing the repairs
and/or modifications. # of Yes ______ # of No ______
(3)Signed statement from the landlord or entity
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Home Modification and Repair Review Guide Page 11 of 24
Section Compliance Yes/ No/ N/A
Number Cited Section 314 – Home Modification and Repair Services Comments
controlling the property declaring that the tenant
will not be evicted within one year without
substantial cause. # of Yes ______ # of No ______
(4)Signed statement from the landlord or entity
controlling the property declaring that the rent
will not be raised due to repairs and/or modifications. # of Yes ______ # of No ______
Administrative Requirements Comments:
*9. 314.10.b
A service agreement between the provider and each client or responsible party has been
executed.
Note: Requirement is applicable to construction for home improvements and not
applicable (N/A) for installation of “simple safety and mobility devices”.
Monitor – Information to complete this item is captured on the client file checksheets
completed during review of the random sample of client files.
# of files reviewed: ______ # of Yes: ______ # of No: ______ # of N/A:______
Administrative Requirements Comments:
*10. 314.10.d.2
Service agreements are to be completed/executed prior to work being performed.
Note: Requirement is applicable to construction for home improvements and not
applicable (N/A) for installation of “simple safety and mobility devices”.
Monitor – Compare dates. Information to complete this item is captured on the client
file checksheets completed during review of the random sample of client files.
# of files reviewed: ______ # of Yes: ______ # of No: ______ # of N/A:______
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Section Compliance Yes/ No/ N/A
Number Cited Section 314 – Home Modification and Repair Services Comments
Administrative Requirements Comments:
*11. 314.10.d.3
A work plan is contained in each client’s file for each service performed.
Note: Requirement is applicable to construction for home improvements and not
applicable (N/A) for installation of “simple safety and mobility devices”.
Monitor – Information to complete this item is captured on the client file checksheets
completed during review of the random sample of client files.
# of files reviewed: ______ # of Yes: ______ # of No: ______ # of N/A:______
Administrative Requirements Yes ______ No ______ N/A______
12. 314.10.d.4
Provider has written policies and procedures to assure that all structural modifications, Comments:
such as the installation of ramps, zero-step entries, widening of doorways, etc. conform
to minimum ADA standards.
Note: Requirement is applicable to construction for home improvements and not
applicable (N/A) for installation of “simple safety and mobility devices”.
Monitor – Review policies/procedures/specification for meeting standards.
Administrative Requirements
314.10.d.5 Yes ______ No ______ N/A______
*13.
Affidavit signed by client or representative that the work performed was completed in a Comments:
satisfactory manner.
Note: Requirement is applicable to construction for home improvements and not
applicable (N/A) for installation of “simple safety and mobility devices”.
Monitor – Information to complete this item is captured on the client file checksheets
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Home Modification and Repair Review Guide Page 13 of 24
Section Compliance Yes/ No/ N/A
Number Cited Section 314 – Home Modification and Repair Services Comments
completed during review of the random sample of client files.
# of files reviewed: ______ # of Yes: ______ # of No: ______ # of N/A:______
Administrative Requirements
314.10.d.6 Comments:
*14.
A written warranty for the work performed and signed certification of compliance with
all appropriate codes for building, plumbing, and electrical repairs.
Note: Requirement is applicable to construction for home improvements and not
applicable (N/A) for installation of “simple safety and mobility devices”.
Monitor – Information to complete this item is captured on the client file checksheets
completed during review of the random sample of client files.
# of files reviewed: ______ # of Yes: ______ # of No: ______ # of N/A:______
Provider Qualifications Yes ______ No ______ N/A______
15. 314.5
What qualifies the provider to provide these services? (See list of qualified providers in Comments:
Manual Section 314.5.)
______________________________________________________________________
License #, if applicable: ________________________________________________
Expiration Date: ______________________________________________________
Provider uses: paid staff _____ volunteers _____ paid staff and volunteers _____
Administrative Requirements Comments:
*16. 314.10.d.2
In order to develop a written service agreement with the client or his/her representative,
an on-site evaluation of the residence must be conducted.
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Home Modification and Repair Review Guide Page 14 of 24
Section Compliance Yes/ No/ N/A
Number Cited Section 314 – Home Modification and Repair Services Comments
Note: Requirement is applicable to construction for home improvements and not
applicable (N/A) for installation of “simple safety and mobility devices”.
(A) Monitor – Ask for a copy of the assessment staff’s/case manager’s or the
provider’s home evaluation/assessment tool if Appendix 314-A is not being utilized.
Copy received: Yes _____________ No _____________ N/A _______________
(B) Monitor – Information to complete this item is captured on the client file
checksheets completed during review of the random sample of client files.
# of files reviewed: ______ # of Yes: ______ # of No: ______ # of N/A:______
Administrative Requirements Yes ______ No ______ N/A______
17.
314.10.d Provider has adequate professional liability insurance coverage and bonding for Comments:
and
208.12.d
employees who perform work in and around clients’ homes.
Note: Requirement is applicable to construction for home improvements and not
applicable (N/A) for installation of “simple safety and mobility devices”.
Monitor – Ask for a copy of the provider’s certificates of
insurance/liability/binders/bond for verification of adequate coverage and for the file.
Coverage should include at a minimum workers’ compensation, professional liability,
errors and omissions, general liability, and any agency-owned vehicles.
Copy received: Yes _____________ No _____________ N/A ______________
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Home Modification and Repair Review Guide Page 15 of 24
Section Compliance Yes/ No/ N/A
Number Cited Section 314 – Home Modification and Repair Services Comments
Record Keeping – Client Records Yes ______ No ______ N/A______
208.12.i.1.A;
*18. 208.12.i.1.B;
(Client The AAA, case management agency, or provider shall maintain client records/files as Comments:
208.12.i.1.C;
Files, 208.12.i.1.D; applicable to home repair and modification services in the form and format
AIMS 208.12.i.1.G;
Client 208.12.i.1.I; approved/accepted by the Division of Aging Services. Applicable to the service
Data, and and provided as indicated in this review guide, information contained in the client files shall
AIMS 208.12.i.1.J include, but not is limited to, (A) assessment and reassessment information; (B) client
Reports) identifying information; (C) service agreement; (D) service plan/work plan; (G) reports
from or about the client; (I) AAA referral information; and (J) any additional
information.
Note: As noted in Manual Section 314.10.d.2 and addressed elsewhere in this review
314.10.d.2 guide, assessing staff will conduct an on-site evaluation of the home when assessing the
client for Home Modification and Repair Services.
Monitor – Review client files to evaluate provider file maintenance. The suggested
number of client files to be reviewed would be based on the total number of
unduplicated client files in AIMS for the provider in the HCBS – Missing Data
Elements Report by Individual Service current to this monitoring. Review this report
for the total number of clients. The following chart indicates the number of files to be
reviewed.
Number of Client Files in AIMS Number of Client Files to Review
1 – 60 *Minimum of 6 files
60 + *Minimum of 10%
*If multiple errors are found, increase your sample size.
(A) Number/unduplicated count of home repair clients
in AIMS for the site: __________________
(B) Number of home repair client files to be reviewed. __________________
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Section Compliance Yes/ No/ N/A
Number Cited Section 314 – Home Modification and Repair Services Comments
A “Client File Checksheet” has been included in the beginning of this document to
capture the information required to complete this item and other review guide items.
Enter the totals for each client into Part II of the Excel spreadsheet (Home Mod &
Repair Chksheet.xls). (The Client File Checksheet and Excel spreadsheet are suggested
tools and may be altered to accommodate “searches and findings” for additional data
elements, information, or forms.)
(C) Enter overall compliance/non-compliance rates/percentages from Part II Excel
spreadsheet.
Yes (#)______ _______(%) No (#)_______ _______(%) N/A (#)_______
(D) Were there discrepancies found relating to the provider’s performance of client file
maintenance (i.e., the presence of current,
required information and/or forms)? YES ___________ NO ___________
(E) If “yes”, what kinds of discrepancies were found?
NOTE: Reference “Appendix A” to this review guide for an optional monitoring tool to
evaluate the accuracy of client data entered into AIMS compared to the information
contained in the source document, the client file.
Administrative Requirements Yes ______ No ______ N/A______
314.10.d.3
19.
The provider has designated the following staff to develop and implement a scheduled Comments:
work plan for the services to be performed.
Note: Requirement is applicable to construction for home improvements and not
applicable (N/A) for installation of “simple safety and mobility devices”.
(Name/Title)
(Name/Title)
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Section Compliance Yes/ No/ N/A
Number Cited Section 314 – Home Modification and Repair Services Comments
(Name/Title)
Administrative Requirements – Identification Yes ______ No ______ N/A______
20.
208.12.e.1; The provider agency provides adequate identification (ID) to each employee, including Comments:
208.12.e.2
Rev.
volunteers, who has direct contact with clients/caregivers.
6/2002);
and Monitor – Ask to see a sample of the employees’ ID to verify the following:
208.12.e.3
(1)ID is made of permanent materials. YES __________ NO ____________
(2)ID has provider agency name. YES __________ NO ____________
(3)ID has employee’s name. YES __________ NO ____________
(4)ID has employee’s title. YES __________ NO ____________
(5)ID has employee’s photograph. YES __________ NO ____________
(6)ID is issued at the time of employment. YES __________ NO ____________
(7)Agency requires the ID to be returned
from each employee upon termination. YES __________ NO ____________
Administrative Requirements – Retention and confidentially of client records Yes ______ No ______ N/A______
208.12.i.2.A;
21. 208.12.i.2.B
The AAA, case management agency, or provider has and follows written policies and Comments:
(Revised);
and procedures for the maintenance, security, and confidentiality of client records.
208.12.i.2.C
Monitor – Review a copy of the written policies and procedures, specifically looking at
the following:
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Section Compliance Yes/ No/ N/A
Number Cited Section 314 – Home Modification and Repair Services Comments
(1)The policies specify who supervises the
maintenance of the records. YES __________ NO ____________
(2)The policies specify who shall have
custody of the records. YES __________ NO ____________
(3)The policies specify to whom the record
shall be released to and for what purposes. YES __________ NO ____________
(4)Provision for maintaining records for six (6)
years from the date of the last service provided. YES __________ NO ____________
Administrative Requirements – Personnel records Yes ______ No ______ N/A______
22.
208.12.i.3 Comments:
The provider maintains separate written records for each of its employees. (Not
required for volunteers and sub-contractors.)
Monitor – Review personnel files for documentation of Items A – I, with particular
emphasis on B, C, D, F, G, H, and I (when applicable).
202.17 Monitor - Review documentation or staff personal files to confirm that all employees
have been screened and approved through the state criminal records inspection
process in accordance to state law and the current policy of the Department of Human
Services.
(1) Documentation of approved criminal records
check. YES ______ NO _______
(2) Identifying information: name, address,
208.12.i.3.A
number, emergency contacts. YES ______ NO _______
(3) Documentation of employment or complete history
208.12.i.3.B
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Home Modification and Repair Review Guide Page 19 of 24
Section Compliance Yes/ No/ N/A
Number Cited Section 314 – Home Modification and Repair Services Comments
if unemployed for past five years. YES ______ NO _______
208.12.i.3.C (4) Documentation of qualifications. YES ______ NO _______
(5) Date of employment. YES ______ NO _______
208.12.i.3.E
(6) Description of job descriptions or
208.12.i.3.F
statement of duties and responsibilities. YES ______ NO _______
(7) Documentation of completion of
208.12.i.3.G Orientation and training requirements. YES ______ NO _______
(8) Documentation of annual performance
208.12.i.3.H evaluation. YES ______ NO _______
(9) Documentation of bonding if coverage
208.12.i.3.I for individuals is not provided through a
General liability policy. YES ______ NO _______
Administrative Requirements – Reports of complaints and incidents (1)
Yes ______ No ______ N/A______
23.
208.12.i.4 Comments:
The AAA, case management agency, or provider shall maintain:
208.12.i.4.A (1) All documentation of complaints submitted in accordance with Rules and Regulations
of the State of Georgia.
Monitor – Review the complaint file.
Comments:
(2) All incident reports or reports of unusual occurrences (falls, accidents, etc.). (2)
208.12.i.4.B Yes ______ No ______ N/A______
Comments:
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Georgia DHS Division of Aging Services HCBS Section 314 Revised June 2002
Home Modification and Repair Review Guide Page 20 of 24
Section Compliance Yes/ No/ N/A
Number Cited Section 314 – Home Modification and Repair Services Comments
Monitor – Review the incident/occurrence reports.
Comments:
(3)
208.12.i.4.C (3)Documentation of action taken by the provider to resolve clients’ complaints and to Yes ______ No ______ N/A______
address any incident reports or unusual occurrences. Comments:
Monitor – Review follow-up documentation.
Comments:
Mandatory reporting of suspected abuse, neglect, or exploitation Yes ______ No ______ N/A______
24. 208.13
If the provider is an entity which also provides other social/health services, staff and Comments:
volunteers shall be trained in the responsibility of being mandatory reporters of
suspected situations of abuse, neglect, exploitation, or the likelihood of serious physical
harm involving older persons and reporting such incidents to the proper authorities.
Does the provider agency also provide social/health services? Yes ______ No ______
If “yes” how, when and by whom are staff/volunteers trained to recognize and report
abuse, neglect, exploitation, etc.?
Describe:
Note: Any other agency or person having reason to believe an elderly adult is being
abused, neglected or exploited can make a report.
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Georgia DHS Division of Aging Services HCBS Section 314 Revised June 2002
Home Modification and Repair Review Guide Page 21 of 24
“Appendix A”
Section 314 – Home Modification and Repair Services
Instructions to Complete the Client File Checksheet and
Part I of the Attached Excel Spreadsheet
This is an optional monitoring tool to evaluate the accuracy of client data entered into AIMS
compared to information contained in the source document - the client file.
1. Determine the number of clients in AIMS for the service provider.
2. Determine the number of client files to be reviewed.
3. Request files from service provider.
4. Compare information contained in the client files to information entered into AIMS noting findings on
copies of the checksheet using codes below. Checksheet may be adapted to include additional data
elements in the review.
5. Adjust the number of lines in the Excel spreadsheet. (See Part I of the attached file: Home Mod &
Repair Chksheet.xls) to accommodate the number of client files reviewed.
6. Total the number of marks in the “yes”, “no”, “other”, and “both” columns on the checksheet.
7. Enter the number of data elements reviewed into the attached Excel spreadsheet. (Same number of data
elements for each client.)
8. Enter column totals for each client into the attached Excel spreadsheet from checksheet.
9. Enter overall compliance/non-compliance rates/percentages in appropriate spaces in “Appendix A”.
Codes for comparing information contained in client files to information in AIMS (data elements):
Yes - AIMS Information and the source document information matched.
No - AIMS Information and the source document information did not match or the information was
contained in the source document and not entered into AIMS.
Other - No information contained in source document.
Both - Information was blank in both the source document and in AIMS.
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Home Modification and Repair Review Guide Page 22 of 24
“Appendix A”
to Section 314 – Home Modification and Repair Services
This is an optional monitoring tool to evaluate the accuracy of client data entered into AIMS
compared to information contained in the source document, the client file.
CLIENT FILE CHECKSHEET
Client Name:_______________________________________________________ Client I.D. #:________________
(Last) (First) (Middle)
Provider:_______________________________ _ Reviewer’s Name:__________________________________
File #_____of _____ (number) of files to be reviewed.
Item
Data Elements Yes No Other Both Comments
#
1. Client Name
2. SSN
3. Address
4. City
5. State
6. Zip
7. County
8. Phone #
9. Gender
10. Birth Date
11. Martial Status
12. Race
13. Living Arrangements
14. # in Household
15. Client Income
16. Current Assessment
Information In AIMS
17.
18.
19
20.
21.
Total
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Home Modification and Repair Review Guide Page 23 of 24
“Appendix A” to Section 314
This is an optional monitoring tool to evaluate the accuracy of client data entered into AIMS compared to
information contained in the source document, the client file.
Comments:
1. Provider: ________________________________________________________________
Site: ____________________________________________________________________
Service Provided to Clients Reviewed: _________________________________________
Date of Evaluation: ________________________________________________________
Monitor – To evaluate the integrity of AIMS data entry of information contained in
client files, randomly select and request client files/source documents from the provider.
Compare the client’s information as entered into AIMS to the information contained in
the client files. The suggested number of client files to be reviewed would be based on
the total number of unduplicated client files in AIMS for a provider’s site by service
current to this evaluation. The HCBS – Missing Data Elements Report by Individual
Service Report will total the number of clients in AIMS. The following chart indicates
the number of files to be reviewed.
Number of Client Files in AIMS Number of Client Files to Review
1 – 60 *Minimum of 6 files
60 + *Minimum of 10%
*If multiple errors are found, increase your sample size.
Fill out a checksheet for each participant by comparing the information entered into AIMS
to the information contained in the client’s file. Enter the totals for each client into Part I
of the attached Excel spreadsheet. (See attached Excel file: Home Mod & Repair
Chksheet.xls.) The checksheet and attached Excel spreadsheets may be adapted to
accommodate a review for additional information as desired by the AAA.
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Home Modification and Repair Review Guide Page 24 of 24
“Appendix A” to Section 314
This is an optional monitoring tool to evaluate the accuracy of client data entered into AIMS compared to
information contained in the source document, the client file.
(A.)Number/unduplicated count of clients
in AIMS for the site as indicated on the AMS report: ____
(B) Number of these files with one or more
missing data elements as indicated on the AIMS report: ____
(C) Percent of these files with one or more
missing data elements as indicated on the AIMS report: ____
(D) Number of clients files to be reviewed. _____
(E) Enter overall compliance/non-compliance rates/percentages of the client file review
from Part I of the Excel spreadsheet or from you own worksheet.
Yes _________% No _________% Other _________% Both _________%
(F) Who performs data entry of client information into AIMS for provider/site?
_____ Provider Staff OR ______ AAA Staff
(G) Were there discrepancies found in the information
contained in the client files compared to the
information entered into AIMS? YES ____ NO _____
(H) If “yes” to “G”, what kinds of discrepancies were found?
(I) If “yes” to “G”, were discrepancies reported to the
appropriate agency or person for corrections? YES _____ NO _____
Monitor Findings/Comments:
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