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Authorization of Designated Person to Perform Listed Tasks document sample
Document Sample
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 1
COMMUNITY ATTENDANT SERVICES (PHC/FC/CAS)
MONITORING WORKBOOK
Name of Legal Entity Review Level: Review Type: Contract No.
Current Status
Contract Begin Date: Contract End Date:
Completed By Date of Entrance Date of Exit Dates of Review Period
Last Name: (First day on-site) (Last day on-site) Begin: 01/00/1900
First Name: End: 01/00/1900
A response of “Y” means the contractor has met the requirement. “N” means the contractor has not met the requirement. “NA” means the
requirement is not applicable. For any item marked as “N” attach copies of supporting documents. All attachments should be numbered and
indicate the applicable Standard and item.
STANDARD I. POLICIES AND PROCEDURES
(Standard I starts with Question 3)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 2
COMMUNITY ATTENDANT SERVICES (PHC/FC/CAS)
MONITORING WORKBOOK
Name of Legal Entity Review Level: Review Type: Contract No.
Current Status
Contract Begin Date: Contract End Date:
Completed By Date of Entrance Date of Exit Dates of Review Period
Last Name: (First day on-site) (Last day on-site) Begin: 01/00/1900
First Name: End: 01/00/1900
3. Does the means the contractor has met the requirement. “N” means the employees and the requirement. “NA” means the
A response of “Y” contractor have a written process for screeningcontractor has not metcontractors for
requirement is not applicable. For any item marked as “N” attach copies of supporting documents. All attachments should be numbered and
exclusion from participation in Medicare, Medicaid, the State Children’s Health Insurance
indicate the applicable Standard and item.
Answer
Program and all Federal health care programs:
• prior to hiring or contracting and on a monthly basis;
• that includes a search of the federal HHS Office of Inspector General (HHS-OIG) List of Excluded
Individuals/Entities (LEIE) website and the Texas HHSC Office of the Inspector General List of
Excluded Individuals/Entities (LEIE) website;
• prohibits payment for any items or services furnished, ordered, or prescribed by an excluded
individual or entity; and
• requires the contractor to immediately self report any exclusion information discovered to HHSC
OIG
Reference: State Medicaid Director Letter, 09-001; Information Letter 09-33; Information Letter 10-20; Information Letter 11-07
Comments:
Total Yes Total No
STANDARD I. POLICIES AND PROCEDURES 0 0
STANDARD II. ATTENDANT REQUIREMENTS
(See Individual Work Papers for items II. 1-3)
1. Does each of the individual’s attendants meets 1 2 3 4 5
the required qualifications?
6 7 8 9 10
11 12 13 14 15
16 17 18 19 20
21 22 23 24 25
26 27 28 29 30
Reference: 40 TAC §47.23 Attendant Qualifications
Comments: Number Yes Number No
0 0
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 3
COMMUNITY ATTENDANT SERVICES (PHC/FC/CAS)
MONITORING WORKBOOK
Name of Legal Entity Review Level: Review Type: Contract No.
Current Status
Contract Begin Date: Contract End Date:
Completed By Date of Entrance Date of Exit Dates of Review Period
Last Name: (First day on-site) (Last day on-site) Begin: 01/00/1900
First Name: End: 01/00/1900
3. Was of “Y” attendant who began the requirement. “N” means the contractor has not met the 3
A response eachmeans the contractor has metproviding care to requirement. “NA” means the
1 2 4 5
requirement is not applicable. For any item marked as “N” attach copies of supporting documents. All attachments should be numbered and
the individual during the last six months of service
indicate the applicable Standard and item.
delivery within the review period, oriented, as
6 7 8 9 10
required, on or before the first date of service
delivery?
11 12 13 14 15
16 17 18 19 20
21 22 23 24 25
26 27 28 29 30
Reference: 40 TAC §47.25 Attendant Orientation
Comments: Number Yes Number No
0 0
Total Yes Total No
STANDARD II. ATTENDANT REQUIREMENTS 0 0
STANDARD III. PRE-INITIATION ACTIVITIES
(See Individual Work Papers for items III. 1-3)
1. Did the contractor complete an evaluation of the 1 2 3 4 5
individual as required?
6 7 8 9 10
11 12 13 14 15
16 17 18 19 20
21 22 23 24 25
26 27 28 29 30
Reference: 40 TAC §47.45 Pre-Initiation Activities
Comments: Number Yes Number No
0 0
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 4
COMMUNITY ATTENDANT SERVICES (PHC/FC/CAS)
MONITORING WORKBOOK
Name of Legal Entity Review Level: Review Type: Contract No.
Current Status
Contract Begin Date: Contract End Date:
Completed By Date of Entrance Date of Exit Dates of Review Period
Last Name: (First day on-site) (Last day on-site) Begin: 01/00/1900
First Name: End: 01/00/1900
A response of “Y” means the contractor has met the requirement. “N” means the contractor has not met the requirement. “NA” means the
2. Did the contractor develop an initial service 1 2 3 4 5
requirement is not applicable. For any item marked as “N” attach copies of supporting documents. All attachments should be numbered and
required?
delivery plan asStandard and item.
indicate the applicable
6 7 8 9 10
11 12 13 14 15
16 17 18 19 20
21 22 23 24 25
26 27 28 29 30
Reference: 40 TAC §47.45 Pre-Initiation Activities
Comments: Number Yes Number No
0 0
3. Did the contractor meet the requirements for the 1 2 3 4 5
individual’s practitioner’s statement?
6 7 8 9 10
11 12 13 14 15
16 17 18 19 20
21 22 23 24 25
Reference: 40 TAC §47.45 Pre-Initiation Activities; 40 TAC §47.47
26 27 28 29 30
Medical Need Determination
Comments: Number Yes Number No
0 0
Total Yes Total No
STANDARD III. PRE-INITIATION ACTIVITIES 0 0
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 5
COMMUNITY ATTENDANT SERVICES (PHC/FC/CAS)
MONITORING WORKBOOK
Name of Legal Entity Review Level: Review Type: Contract No.
Current Status
Contract Begin Date: Contract End Date:
Completed By Date of Entrance Date of Exit Dates of Review Period
Last Name: (First day on-site) (Last day on-site) Begin: 01/00/1900
First Name: End: 01/00/1900
A response of “Y” means the contractor has met the requirement. “N” means the contractor has not met the requirement. “NA” means the
STANDARD IV. SERVICE INITIATION
requirement is not applicable. For any item marked as “N” attach copies of supporting documents. All attachments should be numbered and
(See Individual Work Papers item.
indicate the applicable Standard andfor item IV. 1)
1. Were services initiated as required? 1 2 3 4 5
6 7 8 9 10
11 12 13 14 15
16 17 18 19 20
21 22 23 24 25
26 27 28 29 30
Reference: 40 TAC §47.61 Service Initiation
Comments:
Total Yes Total No
STANDARD IV. SERVICE INITIATION 0 0
STANDARD VI. SERVICE DELIVERY
(See Individual Work Papers for item VI.1)
1. Were personal assistance service hours provided 1 2 3 4 5
in accordance with the individual’s service plans or
as required?
6 7 8 9 10
11 12 13 14 15
16 17 18 19 20
21 22 23 24 25
26 27 28 29 30
Reference: 40 TAC §47.63 Service Delivery
Comments:
Total Yes Total No
STANDARD VI. SERVICE DELIVERY 0 0
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 6
COMMUNITY ATTENDANT SERVICES (PHC/FC/CAS)
MONITORING WORKBOOK
Name of Legal Entity Review Level: Review Type: Contract No.
Current Status
Contract Begin Date: Contract End Date:
Completed By Date of Entrance Date of Exit Dates of Review Period
Last Name: (First day on-site) (Last day on-site) Begin: 01/00/1900
First Name: End: 01/00/1900
A response of “Y” means the contractor has met the requirement. “N” means the contractor has not met the requirement. “NA” means the
STANDARD VII. SERVICE PLAN CHANGE
requirement is not applicable. For any item marked as “N” attach copies of supporting documents. All attachments should be numbered and
(See Individual Work Papers item.
indicate the applicable Standard andfor item VII.1)
1. If a service plan change for PAS was identified or 1 2 3 4 5
requested, did the contractor meet all
requirements?
6 7 8 9 10
11 12 13 14 15
16 17 18 19 20
21 22 23 24 25
26 27 28 29 30
Reference: 40 TAC §47.67 Service Plan Changes
Comments:
Total Yes Total No
STANDARD VII. SERVICE PLAN CHANGE 0 0
STANDARD IX. BILLING
(See Monitoring Workbook-Demand for Payment Notice for item IX.1)
1. DADS did not identify a financial error? 1 2 3 4 5
6 7 8 9 10
11 12 13 14 15
16 17 18 19 20
21 22 23 24 25
Reference: 40 TAC §47.63 Service Delivery; 40 TAC §47.83
26 27 28 29 30
Monitoring Reviews
Comments:
Total Yes Total No
STANDARD IX. BILLING 0 0
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 7
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
1 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
II.1 Complete the Attendants Requirements Table below.
Column A: Enter the name(s) of each attendant that provided direct care to the individual during the last six
months of service delivery to the individual.
Review the contractor’s supporting documentation to answer Columns B, C and G.
Column B: Select “Y” if the attendant is at least 18 years of age or, if under 18 years of age, is a high school
graduate or is enrolled in a vocational educational program and has demonstrated competency to perform the
tasks assigned by the supervisor.
Column C: Select “NA” if Family Care. PHC/CAS- Select “Y” if the attendant is not the individual’s legal parent,
foster parent or spouse of a parent (if a minor- under the age of 18 years) or spouse (if an adult- 18 yrs or older)
Column G: For each attendant review F2101. If hired prior to 6/1/2010, select "NA". If the case manager did NOT
designate the attendant as “Do Not Hire,” select “Y”. If listed as “Do Not Hire”, select “N”. If “N” identify the number
of units provided by the attendant and paid by DADS for the last two months of service to the individual. If DADS
paid for services provided by the attendant, complete the Demand for Payment Notice columns A-H from Contract
Monitoring Claims Report, enter the number of verified units provided by the “DNH” attendant in Column J.
A. B. C. G.
Name of Attendant Attendant Attendant Attendant is
Meets the Meets the NOT
Age Relationship designated
Requirement Requirement COLUMNS LEFT BLANK as "Do Not
INTENTIONALLY Hire"
If hired on or
after
6/1/2010
`
II.1 Does each of the individual’s attendants meet the required qualifications?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 8
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
1 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• Select “Y” if ATTENDANT REQUIREMENTS
STANDARD II.for each row, all responses in column B are "Y" and all responses in
columns C and G are “Y” or "NA" (note: column C will only be NA for Family Care)
• Select “N” if for any row, a response in columns B, C or G is “N”
ORIENTATION CHECKLIST
A. B. C. D. E. F. G.
Name of Individual’s Attendant Date of First Service Date of Orientation Orientation Orientation Provided Orientation Elements not
to Individual Conducted in On or Before First Included All included in the
Person with Date of Service to the Required Orientation
Review service delivery documentation for (Review service delivery (Refer to Participation of the Individual Elements (Enter the
the last six months of service delivery within documentation for the documentation of corresponding
Individual or
review period to determine if
the review period and enter the name of first date of service to the
Attendant Attendant Met elements that were
each attendant that provided care to the sample individual was within Orientations Requirements for not addressed)
individual- NA for a Supervisor providing the last six months of conducted during the Orientation Without
personal assistance services service delivery. If the review period)
unlicensed attendant began
Participation of the
providing services to the Individual
sample individual during the
last six months of service
delivery, enter the first date
of service and complete
columns C - G. If the
unlicensed attendant worked
with the sample individual
prior to the last six months
of service delivery, select
“N” and leave columns C –
G blank.)
Last Six Months
Begin: End:
Last Name: First Name; Answer Date:
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 9
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
1 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Attendant Requirements for Orientation without Participation of the Individual (telephone/verbal): Meet the requirements of a Home health Aide*; have six continuous months of experience
delivering attendant care; has been oriented to the individual and the service plan has not changed; or has previously provided services to the individual.
Required elements:
1. Name of the individual for whom the attendant is to provide care
2. Name of the attendant
3. Date of the attendant orientation
4. Orientation conducted in person with the individual or without the participation of the individual
5. How the individual’s condition affects the performance of tasks
6. Tasks to be performed
7. Service schedule
8. Number of hours of service the attendant is to provide
9. Total number of hours the individual is authorized to receive
10. Safety and emergency procedures, including universal precautions
11. Specific situations about which the attendant should notify the contractor (e.g., changes in the individual’s needs; incidents that affect the individual’s condition; hospitalization;
absence or relocation from home; attendant’s inability to work; and suspicion/allegation of abuse, neglect or exploitation of the individual).
12. Signature of the Supervisor who conducted the orientation
13. Signature of the attendant, if present
14. Signature of the individual, if present
*A Home Health Aide must:
o have a minimum of six months experience in delivering personal care tasks in family care, primary home care, personal assistance services, client managed personal attendant
services; or
o be listed on the DADS Nurses Aide Registry with an employable “Active’ status.
II. 3. Was each attendant who began providing care to the individual during the last
six months of service delivery within the review period, oriented, as required, on or
before the first date of service delivery?
• Select “NA” if the individual’s attendant(s) began providing care to the individual prior
to the review period.
• Select “Y” if column B is “Y” and columns D., E and F. are “Y”
• Select “N” if column B is “Y” and column D., E and/or F is “N”.
STANDARD III. PRE-INITIATION ACTIVITIES
OVERARCHING QUESTION Did
the individual's pre-initiation activities occur during the review period?
III.1 • If overarching question III.1 is “N”, select “NA” for Standard III.1-3. Not Calculated in
Continue to Standard IV.1. Score
• If overarching question III.1 is “Y”, verify pre-initiation activities were
completed as required.
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 10
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
1 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Date of Referral Date of Referral Negotiated Date Stamp on Date of
(F2101, item 1) (F2101, item 25) Service Initiation F2101 Notification for
Date Intake
(Routine) (Expedited/Transf (Expedited/Transf (Retroactive)
er) er)
Date of Evaluation:
a. Routine Referral
i) Is the date of the evaluation within 14 calendar days after the date of referral or the date
the contractor received F-2101 as indicated by a date stamp- whichever is later; or
ii) If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the evaluation?
b. Expedited Referral (transfers are reviewed as an expedited referral)
i) Is the date of the evaluation on or before the date negotiated between the case
manager and contractor, which must be less than 14 days after the oral request; or
ii) If a delay, did the contractor notify the case manager of any failure to complete the
evaluation before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i) Is the date of the evaluation on or before the date of notification to DADS for intake?
d. Does the evaluation include the individual’s self-report of the dates and reasons for any
hospitalizations within 3 months prior to the evaluation were addressed?
e. Does the evaluation identify assistance needed to achieve activities of daily living,
including any assistive devices or medical equipment used by the person?
III.1. Did the contractor complete an evaluation of the individual as required?
o Select “Y” if a, b, or c is “Y” and d and e are “Y”
o Select “N” if a, b, or c is “N” and d and/or e is “N”
Date of Initial Service Delivery Plan:
a. Routine Referral
i. Was the initial service delivery plan completed within 14 calendar days after the referral
date or the date the contractor received F- 2101 as indicated by a date stamp- whichever
is later; or
ii. If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the service plan?
b. Expedited Referral (transfers are reviewed as an expedited referral)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 11
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
1 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
i. Is the date of the service delivery plan on or before the date negotiated between the
case manager and contractor, which must be less than 14 days after the oral request; or
ii If a delay, did the contractor notify the case manager of any failure to complete the
service delivery plan before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i. Was the service plan complete prior to the date of notification to DADS for intake?
d. The service plan is agreed upon and was signed by the individual and the contractor
e. The service plan identifies the location of service delivery
f. The service plan identifies the tasks the individual will receive (includes at least one
personal care task, unless FC)
g. The service plan identifies the total weekly hours authorized
h. The service plan identifies the service schedule which includes as necessary, based
on the individual’s needs, certain time periods for the delivery of specified tasks
i. The service plan identifies the frequency of supervisory visits
j. The service plan includes the statement that the contractor is responsible for providing
the tasks allowable in the PHC program (47.41) and agreed to on the service plan.
III. 2. Did the contractor develop an initial service delivery plan as required?
• Select “Y” if a, b, or c is “Y” and d - j are “Y”
• Select “N” if a, b, or c is “N” and/or d – j is “N”
OVERARCHING QUESTION Does
the individual receive family care or did the individual transfer from one
PHC contractor to another PHC, transfer from PHC to CAS or transfer from
Not Calculated in
CAS to PHC during the review period?
III.3 Score
• If overarching question III.3 is “Y”, select “NA” for Standard III.3. Continue
to Standard IV.1.
• If overarching question III.3 is “N”, verify the contractor met the
requirements for the individual’s practitioner’s statement.
Date of Practitioner’s Statement:
a. Routine Referral
i. Did the contractor obtain and submit to DADS a complete practitioner’s statement
within 14 calendar days after the date of referral or the date the contractor received F-
2101 as indicated by a date stamp- whichever is later. Review the contractor's fax, email
or other documentation that verifies the practitioner's statement was submitted to DADS
within the required timeframe; or
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 12
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
1 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. If a delay, II. ATTENDANT REQUIREMENTS
STANDARDdid the contractor document by due date the reason for the delay, an
anticipated date of completion or reason why a completion date cannot be anticipated;
and a description of the contractor’s efforts to obtain the practitioner’s statement?
b. Expedited Referral
i. Did the contractor send a complete practitioner’s statement to DADS within seven (7)
work days after service initiation? Review the contractor's fax, email or other
documentation that verifies the practitioner's statement was submitted to DADS within the
required timeframe.
c. Retroactive
i. Was the practitioner’s statement completed on or before the date of notification to
DADS for intake?
III. 3. Did the contractor meet the requirements for the individual’s practitioner’s
statement?
• Select “Y” if a, b, or c (as applicable) is “Y”
• Select “N” if a, b, or c ( as applicable) is “N”
Potential Billing Error:
If III.3 is “N”, review the Contract Monitoring Claims Report Payment Report for the billing periods within the 12
month review period prior to the date of the practitioner’s statement to determine if DADS paid for services prior to
the date of the practitioner’s statement. If DADS paid for services prior to the date of the practitioner’s statement,
complete Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for Payment. Enter “0” in Column J -
Units Verified for units paid prior to the date of the practitioner’s statement.
STANDARD IV. SERVICE INITIATION
OVERARCHING QUESTION Did
the individual enter services during the review period?
• If overarching question IV.1 is “N”, select “NA” for Standard IV.1. Continue Not Calculated in
IV.1
to Standard V.1. Score
• If overarching question IV.1 is “Y”, verify the contractor met the
requirements for service initiation.
a. Family Care- First Date of Service:
i. Routine Referral-Did services begin within 14 days after the referral date or
within 14 days after the date the contractor date stamped DADS’ authorization
form; or
ii. Transfer- Did services begin on the date negotiated between the case manager
and the contractor?
b. Primary Home Care or Community Attendant Services- First Date of Service:
i. Routine Referral- Did services begin within seven days after the date the
contractor’s receipt of DADS’ Authorization form?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 13
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
1 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. Transfer- Did services begin on the date negotiated between the case manager
STANDARD II. ATTENDANT REQUIREMENTS
and the contractor?
c. If a delay in service initiation did the contractor document the reason for the delay,
either an anticipated date of initiation or specific reasons why the contractor cannot
anticipate a date and a description of the contractor’s efforts to initiate services?
d. Did the contractor send notice of service initiation to the case manager within 14 days
after initiating services?
IV. 1. Were services initiated as required?
• Select “Y” if a is “Y”, b is “NA”, c is “NA” and d is “Y”
• Select “Y” if a is “NA”, b is “Y”, c is “NA” and d is “Y”
• Select “Y” if a or b is “N”, c is “Y” and d is “Y”
• Select “N” if a or b is “N”, c is “N” and d is “Y”
• Select “N” if d is “N”
VI. SERVICE DELIVERY
Complete UNITS OF SERVICE Tables for the last six months of service within the review
VI.1
period then answer VI.1.
a. Priority status- Does the number of documented hours/units of service equal the
number of authorized hours/units; or
Non-Priority status- Does the number of documented hours/units of service indicate that
there were no service interruptions exceeding 14 consecutive days?
b. If a is “N” was the reason for the failure to provide all service hours one of the
following:
• the individual’s revised service plan identified a need for an ongoing decrease in
hours;
• the individual requested that services not be provided;
• the individual requested fewer hours of service than reflected in the service
schedule;
• the individual requested that a specific attendant not provide services;
• the individual was not at home when the service was scheduled;
• services were not delivered for other reasons beyond the control of the provider
agency; or
• services were suspended.
- The individual temporarily or permanently left the contracted services delivery area;
- The individual moved to a location where services could not be provided under the PHC program;
- The individual died;
- The individual was admitted to an institution (hospital, nursing facility, state school, state hospital, or
ICF-MR facility);
- The individual requested that services end;
- DADS denied the individual’s Medicaid eligibility (not applicable to FC);
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 14
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
1 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
- The individual or someone in the individual’s home exhibited reckless behavior, which may have
STANDARD II. ATTENDANT REQUIREMENTS
resulted in imminent danger to the health and safety of the individual, the attendant, or another person;
- The individual or someone else in the individual’s home engaged in discrimination against a provider
agency or DADS employee in violation of applicable law;
- The individual refused services for more than 30 consecutive days.
VI. 1. Were personal assistance service hours provided in accordance with the
individual’s service plans or as required?
• Select “Y” if a is “Y” or a is “N” and b is “Y”
• Select “N” if a and b are “N”
STANDARD VII. SERVICE PLAN CHANGE
• Review the individual’s record for the 12 month review period to determine if a service plan change
was identified and requested.
VII.1.
• Select “NA” if a service plan change was not identified/requested. Continue to Standard VIII.
• If a service plan change was identified/requested, complete the table below.
Date(s) of /identified Date of notification to Effective Date Date of Date(s) of identified Date of revised service
need/request for an the contractor OR (F2101, item 4) Implementation need/request for a plan
increase in service case manager (Service Delivery decrease in service
hours or change that (F2067 or equivalent) Documentation) hours
results in no delivery
of personal care tasks
a. Immediate increase in hours:
i. If requested by the contractor, did the contractor’s documentation include:
• evidence that the contractor discussed the reason for the request of immediate
increase in hours with the case manager? NA
• the date the contractor received approval from the case manager? NA
• the name of the case manager who approved the change? NA
• the effective date of change, and NA
• the number of hours authorized? NA
ii. Did the contractor implement the service plan change on the date negotiated with the
NA
case manager? NA
b. Increase in service hours or no delivery of personal care tasks:
i. If requested by the contractor, was the case manager notified in writing within seven
days from the date of request/identification of need; and NA
ii. Did the notification include:
• date the provider agency learned of the need for the change;
NA
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 15
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
1 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• reason II. ATTENDANT REQUIREMENTS
STANDARD for the change;
NA
• type of change (including the number of service hours) and:
• signature and date of the provider agency representative?
iii. For any increase in service hours requested by the contractor, individual or case manager, did the contractor
implement the change within the required timeframe?
• Was the service plan change implemented on the Begin Date (F2101, item 4) or
five days after the contractor’s date stamp on F2101, whichever is later; or NA
• If delayed, did the contractor document, by the next working day, the failure to
implement the service plan change on the effective date to include the reason and NA
new implementation date? NA
c. Decrease in service hours:
i. Did the contractor develop a new service plan within 21 days from the date of the
individual’s request or identification of need for a service plan change? NA
NA
VII.1. If a service plan change for PAS was identified or requested, did the contractor
meet all requirements?
• If the contractor requested an increase in hours or no delivery of personal care tasks -
select “Y” if a. i-ii or b. i-iii are “Y” NA
• If the case manager requested an increase in hours or no delivery of personal care
tasks - select “Y” if a. ii or b. iii are “Y”
• Select “Y” if a decrease in service hours was requested/identified and c. is “Y”
STANDARD IX. BILLING
Compare the Units of Service tables to the Contract Monitoring Claims Report for the last six months of
service delivery within the review period.
OVERARCHING QUESTION For
the last six months of service delivery to the individual within the review
period,:
i. Were the number of units documented equal to or greater than the
number of units paid? Y or N
ii. Were the number of units paid equal to or less than the number of
IX.1a authorized units? (If No, did the increase meet the criteria of a temporary Not Calculated in
increase)? Y or N Score
• If overarching question IX.1a.i and IX.1a.ii are "Y", mark IX.1a"Y" and skip
overarching question IX.1b and mark Standard IX.1 "Y".
• If either overarching question IX.1a.i or IX.1a.ii is“N”, mark IX.1a "N" and
continue to overarching question IX.1b.
OVERARCHING QUESTION Did
the contractor provide evidence that the contractor negative billed the
over-billed amount due to DADS prior to the date of the Entrance
Not Calculated in
Conference?
IX.1b Score
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 16
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
1 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
IX.1b
• If overarching question IX.1b is “Y”, mark
STANDARD II. ATTENDANT REQUIREMENTS Standard IX.1 “Y”.
• If overarching question IX.1b is “N”, mark Standard IX.1 “N”. Complete
Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for
Payment.
IX. 1. DADS did not identify a financial error?
• Select “Y”, if the contractor does not owe an Amount Due to DADS per the Demand
for Payment Notice (Column L)
• Select “Y”, if the contractor provides evidence that the contractor negative billed the
amount due to DADS prior to the date of the entrance Conference.
• Select “N”, if the contractor owes an Amount Due to DADS per the Demand for
Payment Notice (Column L)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 17
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
2 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
II.1 Complete the Attendants Requirements Table below.
Column A: Enter the name(s) of each attendant that provided direct care to the individual during the last six
months of service delivery to the individual.
Review the contractor’s supporting documentation to answer Columns B, C and G.
Column B: Select “Y” if the attendant is at least 18 years of age or, if under 18 years of age, is a high school
graduate or is enrolled in a vocational educational program and has demonstrated competency to perform the
tasks assigned by the supervisor.
Column C: Select “NA” if Family Care. PHC/CAS- Select “Y” if the attendant is not the individual’s legal parent,
foster parent or spouse of a parent (if a minor- under the age of 18 years) or spouse (if an adult- 18 yrs or older)
Column G: For each attendant review F2101. If hired prior to 6/1/2010, select "NA". If the case manager did NOT
designate the attendant as “Do Not Hire,” select “Y”. If listed as “Do Not Hire”, select “N”. If “N” identify the number
of units provided by the attendant and paid by DADS for the last two months of service to the individual. If DADS
paid for services provided by the attendant, complete the Demand for Payment Notice columns A-H from Contract
Monitoring Claims Report, enter the number of verified units provided by the “DNH” attendant in Column J.
A. B. C. G.
Name of Attendant Attendant Attendant Attendant is
Meets the Meets the NOT
Age Relationship designated
Requirement Requirement COLUMNS LEFT BLANK as "Do Not
INTENTIONALLY Hire"
If hired on or
after
6/1/2010
`
II.1 Does each of the individual’s attendants meet the required qualifications?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 18
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
2 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• Select “Y” if ATTENDANT REQUIREMENTS
STANDARD II.for each row, all responses in column B are "Y" and all responses in
columns C and G are “Y” or "NA" (note: column C will only be NA for Family Care)
• Select “N” if for any row, a response in columns B, C or G is “N”
ORIENTATION CHECKLIST
A. B. C. D. E. F. G.
Name of Individual’s Attendant Date of First Service Date of Orientation Orientation Orientation Provided Orientation Elements not
to Individual Conducted in On or Before First Included All included in the
Person with Date of Service to the Required Orientation
Review service delivery documentation for (Review service delivery (Refer to Participation of the Individual Elements (Enter the
the last six months of service delivery within documentation for the documentation of corresponding
Individual or
review period to determine if
the review period and enter the name of first date of service to the
Attendant Attendant Met elements that were
each attendant that provided care to the sample individual was within Orientations Requirements for not addressed)
individual- NA for a Supervisor providing the last six months of conducted during the Orientation Without
personal assistance services service delivery. If the review period)
unlicensed attendant began
Participation of the
providing services to the Individual
sample individual during the
last six months of service
delivery, enter the first date
of service and complete
columns C - G. If the
unlicensed attendant worked
with the sample individual
prior to the last six months
of service delivery, select
“N” and leave columns C –
G blank.)
Last Six Months
Begin: End:
Last Name: First Name; Answer Date:
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 19
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
2 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Attendant Requirements for Orientation without Participation of the Individual (telephone/verbal): Meet the requirements of a Home health Aide*; have six continuous months of experience
delivering attendant care; has been oriented to the individual and the service plan has not changed; or has previously provided services to the individual.
Required elements:
1. Name of the individual for whom the attendant is to provide care
2. Name of the attendant
3. Date of the attendant orientation
4. Orientation conducted in person with the individual or without the participation of the individual
5. How the individual’s condition affects the performance of tasks
6. Tasks to be performed
7. Service schedule
8. Number of hours of service the attendant is to provide
9. Total number of hours the individual is authorized to receive
10. Safety and emergency procedures, including universal precautions
11. Specific situations about which the attendant should notify the contractor (e.g., changes in the individual’s needs; incidents that affect the individual’s condition; hospitalization;
absence or relocation from home; attendant’s inability to work; and suspicion/allegation of abuse, neglect or exploitation of the individual).
12. Signature of the Supervisor who conducted the orientation
13. Signature of the attendant, if present
14. Signature of the individual, if present
*A Home Health Aide must:
o have a minimum of six months experience in delivering personal care tasks in family care, primary home care, personal assistance services, client managed personal attendant
services; or
o be listed on the DADS Nurses Aide Registry with an employable “Active’ status.
II. 3. Was each attendant who began providing care to the individual during the last
six months of service delivery within the review period, oriented, as required, on or
before the first date of service delivery?
• Select “NA” if the individual’s attendant(s) began providing care to the individual prior
to the review period.
• Select “Y” if column B is “Y” and columns D., E and F. are “Y”
• Select “N” if column B is “Y” and column D., E and/or F is “N”.
STANDARD III. PRE-INITIATION ACTIVITIES
OVERARCHING QUESTION Did
the individual's pre-initiation activities occur during the review period?
III.1 • If overarching question III.1 is “N”, select “NA” for Standard III.1-3. Not Calculated in
Continue to Standard IV.1. Score
• If overarching question III.1 is “Y”, verify pre-initiation activities were
completed as required.
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 20
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
2 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Date of Referral Date of Referral Negotiated Date Stamp on Date of
(F2101, item 1) (F2101, item 25) Service Initiation F2101 Notification for
Date Intake
(Routine) (Expedited/Transf (Expedited/Transf (Retroactive)
er) er)
Date of Evaluation:
a. Routine Referral
i) Is the date of the evaluation within 14 calendar days after the date of referral or the date
the contractor received F-2101 as indicated by a date stamp- whichever is later; or
ii) If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the evaluation?
b. Expedited Referral (transfers are reviewed as an expedited referral)
i) Is the date of the evaluation on or before the date negotiated between the case
manager and contractor, which must be less than 14 days after the oral request; or
ii) If a delay, did the contractor notify the case manager of any failure to complete the
evaluation before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i) Is the date of the evaluation on or before the date of notification to DADS for intake?
d. Does the evaluation include the individual’s self-report of the dates and reasons for any
hospitalizations within 3 months prior to the evaluation were addressed?
e. Does the evaluation identify assistance needed to achieve activities of daily living,
including any assistive devices or medical equipment used by the person?
III.1. Did the contractor complete an evaluation of the individual as required?
o Select “Y” if a, b, or c is “Y” and d and e are “Y”
o Select “N” if a, b, or c is “N” and d and/or e is “N”
Date of Initial Service Delivery Plan:
a. Routine Referral
i. Was the initial service delivery plan completed within 14 calendar days after the referral
date or the date the contractor received F- 2101 as indicated by a date stamp- whichever
is later; or
ii. If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the service plan?
b. Expedited Referral (transfers are reviewed as an expedited referral)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 21
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
2 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
i. Is the date of the service delivery plan on or before the date negotiated between the
case manager and contractor, which must be less than 14 days after the oral request; or
ii If a delay, did the contractor notify the case manager of any failure to complete the
service delivery plan before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i. Was the service plan complete prior to the date of notification to DADS for intake?
d. The service plan is agreed upon and was signed by the individual and the contractor
e. The service plan identifies the location of service delivery
f. The service plan identifies the tasks the individual will receive (includes at least one
personal care task, unless FC)
g. The service plan identifies the total weekly hours authorized
h. The service plan identifies the service schedule which includes as necessary, based
on the individual’s needs, certain time periods for the delivery of specified tasks
i. The service plan identifies the frequency of supervisory visits
j. The service plan includes the statement that the contractor is responsible for providing
the tasks allowable in the PHC program (47.41) and agreed to on the service plan.
III. 2. Did the contractor develop an initial service delivery plan as required?
• Select “Y” if a, b, or c is “Y” and d - j are “Y”
• Select “N” if a, b, or c is “N” and/or d – j is “N”
OVERARCHING QUESTION Does
the individual receive family care or did the individual transfer from one
PHC contractor to another PHC, transfer from PHC to CAS or transfer from
Not Calculated in
CAS to PHC during the review period?
III.3 Score
• If overarching question III.3 is “Y”, select “NA” for Standard III.3. Continue
to Standard IV.1.
• If overarching question III.3 is “N”, verify the contractor met the
requirements for the individual’s practitioner’s statement.
Date of Practitioner’s Statement:
a. Routine Referral
i. Did the contractor obtain and submit to DADS a complete practitioner’s statement
within 14 calendar days after the date of referral or the date the contractor received F-
2101 as indicated by a date stamp- whichever is later. Review the contractor's fax, email
or other documentation that verifies the practitioner's statement was submitted to DADS
within the required timeframe; or
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 22
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
2 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. If a delay, II. ATTENDANT REQUIREMENTS
STANDARDdid the contractor document by due date the reason for the delay, an
anticipated date of completion or reason why a completion date cannot be anticipated;
and a description of the contractor’s efforts to obtain the practitioner’s statement?
b. Expedited Referral
i. Did the contractor send a complete practitioner’s statement to DADS within seven (7)
work days after service initiation? Review the contractor's fax, email or other
documentation that verifies the practitioner's statement was submitted to DADS within the
required timeframe.
c. Retroactive
i. Was the practitioner’s statement completed on or before the date of notification to
DADS for intake?
III. 3. Did the contractor meet the requirements for the individual’s practitioner’s
statement?
• Select “Y” if a, b, or c (as applicable) is “Y”
• Select “N” if a, b, or c ( as applicable) is “N”
Potential Billing Error:
If III.3 is “N”, review the Contract Monitoring Claims Report Payment Report for the billing periods within the 12
month review period prior to the date of the practitioner’s statement to determine if DADS paid for services prior to
the date of the practitioner’s statement. If DADS paid for services prior to the date of the practitioner’s statement,
complete Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for Payment. Enter “0” in Column J -
Units Verified for units paid prior to the date of the practitioner’s statement.
STANDARD IV. SERVICE INITIATION
OVERARCHING QUESTION Did
the individual enter services during the review period?
• If overarching question IV.1 is “N”, select “NA” for Standard IV.1. Continue Not Calculated in
IV.1
to Standard V.1. Score
• If overarching question IV.1 is “Y”, verify the contractor met the
requirements for service initiation.
a. Family Care- First Date of Service:
i. Routine Referral-Did services begin within 14 days after the referral date or
within 14 days after the date the contractor date stamped DADS’ authorization
form; or
ii. Transfer- Did services begin on the date negotiated between the case manager
and the contractor?
b. Primary Home Care or Community Attendant Services- First Date of Service:
i. Routine Referral- Did services begin within seven days after the date the
contractor’s receipt of DADS’ Authorization form?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 23
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
2 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. Transfer- Did services begin on the date negotiated between the case manager
STANDARD II. ATTENDANT REQUIREMENTS
and the contractor?
c. If a delay in service initiation did the contractor document the reason for the delay,
either an anticipated date of initiation or specific reasons why the contractor cannot
anticipate a date and a description of the contractor’s efforts to initiate services?
d. Did the contractor send notice of service initiation to the case manager within 14 days
after initiating services?
IV. 1. Were services initiated as required?
• Select “Y” if a is “Y”, b is “NA”, c is “NA” and d is “Y”
• Select “Y” if a is “NA”, b is “Y”, c is “NA” and d is “Y”
• Select “Y” if a or b is “N”, c is “Y” and d is “Y”
• Select “N” if a or b is “N”, c is “N” and d is “Y”
• Select “N” if d is “N”
VI. SERVICE DELIVERY
Complete UNITS OF SERVICE Tables for the last six months of service within the review
VI.1
period then answer VI.1.
a. Priority status- Does the number of documented hours/units of service equal the
number of authorized hours/units; or
Non-Priority status- Does the number of documented hours/units of service indicate that
there were no service interruptions exceeding 14 consecutive days?
b. If a is “N” was the reason for the failure to provide all service hours one of the
following:
• the individual’s revised service plan identified a need for an ongoing decrease in
hours;
• the individual requested that services not be provided;
• the individual requested fewer hours of service than reflected in the service
schedule;
• the individual requested that a specific attendant not provide services;
• the individual was not at home when the service was scheduled;
• services were not delivered for other reasons beyond the control of the provider
agency; or
• services were suspended.
- The individual temporarily or permanently left the contracted services delivery area;
- The individual moved to a location where services could not be provided under the PHC program;
- The individual died;
- The individual was admitted to an institution (hospital, nursing facility, state school, state hospital, or
ICF-MR facility);
- The individual requested that services end;
- DADS denied the individual’s Medicaid eligibility (not applicable to FC);
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 24
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
2 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
- The individual or someone in the individual’s home exhibited reckless behavior, which may have
STANDARD II. ATTENDANT REQUIREMENTS
resulted in imminent danger to the health and safety of the individual, the attendant, or another person;
- The individual or someone else in the individual’s home engaged in discrimination against a provider
agency or DADS employee in violation of applicable law;
- The individual refused services for more than 30 consecutive days.
VI. 1. Were personal assistance service hours provided in accordance with the
individual’s service plans or as required?
• Select “Y” if a is “Y” or a is “N” and b is “Y”
• Select “N” if a and b are “N”
STANDARD VII. SERVICE PLAN CHANGE
• Review the individual’s record for the 12 month review period to determine if a service plan change
was identified and requested.
VII.1.
• Select “NA” if a service plan change was not identified/requested. Continue to Standard VIII.
• If a service plan change was identified/requested, complete the table below.
Date(s) of /identified Date of notification to Effective Date Date of Date(s) of identified Date of revised service
need/request for an the contractor OR (F2101, item 4) Implementation need/request for a plan
increase in service case manager (Service Delivery decrease in service
hours or change that (F2067 or equivalent) Documentation) hours
results in no delivery
of personal care tasks
a. Immediate increase in hours:
i. If requested by the contractor, did the contractor’s documentation include:
• evidence that the contractor discussed the reason for the request of immediate
increase in hours with the case manager? NA
• the date the contractor received approval from the case manager? NA
• the name of the case manager who approved the change? NA
• the effective date of change, and NA
• the number of hours authorized? NA
ii. Did the contractor implement the service plan change on the date negotiated with the
NA
case manager? NA
b. Increase in service hours or no delivery of personal care tasks:
i. If requested by the contractor, was the case manager notified in writing within seven
days from the date of request/identification of need; and NA
ii. Did the notification include:
• date the provider agency learned of the need for the change;
NA
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 25
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
2 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• reason II. ATTENDANT REQUIREMENTS
STANDARD for the change;
NA
• type of change (including the number of service hours) and:
• signature and date of the provider agency representative?
iii. For any increase in service hours requested by the contractor, individual or case manager, did the contractor
implement the change within the required timeframe?
• Was the service plan change implemented on the Begin Date (F2101, item 4) or
five days after the contractor’s date stamp on F2101, whichever is later; or NA
• If delayed, did the contractor document, by the next working day, the failure to
implement the service plan change on the effective date to include the reason and NA
new implementation date? NA
c. Decrease in service hours:
i. Did the contractor develop a new service plan within 21 days from the date of the
individual’s request or identification of need for a service plan change? NA
VII.1. If a service plan change for PAS was identified or requested, did the contractor
meet all requirements?
• If the contractor requested an increase in hours or no delivery of personal care tasks -
select “Y” if a. i-ii or b. i-iii are “Y” NA
• If the case manager requested an increase in hours or no delivery of personal care
tasks - select “Y” if a. ii or b. iii are “Y”
• Select “Y” if a decrease in service hours was requested/identified and c. is “Y”
STANDARD IX. BILLING
Compare the Units of Service tables to the Contract Monitoring Claims Report for the last six months of
service delivery within the review period.
OVERARCHING QUESTION For
the last six months of service delivery to the individual within the review
period,:
i. Were the number of units documented equal to or greater than the
number of units paid? Y or N
ii. Were the number of units paid equal to or less than the number of
IX.1a authorized units? (If No, did the increase meet the criteria of a temporary Not Calculated in
increase)? Y or N Score
• If overarching question IX.1a.i and IX.1a.ii are "Y", mark IX.1a"Y" and skip
overarching question IX.1b and mark Standard IX.1 "Y".
• If either overarching question IX.1a.i or IX.1a.ii is“N”, mark IX.1a "N" and
continue to overarching question IX.1b.
OVERARCHING QUESTION Did
the contractor provide evidence that the contractor negative billed the
over-billed amount due to DADS prior to the date of the Entrance
Not Calculated in
Conference?
IX.1b Score
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 26
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
2 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
IX.1b
• If overarching question IX.1b is “Y”, mark
STANDARD II. ATTENDANT REQUIREMENTS Standard IX.1 “Y”.
• If overarching question IX.1b is “N”, mark Standard IX.1 “N”. Complete
Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for
Payment.
IX. 1. DADS did not identify a financial error?
• Select “Y”, if the contractor does not owe an Amount Due to DADS per the Demand
for Payment Notice (Column L)
• Select “Y”, if the contractor provides evidence that the contractor negative billed the
amount due to DADS prior to the date of the entrance Conference.
• Select “N”, if the contractor owes an Amount Due to DADS per the Demand for
Payment Notice (Column L)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 27
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
3 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
II.1 Complete the Attendants Requirements Table below.
Column A: Enter the name(s) of each attendant that provided direct care to the individual during the last six
months of service delivery to the individual.
Review the contractor’s supporting documentation to answer Columns B, C and G.
Column B: Select “Y” if the attendant is at least 18 years of age or, if under 18 years of age, is a high school
graduate or is enrolled in a vocational educational program and has demonstrated competency to perform the
tasks assigned by the supervisor.
Column C: Select “NA” if Family Care. PHC/CAS- Select “Y” if the attendant is not the individual’s legal parent,
foster parent or spouse of a parent (if a minor- under the age of 18 years) or spouse (if an adult- 18 yrs or older)
Column G: For each attendant review F2101. If hired prior to 6/1/2010, select "NA". If the case manager did NOT
designate the attendant as “Do Not Hire,” select “Y”. If listed as “Do Not Hire”, select “N”. If “N” identify the number
of units provided by the attendant and paid by DADS for the last two months of service to the individual. If DADS
paid for services provided by the attendant, complete the Demand for Payment Notice columns A-H from Contract
Monitoring Claims Report, enter the number of verified units provided by the “DNH” attendant in Column J.
A. B. C. G.
Name of Attendant Attendant Attendant Attendant is
Meets the Meets the NOT
Age Relationship designated
Requirement Requirement COLUMNS LEFT BLANK as "Do Not
INTENTIONALLY Hire"
If hired on or
after
6/1/2010
`
II.1 Does each of the individual’s attendants meet the required qualifications?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 28
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
3 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• Select “Y” if ATTENDANT REQUIREMENTS
STANDARD II.for each row, all responses in column B are "Y" and all responses in
columns C and G are “Y” or "NA" (note: column C will only be NA for Family Care)
• Select “N” if for any row, a response in columns B, C or G is “N”
ORIENTATION CHECKLIST
A. B. C. D. E. F. G.
Name of Individual’s Attendant Date of First Service Date of Orientation Orientation Orientation Provided Orientation Elements not
to Individual Conducted in On or Before First Included All included in the
Person with Date of Service to the Required Orientation
Review service delivery documentation for (Review service delivery (Refer to Participation of the Individual Elements (Enter the
the last six months of service delivery within documentation for the documentation of corresponding
Individual or
review period to determine if
the review period and enter the name of first date of service to the
Attendant Attendant Met elements that were
each attendant that provided care to the sample individual was within Orientations Requirements for not addressed)
individual- NA for a Supervisor providing the last six months of conducted during the Orientation Without
personal assistance services service delivery. If the review period)
unlicensed attendant began
Participation of the
providing services to the Individual
sample individual during the
last six months of service
delivery, enter the first date
of service and complete
columns C - G. If the
unlicensed attendant worked
with the sample individual
prior to the last six months
of service delivery, select
“N” and leave columns C –
G blank.)
Last Six Months
Begin: End:
Last Name: First Name; Answer Date:
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 29
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
3 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Attendant Requirements for Orientation without Participation of the Individual (telephone/verbal): Meet the requirements of a Home health Aide*; have six continuous months of experience
delivering attendant care; has been oriented to the individual and the service plan has not changed; or has previously provided services to the individual.
Required elements:
1. Name of the individual for whom the attendant is to provide care
2. Name of the attendant
3. Date of the attendant orientation
4. Orientation conducted in person with the individual or without the participation of the individual
5. How the individual’s condition affects the performance of tasks
6. Tasks to be performed
7. Service schedule
8. Number of hours of service the attendant is to provide
9. Total number of hours the individual is authorized to receive
10. Safety and emergency procedures, including universal precautions
11. Specific situations about which the attendant should notify the contractor (e.g., changes in the individual’s needs; incidents that affect the individual’s condition; hospitalization;
absence or relocation from home; attendant’s inability to work; and suspicion/allegation of abuse, neglect or exploitation of the individual).
12. Signature of the Supervisor who conducted the orientation
13. Signature of the attendant, if present
14. Signature of the individual, if present
*A Home Health Aide must:
o have a minimum of six months experience in delivering personal care tasks in family care, primary home care, personal assistance services, client managed personal attendant
services; or
o be listed on the DADS Nurses Aide Registry with an employable “Active’ status.
II. 3. Was each attendant who began providing care to the individual during the last
six months of service delivery within the review period, oriented, as required, on or
before the first date of service delivery?
• Select “NA” if the individual’s attendant(s) began providing care to the individual prior
to the review period.
• Select “Y” if column B is “Y” and columns D., E and F. are “Y”
• Select “N” if column B is “Y” and column D., E and/or F is “N”.
STANDARD III. PRE-INITIATION ACTIVITIES
OVERARCHING QUESTION Did
the individual's pre-initiation activities occur during the review period?
III.1 • If overarching question III.1 is “N”, select “NA” for Standard III.1-3. Not Calculated in
Continue to Standard IV.1. Score
• If overarching question III.1 is “Y”, verify pre-initiation activities were
completed as required.
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 30
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
3 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Date of Referral Date of Referral Negotiated Date Stamp on Date of
(F2101, item 1) (F2101, item 25) Service Initiation F2101 Notification for
Date Intake
(Routine) (Expedited/Transf (Expedited/Transf (Retroactive)
er) er)
Date of Evaluation:
a. Routine Referral
i) Is the date of the evaluation within 14 calendar days after the date of referral or the date
the contractor received F-2101 as indicated by a date stamp- whichever is later; or
ii) If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the evaluation?
b. Expedited Referral (transfers are reviewed as an expedited referral)
i) Is the date of the evaluation on or before the date negotiated between the case
manager and contractor, which must be less than 14 days after the oral request; or
ii) If a delay, did the contractor notify the case manager of any failure to complete the
evaluation before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i) Is the date of the evaluation on or before the date of notification to DADS for intake?
d. Does the evaluation include the individual’s self-report of the dates and reasons for any
hospitalizations within 3 months prior to the evaluation were addressed?
e. Does the evaluation identify assistance needed to achieve activities of daily living,
including any assistive devices or medical equipment used by the person?
III.1. Did the contractor complete an evaluation of the individual as required?
o Select “Y” if a, b, or c is “Y” and d and e are “Y”
o Select “N” if a, b, or c is “N” and d and/or e is “N”
Date of Initial Service Delivery Plan:
a. Routine Referral
i. Was the initial service delivery plan completed within 14 calendar days after the referral
date or the date the contractor received F- 2101 as indicated by a date stamp- whichever
is later; or
ii. If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the service plan?
b. Expedited Referral (transfers are reviewed as an expedited referral)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 31
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
3 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
i. Is the date of the service delivery plan on or before the date negotiated between the
case manager and contractor, which must be less than 14 days after the oral request; or
ii If a delay, did the contractor notify the case manager of any failure to complete the
service delivery plan before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i. Was the service plan complete prior to the date of notification to DADS for intake?
d. The service plan is agreed upon and was signed by the individual and the contractor
e. The service plan identifies the location of service delivery
f. The service plan identifies the tasks the individual will receive (includes at least one
personal care task, unless FC)
g. The service plan identifies the total weekly hours authorized
h. The service plan identifies the service schedule which includes as necessary, based
on the individual’s needs, certain time periods for the delivery of specified tasks
i. The service plan identifies the frequency of supervisory visits
j. The service plan includes the statement that the contractor is responsible for providing
the tasks allowable in the PHC program (47.41) and agreed to on the service plan.
III. 2. Did the contractor develop an initial service delivery plan as required?
• Select “Y” if a, b, or c is “Y” and d - j are “Y”
• Select “N” if a, b, or c is “N” and/or d – j is “N”
OVERARCHING QUESTION Does
the individual receive family care or did the individual transfer from one
PHC contractor to another PHC, transfer from PHC to CAS or transfer from
Not Calculated in
CAS to PHC during the review period?
III.3 Score
• If overarching question III.3 is “Y”, select “NA” for Standard III.3. Continue
to Standard IV.1.
• If overarching question III.3 is “N”, verify the contractor met the
requirements for the individual’s practitioner’s statement.
Date of Practitioner’s Statement:
a. Routine Referral
i. Did the contractor obtain and submit to DADS a complete practitioner’s statement
within 14 calendar days after the date of referral or the date the contractor received F-
2101 as indicated by a date stamp- whichever is later. Review the contractor's fax, email
or other documentation that verifies the practitioner's statement was submitted to DADS
within the required timeframe; or
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 32
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
3 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. If a delay, II. ATTENDANT REQUIREMENTS
STANDARDdid the contractor document by due date the reason for the delay, an
anticipated date of completion or reason why a completion date cannot be anticipated;
and a description of the contractor’s efforts to obtain the practitioner’s statement?
b. Expedited Referral
i. Did the contractor send a complete practitioner’s statement to DADS within seven (7)
work days after service initiation? Review the contractor's fax, email or other
documentation that verifies the practitioner's statement was submitted to DADS within the
required timeframe.
c. Retroactive
i. Was the practitioner’s statement completed on or before the date of notification to
DADS for intake?
III. 3. Did the contractor meet the requirements for the individual’s practitioner’s
statement?
• Select “Y” if a, b, or c (as applicable) is “Y”
• Select “N” if a, b, or c ( as applicable) is “N”
Potential Billing Error:
If III.3 is “N”, review the Contract Monitoring Claims Report Payment Report for the billing periods within the 12
month review period prior to the date of the practitioner’s statement to determine if DADS paid for services prior to
the date of the practitioner’s statement. If DADS paid for services prior to the date of the practitioner’s statement,
complete Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for Payment. Enter “0” in Column J -
Units Verified for units paid prior to the date of the practitioner’s statement.
STANDARD IV. SERVICE INITIATION
OVERARCHING QUESTION Did
the individual enter services during the review period?
• If overarching question IV.1 is “N”, select “NA” for Standard IV.1. Continue Not Calculated in
IV.1
to Standard V.1. Score
• If overarching question IV.1 is “Y”, verify the contractor met the
requirements for service initiation.
a. Family Care- First Date of Service:
i. Routine Referral-Did services begin within 14 days after the referral date or
within 14 days after the date the contractor date stamped DADS’ authorization
form; or
ii. Transfer- Did services begin on the date negotiated between the case manager
and the contractor?
b. Primary Home Care or Community Attendant Services- First Date of Service:
i. Routine Referral- Did services begin within seven days after the date the
contractor’s receipt of DADS’ Authorization form?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 33
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
3 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. Transfer- Did services begin on the date negotiated between the case manager
STANDARD II. ATTENDANT REQUIREMENTS
and the contractor?
c. If a delay in service initiation did the contractor document the reason for the delay,
either an anticipated date of initiation or specific reasons why the contractor cannot
anticipate a date and a description of the contractor’s efforts to initiate services?
d. Did the contractor send notice of service initiation to the case manager within 14 days
after initiating services?
IV. 1. Were services initiated as required?
• Select “Y” if a is “Y”, b is “NA”, c is “NA” and d is “Y”
• Select “Y” if a is “NA”, b is “Y”, c is “NA” and d is “Y”
• Select “Y” if a or b is “N”, c is “Y” and d is “Y”
• Select “N” if a or b is “N”, c is “N” and d is “Y”
• Select “N” if d is “N”
VI. SERVICE DELIVERY
Complete UNITS OF SERVICE Tables for the last six months of service within the review
VI.1
period then answer VI.1.
a. Priority status- Does the number of documented hours/units of service equal the
number of authorized hours/units; or
Non-Priority status- Does the number of documented hours/units of service indicate that
there were no service interruptions exceeding 14 consecutive days?
b. If a is “N” was the reason for the failure to provide all service hours one of the
following:
• the individual’s revised service plan identified a need for an ongoing decrease in
hours;
• the individual requested that services not be provided;
• the individual requested fewer hours of service than reflected in the service
schedule;
• the individual requested that a specific attendant not provide services;
• the individual was not at home when the service was scheduled;
• services were not delivered for other reasons beyond the control of the provider
agency; or
• services were suspended.
- The individual temporarily or permanently left the contracted services delivery area;
- The individual moved to a location where services could not be provided under the PHC program;
- The individual died;
- The individual was admitted to an institution (hospital, nursing facility, state school, state hospital, or
ICF-MR facility);
- The individual requested that services end;
- DADS denied the individual’s Medicaid eligibility (not applicable to FC);
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 34
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
3 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
- The individual or someone in the individual’s home exhibited reckless behavior, which may have
STANDARD II. ATTENDANT REQUIREMENTS
resulted in imminent danger to the health and safety of the individual, the attendant, or another person;
- The individual or someone else in the individual’s home engaged in discrimination against a provider
agency or DADS employee in violation of applicable law;
- The individual refused services for more than 30 consecutive days.
VI. 1. Were personal assistance service hours provided in accordance with the
individual’s service plans or as required?
• Select “Y” if a is “Y” or a is “N” and b is “Y”
• Select “N” if a and b are “N”
STANDARD VII. SERVICE PLAN CHANGE
• Review the individual’s record for the 12 month review period to determine if a service plan change
was identified and requested.
VII.1.
• Select “NA” if a service plan change was not identified/requested. Continue to Standard VIII.
• If a service plan change was identified/requested, complete the table below.
Date(s) of /identified Date of notification to Effective Date Date of Date(s) of identified Date of revised service
need/request for an the contractor OR (F2101, item 4) Implementation need/request for a plan
increase in service case manager (Service Delivery decrease in service
hours or change that (F2067 or equivalent) Documentation) hours
results in no delivery
of personal care tasks
a. Immediate increase in hours:
i. If requested by the contractor, did the contractor’s documentation include:
• evidence that the contractor discussed the reason for the request of immediate
increase in hours with the case manager? NA
• the date the contractor received approval from the case manager? NA
• the name of the case manager who approved the change? NA
• the effective date of change, and NA
• the number of hours authorized? NA
ii. Did the contractor implement the service plan change on the date negotiated with the
NA
case manager? NA
b. Increase in service hours or no delivery of personal care tasks:
i. If requested by the contractor, was the case manager notified in writing within seven
days from the date of request/identification of need; and NA
ii. Did the notification include:
• date the provider agency learned of the need for the change;
NA
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 35
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
3 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• reason II. ATTENDANT REQUIREMENTS
STANDARD for the change;
NA
• type of change (including the number of service hours) and:
• signature and date of the provider agency representative?
iii. For any increase in service hours requested by the contractor, individual or case manager, did the contractor
implement the change within the required timeframe?
• Was the service plan change implemented on the Begin Date (F2101, item 4) or
five days after the contractor’s date stamp on F2101, whichever is later; or NA
• If delayed, did the contractor document, by the next working day, the failure to
implement the service plan change on the effective date to include the reason and NA
new implementation date? NA
c. Decrease in service hours:
i. Did the contractor develop a new service plan within 21 days from the date of the
individual’s request or identification of need for a service plan change? NA
VII.1. If a service plan change for PAS was identified or requested, did the contractor
meet all requirements?
• If the contractor requested an increase in hours or no delivery of personal care tasks -
select “Y” if a. i-ii or b. i-iii are “Y” NA
• If the case manager requested an increase in hours or no delivery of personal care
tasks - select “Y” if a. ii or b. iii are “Y”
• Select “Y” if a decrease in service hours was requested/identified and c. is “Y”
STANDARD IX. BILLING
Compare the Units of Service tables to the Contract Monitoring Claims Report for the last six months of
service delivery within the review period.
OVERARCHING QUESTION For
the last six months of service delivery to the individual within the review
period,:
i. Were the number of units documented equal to or greater than the
number of units paid? Y or N
ii. Were the number of units paid equal to or less than the number of
IX.1a authorized units? (If No, did the increase meet the criteria of a temporary Not Calculated in
increase)? Y or N Score
• If overarching question IX.1a.i and IX.1a.ii are "Y", mark IX.1a"Y" and skip
overarching question IX.1b and mark Standard IX.1 "Y".
• If either overarching question IX.1a.i or IX.1a.ii is“N”, mark IX.1a "N" and
continue to overarching question IX.1b.
OVERARCHING QUESTION Did
the contractor provide evidence that the contractor negative billed the
over-billed amount due to DADS prior to the date of the Entrance
Not Calculated in
Conference?
IX.1b Score
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 36
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
3 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
IX.1b
• If overarching question IX.1b is “Y”, mark
STANDARD II. ATTENDANT REQUIREMENTS Standard IX.1 “Y”.
• If overarching question IX.1b is “N”, mark Standard IX.1 “N”. Complete
Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for
Payment.
IX. 1. DADS did not identify a financial error?
• Select “Y”, if the contractor does not owe an Amount Due to DADS per the Demand
for Payment Notice (Column L)
• Select “Y”, if the contractor provides evidence that the contractor negative billed the
amount due to DADS prior to the date of the entrance Conference.
• Select “N”, if the contractor owes an Amount Due to DADS per the Demand for
Payment Notice (Column L)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 37
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
4 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
II.1 Complete the Attendants Requirements Table below.
Column A: Enter the name(s) of each attendant that provided direct care to the individual during the last six
months of service delivery to the individual.
Review the contractor’s supporting documentation to answer Columns B, C and G.
Column B: Select “Y” if the attendant is at least 18 years of age or, if under 18 years of age, is a high school
graduate or is enrolled in a vocational educational program and has demonstrated competency to perform the
tasks assigned by the supervisor.
Column C: Select “NA” if Family Care. PHC/CAS- Select “Y” if the attendant is not the individual’s legal parent,
foster parent or spouse of a parent (if a minor- under the age of 18 years) or spouse (if an adult- 18 yrs or older)
Column G: For each attendant review F2101. If hired prior to 6/1/2010, select "NA". If the case manager did NOT
designate the attendant as “Do Not Hire,” select “Y”. If listed as “Do Not Hire”, select “N”. If “N” identify the number
of units provided by the attendant and paid by DADS for the last two months of service to the individual. If DADS
paid for services provided by the attendant, complete the Demand for Payment Notice columns A-H from Contract
Monitoring Claims Report, enter the number of verified units provided by the “DNH” attendant in Column J.
A. B. C. G.
Name of Attendant Attendant Attendant Attendant is
Meets the Meets the NOT
Age Relationship designated
Requirement Requirement COLUMNS LEFT BLANK as "Do Not
INTENTIONALLY Hire"
If hired on or
after
6/1/2010
`
II.1 Does each of the individual’s attendants meet the required qualifications?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 38
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
4 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• Select “Y” if ATTENDANT REQUIREMENTS
STANDARD II.for each row, all responses in column B are "Y" and all responses in
columns C and G are “Y” or "NA" (note: column C will only be NA for Family Care)
• Select “N” if for any row, a response in columns B, C or G is “N”
ORIENTATION CHECKLIST
A. B. C. D. E. F. G.
Name of Individual’s Attendant Date of First Service Date of Orientation Orientation Orientation Provided Orientation Elements not
to Individual Conducted in On or Before First Included All included in the
Person with Date of Service to the Required Orientation
Review service delivery documentation for (Review service delivery (Refer to Participation of the Individual Elements (Enter the
the last six months of service delivery within documentation for the documentation of corresponding
Individual or
review period to determine if
the review period and enter the name of first date of service to the
Attendant Attendant Met elements that were
each attendant that provided care to the sample individual was within Orientations Requirements for not addressed)
individual- NA for a Supervisor providing the last six months of conducted during the Orientation Without
personal assistance services service delivery. If the review period)
unlicensed attendant began
Participation of the
providing services to the Individual
sample individual during the
last six months of service
delivery, enter the first date
of service and complete
columns C - G. If the
unlicensed attendant worked
with the sample individual
prior to the last six months
of service delivery, select
“N” and leave columns C –
G blank.)
Last Six Months
Begin: End:
Last Name: First Name; Answer Date:
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 39
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
4 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Attendant Requirements for Orientation without Participation of the Individual (telephone/verbal): Meet the requirements of a Home health Aide*; have six continuous months of experience
delivering attendant care; has been oriented to the individual and the service plan has not changed; or has previously provided services to the individual.
Required elements:
1. Name of the individual for whom the attendant is to provide care
2. Name of the attendant
3. Date of the attendant orientation
4. Orientation conducted in person with the individual or without the participation of the individual
5. How the individual’s condition affects the performance of tasks
6. Tasks to be performed
7. Service schedule
8. Number of hours of service the attendant is to provide
9. Total number of hours the individual is authorized to receive
10. Safety and emergency procedures, including universal precautions
11. Specific situations about which the attendant should notify the contractor (e.g., changes in the individual’s needs; incidents that affect the individual’s condition; hospitalization;
absence or relocation from home; attendant’s inability to work; and suspicion/allegation of abuse, neglect or exploitation of the individual).
12. Signature of the Supervisor who conducted the orientation
13. Signature of the attendant, if present
14. Signature of the individual, if present
*A Home Health Aide must:
o have a minimum of six months experience in delivering personal care tasks in family care, primary home care, personal assistance services, client managed personal attendant
services; or
o be listed on the DADS Nurses Aide Registry with an employable “Active’ status.
II. 3. Was each attendant who began providing care to the individual during the last
six months of service delivery within the review period, oriented, as required, on or
before the first date of service delivery?
• Select “NA” if the individual’s attendant(s) began providing care to the individual prior
to the review period.
• Select “Y” if column B is “Y” and columns D., E and F. are “Y”
• Select “N” if column B is “Y” and column D., E and/or F is “N”.
STANDARD III. PRE-INITIATION ACTIVITIES
OVERARCHING QUESTION Did
the individual's pre-initiation activities occur during the review period?
III.1 • If overarching question III.1 is “N”, select “NA” for Standard III.1-3. Not Calculated in
Continue to Standard IV.1. Score
• If overarching question III.1 is “Y”, verify pre-initiation activities were
completed as required.
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 40
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
4 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Date of Referral Date of Referral Negotiated Date Stamp on Date of
(F2101, item 1) (F2101, item 25) Service Initiation F2101 Notification for
Date Intake
(Routine) (Expedited/Transf (Expedited/Transf (Retroactive)
er) er)
Date of Evaluation:
a. Routine Referral
i) Is the date of the evaluation within 14 calendar days after the date of referral or the date
the contractor received F-2101 as indicated by a date stamp- whichever is later; or
ii) If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the evaluation?
b. Expedited Referral (transfers are reviewed as an expedited referral)
i) Is the date of the evaluation on or before the date negotiated between the case
manager and contractor, which must be less than 14 days after the oral request; or
ii) If a delay, did the contractor notify the case manager of any failure to complete the
evaluation before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i) Is the date of the evaluation on or before the date of notification to DADS for intake?
d. Does the evaluation include the individual’s self-report of the dates and reasons for any
hospitalizations within 3 months prior to the evaluation were addressed?
e. Does the evaluation identify assistance needed to achieve activities of daily living,
including any assistive devices or medical equipment used by the person?
III.1. Did the contractor complete an evaluation of the individual as required?
o Select “Y” if a, b, or c is “Y” and d and e are “Y”
o Select “N” if a, b, or c is “N” and d and/or e is “N”
Date of Initial Service Delivery Plan:
a. Routine Referral
i. Was the initial service delivery plan completed within 14 calendar days after the referral
date or the date the contractor received F- 2101 as indicated by a date stamp- whichever
is later; or
ii. If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the service plan?
b. Expedited Referral (transfers are reviewed as an expedited referral)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 41
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
4 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
i. Is the date of the service delivery plan on or before the date negotiated between the
case manager and contractor, which must be less than 14 days after the oral request; or
ii If a delay, did the contractor notify the case manager of any failure to complete the
service delivery plan before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i. Was the service plan complete prior to the date of notification to DADS for intake?
d. The service plan is agreed upon and was signed by the individual and the contractor
e. The service plan identifies the location of service delivery
f. The service plan identifies the tasks the individual will receive (includes at least one
personal care task, unless FC)
g. The service plan identifies the total weekly hours authorized
h. The service plan identifies the service schedule which includes as necessary, based
on the individual’s needs, certain time periods for the delivery of specified tasks
i. The service plan identifies the frequency of supervisory visits
j. The service plan includes the statement that the contractor is responsible for providing
the tasks allowable in the PHC program (47.41) and agreed to on the service plan.
III. 2. Did the contractor develop an initial service delivery plan as required?
• Select “Y” if a, b, or c is “Y” and d - j are “Y”
• Select “N” if a, b, or c is “N” and/or d – j is “N”
OVERARCHING QUESTION Does
the individual receive family care or did the individual transfer from one
PHC contractor to another PHC, transfer from PHC to CAS or transfer from
Not Calculated in
CAS to PHC during the review period?
III.3 Score
• If overarching question III.3 is “Y”, select “NA” for Standard III.3. Continue
to Standard IV.1.
• If overarching question III.3 is “N”, verify the contractor met the
requirements for the individual’s practitioner’s statement.
Date of Practitioner’s Statement:
a. Routine Referral
i. Did the contractor obtain and submit to DADS a complete practitioner’s statement
within 14 calendar days after the date of referral or the date the contractor received F-
2101 as indicated by a date stamp- whichever is later. Review the contractor's fax, email
or other documentation that verifies the practitioner's statement was submitted to DADS
within the required timeframe; or
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 42
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
4 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. If a delay, II. ATTENDANT REQUIREMENTS
STANDARDdid the contractor document by due date the reason for the delay, an
anticipated date of completion or reason why a completion date cannot be anticipated;
and a description of the contractor’s efforts to obtain the practitioner’s statement?
b. Expedited Referral
i. Did the contractor send a complete practitioner’s statement to DADS within seven (7)
work days after service initiation? Review the contractor's fax, email or other
documentation that verifies the practitioner's statement was submitted to DADS within the
required timeframe.
c. Retroactive
i. Was the practitioner’s statement completed on or before the date of notification to
DADS for intake?
III. 3. Did the contractor meet the requirements for the individual’s practitioner’s
statement?
• Select “Y” if a, b, or c (as applicable) is “Y”
• Select “N” if a, b, or c ( as applicable) is “N”
Potential Billing Error:
If III.3 is “N”, review the Contract Monitoring Claims Report Payment Report for the billing periods within the 12
month review period prior to the date of the practitioner’s statement to determine if DADS paid for services prior to
the date of the practitioner’s statement. If DADS paid for services prior to the date of the practitioner’s statement,
complete Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for Payment. Enter “0” in Column J -
Units Verified for units paid prior to the date of the practitioner’s statement.
STANDARD IV. SERVICE INITIATION
OVERARCHING QUESTION Did
the individual enter services during the review period?
• If overarching question IV.1 is “N”, select “NA” for Standard IV.1. Continue Not Calculated in
IV.1
to Standard V.1. Score
• If overarching question IV.1 is “Y”, verify the contractor met the
requirements for service initiation.
a. Family Care- First Date of Service:
i. Routine Referral-Did services begin within 14 days after the referral date or
within 14 days after the date the contractor date stamped DADS’ authorization
form; or
ii. Transfer- Did services begin on the date negotiated between the case manager
and the contractor?
b. Primary Home Care or Community Attendant Services- First Date of Service:
i. Routine Referral- Did services begin within seven days after the date the
contractor’s receipt of DADS’ Authorization form?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 43
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
4 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. Transfer- Did services begin on the date negotiated between the case manager
STANDARD II. ATTENDANT REQUIREMENTS
and the contractor?
c. If a delay in service initiation did the contractor document the reason for the delay,
either an anticipated date of initiation or specific reasons why the contractor cannot
anticipate a date and a description of the contractor’s efforts to initiate services?
d. Did the contractor send notice of service initiation to the case manager within 14 days
after initiating services?
IV. 1. Were services initiated as required?
• Select “Y” if a is “Y”, b is “NA”, c is “NA” and d is “Y”
• Select “Y” if a is “NA”, b is “Y”, c is “NA” and d is “Y”
• Select “Y” if a or b is “N”, c is “Y” and d is “Y”
• Select “N” if a or b is “N”, c is “N” and d is “Y”
• Select “N” if d is “N”
VI. SERVICE DELIVERY
Complete UNITS OF SERVICE Tables for the last six months of service within the review
VI.1
period then answer VI.1.
a. Priority status- Does the number of documented hours/units of service equal the
number of authorized hours/units; or
Non-Priority status- Does the number of documented hours/units of service indicate that
there were no service interruptions exceeding 14 consecutive days?
b. If a is “N” was the reason for the failure to provide all service hours one of the
following:
• the individual’s revised service plan identified a need for an ongoing decrease in
hours;
• the individual requested that services not be provided;
• the individual requested fewer hours of service than reflected in the service
schedule;
• the individual requested that a specific attendant not provide services;
• the individual was not at home when the service was scheduled;
• services were not delivered for other reasons beyond the control of the provider
agency; or
• services were suspended.
- The individual temporarily or permanently left the contracted services delivery area;
- The individual moved to a location where services could not be provided under the PHC program;
- The individual died;
- The individual was admitted to an institution (hospital, nursing facility, state school, state hospital, or
ICF-MR facility);
- The individual requested that services end;
- DADS denied the individual’s Medicaid eligibility (not applicable to FC);
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 44
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
4 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
- The individual or someone in the individual’s home exhibited reckless behavior, which may have
STANDARD II. ATTENDANT REQUIREMENTS
resulted in imminent danger to the health and safety of the individual, the attendant, or another person;
- The individual or someone else in the individual’s home engaged in discrimination against a provider
agency or DADS employee in violation of applicable law;
- The individual refused services for more than 30 consecutive days.
VI. 1. Were personal assistance service hours provided in accordance with the
individual’s service plans or as required?
• Select “Y” if a is “Y” or a is “N” and b is “Y”
• Select “N” if a and b are “N”
STANDARD VII. SERVICE PLAN CHANGE
• Review the individual’s record for the 12 month review period to determine if a service plan change
was identified and requested.
VII.1.
• Select “NA” if a service plan change was not identified/requested. Continue to Standard VIII.
• If a service plan change was identified/requested, complete the table below.
Date(s) of /identified Date of notification to Effective Date Date of Date(s) of identified Date of revised service
need/request for an the contractor OR (F2101, item 4) Implementation need/request for a plan
increase in service case manager (Service Delivery decrease in service
hours or change that (F2067 or equivalent) Documentation) hours
results in no delivery
of personal care tasks
a. Immediate increase in hours:
i. If requested by the contractor, did the contractor’s documentation include:
• evidence that the contractor discussed the reason for the request of immediate
increase in hours with the case manager? NA
• the date the contractor received approval from the case manager? NA
• the name of the case manager who approved the change? NA
• the effective date of change, and NA
• the number of hours authorized? NA
ii. Did the contractor implement the service plan change on the date negotiated with the
NA
case manager? NA
b. Increase in service hours or no delivery of personal care tasks:
i. If requested by the contractor, was the case manager notified in writing within seven
days from the date of request/identification of need; and NA
ii. Did the notification include:
• date the provider agency learned of the need for the change;
NA
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 45
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
4 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• reason II. ATTENDANT REQUIREMENTS
STANDARD for the change;
NA
• type of change (including the number of service hours) and:
• signature and date of the provider agency representative?
iii. For any increase in service hours requested by the contractor, individual or case manager, did the contractor
implement the change within the required timeframe?
• Was the service plan change implemented on the Begin Date (F2101, item 4) or
five days after the contractor’s date stamp on F2101, whichever is later; or NA
• If delayed, did the contractor document, by the next working day, the failure to
implement the service plan change on the effective date to include the reason and NA
new implementation date? NA
c. Decrease in service hours:
i. Did the contractor develop a new service plan within 21 days from the date of the
individual’s request or identification of need for a service plan change? NA
VII.1. If a service plan change for PAS was identified or requested, did the contractor
meet all requirements?
• If the contractor requested an increase in hours or no delivery of personal care tasks -
select “Y” if a. i-ii or b. i-iii are “Y” NA
• If the case manager requested an increase in hours or no delivery of personal care
tasks - select “Y” if a. ii or b. iii are “Y”
• Select “Y” if a decrease in service hours was requested/identified and c. is “Y”
STANDARD IX. BILLING
Compare the Units of Service tables to the Contract Monitoring Claims Report for the last six months of
service delivery within the review period.
OVERARCHING QUESTION For
the last six months of service delivery to the individual within the review
period,:
i. Were the number of units documented equal to or greater than the
number of units paid? Y or N
ii. Were the number of units paid equal to or less than the number of
IX.1a authorized units? (If No, did the increase meet the criteria of a temporary Not Calculated in
increase)? Y or N Score
• If overarching question IX.1a.i and IX.1a.ii are "Y", mark IX.1a"Y" and skip
overarching question IX.1b and mark Standard IX.1 "Y".
• If either overarching question IX.1a.i or IX.1a.ii is“N”, mark IX.1a "N" and
continue to overarching question IX.1b.
OVERARCHING QUESTION Did
the contractor provide evidence that the contractor negative billed the
over-billed amount due to DADS prior to the date of the Entrance
Not Calculated in
Conference?
IX.1b Score
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 46
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
4 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
IX.1b
• If overarching question IX.1b is “Y”, mark
STANDARD II. ATTENDANT REQUIREMENTS Standard IX.1 “Y”.
• If overarching question IX.1b is “N”, mark Standard IX.1 “N”. Complete
Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for
Payment.
IX. 1. DADS did not identify a financial error?
• Select “Y”, if the contractor does not owe an Amount Due to DADS per the Demand
for Payment Notice (Column L)
• Select “Y”, if the contractor provides evidence that the contractor negative billed the
amount due to DADS prior to the date of the entrance Conference.
• Select “N”, if the contractor owes an Amount Due to DADS per the Demand for
Payment Notice (Column L)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 47
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
5 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
II.1 Complete the Attendants Requirements Table below.
Column A: Enter the name(s) of each attendant that provided direct care to the individual during the last six
months of service delivery to the individual.
Review the contractor’s supporting documentation to answer Columns B, C and G.
Column B: Select “Y” if the attendant is at least 18 years of age or, if under 18 years of age, is a high school
graduate or is enrolled in a vocational educational program and has demonstrated competency to perform the
tasks assigned by the supervisor.
Column C: Select “NA” if Family Care. PHC/CAS- Select “Y” if the attendant is not the individual’s legal parent,
foster parent or spouse of a parent (if a minor- under the age of 18 years) or spouse (if an adult- 18 yrs or older)
Column G: For each attendant review F2101. If hired prior to 6/1/2010, select "NA". If the case manager did NOT
designate the attendant as “Do Not Hire,” select “Y”. If listed as “Do Not Hire”, select “N”. If “N” identify the number
of units provided by the attendant and paid by DADS for the last two months of service to the individual. If DADS
paid for services provided by the attendant, complete the Demand for Payment Notice columns A-H from Contract
Monitoring Claims Report, enter the number of verified units provided by the “DNH” attendant in Column J.
A. B. C. G.
Name of Attendant Attendant Attendant Attendant is
Meets the Meets the NOT
Age Relationship designated
Requirement Requirement COLUMNS LEFT BLANK as "Do Not
INTENTIONALLY Hire"
If hired on or
after
6/1/2010
`
II.1 Does each of the individual’s attendants meet the required qualifications?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 48
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
5 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• Select “Y” if ATTENDANT REQUIREMENTS
STANDARD II.for each row, all responses in column B are "Y" and all responses in
columns C and G are “Y” or "NA" (note: column C will only be NA for Family Care)
• Select “N” if for any row, a response in columns B, C or G is “N”
ORIENTATION CHECKLIST
A. B. C. D. E. F. G.
Name of Individual’s Attendant Date of First Service Date of Orientation Orientation Orientation Provided Orientation Elements not
to Individual Conducted in On or Before First Included All included in the
Person with Date of Service to the Required Orientation
Review service delivery documentation for (Review service delivery (Refer to Participation of the Individual Elements (Enter the
the last six months of service delivery within documentation for the documentation of corresponding
Individual or
review period to determine if
the review period and enter the name of first date of service to the
Attendant Attendant Met elements that were
each attendant that provided care to the sample individual was within Orientations Requirements for not addressed)
individual- NA for a Supervisor providing the last six months of conducted during the Orientation Without
personal assistance services service delivery. If the review period)
unlicensed attendant began
Participation of the
providing services to the Individual
sample individual during the
last six months of service
delivery, enter the first date
of service and complete
columns C - G. If the
unlicensed attendant worked
with the sample individual
prior to the last six months
of service delivery, select
“N” and leave columns C –
G blank.)
Last Six Months
Begin: End:
Last Name: First Name; Answer Date:
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 49
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
5 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Attendant Requirements for Orientation without Participation of the Individual (telephone/verbal): Meet the requirements of a Home health Aide*; have six continuous months of experience
delivering attendant care; has been oriented to the individual and the service plan has not changed; or has previously provided services to the individual.
Required elements:
1. Name of the individual for whom the attendant is to provide care
2. Name of the attendant
3. Date of the attendant orientation
4. Orientation conducted in person with the individual or without the participation of the individual
5. How the individual’s condition affects the performance of tasks
6. Tasks to be performed
7. Service schedule
8. Number of hours of service the attendant is to provide
9. Total number of hours the individual is authorized to receive
10. Safety and emergency procedures, including universal precautions
11. Specific situations about which the attendant should notify the contractor (e.g., changes in the individual’s needs; incidents that affect the individual’s condition; hospitalization;
absence or relocation from home; attendant’s inability to work; and suspicion/allegation of abuse, neglect or exploitation of the individual).
12. Signature of the Supervisor who conducted the orientation
13. Signature of the attendant, if present
14. Signature of the individual, if present
*A Home Health Aide must:
o have a minimum of six months experience in delivering personal care tasks in family care, primary home care, personal assistance services, client managed personal attendant
services; or
o be listed on the DADS Nurses Aide Registry with an employable “Active’ status.
II. 3. Was each attendant who began providing care to the individual during the last
six months of service delivery within the review period, oriented, as required, on or
before the first date of service delivery?
• Select “NA” if the individual’s attendant(s) began providing care to the individual prior
to the review period.
• Select “Y” if column B is “Y” and columns D., E and F. are “Y”
• Select “N” if column B is “Y” and column D., E and/or F is “N”.
STANDARD III. PRE-INITIATION ACTIVITIES
OVERARCHING QUESTION Did
the individual's pre-initiation activities occur during the review period?
III.1 • If overarching question III.1 is “N”, select “NA” for Standard III.1-3. Not Calculated in
Continue to Standard IV.1. Score
• If overarching question III.1 is “Y”, verify pre-initiation activities were
completed as required.
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 50
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
5 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Date of Referral Date of Referral Negotiated Date Stamp on Date of
(F2101, item 1) (F2101, item 25) Service Initiation F2101 Notification for
Date Intake
(Routine) (Expedited/Transf (Expedited/Transf (Retroactive)
er) er)
Date of Evaluation:
a. Routine Referral
i) Is the date of the evaluation within 14 calendar days after the date of referral or the date
the contractor received F-2101 as indicated by a date stamp- whichever is later; or
ii) If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the evaluation?
b. Expedited Referral (transfers are reviewed as an expedited referral)
i) Is the date of the evaluation on or before the date negotiated between the case
manager and contractor, which must be less than 14 days after the oral request; or
ii) If a delay, did the contractor notify the case manager of any failure to complete the
evaluation before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i) Is the date of the evaluation on or before the date of notification to DADS for intake?
d. Does the evaluation include the individual’s self-report of the dates and reasons for any
hospitalizations within 3 months prior to the evaluation were addressed?
e. Does the evaluation identify assistance needed to achieve activities of daily living,
including any assistive devices or medical equipment used by the person?
III.1. Did the contractor complete an evaluation of the individual as required?
o Select “Y” if a, b, or c is “Y” and d and e are “Y”
o Select “N” if a, b, or c is “N” and d and/or e is “N”
Date of Initial Service Delivery Plan:
a. Routine Referral
i. Was the initial service delivery plan completed within 14 calendar days after the referral
date or the date the contractor received F- 2101 as indicated by a date stamp- whichever
is later; or
ii. If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the service plan?
b. Expedited Referral (transfers are reviewed as an expedited referral)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 51
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
5 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
i. Is the date of the service delivery plan on or before the date negotiated between the
case manager and contractor, which must be less than 14 days after the oral request; or
ii If a delay, did the contractor notify the case manager of any failure to complete the
service delivery plan before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i. Was the service plan complete prior to the date of notification to DADS for intake?
d. The service plan is agreed upon and was signed by the individual and the contractor
e. The service plan identifies the location of service delivery
f. The service plan identifies the tasks the individual will receive (includes at least one
personal care task, unless FC)
g. The service plan identifies the total weekly hours authorized
h. The service plan identifies the service schedule which includes as necessary, based
on the individual’s needs, certain time periods for the delivery of specified tasks
i. The service plan identifies the frequency of supervisory visits
j. The service plan includes the statement that the contractor is responsible for providing
the tasks allowable in the PHC program (47.41) and agreed to on the service plan.
III. 2. Did the contractor develop an initial service delivery plan as required?
• Select “Y” if a, b, or c is “Y” and d - j are “Y”
• Select “N” if a, b, or c is “N” and/or d – j is “N”
OVERARCHING QUESTION Does
the individual receive family care or did the individual transfer from one
PHC contractor to another PHC, transfer from PHC to CAS or transfer from
Not Calculated in
CAS to PHC during the review period?
III.3 Score
• If overarching question III.3 is “Y”, select “NA” for Standard III.3. Continue
to Standard IV.1.
• If overarching question III.3 is “N”, verify the contractor met the
requirements for the individual’s practitioner’s statement.
Date of Practitioner’s Statement:
a. Routine Referral
i. Did the contractor obtain and submit to DADS a complete practitioner’s statement
within 14 calendar days after the date of referral or the date the contractor received F-
2101 as indicated by a date stamp- whichever is later. Review the contractor's fax, email
or other documentation that verifies the practitioner's statement was submitted to DADS
within the required timeframe; or
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 52
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
5 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. If a delay, II. ATTENDANT REQUIREMENTS
STANDARDdid the contractor document by due date the reason for the delay, an
anticipated date of completion or reason why a completion date cannot be anticipated;
and a description of the contractor’s efforts to obtain the practitioner’s statement?
b. Expedited Referral
i. Did the contractor send a complete practitioner’s statement to DADS within seven (7)
work days after service initiation? Review the contractor's fax, email or other
documentation that verifies the practitioner's statement was submitted to DADS within the
required timeframe.
c. Retroactive
i. Was the practitioner’s statement completed on or before the date of notification to
DADS for intake?
III. 3. Did the contractor meet the requirements for the individual’s practitioner’s
statement?
• Select “Y” if a, b, or c (as applicable) is “Y”
• Select “N” if a, b, or c ( as applicable) is “N”
Potential Billing Error:
If III.3 is “N”, review the Contract Monitoring Claims Report Payment Report for the billing periods within the 12
month review period prior to the date of the practitioner’s statement to determine if DADS paid for services prior to
the date of the practitioner’s statement. If DADS paid for services prior to the date of the practitioner’s statement,
complete Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for Payment. Enter “0” in Column J -
Units Verified for units paid prior to the date of the practitioner’s statement.
STANDARD IV. SERVICE INITIATION
OVERARCHING QUESTION Did
the individual enter services during the review period?
• If overarching question IV.1 is “N”, select “NA” for Standard IV.1. Continue Not Calculated in
IV.1
to Standard V.1. Score
• If overarching question IV.1 is “Y”, verify the contractor met the
requirements for service initiation.
a. Family Care- First Date of Service:
i. Routine Referral-Did services begin within 14 days after the referral date or
within 14 days after the date the contractor date stamped DADS’ authorization
form; or
ii. Transfer- Did services begin on the date negotiated between the case manager
and the contractor?
b. Primary Home Care or Community Attendant Services- First Date of Service:
i. Routine Referral- Did services begin within seven days after the date the
contractor’s receipt of DADS’ Authorization form?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 53
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
5 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. Transfer- Did services begin on the date negotiated between the case manager
STANDARD II. ATTENDANT REQUIREMENTS
and the contractor?
c. If a delay in service initiation did the contractor document the reason for the delay,
either an anticipated date of initiation or specific reasons why the contractor cannot
anticipate a date and a description of the contractor’s efforts to initiate services?
d. Did the contractor send notice of service initiation to the case manager within 14 days
after initiating services?
IV. 1. Were services initiated as required?
• Select “Y” if a is “Y”, b is “NA”, c is “NA” and d is “Y”
• Select “Y” if a is “NA”, b is “Y”, c is “NA” and d is “Y”
• Select “Y” if a or b is “N”, c is “Y” and d is “Y”
• Select “N” if a or b is “N”, c is “N” and d is “Y”
• Select “N” if d is “N”
VI. SERVICE DELIVERY
Complete UNITS OF SERVICE Tables for the last six months of service within the review
VI.1
period then answer VI.1.
a. Priority status- Does the number of documented hours/units of service equal the
number of authorized hours/units; or
Non-Priority status- Does the number of documented hours/units of service indicate that
there were no service interruptions exceeding 14 consecutive days?
b. If a is “N” was the reason for the failure to provide all service hours one of the
following:
• the individual’s revised service plan identified a need for an ongoing decrease in
hours;
• the individual requested that services not be provided;
• the individual requested fewer hours of service than reflected in the service
schedule;
• the individual requested that a specific attendant not provide services;
• the individual was not at home when the service was scheduled;
• services were not delivered for other reasons beyond the control of the provider
agency; or
• services were suspended.
- The individual temporarily or permanently left the contracted services delivery area;
- The individual moved to a location where services could not be provided under the PHC program;
- The individual died;
- The individual was admitted to an institution (hospital, nursing facility, state school, state hospital, or
ICF-MR facility);
- The individual requested that services end;
- DADS denied the individual’s Medicaid eligibility (not applicable to FC);
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 54
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
5 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
- The individual or someone in the individual’s home exhibited reckless behavior, which may have
STANDARD II. ATTENDANT REQUIREMENTS
resulted in imminent danger to the health and safety of the individual, the attendant, or another person;
- The individual or someone else in the individual’s home engaged in discrimination against a provider
agency or DADS employee in violation of applicable law;
- The individual refused services for more than 30 consecutive days.
VI. 1. Were personal assistance service hours provided in accordance with the
individual’s service plans or as required?
• Select “Y” if a is “Y” or a is “N” and b is “Y”
• Select “N” if a and b are “N”
STANDARD VII. SERVICE PLAN CHANGE
• Review the individual’s record for the 12 month review period to determine if a service plan change
was identified and requested.
VII.1.
• Select “NA” if a service plan change was not identified/requested. Continue to Standard VIII.
• If a service plan change was identified/requested, complete the table below.
Date(s) of /identified Date of notification to Effective Date Date of Date(s) of identified Date of revised service
need/request for an the contractor OR (F2101, item 4) Implementation need/request for a plan
increase in service case manager (Service Delivery decrease in service
hours or change that (F2067 or equivalent) Documentation) hours
results in no delivery
of personal care tasks
a. Immediate increase in hours:
i. If requested by the contractor, did the contractor’s documentation include:
• evidence that the contractor discussed the reason for the request of immediate
increase in hours with the case manager? NA
• the date the contractor received approval from the case manager? NA
• the name of the case manager who approved the change? NA
• the effective date of change, and NA
• the number of hours authorized? NA
ii. Did the contractor implement the service plan change on the date negotiated with the
NA
case manager? NA
b. Increase in service hours or no delivery of personal care tasks:
i. If requested by the contractor, was the case manager notified in writing within seven
days from the date of request/identification of need; and NA
ii. Did the notification include:
• date the provider agency learned of the need for the change;
NA
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 55
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
5 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• reason II. ATTENDANT REQUIREMENTS
STANDARD for the change;
NA
• type of change (including the number of service hours) and:
• signature and date of the provider agency representative?
iii. For any increase in service hours requested by the contractor, individual or case manager, did the contractor
implement the change within the required timeframe?
• Was the service plan change implemented on the Begin Date (F2101, item 4) or
five days after the contractor’s date stamp on F2101, whichever is later; or NA
• If delayed, did the contractor document, by the next working day, the failure to
implement the service plan change on the effective date to include the reason and NA
new implementation date? NA
c. Decrease in service hours:
i. Did the contractor develop a new service plan within 21 days from the date of the
individual’s request or identification of need for a service plan change? NA
VII.1. If a service plan change for PAS was identified or requested, did the contractor
meet all requirements?
• If the contractor requested an increase in hours or no delivery of personal care tasks -
select “Y” if a. i-ii or b. i-iii are “Y” NA
• If the case manager requested an increase in hours or no delivery of personal care
tasks - select “Y” if a. ii or b. iii are “Y”
• Select “Y” if a decrease in service hours was requested/identified and c. is “Y”
STANDARD IX. BILLING
Compare the Units of Service tables to the Contract Monitoring Claims Report for the last six months of
service delivery within the review period.
OVERARCHING QUESTION For
the last six months of service delivery to the individual within the review
period,:
i. Were the number of units documented equal to or greater than the
number of units paid? Y or N
ii. Were the number of units paid equal to or less than the number of
IX.1a authorized units? (If No, did the increase meet the criteria of a temporary Not Calculated in
increase)? Y or N Score
• If overarching question IX.1a.i and IX.1a.ii are "Y", mark IX.1a"Y" and skip
overarching question IX.1b and mark Standard IX.1 "Y".
• If either overarching question IX.1a.i or IX.1a.ii is“N”, mark IX.1a "N" and
continue to overarching question IX.1b.
OVERARCHING QUESTION Did
the contractor provide evidence that the contractor negative billed the
over-billed amount due to DADS prior to the date of the Entrance
Not Calculated in
Conference?
IX.1b Score
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 56
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
5 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
IX.1b
• If overarching question IX.1b is “Y”, mark
STANDARD II. ATTENDANT REQUIREMENTS Standard IX.1 “Y”.
• If overarching question IX.1b is “N”, mark Standard IX.1 “N”. Complete
Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for
Payment.
IX. 1. DADS did not identify a financial error?
• Select “Y”, if the contractor does not owe an Amount Due to DADS per the Demand
for Payment Notice (Column L)
• Select “Y”, if the contractor provides evidence that the contractor negative billed the
amount due to DADS prior to the date of the entrance Conference.
• Select “N”, if the contractor owes an Amount Due to DADS per the Demand for
Payment Notice (Column L)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 57
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
6 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
II.1 Complete the Attendants Requirements Table below.
Column A: Enter the name(s) of each attendant that provided direct care to the individual during the last six
months of service delivery to the individual.
Review the contractor’s supporting documentation to answer Columns B, C and G.
Column B: Select “Y” if the attendant is at least 18 years of age or, if under 18 years of age, is a high school
graduate or is enrolled in a vocational educational program and has demonstrated competency to perform the
tasks assigned by the supervisor.
Column C: Select “NA” if Family Care. PHC/CAS- Select “Y” if the attendant is not the individual’s legal parent,
foster parent or spouse of a parent (if a minor- under the age of 18 years) or spouse (if an adult- 18 yrs or older)
Column G: For each attendant review F2101. If hired prior to 6/1/2010, select "NA". If the case manager did NOT
designate the attendant as “Do Not Hire,” select “Y”. If listed as “Do Not Hire”, select “N”. If “N” identify the number
of units provided by the attendant and paid by DADS for the last two months of service to the individual. If DADS
paid for services provided by the attendant, complete the Demand for Payment Notice columns A-H from Contract
Monitoring Claims Report, enter the number of verified units provided by the “DNH” attendant in Column J.
A. B. C. G.
Name of Attendant Attendant Attendant Attendant is
Meets the Meets the NOT
Age Relationship designated
Requirement Requirement COLUMNS LEFT BLANK as "Do Not
INTENTIONALLY Hire"
If hired on or
after
6/1/2010
`
II.1 Does each of the individual’s attendants meet the required qualifications?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 58
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
6 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• Select “Y” if ATTENDANT REQUIREMENTS
STANDARD II.for each row, all responses in column B are "Y" and all responses in
columns C and G are “Y” or "NA" (note: column C will only be NA for Family Care)
• Select “N” if for any row, a response in columns B, C or G is “N”
ORIENTATION CHECKLIST
A. B. C. D. E. F. G.
Name of Individual’s Attendant Date of First Service Date of Orientation Orientation Orientation Provided Orientation Elements not
to Individual Conducted in On or Before First Included All included in the
Person with Date of Service to the Required Orientation
Review service delivery documentation for (Review service delivery (Refer to Participation of the Individual Elements (Enter the
the last six months of service delivery within documentation for the documentation of corresponding
Individual or
review period to determine if
the review period and enter the name of first date of service to the
Attendant Attendant Met elements that were
each attendant that provided care to the sample individual was within Orientations Requirements for not addressed)
individual- NA for a Supervisor providing the last six months of conducted during the Orientation Without
personal assistance services service delivery. If the review period)
unlicensed attendant began
Participation of the
providing services to the Individual
sample individual during the
last six months of service
delivery, enter the first date
of service and complete
columns C - G. If the
unlicensed attendant worked
with the sample individual
prior to the last six months
of service delivery, select
“N” and leave columns C –
G blank.)
Last Six Months
Begin: End:
Last Name: First Name; Answer Date:
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 59
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
6 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Attendant Requirements for Orientation without Participation of the Individual (telephone/verbal): Meet the requirements of a Home health Aide*; have six continuous months of experience
delivering attendant care; has been oriented to the individual and the service plan has not changed; or has previously provided services to the individual.
Required elements:
1. Name of the individual for whom the attendant is to provide care
2. Name of the attendant
3. Date of the attendant orientation
4. Orientation conducted in person with the individual or without the participation of the individual
5. How the individual’s condition affects the performance of tasks
6. Tasks to be performed
7. Service schedule
8. Number of hours of service the attendant is to provide
9. Total number of hours the individual is authorized to receive
10. Safety and emergency procedures, including universal precautions
11. Specific situations about which the attendant should notify the contractor (e.g., changes in the individual’s needs; incidents that affect the individual’s condition; hospitalization;
absence or relocation from home; attendant’s inability to work; and suspicion/allegation of abuse, neglect or exploitation of the individual).
12. Signature of the Supervisor who conducted the orientation
13. Signature of the attendant, if present
14. Signature of the individual, if present
*A Home Health Aide must:
o have a minimum of six months experience in delivering personal care tasks in family care, primary home care, personal assistance services, client managed personal attendant
services; or
o be listed on the DADS Nurses Aide Registry with an employable “Active’ status.
II. 3. Was each attendant who began providing care to the individual during the last
six months of service delivery within the review period, oriented, as required, on or
before the first date of service delivery?
• Select “NA” if the individual’s attendant(s) began providing care to the individual prior
to the review period.
• Select “Y” if column B is “Y” and columns D., E and F. are “Y”
• Select “N” if column B is “Y” and column D., E and/or F is “N”.
STANDARD III. PRE-INITIATION ACTIVITIES
OVERARCHING QUESTION Did
the individual's pre-initiation activities occur during the review period?
III.1 • If overarching question III.1 is “N”, select “NA” for Standard III.1-3. Not Calculated in
Continue to Standard IV.1. Score
• If overarching question III.1 is “Y”, verify pre-initiation activities were
completed as required.
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 60
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
6 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Date of Referral Date of Referral Negotiated Date Stamp on Date of
(F2101, item 1) (F2101, item 25) Service Initiation F2101 Notification for
Date Intake
(Routine) (Expedited/Transf (Expedited/Transf (Retroactive)
er) er)
Date of Evaluation:
a. Routine Referral
i) Is the date of the evaluation within 14 calendar days after the date of referral or the date
the contractor received F-2101 as indicated by a date stamp- whichever is later; or
ii) If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the evaluation?
b. Expedited Referral (transfers are reviewed as an expedited referral)
i) Is the date of the evaluation on or before the date negotiated between the case
manager and contractor, which must be less than 14 days after the oral request; or
ii) If a delay, did the contractor notify the case manager of any failure to complete the
evaluation before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i) Is the date of the evaluation on or before the date of notification to DADS for intake?
d. Does the evaluation include the individual’s self-report of the dates and reasons for any
hospitalizations within 3 months prior to the evaluation were addressed?
e. Does the evaluation identify assistance needed to achieve activities of daily living,
including any assistive devices or medical equipment used by the person?
III.1. Did the contractor complete an evaluation of the individual as required?
o Select “Y” if a, b, or c is “Y” and d and e are “Y”
o Select “N” if a, b, or c is “N” and d and/or e is “N”
Date of Initial Service Delivery Plan:
a. Routine Referral
i. Was the initial service delivery plan completed within 14 calendar days after the referral
date or the date the contractor received F- 2101 as indicated by a date stamp- whichever
is later; or
ii. If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the service plan?
b. Expedited Referral (transfers are reviewed as an expedited referral)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 61
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
6 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
i. Is the date of the service delivery plan on or before the date negotiated between the
case manager and contractor, which must be less than 14 days after the oral request; or
ii If a delay, did the contractor notify the case manager of any failure to complete the
service delivery plan before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i. Was the service plan complete prior to the date of notification to DADS for intake?
d. The service plan is agreed upon and was signed by the individual and the contractor
e. The service plan identifies the location of service delivery
f. The service plan identifies the tasks the individual will receive (includes at least one
personal care task, unless FC)
g. The service plan identifies the total weekly hours authorized
h. The service plan identifies the service schedule which includes as necessary, based
on the individual’s needs, certain time periods for the delivery of specified tasks
i. The service plan identifies the frequency of supervisory visits
j. The service plan includes the statement that the contractor is responsible for providing
the tasks allowable in the PHC program (47.41) and agreed to on the service plan.
III. 2. Did the contractor develop an initial service delivery plan as required?
• Select “Y” if a, b, or c is “Y” and d - j are “Y”
• Select “N” if a, b, or c is “N” and/or d – j is “N”
OVERARCHING QUESTION Does
the individual receive family care or did the individual transfer from one
PHC contractor to another PHC, transfer from PHC to CAS or transfer from
Not Calculated in
CAS to PHC during the review period?
III.3 Score
• If overarching question III.3 is “Y”, select “NA” for Standard III.3. Continue
to Standard IV.1.
• If overarching question III.3 is “N”, verify the contractor met the
requirements for the individual’s practitioner’s statement.
Date of Practitioner’s Statement:
a. Routine Referral
i. Did the contractor obtain and submit to DADS a complete practitioner’s statement
within 14 calendar days after the date of referral or the date the contractor received F-
2101 as indicated by a date stamp- whichever is later. Review the contractor's fax, email
or other documentation that verifies the practitioner's statement was submitted to DADS
within the required timeframe; or
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 62
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
6 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. If a delay, II. ATTENDANT REQUIREMENTS
STANDARDdid the contractor document by due date the reason for the delay, an
anticipated date of completion or reason why a completion date cannot be anticipated;
and a description of the contractor’s efforts to obtain the practitioner’s statement?
b. Expedited Referral
i. Did the contractor send a complete practitioner’s statement to DADS within seven (7)
work days after service initiation? Review the contractor's fax, email or other
documentation that verifies the practitioner's statement was submitted to DADS within the
required timeframe.
c. Retroactive
i. Was the practitioner’s statement completed on or before the date of notification to
DADS for intake?
III. 3. Did the contractor meet the requirements for the individual’s practitioner’s
statement?
• Select “Y” if a, b, or c (as applicable) is “Y”
• Select “N” if a, b, or c ( as applicable) is “N”
Potential Billing Error:
If III.3 is “N”, review the Contract Monitoring Claims Report Payment Report for the billing periods within the 12
month review period prior to the date of the practitioner’s statement to determine if DADS paid for services prior to
the date of the practitioner’s statement. If DADS paid for services prior to the date of the practitioner’s statement,
complete Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for Payment. Enter “0” in Column J -
Units Verified for units paid prior to the date of the practitioner’s statement.
STANDARD IV. SERVICE INITIATION
OVERARCHING QUESTION Did
the individual enter services during the review period?
• If overarching question IV.1 is “N”, select “NA” for Standard IV.1. Continue Not Calculated in
IV.1
to Standard V.1. Score
• If overarching question IV.1 is “Y”, verify the contractor met the
requirements for service initiation.
a. Family Care- First Date of Service:
i. Routine Referral-Did services begin within 14 days after the referral date or
within 14 days after the date the contractor date stamped DADS’ authorization
form; or
ii. Transfer- Did services begin on the date negotiated between the case manager
and the contractor?
b. Primary Home Care or Community Attendant Services- First Date of Service:
i. Routine Referral- Did services begin within seven days after the date the
contractor’s receipt of DADS’ Authorization form?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 63
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
6 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. Transfer- Did services begin on the date negotiated between the case manager
STANDARD II. ATTENDANT REQUIREMENTS
and the contractor?
c. If a delay in service initiation did the contractor document the reason for the delay,
either an anticipated date of initiation or specific reasons why the contractor cannot
anticipate a date and a description of the contractor’s efforts to initiate services?
d. Did the contractor send notice of service initiation to the case manager within 14 days
after initiating services?
IV. 1. Were services initiated as required?
• Select “Y” if a is “Y”, b is “NA”, c is “NA” and d is “Y”
• Select “Y” if a is “NA”, b is “Y”, c is “NA” and d is “Y”
• Select “Y” if a or b is “N”, c is “Y” and d is “Y”
• Select “N” if a or b is “N”, c is “N” and d is “Y”
• Select “N” if d is “N”
VI. SERVICE DELIVERY
Complete UNITS OF SERVICE Tables for the last six months of service within the review
VI.1
period then answer VI.1.
a. Priority status- Does the number of documented hours/units of service equal the
number of authorized hours/units; or
Non-Priority status- Does the number of documented hours/units of service indicate that
there were no service interruptions exceeding 14 consecutive days?
b. If a is “N” was the reason for the failure to provide all service hours one of the
following:
• the individual’s revised service plan identified a need for an ongoing decrease in
hours;
• the individual requested that services not be provided;
• the individual requested fewer hours of service than reflected in the service
schedule;
• the individual requested that a specific attendant not provide services;
• the individual was not at home when the service was scheduled;
• services were not delivered for other reasons beyond the control of the provider
agency; or
• services were suspended.
- The individual temporarily or permanently left the contracted services delivery area;
- The individual moved to a location where services could not be provided under the PHC program;
- The individual died;
- The individual was admitted to an institution (hospital, nursing facility, state school, state hospital, or
ICF-MR facility);
- The individual requested that services end;
- DADS denied the individual’s Medicaid eligibility (not applicable to FC);
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 64
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
6 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
- The individual or someone in the individual’s home exhibited reckless behavior, which may have
STANDARD II. ATTENDANT REQUIREMENTS
resulted in imminent danger to the health and safety of the individual, the attendant, or another person;
- The individual or someone else in the individual’s home engaged in discrimination against a provider
agency or DADS employee in violation of applicable law;
- The individual refused services for more than 30 consecutive days.
VI. 1. Were personal assistance service hours provided in accordance with the
individual’s service plans or as required?
• Select “Y” if a is “Y” or a is “N” and b is “Y”
• Select “N” if a and b are “N”
STANDARD VII. SERVICE PLAN CHANGE
• Review the individual’s record for the 12 month review period to determine if a service plan change
was identified and requested.
VII.1.
• Select “NA” if a service plan change was not identified/requested. Continue to Standard VIII.
• If a service plan change was identified/requested, complete the table below.
Date(s) of /identified Date of notification to Effective Date Date of Date(s) of identified Date of revised service
need/request for an the contractor OR (F2101, item 4) Implementation need/request for a plan
increase in service case manager (Service Delivery decrease in service
hours or change that (F2067 or equivalent) Documentation) hours
results in no delivery
of personal care tasks
a. Immediate increase in hours:
i. If requested by the contractor, did the contractor’s documentation include:
• evidence that the contractor discussed the reason for the request of immediate
increase in hours with the case manager? NA
• the date the contractor received approval from the case manager? NA
• the name of the case manager who approved the change? NA
• the effective date of change, and NA
• the number of hours authorized? NA
ii. Did the contractor implement the service plan change on the date negotiated with the
NA
case manager? NA
b. Increase in service hours or no delivery of personal care tasks:
i. If requested by the contractor, was the case manager notified in writing within seven
days from the date of request/identification of need; and NA
ii. Did the notification include:
• date the provider agency learned of the need for the change;
NA
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 65
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
6 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• reason II. ATTENDANT REQUIREMENTS
STANDARD for the change;
NA
• type of change (including the number of service hours) and:
• signature and date of the provider agency representative?
iii. For any increase in service hours requested by the contractor, individual or case manager, did the contractor
implement the change within the required timeframe?
• Was the service plan change implemented on the Begin Date (F2101, item 4) or
five days after the contractor’s date stamp on F2101, whichever is later; or NA
• If delayed, did the contractor document, by the next working day, the failure to
implement the service plan change on the effective date to include the reason and NA
new implementation date? NA
c. Decrease in service hours:
i. Did the contractor develop a new service plan within 21 days from the date of the
individual’s request or identification of need for a service plan change? NA
VII.1. If a service plan change for PAS was identified or requested, did the contractor
meet all requirements?
• If the contractor requested an increase in hours or no delivery of personal care tasks -
select “Y” if a. i-ii or b. i-iii are “Y” NA
• If the case manager requested an increase in hours or no delivery of personal care
tasks - select “Y” if a. ii or b. iii are “Y”
• Select “Y” if a decrease in service hours was requested/identified and c. is “Y”
STANDARD IX. BILLING
Compare the Units of Service tables to the Contract Monitoring Claims Report for the last six months of
service delivery within the review period.
OVERARCHING QUESTION For
the last six months of service delivery to the individual within the review
period,:
i. Were the number of units documented equal to or greater than the
number of units paid? Y or N
ii. Were the number of units paid equal to or less than the number of
IX.1a authorized units? (If No, did the increase meet the criteria of a temporary Not Calculated in
increase)? Y or N Score
• If overarching question IX.1a.i and IX.1a.ii are "Y", mark IX.1a"Y" and skip
overarching question IX.1b and mark Standard IX.1 "Y".
• If either overarching question IX.1a.i or IX.1a.ii is“N”, mark IX.1a "N" and
continue to overarching question IX.1b.
OVERARCHING QUESTION Did
the contractor provide evidence that the contractor negative billed the
over-billed amount due to DADS prior to the date of the Entrance
Not Calculated in
Conference?
IX.1b Score
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 66
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
6 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
IX.1b
• If overarching question IX.1b is “Y”, mark
STANDARD II. ATTENDANT REQUIREMENTS Standard IX.1 “Y”.
• If overarching question IX.1b is “N”, mark Standard IX.1 “N”. Complete
Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for
Payment.
IX. 1. DADS did not identify a financial error?
• Select “Y”, if the contractor does not owe an Amount Due to DADS per the Demand
for Payment Notice (Column L)
• Select “Y”, if the contractor provides evidence that the contractor negative billed the
amount due to DADS prior to the date of the entrance Conference.
• Select “N”, if the contractor owes an Amount Due to DADS per the Demand for
Payment Notice (Column L)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 67
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
7 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
II.1 Complete the Attendants Requirements Table below.
Column A: Enter the name(s) of each attendant that provided direct care to the individual during the last six
months of service delivery to the individual.
Review the contractor’s supporting documentation to answer Columns B, C and G.
Column B: Select “Y” if the attendant is at least 18 years of age or, if under 18 years of age, is a high school
graduate or is enrolled in a vocational educational program and has demonstrated competency to perform the
tasks assigned by the supervisor.
Column C: Select “NA” if Family Care. PHC/CAS- Select “Y” if the attendant is not the individual’s legal parent,
foster parent or spouse of a parent (if a minor- under the age of 18 years) or spouse (if an adult- 18 yrs or older)
Column G: For each attendant review F2101. If hired prior to 6/1/2010, select "NA". If the case manager did NOT
designate the attendant as “Do Not Hire,” select “Y”. If listed as “Do Not Hire”, select “N”. If “N” identify the number
of units provided by the attendant and paid by DADS for the last two months of service to the individual. If DADS
paid for services provided by the attendant, complete the Demand for Payment Notice columns A-H from Contract
Monitoring Claims Report, enter the number of verified units provided by the “DNH” attendant in Column J.
A. B. C. G.
Name of Attendant Attendant Attendant Attendant is
Meets the Meets the NOT
Age Relationship designated
Requirement Requirement COLUMNS LEFT BLANK as "Do Not
INTENTIONALLY Hire"
If hired on or
after
6/1/2010
`
II.1 Does each of the individual’s attendants meet the required qualifications?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 68
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
7 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• Select “Y” if ATTENDANT REQUIREMENTS
STANDARD II.for each row, all responses in column B are "Y" and all responses in
columns C and G are “Y” or "NA" (note: column C will only be NA for Family Care)
• Select “N” if for any row, a response in columns B, C or G is “N”
ORIENTATION CHECKLIST
A. B. C. D. E. F. G.
Name of Individual’s Attendant Date of First Service Date of Orientation Orientation Orientation Provided Orientation Elements not
to Individual Conducted in On or Before First Included All included in the
Person with Date of Service to the Required Orientation
Review service delivery documentation for (Review service delivery (Refer to Participation of the Individual Elements (Enter the
the last six months of service delivery within documentation for the documentation of corresponding
Individual or
review period to determine if
the review period and enter the name of first date of service to the
Attendant Attendant Met elements that were
each attendant that provided care to the sample individual was within Orientations Requirements for not addressed)
individual- NA for a Supervisor providing the last six months of conducted during the Orientation Without
personal assistance services service delivery. If the review period)
unlicensed attendant began
Participation of the
providing services to the Individual
sample individual during the
last six months of service
delivery, enter the first date
of service and complete
columns C - G. If the
unlicensed attendant worked
with the sample individual
prior to the last six months
of service delivery, select
“N” and leave columns C –
G blank.)
Last Six Months
Begin: End:
Last Name: First Name; Answer Date:
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 69
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
7 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Attendant Requirements for Orientation without Participation of the Individual (telephone/verbal): Meet the requirements of a Home health Aide*; have six continuous months of experience
delivering attendant care; has been oriented to the individual and the service plan has not changed; or has previously provided services to the individual.
Required elements:
1. Name of the individual for whom the attendant is to provide care
2. Name of the attendant
3. Date of the attendant orientation
4. Orientation conducted in person with the individual or without the participation of the individual
5. How the individual’s condition affects the performance of tasks
6. Tasks to be performed
7. Service schedule
8. Number of hours of service the attendant is to provide
9. Total number of hours the individual is authorized to receive
10. Safety and emergency procedures, including universal precautions
11. Specific situations about which the attendant should notify the contractor (e.g., changes in the individual’s needs; incidents that affect the individual’s condition; hospitalization;
absence or relocation from home; attendant’s inability to work; and suspicion/allegation of abuse, neglect or exploitation of the individual).
12. Signature of the Supervisor who conducted the orientation
13. Signature of the attendant, if present
14. Signature of the individual, if present
*A Home Health Aide must:
o have a minimum of six months experience in delivering personal care tasks in family care, primary home care, personal assistance services, client managed personal attendant
services; or
o be listed on the DADS Nurses Aide Registry with an employable “Active’ status.
II. 3. Was each attendant who began providing care to the individual during the last
six months of service delivery within the review period, oriented, as required, on or
before the first date of service delivery?
• Select “NA” if the individual’s attendant(s) began providing care to the individual prior
to the review period.
• Select “Y” if column B is “Y” and columns D., E and F. are “Y”
• Select “N” if column B is “Y” and column D., E and/or F is “N”.
STANDARD III. PRE-INITIATION ACTIVITIES
OVERARCHING QUESTION Did
the individual's pre-initiation activities occur during the review period?
III.1 • If overarching question III.1 is “N”, select “NA” for Standard III.1-3. Not Calculated in
Continue to Standard IV.1. Score
• If overarching question III.1 is “Y”, verify pre-initiation activities were
completed as required.
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 70
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
7 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Date of Referral Date of Referral Negotiated Date Stamp on Date of
(F2101, item 1) (F2101, item 25) Service Initiation F2101 Notification for
Date Intake
(Routine) (Expedited/Transf (Expedited/Transf (Retroactive)
er) er)
Date of Evaluation:
a. Routine Referral
i) Is the date of the evaluation within 14 calendar days after the date of referral or the date
the contractor received F-2101 as indicated by a date stamp- whichever is later; or
ii) If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the evaluation?
b. Expedited Referral (transfers are reviewed as an expedited referral)
i) Is the date of the evaluation on or before the date negotiated between the case
manager and contractor, which must be less than 14 days after the oral request; or
ii) If a delay, did the contractor notify the case manager of any failure to complete the
evaluation before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i) Is the date of the evaluation on or before the date of notification to DADS for intake?
d. Does the evaluation include the individual’s self-report of the dates and reasons for any
hospitalizations within 3 months prior to the evaluation were addressed?
e. Does the evaluation identify assistance needed to achieve activities of daily living,
including any assistive devices or medical equipment used by the person?
III.1. Did the contractor complete an evaluation of the individual as required?
o Select “Y” if a, b, or c is “Y” and d and e are “Y”
o Select “N” if a, b, or c is “N” and d and/or e is “N”
Date of Initial Service Delivery Plan:
a. Routine Referral
i. Was the initial service delivery plan completed within 14 calendar days after the referral
date or the date the contractor received F- 2101 as indicated by a date stamp- whichever
is later; or
ii. If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the service plan?
b. Expedited Referral (transfers are reviewed as an expedited referral)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 71
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
7 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
i. Is the date of the service delivery plan on or before the date negotiated between the
case manager and contractor, which must be less than 14 days after the oral request; or
ii If a delay, did the contractor notify the case manager of any failure to complete the
service delivery plan before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i. Was the service plan complete prior to the date of notification to DADS for intake?
d. The service plan is agreed upon and was signed by the individual and the contractor
e. The service plan identifies the location of service delivery
f. The service plan identifies the tasks the individual will receive (includes at least one
personal care task, unless FC)
g. The service plan identifies the total weekly hours authorized
h. The service plan identifies the service schedule which includes as necessary, based
on the individual’s needs, certain time periods for the delivery of specified tasks
i. The service plan identifies the frequency of supervisory visits
j. The service plan includes the statement that the contractor is responsible for providing
the tasks allowable in the PHC program (47.41) and agreed to on the service plan.
III. 2. Did the contractor develop an initial service delivery plan as required?
• Select “Y” if a, b, or c is “Y” and d - j are “Y”
• Select “N” if a, b, or c is “N” and/or d – j is “N”
OVERARCHING QUESTION Does
the individual receive family care or did the individual transfer from one
PHC contractor to another PHC, transfer from PHC to CAS or transfer from
Not Calculated in
CAS to PHC during the review period?
III.3 Score
• If overarching question III.3 is “Y”, select “NA” for Standard III.3. Continue
to Standard IV.1.
• If overarching question III.3 is “N”, verify the contractor met the
requirements for the individual’s practitioner’s statement.
Date of Practitioner’s Statement:
a. Routine Referral
i. Did the contractor obtain and submit to DADS a complete practitioner’s statement
within 14 calendar days after the date of referral or the date the contractor received F-
2101 as indicated by a date stamp- whichever is later. Review the contractor's fax, email
or other documentation that verifies the practitioner's statement was submitted to DADS
within the required timeframe; or
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 72
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
7 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. If a delay, II. ATTENDANT REQUIREMENTS
STANDARDdid the contractor document by due date the reason for the delay, an
anticipated date of completion or reason why a completion date cannot be anticipated;
and a description of the contractor’s efforts to obtain the practitioner’s statement?
b. Expedited Referral
i. Did the contractor send a complete practitioner’s statement to DADS within seven (7)
work days after service initiation? Review the contractor's fax, email or other
documentation that verifies the practitioner's statement was submitted to DADS within the
required timeframe.
c. Retroactive
i. Was the practitioner’s statement completed on or before the date of notification to
DADS for intake?
III. 3. Did the contractor meet the requirements for the individual’s practitioner’s
statement?
• Select “Y” if a, b, or c (as applicable) is “Y”
• Select “N” if a, b, or c ( as applicable) is “N”
Potential Billing Error:
If III.3 is “N”, review the Contract Monitoring Claims Report Payment Report for the billing periods within the 12
month review period prior to the date of the practitioner’s statement to determine if DADS paid for services prior to
the date of the practitioner’s statement. If DADS paid for services prior to the date of the practitioner’s statement,
complete Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for Payment. Enter “0” in Column J -
Units Verified for units paid prior to the date of the practitioner’s statement.
STANDARD IV. SERVICE INITIATION
OVERARCHING QUESTION Did
the individual enter services during the review period?
• If overarching question IV.1 is “N”, select “NA” for Standard IV.1. Continue Not Calculated in
IV.1
to Standard V.1. Score
• If overarching question IV.1 is “Y”, verify the contractor met the
requirements for service initiation.
a. Family Care- First Date of Service:
i. Routine Referral-Did services begin within 14 days after the referral date or
within 14 days after the date the contractor date stamped DADS’ authorization
form; or
ii. Transfer- Did services begin on the date negotiated between the case manager
and the contractor?
b. Primary Home Care or Community Attendant Services- First Date of Service:
i. Routine Referral- Did services begin within seven days after the date the
contractor’s receipt of DADS’ Authorization form?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 73
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
7 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. Transfer- Did services begin on the date negotiated between the case manager
STANDARD II. ATTENDANT REQUIREMENTS
and the contractor?
c. If a delay in service initiation did the contractor document the reason for the delay,
either an anticipated date of initiation or specific reasons why the contractor cannot
anticipate a date and a description of the contractor’s efforts to initiate services?
d. Did the contractor send notice of service initiation to the case manager within 14 days
after initiating services?
IV. 1. Were services initiated as required?
• Select “Y” if a is “Y”, b is “NA”, c is “NA” and d is “Y”
• Select “Y” if a is “NA”, b is “Y”, c is “NA” and d is “Y”
• Select “Y” if a or b is “N”, c is “Y” and d is “Y”
• Select “N” if a or b is “N”, c is “N” and d is “Y”
• Select “N” if d is “N”
VI. SERVICE DELIVERY
Complete UNITS OF SERVICE Tables for the last six months of service within the review
VI.1
period then answer VI.1.
a. Priority status- Does the number of documented hours/units of service equal the
number of authorized hours/units; or
Non-Priority status- Does the number of documented hours/units of service indicate that
there were no service interruptions exceeding 14 consecutive days?
b. If a is “N” was the reason for the failure to provide all service hours one of the
following:
• the individual’s revised service plan identified a need for an ongoing decrease in
hours;
• the individual requested that services not be provided;
• the individual requested fewer hours of service than reflected in the service
schedule;
• the individual requested that a specific attendant not provide services;
• the individual was not at home when the service was scheduled;
• services were not delivered for other reasons beyond the control of the provider
agency; or
• services were suspended.
- The individual temporarily or permanently left the contracted services delivery area;
- The individual moved to a location where services could not be provided under the PHC program;
- The individual died;
- The individual was admitted to an institution (hospital, nursing facility, state school, state hospital, or
ICF-MR facility);
- The individual requested that services end;
- DADS denied the individual’s Medicaid eligibility (not applicable to FC);
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 74
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
7 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
- The individual or someone in the individual’s home exhibited reckless behavior, which may have
STANDARD II. ATTENDANT REQUIREMENTS
resulted in imminent danger to the health and safety of the individual, the attendant, or another person;
- The individual or someone else in the individual’s home engaged in discrimination against a provider
agency or DADS employee in violation of applicable law;
- The individual refused services for more than 30 consecutive days.
VI. 1. Were personal assistance service hours provided in accordance with the
individual’s service plans or as required?
• Select “Y” if a is “Y” or a is “N” and b is “Y”
• Select “N” if a and b are “N”
STANDARD VII. SERVICE PLAN CHANGE
• Review the individual’s record for the 12 month review period to determine if a service plan change
was identified and requested.
VII.1.
• Select “NA” if a service plan change was not identified/requested. Continue to Standard VIII.
• If a service plan change was identified/requested, complete the table below.
Date(s) of /identified Date of notification to Effective Date Date of Date(s) of identified Date of revised service
need/request for an the contractor OR (F2101, item 4) Implementation need/request for a plan
increase in service case manager (Service Delivery decrease in service
hours or change that (F2067 or equivalent) Documentation) hours
results in no delivery
of personal care tasks
a. Immediate increase in hours:
i. If requested by the contractor, did the contractor’s documentation include:
• evidence that the contractor discussed the reason for the request of immediate
increase in hours with the case manager? NA
• the date the contractor received approval from the case manager? NA
• the name of the case manager who approved the change? NA
• the effective date of change, and NA
• the number of hours authorized? NA
ii. Did the contractor implement the service plan change on the date negotiated with the
NA
case manager? NA
b. Increase in service hours or no delivery of personal care tasks:
i. If requested by the contractor, was the case manager notified in writing within seven
days from the date of request/identification of need; and NA
ii. Did the notification include:
• date the provider agency learned of the need for the change;
NA
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 75
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
7 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• reason II. ATTENDANT REQUIREMENTS
STANDARD for the change;
NA
• type of change (including the number of service hours) and:
• signature and date of the provider agency representative?
iii. For any increase in service hours requested by the contractor, individual or case manager, did the contractor
implement the change within the required timeframe?
• Was the service plan change implemented on the Begin Date (F2101, item 4) or
five days after the contractor’s date stamp on F2101, whichever is later; or NA
• If delayed, did the contractor document, by the next working day, the failure to
implement the service plan change on the effective date to include the reason and NA
new implementation date? NA
c. Decrease in service hours:
i. Did the contractor develop a new service plan within 21 days from the date of the
individual’s request or identification of need for a service plan change? NA
VII.1. If a service plan change for PAS was identified or requested, did the contractor
meet all requirements?
• If the contractor requested an increase in hours or no delivery of personal care tasks -
select “Y” if a. i-ii or b. i-iii are “Y” NA
• If the case manager requested an increase in hours or no delivery of personal care
tasks - select “Y” if a. ii or b. iii are “Y”
• Select “Y” if a decrease in service hours was requested/identified and c. is “Y”
STANDARD IX. BILLING
Compare the Units of Service tables to the Contract Monitoring Claims Report for the last six months of
service delivery within the review period.
OVERARCHING QUESTION For
the last six months of service delivery to the individual within the review
period,:
i. Were the number of units documented equal to or greater than the
number of units paid? Y or N
ii. Were the number of units paid equal to or less than the number of
IX.1a authorized units? (If No, did the increase meet the criteria of a temporary Not Calculated in
increase)? Y or N Score
• If overarching question IX.1a.i and IX.1a.ii are "Y", mark IX.1a"Y" and skip
overarching question IX.1b and mark Standard IX.1 "Y".
• If either overarching question IX.1a.i or IX.1a.ii is“N”, mark IX.1a "N" and
continue to overarching question IX.1b.
OVERARCHING QUESTION Did
the contractor provide evidence that the contractor negative billed the
over-billed amount due to DADS prior to the date of the Entrance
Not Calculated in
Conference?
IX.1b Score
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 76
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
7 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
IX.1b
• If overarching question IX.1b is “Y”, mark
STANDARD II. ATTENDANT REQUIREMENTS Standard IX.1 “Y”.
• If overarching question IX.1b is “N”, mark Standard IX.1 “N”. Complete
Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for
Payment.
IX. 1. DADS did not identify a financial error?
• Select “Y”, if the contractor does not owe an Amount Due to DADS per the Demand
for Payment Notice (Column L)
• Select “Y”, if the contractor provides evidence that the contractor negative billed the
amount due to DADS prior to the date of the entrance Conference.
• Select “N”, if the contractor owes an Amount Due to DADS per the Demand for
Payment Notice (Column L)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 77
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
8 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
II.1 Complete the Attendants Requirements Table below.
Column A: Enter the name(s) of each attendant that provided direct care to the individual during the last six
months of service delivery to the individual.
Review the contractor’s supporting documentation to answer Columns B, C and G.
Column B: Select “Y” if the attendant is at least 18 years of age or, if under 18 years of age, is a high school
graduate or is enrolled in a vocational educational program and has demonstrated competency to perform the
tasks assigned by the supervisor.
Column C: Select “NA” if Family Care. PHC/CAS- Select “Y” if the attendant is not the individual’s legal parent,
foster parent or spouse of a parent (if a minor- under the age of 18 years) or spouse (if an adult- 18 yrs or older)
Column G: For each attendant review F2101. If hired prior to 6/1/2010, select "NA". If the case manager did NOT
designate the attendant as “Do Not Hire,” select “Y”. If listed as “Do Not Hire”, select “N”. If “N” identify the number
of units provided by the attendant and paid by DADS for the last two months of service to the individual. If DADS
paid for services provided by the attendant, complete the Demand for Payment Notice columns A-H from Contract
Monitoring Claims Report, enter the number of verified units provided by the “DNH” attendant in Column J.
A. B. C. G.
Name of Attendant Attendant Attendant Attendant is
Meets the Meets the NOT
Age Relationship designated
Requirement Requirement COLUMNS LEFT BLANK as "Do Not
INTENTIONALLY Hire"
If hired on or
after
6/1/2010
`
II.1 Does each of the individual’s attendants meet the required qualifications?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 78
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
8 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• Select “Y” if ATTENDANT REQUIREMENTS
STANDARD II.for each row, all responses in column B are "Y" and all responses in
columns C and G are “Y” or "NA" (note: column C will only be NA for Family Care)
• Select “N” if for any row, a response in columns B, C or G is “N”
ORIENTATION CHECKLIST
A. B. C. D. E. F. G.
Name of Individual’s Attendant Date of First Service Date of Orientation Orientation Orientation Provided Orientation Elements not
to Individual Conducted in On or Before First Included All included in the
Person with Date of Service to the Required Orientation
Review service delivery documentation for (Review service delivery (Refer to Participation of the Individual Elements (Enter the
the last six months of service delivery within documentation for the documentation of corresponding
Individual or
review period to determine if
the review period and enter the name of first date of service to the
Attendant Attendant Met elements that were
each attendant that provided care to the sample individual was within Orientations Requirements for not addressed)
individual- NA for a Supervisor providing the last six months of conducted during the Orientation Without
personal assistance services service delivery. If the review period)
unlicensed attendant began
Participation of the
providing services to the Individual
sample individual during the
last six months of service
delivery, enter the first date
of service and complete
columns C - G. If the
unlicensed attendant worked
with the sample individual
prior to the last six months
of service delivery, select
“N” and leave columns C –
G blank.)
Last Six Months
Begin: End:
Last Name: First Name; Answer Date:
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 79
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
8 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Attendant Requirements for Orientation without Participation of the Individual (telephone/verbal): Meet the requirements of a Home health Aide*; have six continuous months of experience
delivering attendant care; has been oriented to the individual and the service plan has not changed; or has previously provided services to the individual.
Required elements:
1. Name of the individual for whom the attendant is to provide care
2. Name of the attendant
3. Date of the attendant orientation
4. Orientation conducted in person with the individual or without the participation of the individual
5. How the individual’s condition affects the performance of tasks
6. Tasks to be performed
7. Service schedule
8. Number of hours of service the attendant is to provide
9. Total number of hours the individual is authorized to receive
10. Safety and emergency procedures, including universal precautions
11. Specific situations about which the attendant should notify the contractor (e.g., changes in the individual’s needs; incidents that affect the individual’s condition; hospitalization;
absence or relocation from home; attendant’s inability to work; and suspicion/allegation of abuse, neglect or exploitation of the individual).
12. Signature of the Supervisor who conducted the orientation
13. Signature of the attendant, if present
14. Signature of the individual, if present
*A Home Health Aide must:
o have a minimum of six months experience in delivering personal care tasks in family care, primary home care, personal assistance services, client managed personal attendant
services; or
o be listed on the DADS Nurses Aide Registry with an employable “Active’ status.
II. 3. Was each attendant who began providing care to the individual during the last
six months of service delivery within the review period, oriented, as required, on or
before the first date of service delivery?
• Select “NA” if the individual’s attendant(s) began providing care to the individual prior
to the review period.
• Select “Y” if column B is “Y” and columns D., E and F. are “Y”
• Select “N” if column B is “Y” and column D., E and/or F is “N”.
STANDARD III. PRE-INITIATION ACTIVITIES
OVERARCHING QUESTION Did
the individual's pre-initiation activities occur during the review period?
III.1 • If overarching question III.1 is “N”, select “NA” for Standard III.1-3. Not Calculated in
Continue to Standard IV.1. Score
• If overarching question III.1 is “Y”, verify pre-initiation activities were
completed as required.
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 80
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
8 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Date of Referral Date of Referral Negotiated Date Stamp on Date of
(F2101, item 1) (F2101, item 25) Service Initiation F2101 Notification for
Date Intake
(Routine) (Expedited/Transf (Expedited/Transf (Retroactive)
er) er)
Date of Evaluation:
a. Routine Referral
i) Is the date of the evaluation within 14 calendar days after the date of referral or the date
the contractor received F-2101 as indicated by a date stamp- whichever is later; or
ii) If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the evaluation?
b. Expedited Referral (transfers are reviewed as an expedited referral)
i) Is the date of the evaluation on or before the date negotiated between the case
manager and contractor, which must be less than 14 days after the oral request; or
ii) If a delay, did the contractor notify the case manager of any failure to complete the
evaluation before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i) Is the date of the evaluation on or before the date of notification to DADS for intake?
d. Does the evaluation include the individual’s self-report of the dates and reasons for any
hospitalizations within 3 months prior to the evaluation were addressed?
e. Does the evaluation identify assistance needed to achieve activities of daily living,
including any assistive devices or medical equipment used by the person?
III.1. Did the contractor complete an evaluation of the individual as required?
o Select “Y” if a, b, or c is “Y” and d and e are “Y”
o Select “N” if a, b, or c is “N” and d and/or e is “N”
Date of Initial Service Delivery Plan:
a. Routine Referral
i. Was the initial service delivery plan completed within 14 calendar days after the referral
date or the date the contractor received F- 2101 as indicated by a date stamp- whichever
is later; or
ii. If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the service plan?
b. Expedited Referral (transfers are reviewed as an expedited referral)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 81
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
8 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
i. Is the date of the service delivery plan on or before the date negotiated between the
case manager and contractor, which must be less than 14 days after the oral request; or
ii If a delay, did the contractor notify the case manager of any failure to complete the
service delivery plan before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i. Was the service plan complete prior to the date of notification to DADS for intake?
d. The service plan is agreed upon and was signed by the individual and the contractor
e. The service plan identifies the location of service delivery
f. The service plan identifies the tasks the individual will receive (includes at least one
personal care task, unless FC)
g. The service plan identifies the total weekly hours authorized
h. The service plan identifies the service schedule which includes as necessary, based
on the individual’s needs, certain time periods for the delivery of specified tasks
i. The service plan identifies the frequency of supervisory visits
j. The service plan includes the statement that the contractor is responsible for providing
the tasks allowable in the PHC program (47.41) and agreed to on the service plan.
III. 2. Did the contractor develop an initial service delivery plan as required?
• Select “Y” if a, b, or c is “Y” and d - j are “Y”
• Select “N” if a, b, or c is “N” and/or d – j is “N”
OVERARCHING QUESTION Does
the individual receive family care or did the individual transfer from one
PHC contractor to another PHC, transfer from PHC to CAS or transfer from
Not Calculated in
CAS to PHC during the review period?
III.3 Score
• If overarching question III.3 is “Y”, select “NA” for Standard III.3. Continue
to Standard IV.1.
• If overarching question III.3 is “N”, verify the contractor met the
requirements for the individual’s practitioner’s statement.
Date of Practitioner’s Statement:
a. Routine Referral
i. Did the contractor obtain and submit to DADS a complete practitioner’s statement
within 14 calendar days after the date of referral or the date the contractor received F-
2101 as indicated by a date stamp- whichever is later. Review the contractor's fax, email
or other documentation that verifies the practitioner's statement was submitted to DADS
within the required timeframe; or
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 82
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
8 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. If a delay, II. ATTENDANT REQUIREMENTS
STANDARDdid the contractor document by due date the reason for the delay, an
anticipated date of completion or reason why a completion date cannot be anticipated;
and a description of the contractor’s efforts to obtain the practitioner’s statement?
b. Expedited Referral
i. Did the contractor send a complete practitioner’s statement to DADS within seven (7)
work days after service initiation? Review the contractor's fax, email or other
documentation that verifies the practitioner's statement was submitted to DADS within the
required timeframe.
c. Retroactive
i. Was the practitioner’s statement completed on or before the date of notification to
DADS for intake?
III. 3. Did the contractor meet the requirements for the individual’s practitioner’s
statement?
• Select “Y” if a, b, or c (as applicable) is “Y”
• Select “N” if a, b, or c ( as applicable) is “N”
Potential Billing Error:
If III.3 is “N”, review the Contract Monitoring Claims Report Payment Report for the billing periods within the 12
month review period prior to the date of the practitioner’s statement to determine if DADS paid for services prior to
the date of the practitioner’s statement. If DADS paid for services prior to the date of the practitioner’s statement,
complete Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for Payment. Enter “0” in Column J -
Units Verified for units paid prior to the date of the practitioner’s statement.
STANDARD IV. SERVICE INITIATION
OVERARCHING QUESTION Did
the individual enter services during the review period?
• If overarching question IV.1 is “N”, select “NA” for Standard IV.1. Continue Not Calculated in
IV.1
to Standard V.1. Score
• If overarching question IV.1 is “Y”, verify the contractor met the
requirements for service initiation.
a. Family Care- First Date of Service:
i. Routine Referral-Did services begin within 14 days after the referral date or
within 14 days after the date the contractor date stamped DADS’ authorization
form; or
ii. Transfer- Did services begin on the date negotiated between the case manager
and the contractor?
b. Primary Home Care or Community Attendant Services- First Date of Service:
i. Routine Referral- Did services begin within seven days after the date the
contractor’s receipt of DADS’ Authorization form?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 83
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
8 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. Transfer- Did services begin on the date negotiated between the case manager
STANDARD II. ATTENDANT REQUIREMENTS
and the contractor?
c. If a delay in service initiation did the contractor document the reason for the delay,
either an anticipated date of initiation or specific reasons why the contractor cannot
anticipate a date and a description of the contractor’s efforts to initiate services?
d. Did the contractor send notice of service initiation to the case manager within 14 days
after initiating services?
IV. 1. Were services initiated as required?
• Select “Y” if a is “Y”, b is “NA”, c is “NA” and d is “Y”
• Select “Y” if a is “NA”, b is “Y”, c is “NA” and d is “Y”
• Select “Y” if a or b is “N”, c is “Y” and d is “Y”
• Select “N” if a or b is “N”, c is “N” and d is “Y”
• Select “N” if d is “N”
VI. SERVICE DELIVERY
Complete UNITS OF SERVICE Tables for the last six months of service within the review
VI.1
period then answer VI.1.
a. Priority status- Does the number of documented hours/units of service equal the
number of authorized hours/units; or
Non-Priority status- Does the number of documented hours/units of service indicate that
there were no service interruptions exceeding 14 consecutive days?
b. If a is “N” was the reason for the failure to provide all service hours one of the
following:
• the individual’s revised service plan identified a need for an ongoing decrease in
hours;
• the individual requested that services not be provided;
• the individual requested fewer hours of service than reflected in the service
schedule;
• the individual requested that a specific attendant not provide services;
• the individual was not at home when the service was scheduled;
• services were not delivered for other reasons beyond the control of the provider
agency; or
• services were suspended.
- The individual temporarily or permanently left the contracted services delivery area;
- The individual moved to a location where services could not be provided under the PHC program;
- The individual died;
- The individual was admitted to an institution (hospital, nursing facility, state school, state hospital, or
ICF-MR facility);
- The individual requested that services end;
- DADS denied the individual’s Medicaid eligibility (not applicable to FC);
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 84
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
8 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
- The individual or someone in the individual’s home exhibited reckless behavior, which may have
STANDARD II. ATTENDANT REQUIREMENTS
resulted in imminent danger to the health and safety of the individual, the attendant, or another person;
- The individual or someone else in the individual’s home engaged in discrimination against a provider
agency or DADS employee in violation of applicable law;
- The individual refused services for more than 30 consecutive days.
VI. 1. Were personal assistance service hours provided in accordance with the
individual’s service plans or as required?
• Select “Y” if a is “Y” or a is “N” and b is “Y”
• Select “N” if a and b are “N”
STANDARD VII. SERVICE PLAN CHANGE
• Review the individual’s record for the 12 month review period to determine if a service plan change
was identified and requested.
VII.1.
• Select “NA” if a service plan change was not identified/requested. Continue to Standard VIII.
• If a service plan change was identified/requested, complete the table below.
Date(s) of /identified Date of notification to Effective Date Date of Date(s) of identified Date of revised service
need/request for an the contractor OR (F2101, item 4) Implementation need/request for a plan
increase in service case manager (Service Delivery decrease in service
hours or change that (F2067 or equivalent) Documentation) hours
results in no delivery
of personal care tasks
a. Immediate increase in hours:
i. If requested by the contractor, did the contractor’s documentation include:
• evidence that the contractor discussed the reason for the request of immediate
increase in hours with the case manager? NA
• the date the contractor received approval from the case manager? NA
• the name of the case manager who approved the change? NA
• the effective date of change, and NA
• the number of hours authorized? NA
ii. Did the contractor implement the service plan change on the date negotiated with the
NA
case manager? NA
b. Increase in service hours or no delivery of personal care tasks:
i. If requested by the contractor, was the case manager notified in writing within seven
days from the date of request/identification of need; and NA
ii. Did the notification include:
• date the provider agency learned of the need for the change;
NA
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 85
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
8 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• reason II. ATTENDANT REQUIREMENTS
STANDARD for the change;
NA
• type of change (including the number of service hours) and:
• signature and date of the provider agency representative?
iii. For any increase in service hours requested by the contractor, individual or case manager, did the contractor
implement the change within the required timeframe?
• Was the service plan change implemented on the Begin Date (F2101, item 4) or
five days after the contractor’s date stamp on F2101, whichever is later; or NA
• If delayed, did the contractor document, by the next working day, the failure to
implement the service plan change on the effective date to include the reason and NA
new implementation date? NA
c. Decrease in service hours:
i. Did the contractor develop a new service plan within 21 days from the date of the
individual’s request or identification of need for a service plan change? NA
VII.1. If a service plan change for PAS was identified or requested, did the contractor
meet all requirements?
• If the contractor requested an increase in hours or no delivery of personal care tasks -
select “Y” if a. i-ii or b. i-iii are “Y” NA
• If the case manager requested an increase in hours or no delivery of personal care
tasks - select “Y” if a. ii or b. iii are “Y”
• Select “Y” if a decrease in service hours was requested/identified and c. is “Y”
STANDARD IX. BILLING
Compare the Units of Service tables to the Contract Monitoring Claims Report for the last six months of
service delivery within the review period.
OVERARCHING QUESTION For
the last six months of service delivery to the individual within the review
period,:
i. Were the number of units documented equal to or greater than the
number of units paid? Y or N
ii. Were the number of units paid equal to or less than the number of
IX.1a authorized units? (If No, did the increase meet the criteria of a temporary Not Calculated in
increase)? Y or N Score
• If overarching question IX.1a.i and IX.1a.ii are "Y", mark IX.1a"Y" and skip
overarching question IX.1b and mark Standard IX.1 "Y".
• If either overarching question IX.1a.i or IX.1a.ii is“N”, mark IX.1a "N" and
continue to overarching question IX.1b.
OVERARCHING QUESTION Did
the contractor provide evidence that the contractor negative billed the
over-billed amount due to DADS prior to the date of the Entrance
Not Calculated in
Conference?
IX.1b Score
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 86
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
8 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
IX.1b
• If overarching question IX.1b is “Y”, mark
STANDARD II. ATTENDANT REQUIREMENTS Standard IX.1 “Y”.
• If overarching question IX.1b is “N”, mark Standard IX.1 “N”. Complete
Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for
Payment.
IX. 1. DADS did not identify a financial error?
• Select “Y”, if the contractor does not owe an Amount Due to DADS per the Demand
for Payment Notice (Column L)
• Select “Y”, if the contractor provides evidence that the contractor negative billed the
amount due to DADS prior to the date of the entrance Conference.
• Select “N”, if the contractor owes an Amount Due to DADS per the Demand for
Payment Notice (Column L)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 87
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
9 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
II.1 Complete the Attendants Requirements Table below.
Column A: Enter the name(s) of each attendant that provided direct care to the individual during the last six
months of service delivery to the individual.
Review the contractor’s supporting documentation to answer Columns B, C and G.
Column B: Select “Y” if the attendant is at least 18 years of age or, if under 18 years of age, is a high school
graduate or is enrolled in a vocational educational program and has demonstrated competency to perform the
tasks assigned by the supervisor.
Column C: Select “NA” if Family Care. PHC/CAS- Select “Y” if the attendant is not the individual’s legal parent,
foster parent or spouse of a parent (if a minor- under the age of 18 years) or spouse (if an adult- 18 yrs or older)
Column G: For each attendant review F2101. If hired prior to 6/1/2010, select "NA". If the case manager did NOT
designate the attendant as “Do Not Hire,” select “Y”. If listed as “Do Not Hire”, select “N”. If “N” identify the number
of units provided by the attendant and paid by DADS for the last two months of service to the individual. If DADS
paid for services provided by the attendant, complete the Demand for Payment Notice columns A-H from Contract
Monitoring Claims Report, enter the number of verified units provided by the “DNH” attendant in Column J.
A. B. C. G.
Name of Attendant Attendant Attendant Attendant is
Meets the Meets the NOT
Age Relationship designated
Requirement Requirement COLUMNS LEFT BLANK as "Do Not
INTENTIONALLY Hire"
If hired on or
after
6/1/2010
`
II.1 Does each of the individual’s attendants meet the required qualifications?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 88
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
9 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• Select “Y” if ATTENDANT REQUIREMENTS
STANDARD II.for each row, all responses in column B are "Y" and all responses in
columns C and G are “Y” or "NA" (note: column C will only be NA for Family Care)
• Select “N” if for any row, a response in columns B, C or G is “N”
ORIENTATION CHECKLIST
A. B. C. D. E. F. G.
Name of Individual’s Attendant Date of First Service Date of Orientation Orientation Orientation Provided Orientation Elements not
to Individual Conducted in On or Before First Included All included in the
Person with Date of Service to the Required Orientation
Review service delivery documentation for (Review service delivery (Refer to Participation of the Individual Elements (Enter the
the last six months of service delivery within documentation for the documentation of corresponding
Individual or
review period to determine if
the review period and enter the name of first date of service to the
Attendant Attendant Met elements that were
each attendant that provided care to the sample individual was within Orientations Requirements for not addressed)
individual- NA for a Supervisor providing the last six months of conducted during the Orientation Without
personal assistance services service delivery. If the review period)
unlicensed attendant began
Participation of the
providing services to the Individual
sample individual during the
last six months of service
delivery, enter the first date
of service and complete
columns C - G. If the
unlicensed attendant worked
with the sample individual
prior to the last six months
of service delivery, select
“N” and leave columns C –
G blank.)
Last Six Months
Begin: End:
Last Name: First Name; Answer Date:
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 89
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
9 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Attendant Requirements for Orientation without Participation of the Individual (telephone/verbal): Meet the requirements of a Home health Aide*; have six continuous months of experience
delivering attendant care; has been oriented to the individual and the service plan has not changed; or has previously provided services to the individual.
Required elements:
1. Name of the individual for whom the attendant is to provide care
2. Name of the attendant
3. Date of the attendant orientation
4. Orientation conducted in person with the individual or without the participation of the individual
5. How the individual’s condition affects the performance of tasks
6. Tasks to be performed
7. Service schedule
8. Number of hours of service the attendant is to provide
9. Total number of hours the individual is authorized to receive
10. Safety and emergency procedures, including universal precautions
11. Specific situations about which the attendant should notify the contractor (e.g., changes in the individual’s needs; incidents that affect the individual’s condition; hospitalization;
absence or relocation from home; attendant’s inability to work; and suspicion/allegation of abuse, neglect or exploitation of the individual).
12. Signature of the Supervisor who conducted the orientation
13. Signature of the attendant, if present
14. Signature of the individual, if present
*A Home Health Aide must:
o have a minimum of six months experience in delivering personal care tasks in family care, primary home care, personal assistance services, client managed personal attendant
services; or
o be listed on the DADS Nurses Aide Registry with an employable “Active’ status.
II. 3. Was each attendant who began providing care to the individual during the last
six months of service delivery within the review period, oriented, as required, on or
before the first date of service delivery?
• Select “NA” if the individual’s attendant(s) began providing care to the individual prior
to the review period.
• Select “Y” if column B is “Y” and columns D., E and F. are “Y”
• Select “N” if column B is “Y” and column D., E and/or F is “N”.
STANDARD III. PRE-INITIATION ACTIVITIES
OVERARCHING QUESTION Did
the individual's pre-initiation activities occur during the review period?
III.1 • If overarching question III.1 is “N”, select “NA” for Standard III.1-3. Not Calculated in
Continue to Standard IV.1. Score
• If overarching question III.1 is “Y”, verify pre-initiation activities were
completed as required.
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 90
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
9 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Date of Referral Date of Referral Negotiated Date Stamp on Date of
(F2101, item 1) (F2101, item 25) Service Initiation F2101 Notification for
Date Intake
(Routine) (Expedited/Transf (Expedited/Transf (Retroactive)
er) er)
Date of Evaluation:
a. Routine Referral
i) Is the date of the evaluation within 14 calendar days after the date of referral or the date
the contractor received F-2101 as indicated by a date stamp- whichever is later; or
ii) If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the evaluation?
b. Expedited Referral (transfers are reviewed as an expedited referral)
i) Is the date of the evaluation on or before the date negotiated between the case
manager and contractor, which must be less than 14 days after the oral request; or
ii) If a delay, did the contractor notify the case manager of any failure to complete the
evaluation before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i) Is the date of the evaluation on or before the date of notification to DADS for intake?
d. Does the evaluation include the individual’s self-report of the dates and reasons for any
hospitalizations within 3 months prior to the evaluation were addressed?
e. Does the evaluation identify assistance needed to achieve activities of daily living,
including any assistive devices or medical equipment used by the person?
III.1. Did the contractor complete an evaluation of the individual as required?
o Select “Y” if a, b, or c is “Y” and d and e are “Y”
o Select “N” if a, b, or c is “N” and d and/or e is “N”
Date of Initial Service Delivery Plan:
a. Routine Referral
i. Was the initial service delivery plan completed within 14 calendar days after the referral
date or the date the contractor received F- 2101 as indicated by a date stamp- whichever
is later; or
ii. If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the service plan?
b. Expedited Referral (transfers are reviewed as an expedited referral)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 91
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
9 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
i. Is the date of the service delivery plan on or before the date negotiated between the
case manager and contractor, which must be less than 14 days after the oral request; or
ii If a delay, did the contractor notify the case manager of any failure to complete the
service delivery plan before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i. Was the service plan complete prior to the date of notification to DADS for intake?
d. The service plan is agreed upon and was signed by the individual and the contractor
e. The service plan identifies the location of service delivery
f. The service plan identifies the tasks the individual will receive (includes at least one
personal care task, unless FC)
g. The service plan identifies the total weekly hours authorized
h. The service plan identifies the service schedule which includes as necessary, based
on the individual’s needs, certain time periods for the delivery of specified tasks
i. The service plan identifies the frequency of supervisory visits
j. The service plan includes the statement that the contractor is responsible for providing
the tasks allowable in the PHC program (47.41) and agreed to on the service plan.
III. 2. Did the contractor develop an initial service delivery plan as required?
• Select “Y” if a, b, or c is “Y” and d - j are “Y”
• Select “N” if a, b, or c is “N” and/or d – j is “N”
OVERARCHING QUESTION Does
the individual receive family care or did the individual transfer from one
PHC contractor to another PHC, transfer from PHC to CAS or transfer from
Not Calculated in
CAS to PHC during the review period?
III.3 Score
• If overarching question III.3 is “Y”, select “NA” for Standard III.3. Continue
to Standard IV.1.
• If overarching question III.3 is “N”, verify the contractor met the
requirements for the individual’s practitioner’s statement.
Date of Practitioner’s Statement:
a. Routine Referral
i. Did the contractor obtain and submit to DADS a complete practitioner’s statement
within 14 calendar days after the date of referral or the date the contractor received F-
2101 as indicated by a date stamp- whichever is later. Review the contractor's fax, email
or other documentation that verifies the practitioner's statement was submitted to DADS
within the required timeframe; or
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 92
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
9 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. If a delay, II. ATTENDANT REQUIREMENTS
STANDARDdid the contractor document by due date the reason for the delay, an
anticipated date of completion or reason why a completion date cannot be anticipated;
and a description of the contractor’s efforts to obtain the practitioner’s statement?
b. Expedited Referral
i. Did the contractor send a complete practitioner’s statement to DADS within seven (7)
work days after service initiation? Review the contractor's fax, email or other
documentation that verifies the practitioner's statement was submitted to DADS within the
required timeframe.
c. Retroactive
i. Was the practitioner’s statement completed on or before the date of notification to
DADS for intake?
III. 3. Did the contractor meet the requirements for the individual’s practitioner’s
statement?
• Select “Y” if a, b, or c (as applicable) is “Y”
• Select “N” if a, b, or c ( as applicable) is “N”
Potential Billing Error:
If III.3 is “N”, review the Contract Monitoring Claims Report Payment Report for the billing periods within the 12
month review period prior to the date of the practitioner’s statement to determine if DADS paid for services prior to
the date of the practitioner’s statement. If DADS paid for services prior to the date of the practitioner’s statement,
complete Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for Payment. Enter “0” in Column J -
Units Verified for units paid prior to the date of the practitioner’s statement.
STANDARD IV. SERVICE INITIATION
OVERARCHING QUESTION Did
the individual enter services during the review period?
• If overarching question IV.1 is “N”, select “NA” for Standard IV.1. Continue Not Calculated in
IV.1
to Standard V.1. Score
• If overarching question IV.1 is “Y”, verify the contractor met the
requirements for service initiation.
a. Family Care- First Date of Service:
i. Routine Referral-Did services begin within 14 days after the referral date or
within 14 days after the date the contractor date stamped DADS’ authorization
form; or
ii. Transfer- Did services begin on the date negotiated between the case manager
and the contractor?
b. Primary Home Care or Community Attendant Services- First Date of Service:
i. Routine Referral- Did services begin within seven days after the date the
contractor’s receipt of DADS’ Authorization form?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 93
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
9 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. Transfer- Did services begin on the date negotiated between the case manager
STANDARD II. ATTENDANT REQUIREMENTS
and the contractor?
c. If a delay in service initiation did the contractor document the reason for the delay,
either an anticipated date of initiation or specific reasons why the contractor cannot
anticipate a date and a description of the contractor’s efforts to initiate services?
d. Did the contractor send notice of service initiation to the case manager within 14 days
after initiating services?
IV. 1. Were services initiated as required?
• Select “Y” if a is “Y”, b is “NA”, c is “NA” and d is “Y”
• Select “Y” if a is “NA”, b is “Y”, c is “NA” and d is “Y”
• Select “Y” if a or b is “N”, c is “Y” and d is “Y”
• Select “N” if a or b is “N”, c is “N” and d is “Y”
• Select “N” if d is “N”
VI. SERVICE DELIVERY
Complete UNITS OF SERVICE Tables for the last six months of service within the review
VI.1
period then answer VI.1.
a. Priority status- Does the number of documented hours/units of service equal the
number of authorized hours/units; or
Non-Priority status- Does the number of documented hours/units of service indicate that
there were no service interruptions exceeding 14 consecutive days?
b. If a is “N” was the reason for the failure to provide all service hours one of the
following:
• the individual’s revised service plan identified a need for an ongoing decrease in
hours;
• the individual requested that services not be provided;
• the individual requested fewer hours of service than reflected in the service
schedule;
• the individual requested that a specific attendant not provide services;
• the individual was not at home when the service was scheduled;
• services were not delivered for other reasons beyond the control of the provider
agency; or
• services were suspended.
- The individual temporarily or permanently left the contracted services delivery area;
- The individual moved to a location where services could not be provided under the PHC program;
- The individual died;
- The individual was admitted to an institution (hospital, nursing facility, state school, state hospital, or
ICF-MR facility);
- The individual requested that services end;
- DADS denied the individual’s Medicaid eligibility (not applicable to FC);
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 94
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
9 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
- The individual or someone in the individual’s home exhibited reckless behavior, which may have
STANDARD II. ATTENDANT REQUIREMENTS
resulted in imminent danger to the health and safety of the individual, the attendant, or another person;
- The individual or someone else in the individual’s home engaged in discrimination against a provider
agency or DADS employee in violation of applicable law;
- The individual refused services for more than 30 consecutive days.
VI. 1. Were personal assistance service hours provided in accordance with the
individual’s service plans or as required?
• Select “Y” if a is “Y” or a is “N” and b is “Y”
• Select “N” if a and b are “N”
STANDARD VII. SERVICE PLAN CHANGE
• Review the individual’s record for the 12 month review period to determine if a service plan change
was identified and requested.
VII.1.
• Select “NA” if a service plan change was not identified/requested. Continue to Standard VIII.
• If a service plan change was identified/requested, complete the table below.
Date(s) of /identified Date of notification to Effective Date Date of Date(s) of identified Date of revised service
need/request for an the contractor OR (F2101, item 4) Implementation need/request for a plan
increase in service case manager (Service Delivery decrease in service
hours or change that (F2067 or equivalent) Documentation) hours
results in no delivery
of personal care tasks
a. Immediate increase in hours:
i. If requested by the contractor, did the contractor’s documentation include:
• evidence that the contractor discussed the reason for the request of immediate
increase in hours with the case manager? NA
• the date the contractor received approval from the case manager? NA
• the name of the case manager who approved the change? NA
• the effective date of change, and NA
• the number of hours authorized? NA
ii. Did the contractor implement the service plan change on the date negotiated with the
NA
case manager? NA
b. Increase in service hours or no delivery of personal care tasks:
i. If requested by the contractor, was the case manager notified in writing within seven
days from the date of request/identification of need; and NA
ii. Did the notification include:
• date the provider agency learned of the need for the change;
NA
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 95
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
9 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• reason II. ATTENDANT REQUIREMENTS
STANDARD for the change;
NA
• type of change (including the number of service hours) and:
• signature and date of the provider agency representative?
iii. For any increase in service hours requested by the contractor, individual or case manager, did the contractor
implement the change within the required timeframe?
• Was the service plan change implemented on the Begin Date (F2101, item 4) or
five days after the contractor’s date stamp on F2101, whichever is later; or NA
• If delayed, did the contractor document, by the next working day, the failure to
implement the service plan change on the effective date to include the reason and NA
new implementation date? NA
c. Decrease in service hours:
i. Did the contractor develop a new service plan within 21 days from the date of the
individual’s request or identification of need for a service plan change? NA
VII.1. If a service plan change for PAS was identified or requested, did the contractor
meet all requirements?
• If the contractor requested an increase in hours or no delivery of personal care tasks -
select “Y” if a. i-ii or b. i-iii are “Y” NA
• If the case manager requested an increase in hours or no delivery of personal care
tasks - select “Y” if a. ii or b. iii are “Y”
• Select “Y” if a decrease in service hours was requested/identified and c. is “Y”
STANDARD IX. BILLING
Compare the Units of Service tables to the Contract Monitoring Claims Report for the last six months of
service delivery within the review period.
OVERARCHING QUESTION For
the last six months of service delivery to the individual within the review
period,:
i. Were the number of units documented equal to or greater than the
number of units paid? Y or N
ii. Were the number of units paid equal to or less than the number of
IX.1a authorized units? (If No, did the increase meet the criteria of a temporary Not Calculated in
increase)? Y or N Score
• If overarching question IX.1a.i and IX.1a.ii are "Y", mark IX.1a"Y" and skip
overarching question IX.1b and mark Standard IX.1 "Y".
• If either overarching question IX.1a.i or IX.1a.ii is“N”, mark IX.1a "N" and
continue to overarching question IX.1b.
OVERARCHING QUESTION Did
the contractor provide evidence that the contractor negative billed the
over-billed amount due to DADS prior to the date of the Entrance
Not Calculated in
Conference?
IX.1b Score
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 96
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
9 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
IX.1b
• If overarching question IX.1b is “Y”, mark
STANDARD II. ATTENDANT REQUIREMENTS Standard IX.1 “Y”.
• If overarching question IX.1b is “N”, mark Standard IX.1 “N”. Complete
Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for
Payment.
IX. 1. DADS did not identify a financial error?
• Select “Y”, if the contractor does not owe an Amount Due to DADS per the Demand
for Payment Notice (Column L)
• Select “Y”, if the contractor provides evidence that the contractor negative billed the
amount due to DADS prior to the date of the entrance Conference.
• Select “N”, if the contractor owes an Amount Due to DADS per the Demand for
Payment Notice (Column L)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 97
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
10 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
II.1 Complete the Attendants Requirements Table below.
Column A: Enter the name(s) of each attendant that provided direct care to the individual during the last six
months of service delivery to the individual.
Review the contractor’s supporting documentation to answer Columns B, C and G.
Column B: Select “Y” if the attendant is at least 18 years of age or, if under 18 years of age, is a high school
graduate or is enrolled in a vocational educational program and has demonstrated competency to perform the
tasks assigned by the supervisor.
Column C: Select “NA” if Family Care. PHC/CAS- Select “Y” if the attendant is not the individual’s legal parent,
foster parent or spouse of a parent (if a minor- under the age of 18 years) or spouse (if an adult- 18 yrs or older)
Column G: For each attendant review F2101. If hired prior to 6/1/2010, select "NA". If the case manager did NOT
designate the attendant as “Do Not Hire,” select “Y”. If listed as “Do Not Hire”, select “N”. If “N” identify the number
of units provided by the attendant and paid by DADS for the last two months of service to the individual. If DADS
paid for services provided by the attendant, complete the Demand for Payment Notice columns A-H from Contract
Monitoring Claims Report, enter the number of verified units provided by the “DNH” attendant in Column J.
A. B. C. G.
Name of Attendant Attendant Attendant Attendant is
Meets the Meets the NOT
Age Relationship designated
Requirement Requirement COLUMNS LEFT BLANK as "Do Not
INTENTIONALLY Hire"
If hired on or
after
6/1/2010
`
II.1 Does each of the individual’s attendants meet the required qualifications?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 98
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
10 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• Select “Y” if ATTENDANT REQUIREMENTS
STANDARD II.for each row, all responses in column B are "Y" and all responses in
columns C and G are “Y” or "NA" (note: column C will only be NA for Family Care)
• Select “N” if for any row, a response in columns B, C or G is “N”
ORIENTATION CHECKLIST
A. B. C. D. E. F. G.
Name of Individual’s Attendant Date of First Service Date of Orientation Orientation Orientation Provided Orientation Elements not
to Individual Conducted in On or Before First Included All included in the
Person with Date of Service to the Required Orientation
Review service delivery documentation for (Review service delivery (Refer to Participation of the Individual Elements (Enter the
the last six months of service delivery within documentation for the documentation of corresponding
Individual or
review period to determine if
the review period and enter the name of first date of service to the
Attendant Attendant Met elements that were
each attendant that provided care to the sample individual was within Orientations Requirements for not addressed)
individual- NA for a Supervisor providing the last six months of conducted during the Orientation Without
personal assistance services service delivery. If the review period)
unlicensed attendant began
Participation of the
providing services to the Individual
sample individual during the
last six months of service
delivery, enter the first date
of service and complete
columns C - G. If the
unlicensed attendant worked
with the sample individual
prior to the last six months
of service delivery, select
“N” and leave columns C –
G blank.)
Last Six Months
Begin: End:
Last Name: First Name; Answer Date:
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 99
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
10 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Attendant Requirements for Orientation without Participation of the Individual (telephone/verbal): Meet the requirements of a Home health Aide*; have six continuous months of experience
delivering attendant care; has been oriented to the individual and the service plan has not changed; or has previously provided services to the individual.
Required elements:
1. Name of the individual for whom the attendant is to provide care
2. Name of the attendant
3. Date of the attendant orientation
4. Orientation conducted in person with the individual or without the participation of the individual
5. How the individual’s condition affects the performance of tasks
6. Tasks to be performed
7. Service schedule
8. Number of hours of service the attendant is to provide
9. Total number of hours the individual is authorized to receive
10. Safety and emergency procedures, including universal precautions
11. Specific situations about which the attendant should notify the contractor (e.g., changes in the individual’s needs; incidents that affect the individual’s condition; hospitalization;
absence or relocation from home; attendant’s inability to work; and suspicion/allegation of abuse, neglect or exploitation of the individual).
12. Signature of the Supervisor who conducted the orientation
13. Signature of the attendant, if present
14. Signature of the individual, if present
*A Home Health Aide must:
o have a minimum of six months experience in delivering personal care tasks in family care, primary home care, personal assistance services, client managed personal attendant
services; or
o be listed on the DADS Nurses Aide Registry with an employable “Active’ status.
II. 3. Was each attendant who began providing care to the individual during the last
six months of service delivery within the review period, oriented, as required, on or
before the first date of service delivery?
• Select “NA” if the individual’s attendant(s) began providing care to the individual prior
to the review period.
• Select “Y” if column B is “Y” and columns D., E and F. are “Y”
• Select “N” if column B is “Y” and column D., E and/or F is “N”.
STANDARD III. PRE-INITIATION ACTIVITIES
OVERARCHING QUESTION Did
the individual's pre-initiation activities occur during the review period?
III.1 • If overarching question III.1 is “N”, select “NA” for Standard III.1-3. Not Calculated in
Continue to Standard IV.1. Score
• If overarching question III.1 is “Y”, verify pre-initiation activities were
completed as required.
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 100
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
10 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Date of Referral Date of Referral Negotiated Date Stamp on Date of
(F2101, item 1) (F2101, item 25) Service Initiation F2101 Notification for
Date Intake
(Routine) (Expedited/Transf (Expedited/Transf (Retroactive)
er) er)
Date of Evaluation:
a. Routine Referral
i) Is the date of the evaluation within 14 calendar days after the date of referral or the date
the contractor received F-2101 as indicated by a date stamp- whichever is later; or
ii) If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the evaluation?
b. Expedited Referral (transfers are reviewed as an expedited referral)
i) Is the date of the evaluation on or before the date negotiated between the case
manager and contractor, which must be less than 14 days after the oral request; or
ii) If a delay, did the contractor notify the case manager of any failure to complete the
evaluation before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i) Is the date of the evaluation on or before the date of notification to DADS for intake?
d. Does the evaluation include the individual’s self-report of the dates and reasons for any
hospitalizations within 3 months prior to the evaluation were addressed?
e. Does the evaluation identify assistance needed to achieve activities of daily living,
including any assistive devices or medical equipment used by the person?
III.1. Did the contractor complete an evaluation of the individual as required?
o Select “Y” if a, b, or c is “Y” and d and e are “Y”
o Select “N” if a, b, or c is “N” and d and/or e is “N”
Date of Initial Service Delivery Plan:
a. Routine Referral
i. Was the initial service delivery plan completed within 14 calendar days after the referral
date or the date the contractor received F- 2101 as indicated by a date stamp- whichever
is later; or
ii. If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the service plan?
b. Expedited Referral (transfers are reviewed as an expedited referral)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 101
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
10 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
i. Is the date of the service delivery plan on or before the date negotiated between the
case manager and contractor, which must be less than 14 days after the oral request; or
ii If a delay, did the contractor notify the case manager of any failure to complete the
service delivery plan before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i. Was the service plan complete prior to the date of notification to DADS for intake?
d. The service plan is agreed upon and was signed by the individual and the contractor
e. The service plan identifies the location of service delivery
f. The service plan identifies the tasks the individual will receive (includes at least one
personal care task, unless FC)
g. The service plan identifies the total weekly hours authorized
h. The service plan identifies the service schedule which includes as necessary, based
on the individual’s needs, certain time periods for the delivery of specified tasks
i. The service plan identifies the frequency of supervisory visits
j. The service plan includes the statement that the contractor is responsible for providing
the tasks allowable in the PHC program (47.41) and agreed to on the service plan.
III. 2. Did the contractor develop an initial service delivery plan as required?
• Select “Y” if a, b, or c is “Y” and d - j are “Y”
• Select “N” if a, b, or c is “N” and/or d – j is “N”
OVERARCHING QUESTION Does
the individual receive family care or did the individual transfer from one
PHC contractor to another PHC, transfer from PHC to CAS or transfer from
Not Calculated in
CAS to PHC during the review period?
III.3 Score
• If overarching question III.3 is “Y”, select “NA” for Standard III.3. Continue
to Standard IV.1.
• If overarching question III.3 is “N”, verify the contractor met the
requirements for the individual’s practitioner’s statement.
Date of Practitioner’s Statement:
a. Routine Referral
i. Did the contractor obtain and submit to DADS a complete practitioner’s statement
within 14 calendar days after the date of referral or the date the contractor received F-
2101 as indicated by a date stamp- whichever is later. Review the contractor's fax, email
or other documentation that verifies the practitioner's statement was submitted to DADS
within the required timeframe; or
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 102
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
10 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. If a delay, II. ATTENDANT REQUIREMENTS
STANDARDdid the contractor document by due date the reason for the delay, an
anticipated date of completion or reason why a completion date cannot be anticipated;
and a description of the contractor’s efforts to obtain the practitioner’s statement?
b. Expedited Referral
i. Did the contractor send a complete practitioner’s statement to DADS within seven (7)
work days after service initiation? Review the contractor's fax, email or other
documentation that verifies the practitioner's statement was submitted to DADS within the
required timeframe.
c. Retroactive
i. Was the practitioner’s statement completed on or before the date of notification to
DADS for intake?
III. 3. Did the contractor meet the requirements for the individual’s practitioner’s
statement?
• Select “Y” if a, b, or c (as applicable) is “Y”
• Select “N” if a, b, or c ( as applicable) is “N”
Potential Billing Error:
If III.3 is “N”, review the Contract Monitoring Claims Report Payment Report for the billing periods within the 12
month review period prior to the date of the practitioner’s statement to determine if DADS paid for services prior to
the date of the practitioner’s statement. If DADS paid for services prior to the date of the practitioner’s statement,
complete Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for Payment. Enter “0” in Column J -
Units Verified for units paid prior to the date of the practitioner’s statement.
STANDARD IV. SERVICE INITIATION
OVERARCHING QUESTION Did
the individual enter services during the review period?
• If overarching question IV.1 is “N”, select “NA” for Standard IV.1. Continue Not Calculated in
IV.1
to Standard V.1. Score
• If overarching question IV.1 is “Y”, verify the contractor met the
requirements for service initiation.
a. Family Care- First Date of Service:
i. Routine Referral-Did services begin within 14 days after the referral date or
within 14 days after the date the contractor date stamped DADS’ authorization
form; or
ii. Transfer- Did services begin on the date negotiated between the case manager
and the contractor?
b. Primary Home Care or Community Attendant Services- First Date of Service:
i. Routine Referral- Did services begin within seven days after the date the
contractor’s receipt of DADS’ Authorization form?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 103
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
10 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. Transfer- Did services begin on the date negotiated between the case manager
STANDARD II. ATTENDANT REQUIREMENTS
and the contractor?
c. If a delay in service initiation did the contractor document the reason for the delay,
either an anticipated date of initiation or specific reasons why the contractor cannot
anticipate a date and a description of the contractor’s efforts to initiate services?
d. Did the contractor send notice of service initiation to the case manager within 14 days
after initiating services?
IV. 1. Were services initiated as required?
• Select “Y” if a is “Y”, b is “NA”, c is “NA” and d is “Y”
• Select “Y” if a is “NA”, b is “Y”, c is “NA” and d is “Y”
• Select “Y” if a or b is “N”, c is “Y” and d is “Y”
• Select “N” if a or b is “N”, c is “N” and d is “Y”
• Select “N” if d is “N”
VI. SERVICE DELIVERY
Complete UNITS OF SERVICE Tables for the last six months of service within the review
VI.1
period then answer VI.1.
a. Priority status- Does the number of documented hours/units of service equal the
number of authorized hours/units; or
Non-Priority status- Does the number of documented hours/units of service indicate that
there were no service interruptions exceeding 14 consecutive days?
b. If a is “N” was the reason for the failure to provide all service hours one of the
following:
• the individual’s revised service plan identified a need for an ongoing decrease in
hours;
• the individual requested that services not be provided;
• the individual requested fewer hours of service than reflected in the service
schedule;
• the individual requested that a specific attendant not provide services;
• the individual was not at home when the service was scheduled;
• services were not delivered for other reasons beyond the control of the provider
agency; or
• services were suspended.
- The individual temporarily or permanently left the contracted services delivery area;
- The individual moved to a location where services could not be provided under the PHC program;
- The individual died;
- The individual was admitted to an institution (hospital, nursing facility, state school, state hospital, or
ICF-MR facility);
- The individual requested that services end;
- DADS denied the individual’s Medicaid eligibility (not applicable to FC);
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 104
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
10 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
- The individual or someone in the individual’s home exhibited reckless behavior, which may have
STANDARD II. ATTENDANT REQUIREMENTS
resulted in imminent danger to the health and safety of the individual, the attendant, or another person;
- The individual or someone else in the individual’s home engaged in discrimination against a provider
agency or DADS employee in violation of applicable law;
- The individual refused services for more than 30 consecutive days.
VI. 1. Were personal assistance service hours provided in accordance with the
individual’s service plans or as required?
• Select “Y” if a is “Y” or a is “N” and b is “Y”
• Select “N” if a and b are “N”
STANDARD VII. SERVICE PLAN CHANGE
• Review the individual’s record for the 12 month review period to determine if a service plan change
was identified and requested.
VII.1.
• Select “NA” if a service plan change was not identified/requested. Continue to Standard VIII.
• If a service plan change was identified/requested, complete the table below.
Date(s) of /identified Date of notification to Effective Date Date of Date(s) of identified Date of revised service
need/request for an the contractor OR (F2101, item 4) Implementation need/request for a plan
increase in service case manager (Service Delivery decrease in service
hours or change that (F2067 or equivalent) Documentation) hours
results in no delivery
of personal care tasks
a. Immediate increase in hours:
i. If requested by the contractor, did the contractor’s documentation include:
• evidence that the contractor discussed the reason for the request of immediate
increase in hours with the case manager? NA
• the date the contractor received approval from the case manager? NA
• the name of the case manager who approved the change? NA
• the effective date of change, and NA
• the number of hours authorized? NA
ii. Did the contractor implement the service plan change on the date negotiated with the
NA
case manager? NA
b. Increase in service hours or no delivery of personal care tasks:
i. If requested by the contractor, was the case manager notified in writing within seven
days from the date of request/identification of need; and NA
ii. Did the notification include:
• date the provider agency learned of the need for the change;
NA
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 105
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
10 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• reason II. ATTENDANT REQUIREMENTS
STANDARD for the change;
NA
• type of change (including the number of service hours) and:
• signature and date of the provider agency representative?
iii. For any increase in service hours requested by the contractor, individual or case manager, did the contractor
implement the change within the required timeframe?
• Was the service plan change implemented on the Begin Date (F2101, item 4) or
five days after the contractor’s date stamp on F2101, whichever is later; or NA
• If delayed, did the contractor document, by the next working day, the failure to
implement the service plan change on the effective date to include the reason and NA
new implementation date? NA
c. Decrease in service hours:
i. Did the contractor develop a new service plan within 21 days from the date of the
individual’s request or identification of need for a service plan change? NA
VII.1. If a service plan change for PAS was identified or requested, did the contractor
meet all requirements?
• If the contractor requested an increase in hours or no delivery of personal care tasks -
select “Y” if a. i-ii or b. i-iii are “Y” NA
• If the case manager requested an increase in hours or no delivery of personal care
tasks - select “Y” if a. ii or b. iii are “Y”
• Select “Y” if a decrease in service hours was requested/identified and c. is “Y”
STANDARD IX. BILLING
Compare the Units of Service tables to the Contract Monitoring Claims Report for the last six months of
service delivery within the review period.
OVERARCHING QUESTION For
the last six months of service delivery to the individual within the review
period,:
i. Were the number of units documented equal to or greater than the
number of units paid? Y or N
ii. Were the number of units paid equal to or less than the number of
IX.1a authorized units? (If No, did the increase meet the criteria of a temporary Not Calculated in
increase)? Y or N Score
• If overarching question IX.1a.i and IX.1a.ii are "Y", mark IX.1a"Y" and skip
overarching question IX.1b and mark Standard IX.1 "Y".
• If either overarching question IX.1a.i or IX.1a.ii is“N”, mark IX.1a "N" and
continue to overarching question IX.1b.
OVERARCHING QUESTION Did
the contractor provide evidence that the contractor negative billed the
over-billed amount due to DADS prior to the date of the Entrance
Not Calculated in
Conference?
IX.1b Score
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 106
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
10 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
IX.1b
• If overarching question IX.1b is “Y”, mark
STANDARD II. ATTENDANT REQUIREMENTS Standard IX.1 “Y”.
• If overarching question IX.1b is “N”, mark Standard IX.1 “N”. Complete
Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for
Payment.
IX. 1. DADS did not identify a financial error?
• Select “Y”, if the contractor does not owe an Amount Due to DADS per the Demand
for Payment Notice (Column L)
• Select “Y”, if the contractor provides evidence that the contractor negative billed the
amount due to DADS prior to the date of the entrance Conference.
• Select “N”, if the contractor owes an Amount Due to DADS per the Demand for
Payment Notice (Column L)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 107
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
11 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
II.1 Complete the Attendants Requirements Table below.
Column A: Enter the name(s) of each attendant that provided direct care to the individual during the last six
months of service delivery to the individual.
Review the contractor’s supporting documentation to answer Columns B, C and G.
Column B: Select “Y” if the attendant is at least 18 years of age or, if under 18 years of age, is a high school
graduate or is enrolled in a vocational educational program and has demonstrated competency to perform the
tasks assigned by the supervisor.
Column C: Select “NA” if Family Care. PHC/CAS- Select “Y” if the attendant is not the individual’s legal parent,
foster parent or spouse of a parent (if a minor- under the age of 18 years) or spouse (if an adult- 18 yrs or older)
Column G: For each attendant review F2101. If hired prior to 6/1/2010, select "NA". If the case manager did NOT
designate the attendant as “Do Not Hire,” select “Y”. If listed as “Do Not Hire”, select “N”. If “N” identify the number
of units provided by the attendant and paid by DADS for the last two months of service to the individual. If DADS
paid for services provided by the attendant, complete the Demand for Payment Notice columns A-H from Contract
Monitoring Claims Report, enter the number of verified units provided by the “DNH” attendant in Column J.
A. B. C. G.
Name of Attendant Attendant Attendant Attendant is
Meets the Meets the NOT
Age Relationship designated
Requirement Requirement COLUMNS LEFT BLANK as "Do Not
INTENTIONALLY Hire"
If hired on or
after
6/1/2010
`
II.1 Does each of the individual’s attendants meet the required qualifications?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 108
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
11 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• Select “Y” if ATTENDANT REQUIREMENTS
STANDARD II.for each row, all responses in column B are "Y" and all responses in
columns C and G are “Y” or "NA" (note: column C will only be NA for Family Care)
• Select “N” if for any row, a response in columns B, C or G is “N”
ORIENTATION CHECKLIST
A. B. C. D. E. F. G.
Name of Individual’s Attendant Date of First Service Date of Orientation Orientation Orientation Provided Orientation Elements not
to Individual Conducted in On or Before First Included All included in the
Person with Date of Service to the Required Orientation
Review service delivery documentation for (Review service delivery (Refer to Participation of the Individual Elements (Enter the
the last six months of service delivery within documentation for the documentation of corresponding
Individual or
review period to determine if
the review period and enter the name of first date of service to the
Attendant Attendant Met elements that were
each attendant that provided care to the sample individual was within Orientations Requirements for not addressed)
individual- NA for a Supervisor providing the last six months of conducted during the Orientation Without
personal assistance services service delivery. If the review period)
unlicensed attendant began
Participation of the
providing services to the Individual
sample individual during the
last six months of service
delivery, enter the first date
of service and complete
columns C - G. If the
unlicensed attendant worked
with the sample individual
prior to the last six months
of service delivery, select
“N” and leave columns C –
G blank.)
Last Six Months
Begin: End:
Last Name: First Name; Answer Date:
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 109
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
11 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Attendant Requirements for Orientation without Participation of the Individual (telephone/verbal): Meet the requirements of a Home health Aide*; have six continuous months of experience
delivering attendant care; has been oriented to the individual and the service plan has not changed; or has previously provided services to the individual.
Required elements:
1. Name of the individual for whom the attendant is to provide care
2. Name of the attendant
3. Date of the attendant orientation
4. Orientation conducted in person with the individual or without the participation of the individual
5. How the individual’s condition affects the performance of tasks
6. Tasks to be performed
7. Service schedule
8. Number of hours of service the attendant is to provide
9. Total number of hours the individual is authorized to receive
10. Safety and emergency procedures, including universal precautions
11. Specific situations about which the attendant should notify the contractor (e.g., changes in the individual’s needs; incidents that affect the individual’s condition; hospitalization;
absence or relocation from home; attendant’s inability to work; and suspicion/allegation of abuse, neglect or exploitation of the individual).
12. Signature of the Supervisor who conducted the orientation
13. Signature of the attendant, if present
14. Signature of the individual, if present
*A Home Health Aide must:
o have a minimum of six months experience in delivering personal care tasks in family care, primary home care, personal assistance services, client managed personal attendant
services; or
o be listed on the DADS Nurses Aide Registry with an employable “Active’ status.
II. 3. Was each attendant who began providing care to the individual during the last
six months of service delivery within the review period, oriented, as required, on or
before the first date of service delivery?
• Select “NA” if the individual’s attendant(s) began providing care to the individual prior
to the review period.
• Select “Y” if column B is “Y” and columns D., E and F. are “Y”
• Select “N” if column B is “Y” and column D., E and/or F is “N”.
STANDARD III. PRE-INITIATION ACTIVITIES
OVERARCHING QUESTION Did
the individual's pre-initiation activities occur during the review period?
III.1 • If overarching question III.1 is “N”, select “NA” for Standard III.1-3. Not Calculated in
Continue to Standard IV.1. Score
• If overarching question III.1 is “Y”, verify pre-initiation activities were
completed as required.
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 110
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
11 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Date of Referral Date of Referral Negotiated Date Stamp on Date of
(F2101, item 1) (F2101, item 25) Service Initiation F2101 Notification for
Date Intake
(Routine) (Expedited/Transf (Expedited/Transf (Retroactive)
er) er)
Date of Evaluation:
a. Routine Referral
i) Is the date of the evaluation within 14 calendar days after the date of referral or the date
the contractor received F-2101 as indicated by a date stamp- whichever is later; or
ii) If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the evaluation?
b. Expedited Referral (transfers are reviewed as an expedited referral)
i) Is the date of the evaluation on or before the date negotiated between the case
manager and contractor, which must be less than 14 days after the oral request; or
ii) If a delay, did the contractor notify the case manager of any failure to complete the
evaluation before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i) Is the date of the evaluation on or before the date of notification to DADS for intake?
d. Does the evaluation include the individual’s self-report of the dates and reasons for any
hospitalizations within 3 months prior to the evaluation were addressed?
e. Does the evaluation identify assistance needed to achieve activities of daily living,
including any assistive devices or medical equipment used by the person?
III.1. Did the contractor complete an evaluation of the individual as required?
o Select “Y” if a, b, or c is “Y” and d and e are “Y”
o Select “N” if a, b, or c is “N” and d and/or e is “N”
Date of Initial Service Delivery Plan:
a. Routine Referral
i. Was the initial service delivery plan completed within 14 calendar days after the referral
date or the date the contractor received F- 2101 as indicated by a date stamp- whichever
is later; or
ii. If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the service plan?
b. Expedited Referral (transfers are reviewed as an expedited referral)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 111
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
11 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
i. Is the date of the service delivery plan on or before the date negotiated between the
case manager and contractor, which must be less than 14 days after the oral request; or
ii If a delay, did the contractor notify the case manager of any failure to complete the
service delivery plan before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i. Was the service plan complete prior to the date of notification to DADS for intake?
d. The service plan is agreed upon and was signed by the individual and the contractor
e. The service plan identifies the location of service delivery
f. The service plan identifies the tasks the individual will receive (includes at least one
personal care task, unless FC)
g. The service plan identifies the total weekly hours authorized
h. The service plan identifies the service schedule which includes as necessary, based
on the individual’s needs, certain time periods for the delivery of specified tasks
i. The service plan identifies the frequency of supervisory visits
j. The service plan includes the statement that the contractor is responsible for providing
the tasks allowable in the PHC program (47.41) and agreed to on the service plan.
III. 2. Did the contractor develop an initial service delivery plan as required?
• Select “Y” if a, b, or c is “Y” and d - j are “Y”
• Select “N” if a, b, or c is “N” and/or d – j is “N”
OVERARCHING QUESTION Does
the individual receive family care or did the individual transfer from one
PHC contractor to another PHC, transfer from PHC to CAS or transfer from
Not Calculated in
CAS to PHC during the review period?
III.3 Score
• If overarching question III.3 is “Y”, select “NA” for Standard III.3. Continue
to Standard IV.1.
• If overarching question III.3 is “N”, verify the contractor met the
requirements for the individual’s practitioner’s statement.
Date of Practitioner’s Statement:
a. Routine Referral
i. Did the contractor obtain and submit to DADS a complete practitioner’s statement
within 14 calendar days after the date of referral or the date the contractor received F-
2101 as indicated by a date stamp- whichever is later. Review the contractor's fax, email
or other documentation that verifies the practitioner's statement was submitted to DADS
within the required timeframe; or
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 112
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
11 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. If a delay, II. ATTENDANT REQUIREMENTS
STANDARDdid the contractor document by due date the reason for the delay, an
anticipated date of completion or reason why a completion date cannot be anticipated;
and a description of the contractor’s efforts to obtain the practitioner’s statement?
b. Expedited Referral
i. Did the contractor send a complete practitioner’s statement to DADS within seven (7)
work days after service initiation? Review the contractor's fax, email or other
documentation that verifies the practitioner's statement was submitted to DADS within the
required timeframe.
c. Retroactive
i. Was the practitioner’s statement completed on or before the date of notification to
DADS for intake?
III. 3. Did the contractor meet the requirements for the individual’s practitioner’s
statement?
• Select “Y” if a, b, or c (as applicable) is “Y”
• Select “N” if a, b, or c ( as applicable) is “N”
Potential Billing Error:
If III.3 is “N”, review the Contract Monitoring Claims Report Payment Report for the billing periods within the 12
month review period prior to the date of the practitioner’s statement to determine if DADS paid for services prior to
the date of the practitioner’s statement. If DADS paid for services prior to the date of the practitioner’s statement,
complete Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for Payment. Enter “0” in Column J -
Units Verified for units paid prior to the date of the practitioner’s statement.
STANDARD IV. SERVICE INITIATION
OVERARCHING QUESTION Did
the individual enter services during the review period?
• If overarching question IV.1 is “N”, select “NA” for Standard IV.1. Continue Not Calculated in
IV.1
to Standard V.1. Score
• If overarching question IV.1 is “Y”, verify the contractor met the
requirements for service initiation.
a. Family Care- First Date of Service:
i. Routine Referral-Did services begin within 14 days after the referral date or
within 14 days after the date the contractor date stamped DADS’ authorization
form; or
ii. Transfer- Did services begin on the date negotiated between the case manager
and the contractor?
b. Primary Home Care or Community Attendant Services- First Date of Service:
i. Routine Referral- Did services begin within seven days after the date the
contractor’s receipt of DADS’ Authorization form?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 113
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
11 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. Transfer- Did services begin on the date negotiated between the case manager
STANDARD II. ATTENDANT REQUIREMENTS
and the contractor?
c. If a delay in service initiation did the contractor document the reason for the delay,
either an anticipated date of initiation or specific reasons why the contractor cannot
anticipate a date and a description of the contractor’s efforts to initiate services?
d. Did the contractor send notice of service initiation to the case manager within 14 days
after initiating services?
IV. 1. Were services initiated as required?
• Select “Y” if a is “Y”, b is “NA”, c is “NA” and d is “Y”
• Select “Y” if a is “NA”, b is “Y”, c is “NA” and d is “Y”
• Select “Y” if a or b is “N”, c is “Y” and d is “Y”
• Select “N” if a or b is “N”, c is “N” and d is “Y”
• Select “N” if d is “N”
VI. SERVICE DELIVERY
Complete UNITS OF SERVICE Tables for the last six months of service within the review
VI.1
period then answer VI.1.
a. Priority status- Does the number of documented hours/units of service equal the
number of authorized hours/units; or
Non-Priority status- Does the number of documented hours/units of service indicate that
there were no service interruptions exceeding 14 consecutive days?
b. If a is “N” was the reason for the failure to provide all service hours one of the
following:
• the individual’s revised service plan identified a need for an ongoing decrease in
hours;
• the individual requested that services not be provided;
• the individual requested fewer hours of service than reflected in the service
schedule;
• the individual requested that a specific attendant not provide services;
• the individual was not at home when the service was scheduled;
• services were not delivered for other reasons beyond the control of the provider
agency; or
• services were suspended.
- The individual temporarily or permanently left the contracted services delivery area;
- The individual moved to a location where services could not be provided under the PHC program;
- The individual died;
- The individual was admitted to an institution (hospital, nursing facility, state school, state hospital, or
ICF-MR facility);
- The individual requested that services end;
- DADS denied the individual’s Medicaid eligibility (not applicable to FC);
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 114
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
11 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
- The individual or someone in the individual’s home exhibited reckless behavior, which may have
STANDARD II. ATTENDANT REQUIREMENTS
resulted in imminent danger to the health and safety of the individual, the attendant, or another person;
- The individual or someone else in the individual’s home engaged in discrimination against a provider
agency or DADS employee in violation of applicable law;
- The individual refused services for more than 30 consecutive days.
VI. 1. Were personal assistance service hours provided in accordance with the
individual’s service plans or as required?
• Select “Y” if a is “Y” or a is “N” and b is “Y”
• Select “N” if a and b are “N”
STANDARD VII. SERVICE PLAN CHANGE
• Review the individual’s record for the 12 month review period to determine if a service plan change
was identified and requested.
VII.1.
• Select “NA” if a service plan change was not identified/requested. Continue to Standard VIII.
• If a service plan change was identified/requested, complete the table below.
Date(s) of /identified Date of notification to Effective Date Date of Date(s) of identified Date of revised service
need/request for an the contractor OR (F2101, item 4) Implementation need/request for a plan
increase in service case manager (Service Delivery decrease in service
hours or change that (F2067 or equivalent) Documentation) hours
results in no delivery
of personal care tasks
a. Immediate increase in hours:
i. If requested by the contractor, did the contractor’s documentation include:
• evidence that the contractor discussed the reason for the request of immediate
increase in hours with the case manager? NA
• the date the contractor received approval from the case manager? NA
• the name of the case manager who approved the change? NA
• the effective date of change, and NA
• the number of hours authorized? NA
ii. Did the contractor implement the service plan change on the date negotiated with the
NA
case manager? NA
b. Increase in service hours or no delivery of personal care tasks:
i. If requested by the contractor, was the case manager notified in writing within seven
days from the date of request/identification of need; and NA
ii. Did the notification include:
• date the provider agency learned of the need for the change;
NA
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 115
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
11 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• reason II. ATTENDANT REQUIREMENTS
STANDARD for the change;
NA
• type of change (including the number of service hours) and:
• signature and date of the provider agency representative?
iii. For any increase in service hours requested by the contractor, individual or case manager, did the contractor
implement the change within the required timeframe?
• Was the service plan change implemented on the Begin Date (F2101, item 4) or
five days after the contractor’s date stamp on F2101, whichever is later; or NA
• If delayed, did the contractor document, by the next working day, the failure to
implement the service plan change on the effective date to include the reason and NA
new implementation date? NA
c. Decrease in service hours:
i. Did the contractor develop a new service plan within 21 days from the date of the
individual’s request or identification of need for a service plan change? NA
VII.1. If a service plan change for PAS was identified or requested, did the contractor
meet all requirements?
• If the contractor requested an increase in hours or no delivery of personal care tasks -
select “Y” if a. i-ii or b. i-iii are “Y” NA
• If the case manager requested an increase in hours or no delivery of personal care
tasks - select “Y” if a. ii or b. iii are “Y”
• Select “Y” if a decrease in service hours was requested/identified and c. is “Y”
STANDARD IX. BILLING
Compare the Units of Service tables to the Contract Monitoring Claims Report for the last six months of
service delivery within the review period.
OVERARCHING QUESTION For
the last six months of service delivery to the individual within the review
period,:
i. Were the number of units documented equal to or greater than the
number of units paid? Y or N
ii. Were the number of units paid equal to or less than the number of
IX.1a authorized units? (If No, did the increase meet the criteria of a temporary Not Calculated in
increase)? Y or N Score
• If overarching question IX.1a.i and IX.1a.ii are "Y", mark IX.1a"Y" and skip
overarching question IX.1b and mark Standard IX.1 "Y".
• If either overarching question IX.1a.i or IX.1a.ii is“N”, mark IX.1a "N" and
continue to overarching question IX.1b.
OVERARCHING QUESTION Did
the contractor provide evidence that the contractor negative billed the
over-billed amount due to DADS prior to the date of the Entrance
Not Calculated in
Conference?
IX.1b Score
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 116
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
11 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
IX.1b
• If overarching question IX.1b is “Y”, mark
STANDARD II. ATTENDANT REQUIREMENTS Standard IX.1 “Y”.
• If overarching question IX.1b is “N”, mark Standard IX.1 “N”. Complete
Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for
Payment.
IX. 1. DADS did not identify a financial error?
• Select “Y”, if the contractor does not owe an Amount Due to DADS per the Demand
for Payment Notice (Column L)
• Select “Y”, if the contractor provides evidence that the contractor negative billed the
amount due to DADS prior to the date of the entrance Conference.
• Select “N”, if the contractor owes an Amount Due to DADS per the Demand for
Payment Notice (Column L)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 117
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
12 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
II.1 Complete the Attendants Requirements Table below.
Column A: Enter the name(s) of each attendant that provided direct care to the individual during the last six
months of service delivery to the individual.
Review the contractor’s supporting documentation to answer Columns B, C and G.
Column B: Select “Y” if the attendant is at least 18 years of age or, if under 18 years of age, is a high school
graduate or is enrolled in a vocational educational program and has demonstrated competency to perform the
tasks assigned by the supervisor.
Column C: Select “NA” if Family Care. PHC/CAS- Select “Y” if the attendant is not the individual’s legal parent,
foster parent or spouse of a parent (if a minor- under the age of 18 years) or spouse (if an adult- 18 yrs or older)
Column G: For each attendant review F2101. If hired prior to 6/1/2010, select "NA". If the case manager did NOT
designate the attendant as “Do Not Hire,” select “Y”. If listed as “Do Not Hire”, select “N”. If “N” identify the number
of units provided by the attendant and paid by DADS for the last two months of service to the individual. If DADS
paid for services provided by the attendant, complete the Demand for Payment Notice columns A-H from Contract
Monitoring Claims Report, enter the number of verified units provided by the “DNH” attendant in Column J.
A. B. C. G.
Name of Attendant Attendant Attendant Attendant is
Meets the Meets the NOT
Age Relationship designated
Requirement Requirement COLUMNS LEFT BLANK as "Do Not
INTENTIONALLY Hire"
If hired on or
after
6/1/2010
`
II.1 Does each of the individual’s attendants meet the required qualifications?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 118
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
12 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• Select “Y” if ATTENDANT REQUIREMENTS
STANDARD II.for each row, all responses in column B are "Y" and all responses in
columns C and G are “Y” or "NA" (note: column C will only be NA for Family Care)
• Select “N” if for any row, a response in columns B, C or G is “N”
ORIENTATION CHECKLIST
A. B. C. D. E. F. G.
Name of Individual’s Attendant Date of First Service Date of Orientation Orientation Orientation Provided Orientation Elements not
to Individual Conducted in On or Before First Included All included in the
Person with Date of Service to the Required Orientation
Review service delivery documentation for (Review service delivery (Refer to Participation of the Individual Elements (Enter the
the last six months of service delivery within documentation for the documentation of corresponding
Individual or
review period to determine if
the review period and enter the name of first date of service to the
Attendant Attendant Met elements that were
each attendant that provided care to the sample individual was within Orientations Requirements for not addressed)
individual- NA for a Supervisor providing the last six months of conducted during the Orientation Without
personal assistance services service delivery. If the review period)
unlicensed attendant began
Participation of the
providing services to the Individual
sample individual during the
last six months of service
delivery, enter the first date
of service and complete
columns C - G. If the
unlicensed attendant worked
with the sample individual
prior to the last six months
of service delivery, select
“N” and leave columns C –
G blank.)
Last Six Months
Begin: End:
Last Name: First Name; Answer Date:
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 119
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
12 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Attendant Requirements for Orientation without Participation of the Individual (telephone/verbal): Meet the requirements of a Home health Aide*; have six continuous months of experience
delivering attendant care; has been oriented to the individual and the service plan has not changed; or has previously provided services to the individual.
Required elements:
1. Name of the individual for whom the attendant is to provide care
2. Name of the attendant
3. Date of the attendant orientation
4. Orientation conducted in person with the individual or without the participation of the individual
5. How the individual’s condition affects the performance of tasks
6. Tasks to be performed
7. Service schedule
8. Number of hours of service the attendant is to provide
9. Total number of hours the individual is authorized to receive
10. Safety and emergency procedures, including universal precautions
11. Specific situations about which the attendant should notify the contractor (e.g., changes in the individual’s needs; incidents that affect the individual’s condition; hospitalization;
absence or relocation from home; attendant’s inability to work; and suspicion/allegation of abuse, neglect or exploitation of the individual).
12. Signature of the Supervisor who conducted the orientation
13. Signature of the attendant, if present
14. Signature of the individual, if present
*A Home Health Aide must:
o have a minimum of six months experience in delivering personal care tasks in family care, primary home care, personal assistance services, client managed personal attendant
services; or
o be listed on the DADS Nurses Aide Registry with an employable “Active’ status.
II. 3. Was each attendant who began providing care to the individual during the last
six months of service delivery within the review period, oriented, as required, on or
before the first date of service delivery?
• Select “NA” if the individual’s attendant(s) began providing care to the individual prior
to the review period.
• Select “Y” if column B is “Y” and columns D., E and F. are “Y”
• Select “N” if column B is “Y” and column D., E and/or F is “N”.
STANDARD III. PRE-INITIATION ACTIVITIES
OVERARCHING QUESTION Did
the individual's pre-initiation activities occur during the review period?
III.1 • If overarching question III.1 is “N”, select “NA” for Standard III.1-3. Not Calculated in
Continue to Standard IV.1. Score
• If overarching question III.1 is “Y”, verify pre-initiation activities were
completed as required.
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 120
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
12 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Date of Referral Date of Referral Negotiated Date Stamp on Date of
(F2101, item 1) (F2101, item 25) Service Initiation F2101 Notification for
Date Intake
(Routine) (Expedited/Transf (Expedited/Transf (Retroactive)
er) er)
Date of Evaluation:
a. Routine Referral
i) Is the date of the evaluation within 14 calendar days after the date of referral or the date
the contractor received F-2101 as indicated by a date stamp- whichever is later; or
ii) If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the evaluation?
b. Expedited Referral (transfers are reviewed as an expedited referral)
i) Is the date of the evaluation on or before the date negotiated between the case
manager and contractor, which must be less than 14 days after the oral request; or
ii) If a delay, did the contractor notify the case manager of any failure to complete the
evaluation before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i) Is the date of the evaluation on or before the date of notification to DADS for intake?
d. Does the evaluation include the individual’s self-report of the dates and reasons for any
hospitalizations within 3 months prior to the evaluation were addressed?
e. Does the evaluation identify assistance needed to achieve activities of daily living,
including any assistive devices or medical equipment used by the person?
III.1. Did the contractor complete an evaluation of the individual as required?
o Select “Y” if a, b, or c is “Y” and d and e are “Y”
o Select “N” if a, b, or c is “N” and d and/or e is “N”
Date of Initial Service Delivery Plan:
a. Routine Referral
i. Was the initial service delivery plan completed within 14 calendar days after the referral
date or the date the contractor received F- 2101 as indicated by a date stamp- whichever
is later; or
ii. If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the service plan?
b. Expedited Referral (transfers are reviewed as an expedited referral)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 121
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
12 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
i. Is the date of the service delivery plan on or before the date negotiated between the
case manager and contractor, which must be less than 14 days after the oral request; or
ii If a delay, did the contractor notify the case manager of any failure to complete the
service delivery plan before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i. Was the service plan complete prior to the date of notification to DADS for intake?
d. The service plan is agreed upon and was signed by the individual and the contractor
e. The service plan identifies the location of service delivery
f. The service plan identifies the tasks the individual will receive (includes at least one
personal care task, unless FC)
g. The service plan identifies the total weekly hours authorized
h. The service plan identifies the service schedule which includes as necessary, based
on the individual’s needs, certain time periods for the delivery of specified tasks
i. The service plan identifies the frequency of supervisory visits
j. The service plan includes the statement that the contractor is responsible for providing
the tasks allowable in the PHC program (47.41) and agreed to on the service plan.
III. 2. Did the contractor develop an initial service delivery plan as required?
• Select “Y” if a, b, or c is “Y” and d - j are “Y”
• Select “N” if a, b, or c is “N” and/or d – j is “N”
OVERARCHING QUESTION Does
the individual receive family care or did the individual transfer from one
PHC contractor to another PHC, transfer from PHC to CAS or transfer from
Not Calculated in
CAS to PHC during the review period?
III.3 Score
• If overarching question III.3 is “Y”, select “NA” for Standard III.3. Continue
to Standard IV.1.
• If overarching question III.3 is “N”, verify the contractor met the
requirements for the individual’s practitioner’s statement.
Date of Practitioner’s Statement:
a. Routine Referral
i. Did the contractor obtain and submit to DADS a complete practitioner’s statement
within 14 calendar days after the date of referral or the date the contractor received F-
2101 as indicated by a date stamp- whichever is later. Review the contractor's fax, email
or other documentation that verifies the practitioner's statement was submitted to DADS
within the required timeframe; or
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 122
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
12 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. If a delay, II. ATTENDANT REQUIREMENTS
STANDARDdid the contractor document by due date the reason for the delay, an
anticipated date of completion or reason why a completion date cannot be anticipated;
and a description of the contractor’s efforts to obtain the practitioner’s statement?
b. Expedited Referral
i. Did the contractor send a complete practitioner’s statement to DADS within seven (7)
work days after service initiation? Review the contractor's fax, email or other
documentation that verifies the practitioner's statement was submitted to DADS within the
required timeframe.
c. Retroactive
i. Was the practitioner’s statement completed on or before the date of notification to
DADS for intake?
III. 3. Did the contractor meet the requirements for the individual’s practitioner’s
statement?
• Select “Y” if a, b, or c (as applicable) is “Y”
• Select “N” if a, b, or c ( as applicable) is “N”
Potential Billing Error:
If III.3 is “N”, review the Contract Monitoring Claims Report Payment Report for the billing periods within the 12
month review period prior to the date of the practitioner’s statement to determine if DADS paid for services prior to
the date of the practitioner’s statement. If DADS paid for services prior to the date of the practitioner’s statement,
complete Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for Payment. Enter “0” in Column J -
Units Verified for units paid prior to the date of the practitioner’s statement.
STANDARD IV. SERVICE INITIATION
OVERARCHING QUESTION Did
the individual enter services during the review period?
• If overarching question IV.1 is “N”, select “NA” for Standard IV.1. Continue Not Calculated in
IV.1
to Standard V.1. Score
• If overarching question IV.1 is “Y”, verify the contractor met the
requirements for service initiation.
a. Family Care- First Date of Service:
i. Routine Referral-Did services begin within 14 days after the referral date or
within 14 days after the date the contractor date stamped DADS’ authorization
form; or
ii. Transfer- Did services begin on the date negotiated between the case manager
and the contractor?
b. Primary Home Care or Community Attendant Services- First Date of Service:
i. Routine Referral- Did services begin within seven days after the date the
contractor’s receipt of DADS’ Authorization form?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 123
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
12 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. Transfer- Did services begin on the date negotiated between the case manager
STANDARD II. ATTENDANT REQUIREMENTS
and the contractor?
c. If a delay in service initiation did the contractor document the reason for the delay,
either an anticipated date of initiation or specific reasons why the contractor cannot
anticipate a date and a description of the contractor’s efforts to initiate services?
d. Did the contractor send notice of service initiation to the case manager within 14 days
after initiating services?
IV. 1. Were services initiated as required?
• Select “Y” if a is “Y”, b is “NA”, c is “NA” and d is “Y”
• Select “Y” if a is “NA”, b is “Y”, c is “NA” and d is “Y”
• Select “Y” if a or b is “N”, c is “Y” and d is “Y”
• Select “N” if a or b is “N”, c is “N” and d is “Y”
• Select “N” if d is “N”
VI. SERVICE DELIVERY
Complete UNITS OF SERVICE Tables for the last six months of service within the review
VI.1
period then answer VI.1.
a. Priority status- Does the number of documented hours/units of service equal the
number of authorized hours/units; or
Non-Priority status- Does the number of documented hours/units of service indicate that
there were no service interruptions exceeding 14 consecutive days?
b. If a is “N” was the reason for the failure to provide all service hours one of the
following:
• the individual’s revised service plan identified a need for an ongoing decrease in
hours;
• the individual requested that services not be provided;
• the individual requested fewer hours of service than reflected in the service
schedule;
• the individual requested that a specific attendant not provide services;
• the individual was not at home when the service was scheduled;
• services were not delivered for other reasons beyond the control of the provider
agency; or
• services were suspended.
- The individual temporarily or permanently left the contracted services delivery area;
- The individual moved to a location where services could not be provided under the PHC program;
- The individual died;
- The individual was admitted to an institution (hospital, nursing facility, state school, state hospital, or
ICF-MR facility);
- The individual requested that services end;
- DADS denied the individual’s Medicaid eligibility (not applicable to FC);
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 124
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
12 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
- The individual or someone in the individual’s home exhibited reckless behavior, which may have
STANDARD II. ATTENDANT REQUIREMENTS
resulted in imminent danger to the health and safety of the individual, the attendant, or another person;
- The individual or someone else in the individual’s home engaged in discrimination against a provider
agency or DADS employee in violation of applicable law;
- The individual refused services for more than 30 consecutive days.
VI. 1. Were personal assistance service hours provided in accordance with the
individual’s service plans or as required?
• Select “Y” if a is “Y” or a is “N” and b is “Y”
• Select “N” if a and b are “N”
STANDARD VII. SERVICE PLAN CHANGE
• Review the individual’s record for the 12 month review period to determine if a service plan change
was identified and requested.
VII.1.
• Select “NA” if a service plan change was not identified/requested. Continue to Standard VIII.
• If a service plan change was identified/requested, complete the table below.
Date(s) of /identified Date of notification to Effective Date Date of Date(s) of identified Date of revised service
need/request for an the contractor OR (F2101, item 4) Implementation need/request for a plan
increase in service case manager (Service Delivery decrease in service
hours or change that (F2067 or equivalent) Documentation) hours
results in no delivery
of personal care tasks
a. Immediate increase in hours:
i. If requested by the contractor, did the contractor’s documentation include:
• evidence that the contractor discussed the reason for the request of immediate
increase in hours with the case manager? NA
• the date the contractor received approval from the case manager? NA
• the name of the case manager who approved the change? NA
• the effective date of change, and NA
• the number of hours authorized? NA
ii. Did the contractor implement the service plan change on the date negotiated with the
NA
case manager? NA
b. Increase in service hours or no delivery of personal care tasks:
i. If requested by the contractor, was the case manager notified in writing within seven
days from the date of request/identification of need; and NA
ii. Did the notification include:
• date the provider agency learned of the need for the change;
NA
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 125
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
12 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• reason II. ATTENDANT REQUIREMENTS
STANDARD for the change;
NA
• type of change (including the number of service hours) and:
• signature and date of the provider agency representative?
iii. For any increase in service hours requested by the contractor, individual or case manager, did the contractor
implement the change within the required timeframe?
• Was the service plan change implemented on the Begin Date (F2101, item 4) or
five days after the contractor’s date stamp on F2101, whichever is later; or NA
• If delayed, did the contractor document, by the next working day, the failure to
implement the service plan change on the effective date to include the reason and NA
new implementation date? NA
c. Decrease in service hours:
i. Did the contractor develop a new service plan within 21 days from the date of the
individual’s request or identification of need for a service plan change? NA
VII.1. If a service plan change for PAS was identified or requested, did the contractor
meet all requirements?
• If the contractor requested an increase in hours or no delivery of personal care tasks -
select “Y” if a. i-ii or b. i-iii are “Y” NA
• If the case manager requested an increase in hours or no delivery of personal care
tasks - select “Y” if a. ii or b. iii are “Y”
• Select “Y” if a decrease in service hours was requested/identified and c. is “Y”
STANDARD IX. BILLING
Compare the Units of Service tables to the Contract Monitoring Claims Report for the last six months of
service delivery within the review period.
OVERARCHING QUESTION For
the last six months of service delivery to the individual within the review
period,:
i. Were the number of units documented equal to or greater than the
number of units paid? Y or N
ii. Were the number of units paid equal to or less than the number of
IX.1a authorized units? (If No, did the increase meet the criteria of a temporary Not Calculated in
increase)? Y or N Score
• If overarching question IX.1a.i and IX.1a.ii are "Y", mark IX.1a"Y" and skip
overarching question IX.1b and mark Standard IX.1 "Y".
• If either overarching question IX.1a.i or IX.1a.ii is“N”, mark IX.1a "N" and
continue to overarching question IX.1b.
OVERARCHING QUESTION Did
the contractor provide evidence that the contractor negative billed the
over-billed amount due to DADS prior to the date of the Entrance
Not Calculated in
Conference?
IX.1b Score
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 126
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
12 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
IX.1b
• If overarching question IX.1b is “Y”, mark
STANDARD II. ATTENDANT REQUIREMENTS Standard IX.1 “Y”.
• If overarching question IX.1b is “N”, mark Standard IX.1 “N”. Complete
Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for
Payment.
IX. 1. DADS did not identify a financial error?
• Select “Y”, if the contractor does not owe an Amount Due to DADS per the Demand
for Payment Notice (Column L)
• Select “Y”, if the contractor provides evidence that the contractor negative billed the
amount due to DADS prior to the date of the entrance Conference.
• Select “N”, if the contractor owes an Amount Due to DADS per the Demand for
Payment Notice (Column L)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 127
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
13 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
II.1 Complete the Attendants Requirements Table below.
Column A: Enter the name(s) of each attendant that provided direct care to the individual during the last six
months of service delivery to the individual.
Review the contractor’s supporting documentation to answer Columns B, C and G.
Column B: Select “Y” if the attendant is at least 18 years of age or, if under 18 years of age, is a high school
graduate or is enrolled in a vocational educational program and has demonstrated competency to perform the
tasks assigned by the supervisor.
Column C: Select “NA” if Family Care. PHC/CAS- Select “Y” if the attendant is not the individual’s legal parent,
foster parent or spouse of a parent (if a minor- under the age of 18 years) or spouse (if an adult- 18 yrs or older)
Column G: For each attendant review F2101. If hired prior to 6/1/2010, select "NA". If the case manager did NOT
designate the attendant as “Do Not Hire,” select “Y”. If listed as “Do Not Hire”, select “N”. If “N” identify the number
of units provided by the attendant and paid by DADS for the last two months of service to the individual. If DADS
paid for services provided by the attendant, complete the Demand for Payment Notice columns A-H from Contract
Monitoring Claims Report, enter the number of verified units provided by the “DNH” attendant in Column J.
A. B. C. G.
Name of Attendant Attendant Attendant Attendant is
Meets the Meets the NOT
Age Relationship designated
Requirement Requirement COLUMNS LEFT BLANK as "Do Not
INTENTIONALLY Hire"
If hired on or
after
6/1/2010
`
II.1 Does each of the individual’s attendants meet the required qualifications?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 128
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
13 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• Select “Y” if ATTENDANT REQUIREMENTS
STANDARD II.for each row, all responses in column B are "Y" and all responses in
columns C and G are “Y” or "NA" (note: column C will only be NA for Family Care)
• Select “N” if for any row, a response in columns B, C or G is “N”
ORIENTATION CHECKLIST
A. B. C. D. E. F. G.
Name of Individual’s Attendant Date of First Service Date of Orientation Orientation Orientation Provided Orientation Elements not
to Individual Conducted in On or Before First Included All included in the
Person with Date of Service to the Required Orientation
Review service delivery documentation for (Review service delivery (Refer to Participation of the Individual Elements (Enter the
the last six months of service delivery within documentation for the documentation of corresponding
Individual or
review period to determine if
the review period and enter the name of first date of service to the
Attendant Attendant Met elements that were
each attendant that provided care to the sample individual was within Orientations Requirements for not addressed)
individual- NA for a Supervisor providing the last six months of conducted during the Orientation Without
personal assistance services service delivery. If the review period)
unlicensed attendant began
Participation of the
providing services to the Individual
sample individual during the
last six months of service
delivery, enter the first date
of service and complete
columns C - G. If the
unlicensed attendant worked
with the sample individual
prior to the last six months
of service delivery, select
“N” and leave columns C –
G blank.)
Last Six Months
Begin: End:
Last Name: First Name; Answer Date:
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 129
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
13 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Attendant Requirements for Orientation without Participation of the Individual (telephone/verbal): Meet the requirements of a Home health Aide*; have six continuous months of experience
delivering attendant care; has been oriented to the individual and the service plan has not changed; or has previously provided services to the individual.
Required elements:
1. Name of the individual for whom the attendant is to provide care
2. Name of the attendant
3. Date of the attendant orientation
4. Orientation conducted in person with the individual or without the participation of the individual
5. How the individual’s condition affects the performance of tasks
6. Tasks to be performed
7. Service schedule
8. Number of hours of service the attendant is to provide
9. Total number of hours the individual is authorized to receive
10. Safety and emergency procedures, including universal precautions
11. Specific situations about which the attendant should notify the contractor (e.g., changes in the individual’s needs; incidents that affect the individual’s condition; hospitalization;
absence or relocation from home; attendant’s inability to work; and suspicion/allegation of abuse, neglect or exploitation of the individual).
12. Signature of the Supervisor who conducted the orientation
13. Signature of the attendant, if present
14. Signature of the individual, if present
*A Home Health Aide must:
o have a minimum of six months experience in delivering personal care tasks in family care, primary home care, personal assistance services, client managed personal attendant
services; or
o be listed on the DADS Nurses Aide Registry with an employable “Active’ status.
II. 3. Was each attendant who began providing care to the individual during the last
six months of service delivery within the review period, oriented, as required, on or
before the first date of service delivery?
• Select “NA” if the individual’s attendant(s) began providing care to the individual prior
to the review period.
• Select “Y” if column B is “Y” and columns D., E and F. are “Y”
• Select “N” if column B is “Y” and column D., E and/or F is “N”.
STANDARD III. PRE-INITIATION ACTIVITIES
OVERARCHING QUESTION Did
the individual's pre-initiation activities occur during the review period?
III.1 • If overarching question III.1 is “N”, select “NA” for Standard III.1-3. Not Calculated in
Continue to Standard IV.1. Score
• If overarching question III.1 is “Y”, verify pre-initiation activities were
completed as required.
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 130
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
13 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Date of Referral Date of Referral Negotiated Date Stamp on Date of
(F2101, item 1) (F2101, item 25) Service Initiation F2101 Notification for
Date Intake
(Routine) (Expedited/Transf (Expedited/Transf (Retroactive)
er) er)
Date of Evaluation:
a. Routine Referral
i) Is the date of the evaluation within 14 calendar days after the date of referral or the date
the contractor received F-2101 as indicated by a date stamp- whichever is later; or
ii) If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the evaluation?
b. Expedited Referral (transfers are reviewed as an expedited referral)
i) Is the date of the evaluation on or before the date negotiated between the case
manager and contractor, which must be less than 14 days after the oral request; or
ii) If a delay, did the contractor notify the case manager of any failure to complete the
evaluation before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i) Is the date of the evaluation on or before the date of notification to DADS for intake?
d. Does the evaluation include the individual’s self-report of the dates and reasons for any
hospitalizations within 3 months prior to the evaluation were addressed?
e. Does the evaluation identify assistance needed to achieve activities of daily living,
including any assistive devices or medical equipment used by the person?
III.1. Did the contractor complete an evaluation of the individual as required?
o Select “Y” if a, b, or c is “Y” and d and e are “Y”
o Select “N” if a, b, or c is “N” and d and/or e is “N”
Date of Initial Service Delivery Plan:
a. Routine Referral
i. Was the initial service delivery plan completed within 14 calendar days after the referral
date or the date the contractor received F- 2101 as indicated by a date stamp- whichever
is later; or
ii. If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the service plan?
b. Expedited Referral (transfers are reviewed as an expedited referral)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 131
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
13 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
i. Is the date of the service delivery plan on or before the date negotiated between the
case manager and contractor, which must be less than 14 days after the oral request; or
ii If a delay, did the contractor notify the case manager of any failure to complete the
service delivery plan before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i. Was the service plan complete prior to the date of notification to DADS for intake?
d. The service plan is agreed upon and was signed by the individual and the contractor
e. The service plan identifies the location of service delivery
f. The service plan identifies the tasks the individual will receive (includes at least one
personal care task, unless FC)
g. The service plan identifies the total weekly hours authorized
h. The service plan identifies the service schedule which includes as necessary, based
on the individual’s needs, certain time periods for the delivery of specified tasks
i. The service plan identifies the frequency of supervisory visits
j. The service plan includes the statement that the contractor is responsible for providing
the tasks allowable in the PHC program (47.41) and agreed to on the service plan.
III. 2. Did the contractor develop an initial service delivery plan as required?
• Select “Y” if a, b, or c is “Y” and d - j are “Y”
• Select “N” if a, b, or c is “N” and/or d – j is “N”
OVERARCHING QUESTION Does
the individual receive family care or did the individual transfer from one
PHC contractor to another PHC, transfer from PHC to CAS or transfer from
Not Calculated in
CAS to PHC during the review period?
III.3 Score
• If overarching question III.3 is “Y”, select “NA” for Standard III.3. Continue
to Standard IV.1.
• If overarching question III.3 is “N”, verify the contractor met the
requirements for the individual’s practitioner’s statement.
Date of Practitioner’s Statement:
a. Routine Referral
i. Did the contractor obtain and submit to DADS a complete practitioner’s statement
within 14 calendar days after the date of referral or the date the contractor received F-
2101 as indicated by a date stamp- whichever is later. Review the contractor's fax, email
or other documentation that verifies the practitioner's statement was submitted to DADS
within the required timeframe; or
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 132
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
13 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. If a delay, II. ATTENDANT REQUIREMENTS
STANDARDdid the contractor document by due date the reason for the delay, an
anticipated date of completion or reason why a completion date cannot be anticipated;
and a description of the contractor’s efforts to obtain the practitioner’s statement?
b. Expedited Referral
i. Did the contractor send a complete practitioner’s statement to DADS within seven (7)
work days after service initiation? Review the contractor's fax, email or other
documentation that verifies the practitioner's statement was submitted to DADS within the
required timeframe.
c. Retroactive
i. Was the practitioner’s statement completed on or before the date of notification to
DADS for intake?
III. 3. Did the contractor meet the requirements for the individual’s practitioner’s
statement?
• Select “Y” if a, b, or c (as applicable) is “Y”
• Select “N” if a, b, or c ( as applicable) is “N”
Potential Billing Error:
If III.3 is “N”, review the Contract Monitoring Claims Report Payment Report for the billing periods within the 12
month review period prior to the date of the practitioner’s statement to determine if DADS paid for services prior to
the date of the practitioner’s statement. If DADS paid for services prior to the date of the practitioner’s statement,
complete Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for Payment. Enter “0” in Column J -
Units Verified for units paid prior to the date of the practitioner’s statement.
STANDARD IV. SERVICE INITIATION
OVERARCHING QUESTION Did
the individual enter services during the review period?
• If overarching question IV.1 is “N”, select “NA” for Standard IV.1. Continue Not Calculated in
IV.1
to Standard V.1. Score
• If overarching question IV.1 is “Y”, verify the contractor met the
requirements for service initiation.
a. Family Care- First Date of Service:
i. Routine Referral-Did services begin within 14 days after the referral date or
within 14 days after the date the contractor date stamped DADS’ authorization
form; or
ii. Transfer- Did services begin on the date negotiated between the case manager
and the contractor?
b. Primary Home Care or Community Attendant Services- First Date of Service:
i. Routine Referral- Did services begin within seven days after the date the
contractor’s receipt of DADS’ Authorization form?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 133
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
13 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. Transfer- Did services begin on the date negotiated between the case manager
STANDARD II. ATTENDANT REQUIREMENTS
and the contractor?
c. If a delay in service initiation did the contractor document the reason for the delay,
either an anticipated date of initiation or specific reasons why the contractor cannot
anticipate a date and a description of the contractor’s efforts to initiate services?
d. Did the contractor send notice of service initiation to the case manager within 14 days
after initiating services?
IV. 1. Were services initiated as required?
• Select “Y” if a is “Y”, b is “NA”, c is “NA” and d is “Y”
• Select “Y” if a is “NA”, b is “Y”, c is “NA” and d is “Y”
• Select “Y” if a or b is “N”, c is “Y” and d is “Y”
• Select “N” if a or b is “N”, c is “N” and d is “Y”
• Select “N” if d is “N”
VI. SERVICE DELIVERY
Complete UNITS OF SERVICE Tables for the last six months of service within the review
VI.1
period then answer VI.1.
a. Priority status- Does the number of documented hours/units of service equal the
number of authorized hours/units; or
Non-Priority status- Does the number of documented hours/units of service indicate that
there were no service interruptions exceeding 14 consecutive days?
b. If a is “N” was the reason for the failure to provide all service hours one of the
following:
• the individual’s revised service plan identified a need for an ongoing decrease in
hours;
• the individual requested that services not be provided;
• the individual requested fewer hours of service than reflected in the service
schedule;
• the individual requested that a specific attendant not provide services;
• the individual was not at home when the service was scheduled;
• services were not delivered for other reasons beyond the control of the provider
agency; or
• services were suspended.
- The individual temporarily or permanently left the contracted services delivery area;
- The individual moved to a location where services could not be provided under the PHC program;
- The individual died;
- The individual was admitted to an institution (hospital, nursing facility, state school, state hospital, or
ICF-MR facility);
- The individual requested that services end;
- DADS denied the individual’s Medicaid eligibility (not applicable to FC);
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 134
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
13 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
- The individual or someone in the individual’s home exhibited reckless behavior, which may have
STANDARD II. ATTENDANT REQUIREMENTS
resulted in imminent danger to the health and safety of the individual, the attendant, or another person;
- The individual or someone else in the individual’s home engaged in discrimination against a provider
agency or DADS employee in violation of applicable law;
- The individual refused services for more than 30 consecutive days.
VI. 1. Were personal assistance service hours provided in accordance with the
individual’s service plans or as required?
• Select “Y” if a is “Y” or a is “N” and b is “Y”
• Select “N” if a and b are “N”
STANDARD VII. SERVICE PLAN CHANGE
• Review the individual’s record for the 12 month review period to determine if a service plan change
was identified and requested.
VII.1.
• Select “NA” if a service plan change was not identified/requested. Continue to Standard VIII.
• If a service plan change was identified/requested, complete the table below.
Date(s) of /identified Date of notification to Effective Date Date of Date(s) of identified Date of revised service
need/request for an the contractor OR (F2101, item 4) Implementation need/request for a plan
increase in service case manager (Service Delivery decrease in service
hours or change that (F2067 or equivalent) Documentation) hours
results in no delivery
of personal care tasks
a. Immediate increase in hours:
i. If requested by the contractor, did the contractor’s documentation include:
• evidence that the contractor discussed the reason for the request of immediate
increase in hours with the case manager? NA
• the date the contractor received approval from the case manager? NA
• the name of the case manager who approved the change? NA
• the effective date of change, and NA
• the number of hours authorized? NA
ii. Did the contractor implement the service plan change on the date negotiated with the
NA
case manager? NA
b. Increase in service hours or no delivery of personal care tasks:
i. If requested by the contractor, was the case manager notified in writing within seven
days from the date of request/identification of need; and NA
ii. Did the notification include:
• date the provider agency learned of the need for the change;
NA
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 135
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
13 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• reason II. ATTENDANT REQUIREMENTS
STANDARD for the change;
NA
• type of change (including the number of service hours) and:
• signature and date of the provider agency representative?
iii. For any increase in service hours requested by the contractor, individual or case manager, did the contractor
implement the change within the required timeframe?
• Was the service plan change implemented on the Begin Date (F2101, item 4) or
five days after the contractor’s date stamp on F2101, whichever is later; or NA
• If delayed, did the contractor document, by the next working day, the failure to
implement the service plan change on the effective date to include the reason and NA
new implementation date? NA
c. Decrease in service hours:
i. Did the contractor develop a new service plan within 21 days from the date of the
individual’s request or identification of need for a service plan change? NA
VII.1. If a service plan change for PAS was identified or requested, did the contractor
meet all requirements?
• If the contractor requested an increase in hours or no delivery of personal care tasks -
select “Y” if a. i-ii or b. i-iii are “Y” NA
• If the case manager requested an increase in hours or no delivery of personal care
tasks - select “Y” if a. ii or b. iii are “Y”
• Select “Y” if a decrease in service hours was requested/identified and c. is “Y”
STANDARD IX. BILLING
Compare the Units of Service tables to the Contract Monitoring Claims Report for the last six months of
service delivery within the review period.
OVERARCHING QUESTION For
the last six months of service delivery to the individual within the review
period,:
i. Were the number of units documented equal to or greater than the
number of units paid? Y or N
ii. Were the number of units paid equal to or less than the number of
IX.1a authorized units? (If No, did the increase meet the criteria of a temporary Not Calculated in
increase)? Y or N Score
• If overarching question IX.1a.i and IX.1a.ii are "Y", mark IX.1a"Y" and skip
overarching question IX.1b and mark Standard IX.1 "Y".
• If either overarching question IX.1a.i or IX.1a.ii is“N”, mark IX.1a "N" and
continue to overarching question IX.1b.
OVERARCHING QUESTION Did
the contractor provide evidence that the contractor negative billed the
over-billed amount due to DADS prior to the date of the Entrance
Not Calculated in
Conference?
IX.1b Score
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 136
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
13 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
IX.1b
• If overarching question IX.1b is “Y”, mark
STANDARD II. ATTENDANT REQUIREMENTS Standard IX.1 “Y”.
• If overarching question IX.1b is “N”, mark Standard IX.1 “N”. Complete
Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for
Payment.
IX. 1. DADS did not identify a financial error?
• Select “Y”, if the contractor does not owe an Amount Due to DADS per the Demand
for Payment Notice (Column L)
• Select “Y”, if the contractor provides evidence that the contractor negative billed the
amount due to DADS prior to the date of the entrance Conference.
• Select “N”, if the contractor owes an Amount Due to DADS per the Demand for
Payment Notice (Column L)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 137
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
14 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
II.1 Complete the Attendants Requirements Table below.
Column A: Enter the name(s) of each attendant that provided direct care to the individual during the last six
months of service delivery to the individual.
Review the contractor’s supporting documentation to answer Columns B, C and G.
Column B: Select “Y” if the attendant is at least 18 years of age or, if under 18 years of age, is a high school
graduate or is enrolled in a vocational educational program and has demonstrated competency to perform the
tasks assigned by the supervisor.
Column C: Select “NA” if Family Care. PHC/CAS- Select “Y” if the attendant is not the individual’s legal parent,
foster parent or spouse of a parent (if a minor- under the age of 18 years) or spouse (if an adult- 18 yrs or older)
Column G: For each attendant review F2101. If hired prior to 6/1/2010, select "NA". If the case manager did NOT
designate the attendant as “Do Not Hire,” select “Y”. If listed as “Do Not Hire”, select “N”. If “N” identify the number
of units provided by the attendant and paid by DADS for the last two months of service to the individual. If DADS
paid for services provided by the attendant, complete the Demand for Payment Notice columns A-H from Contract
Monitoring Claims Report, enter the number of verified units provided by the “DNH” attendant in Column J.
A. B. C. G.
Name of Attendant Attendant Attendant Attendant is
Meets the Meets the NOT
Age Relationship designated
Requirement Requirement COLUMNS LEFT BLANK as "Do Not
INTENTIONALLY Hire"
If hired on or
after
6/1/2010
`
II.1 Does each of the individual’s attendants meet the required qualifications?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 138
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
14 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• Select “Y” if ATTENDANT REQUIREMENTS
STANDARD II.for each row, all responses in column B are "Y" and all responses in
columns C and G are “Y” or "NA" (note: column C will only be NA for Family Care)
• Select “N” if for any row, a response in columns B, C or G is “N”
ORIENTATION CHECKLIST
A. B. C. D. E. F. G.
Name of Individual’s Attendant Date of First Service Date of Orientation Orientation Orientation Provided Orientation Elements not
to Individual Conducted in On or Before First Included All included in the
Person with Date of Service to the Required Orientation
Review service delivery documentation for (Review service delivery (Refer to Participation of the Individual Elements (Enter the
the last six months of service delivery within documentation for the documentation of corresponding
Individual or
review period to determine if
the review period and enter the name of first date of service to the
Attendant Attendant Met elements that were
each attendant that provided care to the sample individual was within Orientations Requirements for not addressed)
individual- NA for a Supervisor providing the last six months of conducted during the Orientation Without
personal assistance services service delivery. If the review period)
unlicensed attendant began
Participation of the
providing services to the Individual
sample individual during the
last six months of service
delivery, enter the first date
of service and complete
columns C - G. If the
unlicensed attendant worked
with the sample individual
prior to the last six months
of service delivery, select
“N” and leave columns C –
G blank.)
Last Six Months
Begin: End:
Last Name: First Name; Answer Date:
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 139
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
14 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Attendant Requirements for Orientation without Participation of the Individual (telephone/verbal): Meet the requirements of a Home health Aide*; have six continuous months of experience
delivering attendant care; has been oriented to the individual and the service plan has not changed; or has previously provided services to the individual.
Required elements:
1. Name of the individual for whom the attendant is to provide care
2. Name of the attendant
3. Date of the attendant orientation
4. Orientation conducted in person with the individual or without the participation of the individual
5. How the individual’s condition affects the performance of tasks
6. Tasks to be performed
7. Service schedule
8. Number of hours of service the attendant is to provide
9. Total number of hours the individual is authorized to receive
10. Safety and emergency procedures, including universal precautions
11. Specific situations about which the attendant should notify the contractor (e.g., changes in the individual’s needs; incidents that affect the individual’s condition; hospitalization;
absence or relocation from home; attendant’s inability to work; and suspicion/allegation of abuse, neglect or exploitation of the individual).
12. Signature of the Supervisor who conducted the orientation
13. Signature of the attendant, if present
14. Signature of the individual, if present
*A Home Health Aide must:
o have a minimum of six months experience in delivering personal care tasks in family care, primary home care, personal assistance services, client managed personal attendant
services; or
o be listed on the DADS Nurses Aide Registry with an employable “Active’ status.
II. 3. Was each attendant who began providing care to the individual during the last
six months of service delivery within the review period, oriented, as required, on or
before the first date of service delivery?
• Select “NA” if the individual’s attendant(s) began providing care to the individual prior
to the review period.
• Select “Y” if column B is “Y” and columns D., E and F. are “Y”
• Select “N” if column B is “Y” and column D., E and/or F is “N”.
STANDARD III. PRE-INITIATION ACTIVITIES
OVERARCHING QUESTION Did
the individual's pre-initiation activities occur during the review period?
III.1 • If overarching question III.1 is “N”, select “NA” for Standard III.1-3. Not Calculated in
Continue to Standard IV.1. Score
• If overarching question III.1 is “Y”, verify pre-initiation activities were
completed as required.
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 140
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
14 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Date of Referral Date of Referral Negotiated Date Stamp on Date of
(F2101, item 1) (F2101, item 25) Service Initiation F2101 Notification for
Date Intake
(Routine) (Expedited/Transf (Expedited/Transf (Retroactive)
er) er)
Date of Evaluation:
a. Routine Referral
i) Is the date of the evaluation within 14 calendar days after the date of referral or the date
the contractor received F-2101 as indicated by a date stamp- whichever is later; or
ii) If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the evaluation?
b. Expedited Referral (transfers are reviewed as an expedited referral)
i) Is the date of the evaluation on or before the date negotiated between the case
manager and contractor, which must be less than 14 days after the oral request; or
ii) If a delay, did the contractor notify the case manager of any failure to complete the
evaluation before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i) Is the date of the evaluation on or before the date of notification to DADS for intake?
d. Does the evaluation include the individual’s self-report of the dates and reasons for any
hospitalizations within 3 months prior to the evaluation were addressed?
e. Does the evaluation identify assistance needed to achieve activities of daily living,
including any assistive devices or medical equipment used by the person?
III.1. Did the contractor complete an evaluation of the individual as required?
o Select “Y” if a, b, or c is “Y” and d and e are “Y”
o Select “N” if a, b, or c is “N” and d and/or e is “N”
Date of Initial Service Delivery Plan:
a. Routine Referral
i. Was the initial service delivery plan completed within 14 calendar days after the referral
date or the date the contractor received F- 2101 as indicated by a date stamp- whichever
is later; or
ii. If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the service plan?
b. Expedited Referral (transfers are reviewed as an expedited referral)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 141
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
14 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
i. Is the date of the service delivery plan on or before the date negotiated between the
case manager and contractor, which must be less than 14 days after the oral request; or
ii If a delay, did the contractor notify the case manager of any failure to complete the
service delivery plan before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i. Was the service plan complete prior to the date of notification to DADS for intake?
d. The service plan is agreed upon and was signed by the individual and the contractor
e. The service plan identifies the location of service delivery
f. The service plan identifies the tasks the individual will receive (includes at least one
personal care task, unless FC)
g. The service plan identifies the total weekly hours authorized
h. The service plan identifies the service schedule which includes as necessary, based
on the individual’s needs, certain time periods for the delivery of specified tasks
i. The service plan identifies the frequency of supervisory visits
j. The service plan includes the statement that the contractor is responsible for providing
the tasks allowable in the PHC program (47.41) and agreed to on the service plan.
III. 2. Did the contractor develop an initial service delivery plan as required?
• Select “Y” if a, b, or c is “Y” and d - j are “Y”
• Select “N” if a, b, or c is “N” and/or d – j is “N”
OVERARCHING QUESTION Does
the individual receive family care or did the individual transfer from one
PHC contractor to another PHC, transfer from PHC to CAS or transfer from
Not Calculated in
CAS to PHC during the review period?
III.3 Score
• If overarching question III.3 is “Y”, select “NA” for Standard III.3. Continue
to Standard IV.1.
• If overarching question III.3 is “N”, verify the contractor met the
requirements for the individual’s practitioner’s statement.
Date of Practitioner’s Statement:
a. Routine Referral
i. Did the contractor obtain and submit to DADS a complete practitioner’s statement
within 14 calendar days after the date of referral or the date the contractor received F-
2101 as indicated by a date stamp- whichever is later. Review the contractor's fax, email
or other documentation that verifies the practitioner's statement was submitted to DADS
within the required timeframe; or
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 142
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
14 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. If a delay, II. ATTENDANT REQUIREMENTS
STANDARDdid the contractor document by due date the reason for the delay, an
anticipated date of completion or reason why a completion date cannot be anticipated;
and a description of the contractor’s efforts to obtain the practitioner’s statement?
b. Expedited Referral
i. Did the contractor send a complete practitioner’s statement to DADS within seven (7)
work days after service initiation? Review the contractor's fax, email or other
documentation that verifies the practitioner's statement was submitted to DADS within the
required timeframe.
c. Retroactive
i. Was the practitioner’s statement completed on or before the date of notification to
DADS for intake?
III. 3. Did the contractor meet the requirements for the individual’s practitioner’s
statement?
• Select “Y” if a, b, or c (as applicable) is “Y”
• Select “N” if a, b, or c ( as applicable) is “N”
Potential Billing Error:
If III.3 is “N”, review the Contract Monitoring Claims Report Payment Report for the billing periods within the 12
month review period prior to the date of the practitioner’s statement to determine if DADS paid for services prior to
the date of the practitioner’s statement. If DADS paid for services prior to the date of the practitioner’s statement,
complete Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for Payment. Enter “0” in Column J -
Units Verified for units paid prior to the date of the practitioner’s statement.
STANDARD IV. SERVICE INITIATION
OVERARCHING QUESTION Did
the individual enter services during the review period?
• If overarching question IV.1 is “N”, select “NA” for Standard IV.1. Continue Not Calculated in
IV.1
to Standard V.1. Score
• If overarching question IV.1 is “Y”, verify the contractor met the
requirements for service initiation.
a. Family Care- First Date of Service:
i. Routine Referral-Did services begin within 14 days after the referral date or
within 14 days after the date the contractor date stamped DADS’ authorization
form; or
ii. Transfer- Did services begin on the date negotiated between the case manager
and the contractor?
b. Primary Home Care or Community Attendant Services- First Date of Service:
i. Routine Referral- Did services begin within seven days after the date the
contractor’s receipt of DADS’ Authorization form?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 143
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
14 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. Transfer- Did services begin on the date negotiated between the case manager
STANDARD II. ATTENDANT REQUIREMENTS
and the contractor?
c. If a delay in service initiation did the contractor document the reason for the delay,
either an anticipated date of initiation or specific reasons why the contractor cannot
anticipate a date and a description of the contractor’s efforts to initiate services?
d. Did the contractor send notice of service initiation to the case manager within 14 days
after initiating services?
IV. 1. Were services initiated as required?
• Select “Y” if a is “Y”, b is “NA”, c is “NA” and d is “Y”
• Select “Y” if a is “NA”, b is “Y”, c is “NA” and d is “Y”
• Select “Y” if a or b is “N”, c is “Y” and d is “Y”
• Select “N” if a or b is “N”, c is “N” and d is “Y”
• Select “N” if d is “N”
VI. SERVICE DELIVERY
Complete UNITS OF SERVICE Tables for the last six months of service within the review
VI.1
period then answer VI.1.
a. Priority status- Does the number of documented hours/units of service equal the
number of authorized hours/units; or
Non-Priority status- Does the number of documented hours/units of service indicate that
there were no service interruptions exceeding 14 consecutive days?
b. If a is “N” was the reason for the failure to provide all service hours one of the
following:
• the individual’s revised service plan identified a need for an ongoing decrease in
hours;
• the individual requested that services not be provided;
• the individual requested fewer hours of service than reflected in the service
schedule;
• the individual requested that a specific attendant not provide services;
• the individual was not at home when the service was scheduled;
• services were not delivered for other reasons beyond the control of the provider
agency; or
• services were suspended.
- The individual temporarily or permanently left the contracted services delivery area;
- The individual moved to a location where services could not be provided under the PHC program;
- The individual died;
- The individual was admitted to an institution (hospital, nursing facility, state school, state hospital, or
ICF-MR facility);
- The individual requested that services end;
- DADS denied the individual’s Medicaid eligibility (not applicable to FC);
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 144
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
14 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
- The individual or someone in the individual’s home exhibited reckless behavior, which may have
STANDARD II. ATTENDANT REQUIREMENTS
resulted in imminent danger to the health and safety of the individual, the attendant, or another person;
- The individual or someone else in the individual’s home engaged in discrimination against a provider
agency or DADS employee in violation of applicable law;
- The individual refused services for more than 30 consecutive days.
VI. 1. Were personal assistance service hours provided in accordance with the
individual’s service plans or as required?
• Select “Y” if a is “Y” or a is “N” and b is “Y”
• Select “N” if a and b are “N”
STANDARD VII. SERVICE PLAN CHANGE
• Review the individual’s record for the 12 month review period to determine if a service plan change
was identified and requested.
VII.1.
• Select “NA” if a service plan change was not identified/requested. Continue to Standard VIII.
• If a service plan change was identified/requested, complete the table below.
Date(s) of /identified Date of notification to Effective Date Date of Date(s) of identified Date of revised service
need/request for an the contractor OR (F2101, item 4) Implementation need/request for a plan
increase in service case manager (Service Delivery decrease in service
hours or change that (F2067 or equivalent) Documentation) hours
results in no delivery
of personal care tasks
a. Immediate increase in hours:
i. If requested by the contractor, did the contractor’s documentation include:
• evidence that the contractor discussed the reason for the request of immediate
increase in hours with the case manager? NA
• the date the contractor received approval from the case manager? NA
• the name of the case manager who approved the change? NA
• the effective date of change, and NA
• the number of hours authorized? NA
ii. Did the contractor implement the service plan change on the date negotiated with the
NA
case manager? NA
b. Increase in service hours or no delivery of personal care tasks:
i. If requested by the contractor, was the case manager notified in writing within seven
days from the date of request/identification of need; and NA
ii. Did the notification include:
• date the provider agency learned of the need for the change;
NA
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 145
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
14 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• reason II. ATTENDANT REQUIREMENTS
STANDARD for the change;
NA
• type of change (including the number of service hours) and:
• signature and date of the provider agency representative?
iii. For any increase in service hours requested by the contractor, individual or case manager, did the contractor
implement the change within the required timeframe?
• Was the service plan change implemented on the Begin Date (F2101, item 4) or
five days after the contractor’s date stamp on F2101, whichever is later; or NA
• If delayed, did the contractor document, by the next working day, the failure to
implement the service plan change on the effective date to include the reason and NA
new implementation date? NA
c. Decrease in service hours:
i. Did the contractor develop a new service plan within 21 days from the date of the
individual’s request or identification of need for a service plan change? NA
VII.1. If a service plan change for PAS was identified or requested, did the contractor
meet all requirements?
• If the contractor requested an increase in hours or no delivery of personal care tasks -
select “Y” if a. i-ii or b. i-iii are “Y” NA
• If the case manager requested an increase in hours or no delivery of personal care
tasks - select “Y” if a. ii or b. iii are “Y”
• Select “Y” if a decrease in service hours was requested/identified and c. is “Y”
STANDARD IX. BILLING
Compare the Units of Service tables to the Contract Monitoring Claims Report for the last six months of
service delivery within the review period.
OVERARCHING QUESTION For
the last six months of service delivery to the individual within the review
period,:
i. Were the number of units documented equal to or greater than the
number of units paid? Y or N
ii. Were the number of units paid equal to or less than the number of
IX.1a authorized units? (If No, did the increase meet the criteria of a temporary Not Calculated in
increase)? Y or N Score
• If overarching question IX.1a.i and IX.1a.ii are "Y", mark IX.1a"Y" and skip
overarching question IX.1b and mark Standard IX.1 "Y".
• If either overarching question IX.1a.i or IX.1a.ii is“N”, mark IX.1a "N" and
continue to overarching question IX.1b.
OVERARCHING QUESTION Did
the contractor provide evidence that the contractor negative billed the
over-billed amount due to DADS prior to the date of the Entrance
Not Calculated in
Conference?
IX.1b Score
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 146
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
14 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
IX.1b
• If overarching question IX.1b is “Y”, mark
STANDARD II. ATTENDANT REQUIREMENTS Standard IX.1 “Y”.
• If overarching question IX.1b is “N”, mark Standard IX.1 “N”. Complete
Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for
Payment.
IX. 1. DADS did not identify a financial error?
• Select “Y”, if the contractor does not owe an Amount Due to DADS per the Demand
for Payment Notice (Column L)
• Select “Y”, if the contractor provides evidence that the contractor negative billed the
amount due to DADS prior to the date of the entrance Conference.
• Select “N”, if the contractor owes an Amount Due to DADS per the Demand for
Payment Notice (Column L)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 147
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
15 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
II.1 Complete the Attendants Requirements Table below.
Column A: Enter the name(s) of each attendant that provided direct care to the individual during the last six
months of service delivery to the individual.
Review the contractor’s supporting documentation to answer Columns B, C and G.
Column B: Select “Y” if the attendant is at least 18 years of age or, if under 18 years of age, is a high school
graduate or is enrolled in a vocational educational program and has demonstrated competency to perform the
tasks assigned by the supervisor.
Column C: Select “NA” if Family Care. PHC/CAS- Select “Y” if the attendant is not the individual’s legal parent,
foster parent or spouse of a parent (if a minor- under the age of 18 years) or spouse (if an adult- 18 yrs or older)
Column G: For each attendant review F2101. If hired prior to 6/1/2010, select "NA". If the case manager did NOT
designate the attendant as “Do Not Hire,” select “Y”. If listed as “Do Not Hire”, select “N”. If “N” identify the number
of units provided by the attendant and paid by DADS for the last two months of service to the individual. If DADS
paid for services provided by the attendant, complete the Demand for Payment Notice columns A-H from Contract
Monitoring Claims Report, enter the number of verified units provided by the “DNH” attendant in Column J.
A. B. C. G.
Name of Attendant Attendant Attendant Attendant is
Meets the Meets the NOT
Age Relationship designated
Requirement Requirement COLUMNS LEFT BLANK as "Do Not
INTENTIONALLY Hire"
If hired on or
after
6/1/2010
`
II.1 Does each of the individual’s attendants meet the required qualifications?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 148
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
15 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• Select “Y” if ATTENDANT REQUIREMENTS
STANDARD II.for each row, all responses in column B are "Y" and all responses in
columns C and G are “Y” or "NA" (note: column C will only be NA for Family Care)
• Select “N” if for any row, a response in columns B, C or G is “N”
ORIENTATION CHECKLIST
A. B. C. D. E. F. G.
Name of Individual’s Attendant Date of First Service Date of Orientation Orientation Orientation Provided Orientation Elements not
to Individual Conducted in On or Before First Included All included in the
Person with Date of Service to the Required Orientation
Review service delivery documentation for (Review service delivery (Refer to Participation of the Individual Elements (Enter the
the last six months of service delivery within documentation for the documentation of corresponding
Individual or
review period to determine if
the review period and enter the name of first date of service to the
Attendant Attendant Met elements that were
each attendant that provided care to the sample individual was within Orientations Requirements for not addressed)
individual- NA for a Supervisor providing the last six months of conducted during the Orientation Without
personal assistance services service delivery. If the review period)
unlicensed attendant began
Participation of the
providing services to the Individual
sample individual during the
last six months of service
delivery, enter the first date
of service and complete
columns C - G. If the
unlicensed attendant worked
with the sample individual
prior to the last six months
of service delivery, select
“N” and leave columns C –
G blank.)
Last Six Months
Begin: End:
Last Name: First Name; Answer Date:
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 149
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
15 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Attendant Requirements for Orientation without Participation of the Individual (telephone/verbal): Meet the requirements of a Home health Aide*; have six continuous months of experience
delivering attendant care; has been oriented to the individual and the service plan has not changed; or has previously provided services to the individual.
Required elements:
1. Name of the individual for whom the attendant is to provide care
2. Name of the attendant
3. Date of the attendant orientation
4. Orientation conducted in person with the individual or without the participation of the individual
5. How the individual’s condition affects the performance of tasks
6. Tasks to be performed
7. Service schedule
8. Number of hours of service the attendant is to provide
9. Total number of hours the individual is authorized to receive
10. Safety and emergency procedures, including universal precautions
11. Specific situations about which the attendant should notify the contractor (e.g., changes in the individual’s needs; incidents that affect the individual’s condition; hospitalization;
absence or relocation from home; attendant’s inability to work; and suspicion/allegation of abuse, neglect or exploitation of the individual).
12. Signature of the Supervisor who conducted the orientation
13. Signature of the attendant, if present
14. Signature of the individual, if present
*A Home Health Aide must:
o have a minimum of six months experience in delivering personal care tasks in family care, primary home care, personal assistance services, client managed personal attendant
services; or
o be listed on the DADS Nurses Aide Registry with an employable “Active’ status.
II. 3. Was each attendant who began providing care to the individual during the last
six months of service delivery within the review period, oriented, as required, on or
before the first date of service delivery?
• Select “NA” if the individual’s attendant(s) began providing care to the individual prior
to the review period.
• Select “Y” if column B is “Y” and columns D., E and F. are “Y”
• Select “N” if column B is “Y” and column D., E and/or F is “N”.
STANDARD III. PRE-INITIATION ACTIVITIES
OVERARCHING QUESTION Did
the individual's pre-initiation activities occur during the review period?
III.1 • If overarching question III.1 is “N”, select “NA” for Standard III.1-3. Not Calculated in
Continue to Standard IV.1. Score
• If overarching question III.1 is “Y”, verify pre-initiation activities were
completed as required.
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 150
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
15 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Date of Referral Date of Referral Negotiated Date Stamp on Date of
(F2101, item 1) (F2101, item 25) Service Initiation F2101 Notification for
Date Intake
(Routine) (Expedited/Transf (Expedited/Transf (Retroactive)
er) er)
Date of Evaluation:
a. Routine Referral
i) Is the date of the evaluation within 14 calendar days after the date of referral or the date
the contractor received F-2101 as indicated by a date stamp- whichever is later; or
ii) If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the evaluation?
b. Expedited Referral (transfers are reviewed as an expedited referral)
i) Is the date of the evaluation on or before the date negotiated between the case
manager and contractor, which must be less than 14 days after the oral request; or
ii) If a delay, did the contractor notify the case manager of any failure to complete the
evaluation before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i) Is the date of the evaluation on or before the date of notification to DADS for intake?
d. Does the evaluation include the individual’s self-report of the dates and reasons for any
hospitalizations within 3 months prior to the evaluation were addressed?
e. Does the evaluation identify assistance needed to achieve activities of daily living,
including any assistive devices or medical equipment used by the person?
III.1. Did the contractor complete an evaluation of the individual as required?
o Select “Y” if a, b, or c is “Y” and d and e are “Y”
o Select “N” if a, b, or c is “N” and d and/or e is “N”
Date of Initial Service Delivery Plan:
a. Routine Referral
i. Was the initial service delivery plan completed within 14 calendar days after the referral
date or the date the contractor received F- 2101 as indicated by a date stamp- whichever
is later; or
ii. If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the service plan?
b. Expedited Referral (transfers are reviewed as an expedited referral)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 151
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
15 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
i. Is the date of the service delivery plan on or before the date negotiated between the
case manager and contractor, which must be less than 14 days after the oral request; or
ii If a delay, did the contractor notify the case manager of any failure to complete the
service delivery plan before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i. Was the service plan complete prior to the date of notification to DADS for intake?
d. The service plan is agreed upon and was signed by the individual and the contractor
e. The service plan identifies the location of service delivery
f. The service plan identifies the tasks the individual will receive (includes at least one
personal care task, unless FC)
g. The service plan identifies the total weekly hours authorized
h. The service plan identifies the service schedule which includes as necessary, based
on the individual’s needs, certain time periods for the delivery of specified tasks
i. The service plan identifies the frequency of supervisory visits
j. The service plan includes the statement that the contractor is responsible for providing
the tasks allowable in the PHC program (47.41) and agreed to on the service plan.
III. 2. Did the contractor develop an initial service delivery plan as required?
• Select “Y” if a, b, or c is “Y” and d - j are “Y”
• Select “N” if a, b, or c is “N” and/or d – j is “N”
OVERARCHING QUESTION Does
the individual receive family care or did the individual transfer from one
PHC contractor to another PHC, transfer from PHC to CAS or transfer from
Not Calculated in
CAS to PHC during the review period?
III.3 Score
• If overarching question III.3 is “Y”, select “NA” for Standard III.3. Continue
to Standard IV.1.
• If overarching question III.3 is “N”, verify the contractor met the
requirements for the individual’s practitioner’s statement.
Date of Practitioner’s Statement:
a. Routine Referral
i. Did the contractor obtain and submit to DADS a complete practitioner’s statement
within 14 calendar days after the date of referral or the date the contractor received F-
2101 as indicated by a date stamp- whichever is later. Review the contractor's fax, email
or other documentation that verifies the practitioner's statement was submitted to DADS
within the required timeframe; or
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 152
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
15 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. If a delay, II. ATTENDANT REQUIREMENTS
STANDARDdid the contractor document by due date the reason for the delay, an
anticipated date of completion or reason why a completion date cannot be anticipated;
and a description of the contractor’s efforts to obtain the practitioner’s statement?
b. Expedited Referral
i. Did the contractor send a complete practitioner’s statement to DADS within seven (7)
work days after service initiation? Review the contractor's fax, email or other
documentation that verifies the practitioner's statement was submitted to DADS within the
required timeframe.
c. Retroactive
i. Was the practitioner’s statement completed on or before the date of notification to
DADS for intake?
III. 3. Did the contractor meet the requirements for the individual’s practitioner’s
statement?
• Select “Y” if a, b, or c (as applicable) is “Y”
• Select “N” if a, b, or c ( as applicable) is “N”
Potential Billing Error:
If III.3 is “N”, review the Contract Monitoring Claims Report Payment Report for the billing periods within the 12
month review period prior to the date of the practitioner’s statement to determine if DADS paid for services prior to
the date of the practitioner’s statement. If DADS paid for services prior to the date of the practitioner’s statement,
complete Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for Payment. Enter “0” in Column J -
Units Verified for units paid prior to the date of the practitioner’s statement.
STANDARD IV. SERVICE INITIATION
OVERARCHING QUESTION Did
the individual enter services during the review period?
• If overarching question IV.1 is “N”, select “NA” for Standard IV.1. Continue Not Calculated in
IV.1
to Standard V.1. Score
• If overarching question IV.1 is “Y”, verify the contractor met the
requirements for service initiation.
a. Family Care- First Date of Service:
i. Routine Referral-Did services begin within 14 days after the referral date or
within 14 days after the date the contractor date stamped DADS’ authorization
form; or
ii. Transfer- Did services begin on the date negotiated between the case manager
and the contractor?
b. Primary Home Care or Community Attendant Services- First Date of Service:
i. Routine Referral- Did services begin within seven days after the date the
contractor’s receipt of DADS’ Authorization form?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 153
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
15 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. Transfer- Did services begin on the date negotiated between the case manager
STANDARD II. ATTENDANT REQUIREMENTS
and the contractor?
c. If a delay in service initiation did the contractor document the reason for the delay,
either an anticipated date of initiation or specific reasons why the contractor cannot
anticipate a date and a description of the contractor’s efforts to initiate services?
d. Did the contractor send notice of service initiation to the case manager within 14 days
after initiating services?
IV. 1. Were services initiated as required?
• Select “Y” if a is “Y”, b is “NA”, c is “NA” and d is “Y”
• Select “Y” if a is “NA”, b is “Y”, c is “NA” and d is “Y”
• Select “Y” if a or b is “N”, c is “Y” and d is “Y”
• Select “N” if a or b is “N”, c is “N” and d is “Y”
• Select “N” if d is “N”
VI. SERVICE DELIVERY
Complete UNITS OF SERVICE Tables for the last six months of service within the review
VI.1
period then answer VI.1.
a. Priority status- Does the number of documented hours/units of service equal the
number of authorized hours/units; or
Non-Priority status- Does the number of documented hours/units of service indicate that
there were no service interruptions exceeding 14 consecutive days?
b. If a is “N” was the reason for the failure to provide all service hours one of the
following:
• the individual’s revised service plan identified a need for an ongoing decrease in
hours;
• the individual requested that services not be provided;
• the individual requested fewer hours of service than reflected in the service
schedule;
• the individual requested that a specific attendant not provide services;
• the individual was not at home when the service was scheduled;
• services were not delivered for other reasons beyond the control of the provider
agency; or
• services were suspended.
- The individual temporarily or permanently left the contracted services delivery area;
- The individual moved to a location where services could not be provided under the PHC program;
- The individual died;
- The individual was admitted to an institution (hospital, nursing facility, state school, state hospital, or
ICF-MR facility);
- The individual requested that services end;
- DADS denied the individual’s Medicaid eligibility (not applicable to FC);
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 154
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
15 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
- The individual or someone in the individual’s home exhibited reckless behavior, which may have
STANDARD II. ATTENDANT REQUIREMENTS
resulted in imminent danger to the health and safety of the individual, the attendant, or another person;
- The individual or someone else in the individual’s home engaged in discrimination against a provider
agency or DADS employee in violation of applicable law;
- The individual refused services for more than 30 consecutive days.
VI. 1. Were personal assistance service hours provided in accordance with the
individual’s service plans or as required?
• Select “Y” if a is “Y” or a is “N” and b is “Y”
• Select “N” if a and b are “N”
STANDARD VII. SERVICE PLAN CHANGE
• Review the individual’s record for the 12 month review period to determine if a service plan change
was identified and requested.
VII.1.
• Select “NA” if a service plan change was not identified/requested. Continue to Standard VIII.
• If a service plan change was identified/requested, complete the table below.
Date(s) of /identified Date of notification to Effective Date Date of Date(s) of identified Date of revised service
need/request for an the contractor OR (F2101, item 4) Implementation need/request for a plan
increase in service case manager (Service Delivery decrease in service
hours or change that (F2067 or equivalent) Documentation) hours
results in no delivery
of personal care tasks
a. Immediate increase in hours:
i. If requested by the contractor, did the contractor’s documentation include:
• evidence that the contractor discussed the reason for the request of immediate
increase in hours with the case manager? NA
• the date the contractor received approval from the case manager? NA
• the name of the case manager who approved the change? NA
• the effective date of change, and NA
• the number of hours authorized? NA
ii. Did the contractor implement the service plan change on the date negotiated with the
NA
case manager? NA
b. Increase in service hours or no delivery of personal care tasks:
i. If requested by the contractor, was the case manager notified in writing within seven
days from the date of request/identification of need; and NA
ii. Did the notification include:
• date the provider agency learned of the need for the change;
NA
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 155
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
15 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• reason II. ATTENDANT REQUIREMENTS
STANDARD for the change;
NA
• type of change (including the number of service hours) and:
• signature and date of the provider agency representative?
iii. For any increase in service hours requested by the contractor, individual or case manager, did the contractor
implement the change within the required timeframe?
• Was the service plan change implemented on the Begin Date (F2101, item 4) or
five days after the contractor’s date stamp on F2101, whichever is later; or NA
• If delayed, did the contractor document, by the next working day, the failure to
implement the service plan change on the effective date to include the reason and NA
new implementation date? NA
c. Decrease in service hours:
i. Did the contractor develop a new service plan within 21 days from the date of the
individual’s request or identification of need for a service plan change? NA
VII.1. If a service plan change for PAS was identified or requested, did the contractor
meet all requirements?
• If the contractor requested an increase in hours or no delivery of personal care tasks -
select “Y” if a. i-ii or b. i-iii are “Y” NA
• If the case manager requested an increase in hours or no delivery of personal care
tasks - select “Y” if a. ii or b. iii are “Y”
• Select “Y” if a decrease in service hours was requested/identified and c. is “Y”
STANDARD IX. BILLING
Compare the Units of Service tables to the Contract Monitoring Claims Report for the last six months of
service delivery within the review period.
OVERARCHING QUESTION For
the last six months of service delivery to the individual within the review
period,:
i. Were the number of units documented equal to or greater than the
number of units paid? Y or N
ii. Were the number of units paid equal to or less than the number of
IX.1a authorized units? (If No, did the increase meet the criteria of a temporary Not Calculated in
increase)? Y or N Score
• If overarching question IX.1a.i and IX.1a.ii are "Y", mark IX.1a"Y" and skip
overarching question IX.1b and mark Standard IX.1 "Y".
• If either overarching question IX.1a.i or IX.1a.ii is“N”, mark IX.1a "N" and
continue to overarching question IX.1b.
OVERARCHING QUESTION Did
the contractor provide evidence that the contractor negative billed the
over-billed amount due to DADS prior to the date of the Entrance
Not Calculated in
Conference?
IX.1b Score
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 156
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
15 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
IX.1b
• If overarching question IX.1b is “Y”, mark
STANDARD II. ATTENDANT REQUIREMENTS Standard IX.1 “Y”.
• If overarching question IX.1b is “N”, mark Standard IX.1 “N”. Complete
Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for
Payment.
IX. 1. DADS did not identify a financial error?
• Select “Y”, if the contractor does not owe an Amount Due to DADS per the Demand
for Payment Notice (Column L)
• Select “Y”, if the contractor provides evidence that the contractor negative billed the
amount due to DADS prior to the date of the entrance Conference.
• Select “N”, if the contractor owes an Amount Due to DADS per the Demand for
Payment Notice (Column L)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 157
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
16 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
II.1 Complete the Attendants Requirements Table below.
Column A: Enter the name(s) of each attendant that provided direct care to the individual during the last six
months of service delivery to the individual.
Review the contractor’s supporting documentation to answer Columns B, C and G.
Column B: Select “Y” if the attendant is at least 18 years of age or, if under 18 years of age, is a high school
graduate or is enrolled in a vocational educational program and has demonstrated competency to perform the
tasks assigned by the supervisor.
Column C: Select “NA” if Family Care. PHC/CAS- Select “Y” if the attendant is not the individual’s legal parent,
foster parent or spouse of a parent (if a minor- under the age of 18 years) or spouse (if an adult- 18 yrs or older)
Column G: For each attendant review F2101. If hired prior to 6/1/2010, select "NA". If the case manager did NOT
designate the attendant as “Do Not Hire,” select “Y”. If listed as “Do Not Hire”, select “N”. If “N” identify the number
of units provided by the attendant and paid by DADS for the last two months of service to the individual. If DADS
paid for services provided by the attendant, complete the Demand for Payment Notice columns A-H from Contract
Monitoring Claims Report, enter the number of verified units provided by the “DNH” attendant in Column J.
A. B. C. G.
Name of Attendant Attendant Attendant Attendant is
Meets the Meets the NOT
Age Relationship designated
Requirement Requirement COLUMNS LEFT BLANK as "Do Not
INTENTIONALLY Hire"
If hired on or
after
6/1/2010
`
II.1 Does each of the individual’s attendants meet the required qualifications?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 158
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
16 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• Select “Y” if ATTENDANT REQUIREMENTS
STANDARD II.for each row, all responses in column B are "Y" and all responses in
columns C and G are “Y” or "NA" (note: column C will only be NA for Family Care)
• Select “N” if for any row, a response in columns B, C or G is “N”
ORIENTATION CHECKLIST
A. B. C. D. E. F. G.
Name of Individual’s Attendant Date of First Service Date of Orientation Orientation Orientation Provided Orientation Elements not
to Individual Conducted in On or Before First Included All included in the
Person with Date of Service to the Required Orientation
Review service delivery documentation for (Review service delivery (Refer to Participation of the Individual Elements (Enter the
the last six months of service delivery within documentation for the documentation of corresponding
Individual or
review period to determine if
the review period and enter the name of first date of service to the
Attendant Attendant Met elements that were
each attendant that provided care to the sample individual was within Orientations Requirements for not addressed)
individual- NA for a Supervisor providing the last six months of conducted during the Orientation Without
personal assistance services service delivery. If the review period)
unlicensed attendant began
Participation of the
providing services to the Individual
sample individual during the
last six months of service
delivery, enter the first date
of service and complete
columns C - G. If the
unlicensed attendant worked
with the sample individual
prior to the last six months
of service delivery, select
“N” and leave columns C –
G blank.)
Last Six Months
Begin: End:
Last Name: First Name; Answer Date:
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 159
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
16 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Attendant Requirements for Orientation without Participation of the Individual (telephone/verbal): Meet the requirements of a Home health Aide*; have six continuous months of experience
delivering attendant care; has been oriented to the individual and the service plan has not changed; or has previously provided services to the individual.
Required elements:
1. Name of the individual for whom the attendant is to provide care
2. Name of the attendant
3. Date of the attendant orientation
4. Orientation conducted in person with the individual or without the participation of the individual
5. How the individual’s condition affects the performance of tasks
6. Tasks to be performed
7. Service schedule
8. Number of hours of service the attendant is to provide
9. Total number of hours the individual is authorized to receive
10. Safety and emergency procedures, including universal precautions
11. Specific situations about which the attendant should notify the contractor (e.g., changes in the individual’s needs; incidents that affect the individual’s condition; hospitalization;
absence or relocation from home; attendant’s inability to work; and suspicion/allegation of abuse, neglect or exploitation of the individual).
12. Signature of the Supervisor who conducted the orientation
13. Signature of the attendant, if present
14. Signature of the individual, if present
*A Home Health Aide must:
o have a minimum of six months experience in delivering personal care tasks in family care, primary home care, personal assistance services, client managed personal attendant
services; or
o be listed on the DADS Nurses Aide Registry with an employable “Active’ status.
II. 3. Was each attendant who began providing care to the individual during the last
six months of service delivery within the review period, oriented, as required, on or
before the first date of service delivery?
• Select “NA” if the individual’s attendant(s) began providing care to the individual prior
to the review period.
• Select “Y” if column B is “Y” and columns D., E and F. are “Y”
• Select “N” if column B is “Y” and column D., E and/or F is “N”.
STANDARD III. PRE-INITIATION ACTIVITIES
OVERARCHING QUESTION Did
the individual's pre-initiation activities occur during the review period?
III.1 • If overarching question III.1 is “N”, select “NA” for Standard III.1-3. Not Calculated in
Continue to Standard IV.1. Score
• If overarching question III.1 is “Y”, verify pre-initiation activities were
completed as required.
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 160
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
16 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Date of Referral Date of Referral Negotiated Date Stamp on Date of
(F2101, item 1) (F2101, item 25) Service Initiation F2101 Notification for
Date Intake
(Routine) (Expedited/Transf (Expedited/Transf (Retroactive)
er) er)
Date of Evaluation:
a. Routine Referral
i) Is the date of the evaluation within 14 calendar days after the date of referral or the date
the contractor received F-2101 as indicated by a date stamp- whichever is later; or
ii) If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the evaluation?
b. Expedited Referral (transfers are reviewed as an expedited referral)
i) Is the date of the evaluation on or before the date negotiated between the case
manager and contractor, which must be less than 14 days after the oral request; or
ii) If a delay, did the contractor notify the case manager of any failure to complete the
evaluation before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i) Is the date of the evaluation on or before the date of notification to DADS for intake?
d. Does the evaluation include the individual’s self-report of the dates and reasons for any
hospitalizations within 3 months prior to the evaluation were addressed?
e. Does the evaluation identify assistance needed to achieve activities of daily living,
including any assistive devices or medical equipment used by the person?
III.1. Did the contractor complete an evaluation of the individual as required?
o Select “Y” if a, b, or c is “Y” and d and e are “Y”
o Select “N” if a, b, or c is “N” and d and/or e is “N”
Date of Initial Service Delivery Plan:
a. Routine Referral
i. Was the initial service delivery plan completed within 14 calendar days after the referral
date or the date the contractor received F- 2101 as indicated by a date stamp- whichever
is later; or
ii. If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the service plan?
b. Expedited Referral (transfers are reviewed as an expedited referral)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 161
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
16 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
i. Is the date of the service delivery plan on or before the date negotiated between the
case manager and contractor, which must be less than 14 days after the oral request; or
ii If a delay, did the contractor notify the case manager of any failure to complete the
service delivery plan before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i. Was the service plan complete prior to the date of notification to DADS for intake?
d. The service plan is agreed upon and was signed by the individual and the contractor
e. The service plan identifies the location of service delivery
f. The service plan identifies the tasks the individual will receive (includes at least one
personal care task, unless FC)
g. The service plan identifies the total weekly hours authorized
h. The service plan identifies the service schedule which includes as necessary, based
on the individual’s needs, certain time periods for the delivery of specified tasks
i. The service plan identifies the frequency of supervisory visits
j. The service plan includes the statement that the contractor is responsible for providing
the tasks allowable in the PHC program (47.41) and agreed to on the service plan.
III. 2. Did the contractor develop an initial service delivery plan as required?
• Select “Y” if a, b, or c is “Y” and d - j are “Y”
• Select “N” if a, b, or c is “N” and/or d – j is “N”
OVERARCHING QUESTION Does
the individual receive family care or did the individual transfer from one
PHC contractor to another PHC, transfer from PHC to CAS or transfer from
Not Calculated in
CAS to PHC during the review period?
III.3 Score
• If overarching question III.3 is “Y”, select “NA” for Standard III.3. Continue
to Standard IV.1.
• If overarching question III.3 is “N”, verify the contractor met the
requirements for the individual’s practitioner’s statement.
Date of Practitioner’s Statement:
a. Routine Referral
i. Did the contractor obtain and submit to DADS a complete practitioner’s statement
within 14 calendar days after the date of referral or the date the contractor received F-
2101 as indicated by a date stamp- whichever is later. Review the contractor's fax, email
or other documentation that verifies the practitioner's statement was submitted to DADS
within the required timeframe; or
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 162
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
16 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. If a delay, II. ATTENDANT REQUIREMENTS
STANDARDdid the contractor document by due date the reason for the delay, an
anticipated date of completion or reason why a completion date cannot be anticipated;
and a description of the contractor’s efforts to obtain the practitioner’s statement?
b. Expedited Referral
i. Did the contractor send a complete practitioner’s statement to DADS within seven (7)
work days after service initiation? Review the contractor's fax, email or other
documentation that verifies the practitioner's statement was submitted to DADS within the
required timeframe.
c. Retroactive
i. Was the practitioner’s statement completed on or before the date of notification to
DADS for intake?
III. 3. Did the contractor meet the requirements for the individual’s practitioner’s
statement?
• Select “Y” if a, b, or c (as applicable) is “Y”
• Select “N” if a, b, or c ( as applicable) is “N”
Potential Billing Error:
If III.3 is “N”, review the Contract Monitoring Claims Report Payment Report for the billing periods within the 12
month review period prior to the date of the practitioner’s statement to determine if DADS paid for services prior to
the date of the practitioner’s statement. If DADS paid for services prior to the date of the practitioner’s statement,
complete Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for Payment. Enter “0” in Column J -
Units Verified for units paid prior to the date of the practitioner’s statement.
STANDARD IV. SERVICE INITIATION
OVERARCHING QUESTION Did
the individual enter services during the review period?
• If overarching question IV.1 is “N”, select “NA” for Standard IV.1. Continue Not Calculated in
IV.1
to Standard V.1. Score
• If overarching question IV.1 is “Y”, verify the contractor met the
requirements for service initiation.
a. Family Care- First Date of Service:
i. Routine Referral-Did services begin within 14 days after the referral date or
within 14 days after the date the contractor date stamped DADS’ authorization
form; or
ii. Transfer- Did services begin on the date negotiated between the case manager
and the contractor?
b. Primary Home Care or Community Attendant Services- First Date of Service:
i. Routine Referral- Did services begin within seven days after the date the
contractor’s receipt of DADS’ Authorization form?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 163
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
16 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. Transfer- Did services begin on the date negotiated between the case manager
STANDARD II. ATTENDANT REQUIREMENTS
and the contractor?
c. If a delay in service initiation did the contractor document the reason for the delay,
either an anticipated date of initiation or specific reasons why the contractor cannot
anticipate a date and a description of the contractor’s efforts to initiate services?
d. Did the contractor send notice of service initiation to the case manager within 14 days
after initiating services?
IV. 1. Were services initiated as required?
• Select “Y” if a is “Y”, b is “NA”, c is “NA” and d is “Y”
• Select “Y” if a is “NA”, b is “Y”, c is “NA” and d is “Y”
• Select “Y” if a or b is “N”, c is “Y” and d is “Y”
• Select “N” if a or b is “N”, c is “N” and d is “Y”
• Select “N” if d is “N”
VI. SERVICE DELIVERY
Complete UNITS OF SERVICE Tables for the last six months of service within the review
VI.1
period then answer VI.1.
a. Priority status- Does the number of documented hours/units of service equal the
number of authorized hours/units; or
Non-Priority status- Does the number of documented hours/units of service indicate that
there were no service interruptions exceeding 14 consecutive days?
b. If a is “N” was the reason for the failure to provide all service hours one of the
following:
• the individual’s revised service plan identified a need for an ongoing decrease in
hours;
• the individual requested that services not be provided;
• the individual requested fewer hours of service than reflected in the service
schedule;
• the individual requested that a specific attendant not provide services;
• the individual was not at home when the service was scheduled;
• services were not delivered for other reasons beyond the control of the provider
agency; or
• services were suspended.
- The individual temporarily or permanently left the contracted services delivery area;
- The individual moved to a location where services could not be provided under the PHC program;
- The individual died;
- The individual was admitted to an institution (hospital, nursing facility, state school, state hospital, or
ICF-MR facility);
- The individual requested that services end;
- DADS denied the individual’s Medicaid eligibility (not applicable to FC);
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 164
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
16 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
- The individual or someone in the individual’s home exhibited reckless behavior, which may have
STANDARD II. ATTENDANT REQUIREMENTS
resulted in imminent danger to the health and safety of the individual, the attendant, or another person;
- The individual or someone else in the individual’s home engaged in discrimination against a provider
agency or DADS employee in violation of applicable law;
- The individual refused services for more than 30 consecutive days.
VI. 1. Were personal assistance service hours provided in accordance with the
individual’s service plans or as required?
• Select “Y” if a is “Y” or a is “N” and b is “Y”
• Select “N” if a and b are “N”
STANDARD VII. SERVICE PLAN CHANGE
• Review the individual’s record for the 12 month review period to determine if a service plan change
was identified and requested.
VII.1.
• Select “NA” if a service plan change was not identified/requested. Continue to Standard VIII.
• If a service plan change was identified/requested, complete the table below.
Date(s) of /identified Date of notification to Effective Date Date of Date(s) of identified Date of revised service
need/request for an the contractor OR (F2101, item 4) Implementation need/request for a plan
increase in service case manager (Service Delivery decrease in service
hours or change that (F2067 or equivalent) Documentation) hours
results in no delivery
of personal care tasks
a. Immediate increase in hours:
i. If requested by the contractor, did the contractor’s documentation include:
• evidence that the contractor discussed the reason for the request of immediate
increase in hours with the case manager? NA
• the date the contractor received approval from the case manager? NA
• the name of the case manager who approved the change? NA
• the effective date of change, and NA
• the number of hours authorized? NA
ii. Did the contractor implement the service plan change on the date negotiated with the
NA
case manager? NA
b. Increase in service hours or no delivery of personal care tasks:
i. If requested by the contractor, was the case manager notified in writing within seven
days from the date of request/identification of need; and NA
ii. Did the notification include:
• date the provider agency learned of the need for the change;
NA
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 165
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
16 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• reason II. ATTENDANT REQUIREMENTS
STANDARD for the change;
NA
• type of change (including the number of service hours) and:
• signature and date of the provider agency representative?
iii. For any increase in service hours requested by the contractor, individual or case manager, did the contractor
implement the change within the required timeframe?
• Was the service plan change implemented on the Begin Date (F2101, item 4) or
five days after the contractor’s date stamp on F2101, whichever is later; or NA
• If delayed, did the contractor document, by the next working day, the failure to
implement the service plan change on the effective date to include the reason and NA
new implementation date? NA
c. Decrease in service hours:
i. Did the contractor develop a new service plan within 21 days from the date of the
individual’s request or identification of need for a service plan change? NA
VII.1. If a service plan change for PAS was identified or requested, did the contractor
meet all requirements?
• If the contractor requested an increase in hours or no delivery of personal care tasks -
select “Y” if a. i-ii or b. i-iii are “Y” NA
• If the case manager requested an increase in hours or no delivery of personal care
tasks - select “Y” if a. ii or b. iii are “Y”
• Select “Y” if a decrease in service hours was requested/identified and c. is “Y”
STANDARD IX. BILLING
Compare the Units of Service tables to the Contract Monitoring Claims Report for the last six months of
service delivery within the review period.
OVERARCHING QUESTION For
the last six months of service delivery to the individual within the review
period,:
i. Were the number of units documented equal to or greater than the
number of units paid? Y or N
ii. Were the number of units paid equal to or less than the number of
IX.1a authorized units? (If No, did the increase meet the criteria of a temporary Not Calculated in
increase)? Y or N Score
• If overarching question IX.1a.i and IX.1a.ii are "Y", mark IX.1a"Y" and skip
overarching question IX.1b and mark Standard IX.1 "Y".
• If either overarching question IX.1a.i or IX.1a.ii is“N”, mark IX.1a "N" and
continue to overarching question IX.1b.
OVERARCHING QUESTION Did
the contractor provide evidence that the contractor negative billed the
over-billed amount due to DADS prior to the date of the Entrance
Not Calculated in
Conference?
IX.1b Score
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 166
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
16 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
IX.1b
• If overarching question IX.1b is “Y”, mark
STANDARD II. ATTENDANT REQUIREMENTS Standard IX.1 “Y”.
• If overarching question IX.1b is “N”, mark Standard IX.1 “N”. Complete
Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for
Payment.
IX. 1. DADS did not identify a financial error?
• Select “Y”, if the contractor does not owe an Amount Due to DADS per the Demand
for Payment Notice (Column L)
• Select “Y”, if the contractor provides evidence that the contractor negative billed the
amount due to DADS prior to the date of the entrance Conference.
• Select “N”, if the contractor owes an Amount Due to DADS per the Demand for
Payment Notice (Column L)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 167
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
17 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
II.1 Complete the Attendants Requirements Table below.
Column A: Enter the name(s) of each attendant that provided direct care to the individual during the last six
months of service delivery to the individual.
Review the contractor’s supporting documentation to answer Columns B, C and G.
Column B: Select “Y” if the attendant is at least 18 years of age or, if under 18 years of age, is a high school
graduate or is enrolled in a vocational educational program and has demonstrated competency to perform the
tasks assigned by the supervisor.
Column C: Select “NA” if Family Care. PHC/CAS- Select “Y” if the attendant is not the individual’s legal parent,
foster parent or spouse of a parent (if a minor- under the age of 18 years) or spouse (if an adult- 18 yrs or older)
Column G: For each attendant review F2101. If hired prior to 6/1/2010, select "NA". If the case manager did NOT
designate the attendant as “Do Not Hire,” select “Y”. If listed as “Do Not Hire”, select “N”. If “N” identify the number
of units provided by the attendant and paid by DADS for the last two months of service to the individual. If DADS
paid for services provided by the attendant, complete the Demand for Payment Notice columns A-H from Contract
Monitoring Claims Report, enter the number of verified units provided by the “DNH” attendant in Column J.
A. B. C. G.
Name of Attendant Attendant Attendant Attendant is
Meets the Meets the NOT
Age Relationship designated
Requirement Requirement COLUMNS LEFT BLANK as "Do Not
INTENTIONALLY Hire"
If hired on or
after
6/1/2010
`
II.1 Does each of the individual’s attendants meet the required qualifications?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 168
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
17 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• Select “Y” if ATTENDANT REQUIREMENTS
STANDARD II.for each row, all responses in column B are "Y" and all responses in
columns C and G are “Y” or "NA" (note: column C will only be NA for Family Care)
• Select “N” if for any row, a response in columns B, C or G is “N”
ORIENTATION CHECKLIST
A. B. C. D. E. F. G.
Name of Individual’s Attendant Date of First Service Date of Orientation Orientation Orientation Provided Orientation Elements not
to Individual Conducted in On or Before First Included All included in the
Person with Date of Service to the Required Orientation
Review service delivery documentation for (Review service delivery (Refer to Participation of the Individual Elements (Enter the
the last six months of service delivery within documentation for the documentation of corresponding
Individual or
review period to determine if
the review period and enter the name of first date of service to the
Attendant Attendant Met elements that were
each attendant that provided care to the sample individual was within Orientations Requirements for not addressed)
individual- NA for a Supervisor providing the last six months of conducted during the Orientation Without
personal assistance services service delivery. If the review period)
unlicensed attendant began
Participation of the
providing services to the Individual
sample individual during the
last six months of service
delivery, enter the first date
of service and complete
columns C - G. If the
unlicensed attendant worked
with the sample individual
prior to the last six months
of service delivery, select
“N” and leave columns C –
G blank.)
Last Six Months
Begin: End:
Last Name: First Name; Answer Date:
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 169
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
17 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Attendant Requirements for Orientation without Participation of the Individual (telephone/verbal): Meet the requirements of a Home health Aide*; have six continuous months of experience
delivering attendant care; has been oriented to the individual and the service plan has not changed; or has previously provided services to the individual.
Required elements:
1. Name of the individual for whom the attendant is to provide care
2. Name of the attendant
3. Date of the attendant orientation
4. Orientation conducted in person with the individual or without the participation of the individual
5. How the individual’s condition affects the performance of tasks
6. Tasks to be performed
7. Service schedule
8. Number of hours of service the attendant is to provide
9. Total number of hours the individual is authorized to receive
10. Safety and emergency procedures, including universal precautions
11. Specific situations about which the attendant should notify the contractor (e.g., changes in the individual’s needs; incidents that affect the individual’s condition; hospitalization;
absence or relocation from home; attendant’s inability to work; and suspicion/allegation of abuse, neglect or exploitation of the individual).
12. Signature of the Supervisor who conducted the orientation
13. Signature of the attendant, if present
14. Signature of the individual, if present
*A Home Health Aide must:
o have a minimum of six months experience in delivering personal care tasks in family care, primary home care, personal assistance services, client managed personal attendant
services; or
o be listed on the DADS Nurses Aide Registry with an employable “Active’ status.
II. 3. Was each attendant who began providing care to the individual during the last
six months of service delivery within the review period, oriented, as required, on or
before the first date of service delivery?
• Select “NA” if the individual’s attendant(s) began providing care to the individual prior
to the review period.
• Select “Y” if column B is “Y” and columns D., E and F. are “Y”
• Select “N” if column B is “Y” and column D., E and/or F is “N”.
STANDARD III. PRE-INITIATION ACTIVITIES
OVERARCHING QUESTION Did
the individual's pre-initiation activities occur during the review period?
III.1 • If overarching question III.1 is “N”, select “NA” for Standard III.1-3. Not Calculated in
Continue to Standard IV.1. Score
• If overarching question III.1 is “Y”, verify pre-initiation activities were
completed as required.
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 170
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
17 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Date of Referral Date of Referral Negotiated Date Stamp on Date of
(F2101, item 1) (F2101, item 25) Service Initiation F2101 Notification for
Date Intake
(Routine) (Expedited/Transf (Expedited/Transf (Retroactive)
er) er)
Date of Evaluation:
a. Routine Referral
i) Is the date of the evaluation within 14 calendar days after the date of referral or the date
the contractor received F-2101 as indicated by a date stamp- whichever is later; or
ii) If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the evaluation?
b. Expedited Referral (transfers are reviewed as an expedited referral)
i) Is the date of the evaluation on or before the date negotiated between the case
manager and contractor, which must be less than 14 days after the oral request; or
ii) If a delay, did the contractor notify the case manager of any failure to complete the
evaluation before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i) Is the date of the evaluation on or before the date of notification to DADS for intake?
d. Does the evaluation include the individual’s self-report of the dates and reasons for any
hospitalizations within 3 months prior to the evaluation were addressed?
e. Does the evaluation identify assistance needed to achieve activities of daily living,
including any assistive devices or medical equipment used by the person?
III.1. Did the contractor complete an evaluation of the individual as required?
o Select “Y” if a, b, or c is “Y” and d and e are “Y”
o Select “N” if a, b, or c is “N” and d and/or e is “N”
Date of Initial Service Delivery Plan:
a. Routine Referral
i. Was the initial service delivery plan completed within 14 calendar days after the referral
date or the date the contractor received F- 2101 as indicated by a date stamp- whichever
is later; or
ii. If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the service plan?
b. Expedited Referral (transfers are reviewed as an expedited referral)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 171
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
17 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
i. Is the date of the service delivery plan on or before the date negotiated between the
case manager and contractor, which must be less than 14 days after the oral request; or
ii If a delay, did the contractor notify the case manager of any failure to complete the
service delivery plan before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i. Was the service plan complete prior to the date of notification to DADS for intake?
d. The service plan is agreed upon and was signed by the individual and the contractor
e. The service plan identifies the location of service delivery
f. The service plan identifies the tasks the individual will receive (includes at least one
personal care task, unless FC)
g. The service plan identifies the total weekly hours authorized
h. The service plan identifies the service schedule which includes as necessary, based
on the individual’s needs, certain time periods for the delivery of specified tasks
i. The service plan identifies the frequency of supervisory visits
j. The service plan includes the statement that the contractor is responsible for providing
the tasks allowable in the PHC program (47.41) and agreed to on the service plan.
III. 2. Did the contractor develop an initial service delivery plan as required?
• Select “Y” if a, b, or c is “Y” and d - j are “Y”
• Select “N” if a, b, or c is “N” and/or d – j is “N”
OVERARCHING QUESTION Does
the individual receive family care or did the individual transfer from one
PHC contractor to another PHC, transfer from PHC to CAS or transfer from
Not Calculated in
CAS to PHC during the review period?
III.3 Score
• If overarching question III.3 is “Y”, select “NA” for Standard III.3. Continue
to Standard IV.1.
• If overarching question III.3 is “N”, verify the contractor met the
requirements for the individual’s practitioner’s statement.
Date of Practitioner’s Statement:
a. Routine Referral
i. Did the contractor obtain and submit to DADS a complete practitioner’s statement
within 14 calendar days after the date of referral or the date the contractor received F-
2101 as indicated by a date stamp- whichever is later. Review the contractor's fax, email
or other documentation that verifies the practitioner's statement was submitted to DADS
within the required timeframe; or
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 172
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
17 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. If a delay, II. ATTENDANT REQUIREMENTS
STANDARDdid the contractor document by due date the reason for the delay, an
anticipated date of completion or reason why a completion date cannot be anticipated;
and a description of the contractor’s efforts to obtain the practitioner’s statement?
b. Expedited Referral
i. Did the contractor send a complete practitioner’s statement to DADS within seven (7)
work days after service initiation? Review the contractor's fax, email or other
documentation that verifies the practitioner's statement was submitted to DADS within the
required timeframe.
c. Retroactive
i. Was the practitioner’s statement completed on or before the date of notification to
DADS for intake?
III. 3. Did the contractor meet the requirements for the individual’s practitioner’s
statement?
• Select “Y” if a, b, or c (as applicable) is “Y”
• Select “N” if a, b, or c ( as applicable) is “N”
Potential Billing Error:
If III.3 is “N”, review the Contract Monitoring Claims Report Payment Report for the billing periods within the 12
month review period prior to the date of the practitioner’s statement to determine if DADS paid for services prior to
the date of the practitioner’s statement. If DADS paid for services prior to the date of the practitioner’s statement,
complete Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for Payment. Enter “0” in Column J -
Units Verified for units paid prior to the date of the practitioner’s statement.
STANDARD IV. SERVICE INITIATION
OVERARCHING QUESTION Did
the individual enter services during the review period?
• If overarching question IV.1 is “N”, select “NA” for Standard IV.1. Continue Not Calculated in
IV.1
to Standard V.1. Score
• If overarching question IV.1 is “Y”, verify the contractor met the
requirements for service initiation.
a. Family Care- First Date of Service:
i. Routine Referral-Did services begin within 14 days after the referral date or
within 14 days after the date the contractor date stamped DADS’ authorization
form; or
ii. Transfer- Did services begin on the date negotiated between the case manager
and the contractor?
b. Primary Home Care or Community Attendant Services- First Date of Service:
i. Routine Referral- Did services begin within seven days after the date the
contractor’s receipt of DADS’ Authorization form?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 173
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
17 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. Transfer- Did services begin on the date negotiated between the case manager
STANDARD II. ATTENDANT REQUIREMENTS
and the contractor?
c. If a delay in service initiation did the contractor document the reason for the delay,
either an anticipated date of initiation or specific reasons why the contractor cannot
anticipate a date and a description of the contractor’s efforts to initiate services?
d. Did the contractor send notice of service initiation to the case manager within 14 days
after initiating services?
IV. 1. Were services initiated as required?
• Select “Y” if a is “Y”, b is “NA”, c is “NA” and d is “Y”
• Select “Y” if a is “NA”, b is “Y”, c is “NA” and d is “Y”
• Select “Y” if a or b is “N”, c is “Y” and d is “Y”
• Select “N” if a or b is “N”, c is “N” and d is “Y”
• Select “N” if d is “N”
VI. SERVICE DELIVERY
Complete UNITS OF SERVICE Tables for the last six months of service within the review
VI.1
period then answer VI.1.
a. Priority status- Does the number of documented hours/units of service equal the
number of authorized hours/units; or
Non-Priority status- Does the number of documented hours/units of service indicate that
there were no service interruptions exceeding 14 consecutive days?
b. If a is “N” was the reason for the failure to provide all service hours one of the
following:
• the individual’s revised service plan identified a need for an ongoing decrease in
hours;
• the individual requested that services not be provided;
• the individual requested fewer hours of service than reflected in the service
schedule;
• the individual requested that a specific attendant not provide services;
• the individual was not at home when the service was scheduled;
• services were not delivered for other reasons beyond the control of the provider
agency; or
• services were suspended.
- The individual temporarily or permanently left the contracted services delivery area;
- The individual moved to a location where services could not be provided under the PHC program;
- The individual died;
- The individual was admitted to an institution (hospital, nursing facility, state school, state hospital, or
ICF-MR facility);
- The individual requested that services end;
- DADS denied the individual’s Medicaid eligibility (not applicable to FC);
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 174
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
17 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
- The individual or someone in the individual’s home exhibited reckless behavior, which may have
STANDARD II. ATTENDANT REQUIREMENTS
resulted in imminent danger to the health and safety of the individual, the attendant, or another person;
- The individual or someone else in the individual’s home engaged in discrimination against a provider
agency or DADS employee in violation of applicable law;
- The individual refused services for more than 30 consecutive days.
VI. 1. Were personal assistance service hours provided in accordance with the
individual’s service plans or as required?
• Select “Y” if a is “Y” or a is “N” and b is “Y”
• Select “N” if a and b are “N”
STANDARD VII. SERVICE PLAN CHANGE
• Review the individual’s record for the 12 month review period to determine if a service plan change
was identified and requested.
VII.1.
• Select “NA” if a service plan change was not identified/requested. Continue to Standard VIII.
• If a service plan change was identified/requested, complete the table below.
Date(s) of /identified Date of notification to Effective Date Date of Date(s) of identified Date of revised service
need/request for an the contractor OR (F2101, item 4) Implementation need/request for a plan
increase in service case manager (Service Delivery decrease in service
hours or change that (F2067 or equivalent) Documentation) hours
results in no delivery
of personal care tasks
a. Immediate increase in hours:
i. If requested by the contractor, did the contractor’s documentation include:
• evidence that the contractor discussed the reason for the request of immediate
increase in hours with the case manager? NA
• the date the contractor received approval from the case manager? NA
• the name of the case manager who approved the change? NA
• the effective date of change, and NA
• the number of hours authorized? NA
ii. Did the contractor implement the service plan change on the date negotiated with the
NA
case manager? NA
b. Increase in service hours or no delivery of personal care tasks:
i. If requested by the contractor, was the case manager notified in writing within seven
days from the date of request/identification of need; and NA
ii. Did the notification include:
• date the provider agency learned of the need for the change;
NA
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 175
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
17 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• reason II. ATTENDANT REQUIREMENTS
STANDARD for the change;
NA
• type of change (including the number of service hours) and:
• signature and date of the provider agency representative?
iii. For any increase in service hours requested by the contractor, individual or case manager, did the contractor
implement the change within the required timeframe?
• Was the service plan change implemented on the Begin Date (F2101, item 4) or
five days after the contractor’s date stamp on F2101, whichever is later; or NA
• If delayed, did the contractor document, by the next working day, the failure to
implement the service plan change on the effective date to include the reason and NA
new implementation date? NA
c. Decrease in service hours:
i. Did the contractor develop a new service plan within 21 days from the date of the
individual’s request or identification of need for a service plan change? NA
VII.1. If a service plan change for PAS was identified or requested, did the contractor
meet all requirements?
• If the contractor requested an increase in hours or no delivery of personal care tasks -
select “Y” if a. i-ii or b. i-iii are “Y” NA
• If the case manager requested an increase in hours or no delivery of personal care
tasks - select “Y” if a. ii or b. iii are “Y”
• Select “Y” if a decrease in service hours was requested/identified and c. is “Y”
STANDARD IX. BILLING
Compare the Units of Service tables to the Contract Monitoring Claims Report for the last six months of
service delivery within the review period.
OVERARCHING QUESTION For
the last six months of service delivery to the individual within the review
period,:
i. Were the number of units documented equal to or greater than the
number of units paid? Y or N
ii. Were the number of units paid equal to or less than the number of
IX.1a authorized units? (If No, did the increase meet the criteria of a temporary Not Calculated in
increase)? Y or N Score
• If overarching question IX.1a.i and IX.1a.ii are "Y", mark IX.1a"Y" and skip
overarching question IX.1b and mark Standard IX.1 "Y".
• If either overarching question IX.1a.i or IX.1a.ii is“N”, mark IX.1a "N" and
continue to overarching question IX.1b.
OVERARCHING QUESTION Did
the contractor provide evidence that the contractor negative billed the
over-billed amount due to DADS prior to the date of the Entrance
Not Calculated in
Conference?
IX.1b Score
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 176
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
17 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
IX.1b
• If overarching question IX.1b is “Y”, mark
STANDARD II. ATTENDANT REQUIREMENTS Standard IX.1 “Y”.
• If overarching question IX.1b is “N”, mark Standard IX.1 “N”. Complete
Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for
Payment.
IX. 1. DADS did not identify a financial error?
• Select “Y”, if the contractor does not owe an Amount Due to DADS per the Demand
for Payment Notice (Column L)
• Select “Y”, if the contractor provides evidence that the contractor negative billed the
amount due to DADS prior to the date of the entrance Conference.
• Select “N”, if the contractor owes an Amount Due to DADS per the Demand for
Payment Notice (Column L)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 177
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
18 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
II.1 Complete the Attendants Requirements Table below.
Column A: Enter the name(s) of each attendant that provided direct care to the individual during the last six
months of service delivery to the individual.
Review the contractor’s supporting documentation to answer Columns B, C and G.
Column B: Select “Y” if the attendant is at least 18 years of age or, if under 18 years of age, is a high school
graduate or is enrolled in a vocational educational program and has demonstrated competency to perform the
tasks assigned by the supervisor.
Column C: Select “NA” if Family Care. PHC/CAS- Select “Y” if the attendant is not the individual’s legal parent,
foster parent or spouse of a parent (if a minor- under the age of 18 years) or spouse (if an adult- 18 yrs or older)
Column G: For each attendant review F2101. If hired prior to 6/1/2010, select "NA". If the case manager did NOT
designate the attendant as “Do Not Hire,” select “Y”. If listed as “Do Not Hire”, select “N”. If “N” identify the number
of units provided by the attendant and paid by DADS for the last two months of service to the individual. If DADS
paid for services provided by the attendant, complete the Demand for Payment Notice columns A-H from Contract
Monitoring Claims Report, enter the number of verified units provided by the “DNH” attendant in Column J.
A. B. C. G.
Name of Attendant Attendant Attendant Attendant is
Meets the Meets the NOT
Age Relationship designated
Requirement Requirement COLUMNS LEFT BLANK as "Do Not
INTENTIONALLY Hire"
If hired on or
after
6/1/2010
`
II.1 Does each of the individual’s attendants meet the required qualifications?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 178
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
18 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• Select “Y” if ATTENDANT REQUIREMENTS
STANDARD II.for each row, all responses in column B are "Y" and all responses in
columns C and G are “Y” or "NA" (note: column C will only be NA for Family Care)
• Select “N” if for any row, a response in columns B, C or G is “N”
ORIENTATION CHECKLIST
A. B. C. D. E. F. G.
Name of Individual’s Attendant Date of First Service Date of Orientation Orientation Orientation Provided Orientation Elements not
to Individual Conducted in On or Before First Included All included in the
Person with Date of Service to the Required Orientation
Review service delivery documentation for (Review service delivery (Refer to Participation of the Individual Elements (Enter the
the last six months of service delivery within documentation for the documentation of corresponding
Individual or
review period to determine if
the review period and enter the name of first date of service to the
Attendant Attendant Met elements that were
each attendant that provided care to the sample individual was within Orientations Requirements for not addressed)
individual- NA for a Supervisor providing the last six months of conducted during the Orientation Without
personal assistance services service delivery. If the review period)
unlicensed attendant began
Participation of the
providing services to the Individual
sample individual during the
last six months of service
delivery, enter the first date
of service and complete
columns C - G. If the
unlicensed attendant worked
with the sample individual
prior to the last six months
of service delivery, select
“N” and leave columns C –
G blank.)
Last Six Months
Begin: End:
Last Name: First Name; Answer Date:
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 179
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
18 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Attendant Requirements for Orientation without Participation of the Individual (telephone/verbal): Meet the requirements of a Home health Aide*; have six continuous months of experience
delivering attendant care; has been oriented to the individual and the service plan has not changed; or has previously provided services to the individual.
Required elements:
1. Name of the individual for whom the attendant is to provide care
2. Name of the attendant
3. Date of the attendant orientation
4. Orientation conducted in person with the individual or without the participation of the individual
5. How the individual’s condition affects the performance of tasks
6. Tasks to be performed
7. Service schedule
8. Number of hours of service the attendant is to provide
9. Total number of hours the individual is authorized to receive
10. Safety and emergency procedures, including universal precautions
11. Specific situations about which the attendant should notify the contractor (e.g., changes in the individual’s needs; incidents that affect the individual’s condition; hospitalization;
absence or relocation from home; attendant’s inability to work; and suspicion/allegation of abuse, neglect or exploitation of the individual).
12. Signature of the Supervisor who conducted the orientation
13. Signature of the attendant, if present
14. Signature of the individual, if present
*A Home Health Aide must:
o have a minimum of six months experience in delivering personal care tasks in family care, primary home care, personal assistance services, client managed personal attendant
services; or
o be listed on the DADS Nurses Aide Registry with an employable “Active’ status.
II. 3. Was each attendant who began providing care to the individual during the last
six months of service delivery within the review period, oriented, as required, on or
before the first date of service delivery?
• Select “NA” if the individual’s attendant(s) began providing care to the individual prior
to the review period.
• Select “Y” if column B is “Y” and columns D., E and F. are “Y”
• Select “N” if column B is “Y” and column D., E and/or F is “N”.
STANDARD III. PRE-INITIATION ACTIVITIES
OVERARCHING QUESTION Did
the individual's pre-initiation activities occur during the review period?
III.1 • If overarching question III.1 is “N”, select “NA” for Standard III.1-3. Not Calculated in
Continue to Standard IV.1. Score
• If overarching question III.1 is “Y”, verify pre-initiation activities were
completed as required.
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 180
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
18 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Date of Referral Date of Referral Negotiated Date Stamp on Date of
(F2101, item 1) (F2101, item 25) Service Initiation F2101 Notification for
Date Intake
(Routine) (Expedited/Transf (Expedited/Transf (Retroactive)
er) er)
Date of Evaluation:
a. Routine Referral
i) Is the date of the evaluation within 14 calendar days after the date of referral or the date
the contractor received F-2101 as indicated by a date stamp- whichever is later; or
ii) If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the evaluation?
b. Expedited Referral (transfers are reviewed as an expedited referral)
i) Is the date of the evaluation on or before the date negotiated between the case
manager and contractor, which must be less than 14 days after the oral request; or
ii) If a delay, did the contractor notify the case manager of any failure to complete the
evaluation before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i) Is the date of the evaluation on or before the date of notification to DADS for intake?
d. Does the evaluation include the individual’s self-report of the dates and reasons for any
hospitalizations within 3 months prior to the evaluation were addressed?
e. Does the evaluation identify assistance needed to achieve activities of daily living,
including any assistive devices or medical equipment used by the person?
III.1. Did the contractor complete an evaluation of the individual as required?
o Select “Y” if a, b, or c is “Y” and d and e are “Y”
o Select “N” if a, b, or c is “N” and d and/or e is “N”
Date of Initial Service Delivery Plan:
a. Routine Referral
i. Was the initial service delivery plan completed within 14 calendar days after the referral
date or the date the contractor received F- 2101 as indicated by a date stamp- whichever
is later; or
ii. If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the service plan?
b. Expedited Referral (transfers are reviewed as an expedited referral)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 181
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
18 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
i. Is the date of the service delivery plan on or before the date negotiated between the
case manager and contractor, which must be less than 14 days after the oral request; or
ii If a delay, did the contractor notify the case manager of any failure to complete the
service delivery plan before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i. Was the service plan complete prior to the date of notification to DADS for intake?
d. The service plan is agreed upon and was signed by the individual and the contractor
e. The service plan identifies the location of service delivery
f. The service plan identifies the tasks the individual will receive (includes at least one
personal care task, unless FC)
g. The service plan identifies the total weekly hours authorized
h. The service plan identifies the service schedule which includes as necessary, based
on the individual’s needs, certain time periods for the delivery of specified tasks
i. The service plan identifies the frequency of supervisory visits
j. The service plan includes the statement that the contractor is responsible for providing
the tasks allowable in the PHC program (47.41) and agreed to on the service plan.
III. 2. Did the contractor develop an initial service delivery plan as required?
• Select “Y” if a, b, or c is “Y” and d - j are “Y”
• Select “N” if a, b, or c is “N” and/or d – j is “N”
OVERARCHING QUESTION Does
the individual receive family care or did the individual transfer from one
PHC contractor to another PHC, transfer from PHC to CAS or transfer from
Not Calculated in
CAS to PHC during the review period?
III.3 Score
• If overarching question III.3 is “Y”, select “NA” for Standard III.3. Continue
to Standard IV.1.
• If overarching question III.3 is “N”, verify the contractor met the
requirements for the individual’s practitioner’s statement.
Date of Practitioner’s Statement:
a. Routine Referral
i. Did the contractor obtain and submit to DADS a complete practitioner’s statement
within 14 calendar days after the date of referral or the date the contractor received F-
2101 as indicated by a date stamp- whichever is later. Review the contractor's fax, email
or other documentation that verifies the practitioner's statement was submitted to DADS
within the required timeframe; or
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 182
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
18 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. If a delay, II. ATTENDANT REQUIREMENTS
STANDARDdid the contractor document by due date the reason for the delay, an
anticipated date of completion or reason why a completion date cannot be anticipated;
and a description of the contractor’s efforts to obtain the practitioner’s statement?
b. Expedited Referral
i. Did the contractor send a complete practitioner’s statement to DADS within seven (7)
work days after service initiation? Review the contractor's fax, email or other
documentation that verifies the practitioner's statement was submitted to DADS within the
required timeframe.
c. Retroactive
i. Was the practitioner’s statement completed on or before the date of notification to
DADS for intake?
III. 3. Did the contractor meet the requirements for the individual’s practitioner’s
statement?
• Select “Y” if a, b, or c (as applicable) is “Y”
• Select “N” if a, b, or c ( as applicable) is “N”
Potential Billing Error:
If III.3 is “N”, review the Contract Monitoring Claims Report Payment Report for the billing periods within the 12
month review period prior to the date of the practitioner’s statement to determine if DADS paid for services prior to
the date of the practitioner’s statement. If DADS paid for services prior to the date of the practitioner’s statement,
complete Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for Payment. Enter “0” in Column J -
Units Verified for units paid prior to the date of the practitioner’s statement.
STANDARD IV. SERVICE INITIATION
OVERARCHING QUESTION Did
the individual enter services during the review period?
• If overarching question IV.1 is “N”, select “NA” for Standard IV.1. Continue Not Calculated in
IV.1
to Standard V.1. Score
• If overarching question IV.1 is “Y”, verify the contractor met the
requirements for service initiation.
a. Family Care- First Date of Service:
i. Routine Referral-Did services begin within 14 days after the referral date or
within 14 days after the date the contractor date stamped DADS’ authorization
form; or
ii. Transfer- Did services begin on the date negotiated between the case manager
and the contractor?
b. Primary Home Care or Community Attendant Services- First Date of Service:
i. Routine Referral- Did services begin within seven days after the date the
contractor’s receipt of DADS’ Authorization form?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 183
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
18 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. Transfer- Did services begin on the date negotiated between the case manager
STANDARD II. ATTENDANT REQUIREMENTS
and the contractor?
c. If a delay in service initiation did the contractor document the reason for the delay,
either an anticipated date of initiation or specific reasons why the contractor cannot
anticipate a date and a description of the contractor’s efforts to initiate services?
d. Did the contractor send notice of service initiation to the case manager within 14 days
after initiating services?
IV. 1. Were services initiated as required?
• Select “Y” if a is “Y”, b is “NA”, c is “NA” and d is “Y”
• Select “Y” if a is “NA”, b is “Y”, c is “NA” and d is “Y”
• Select “Y” if a or b is “N”, c is “Y” and d is “Y”
• Select “N” if a or b is “N”, c is “N” and d is “Y”
• Select “N” if d is “N”
VI. SERVICE DELIVERY
Complete UNITS OF SERVICE Tables for the last six months of service within the review
VI.1
period then answer VI.1.
a. Priority status- Does the number of documented hours/units of service equal the
number of authorized hours/units; or
Non-Priority status- Does the number of documented hours/units of service indicate that
there were no service interruptions exceeding 14 consecutive days?
b. If a is “N” was the reason for the failure to provide all service hours one of the
following:
• the individual’s revised service plan identified a need for an ongoing decrease in
hours;
• the individual requested that services not be provided;
• the individual requested fewer hours of service than reflected in the service
schedule;
• the individual requested that a specific attendant not provide services;
• the individual was not at home when the service was scheduled;
• services were not delivered for other reasons beyond the control of the provider
agency; or
• services were suspended.
- The individual temporarily or permanently left the contracted services delivery area;
- The individual moved to a location where services could not be provided under the PHC program;
- The individual died;
- The individual was admitted to an institution (hospital, nursing facility, state school, state hospital, or
ICF-MR facility);
- The individual requested that services end;
- DADS denied the individual’s Medicaid eligibility (not applicable to FC);
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 184
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
18 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
- The individual or someone in the individual’s home exhibited reckless behavior, which may have
STANDARD II. ATTENDANT REQUIREMENTS
resulted in imminent danger to the health and safety of the individual, the attendant, or another person;
- The individual or someone else in the individual’s home engaged in discrimination against a provider
agency or DADS employee in violation of applicable law;
- The individual refused services for more than 30 consecutive days.
VI. 1. Were personal assistance service hours provided in accordance with the
individual’s service plans or as required?
• Select “Y” if a is “Y” or a is “N” and b is “Y”
• Select “N” if a and b are “N”
STANDARD VII. SERVICE PLAN CHANGE
• Review the individual’s record for the 12 month review period to determine if a service plan change
was identified and requested.
VII.1.
• Select “NA” if a service plan change was not identified/requested. Continue to Standard VIII.
• If a service plan change was identified/requested, complete the table below.
Date(s) of /identified Date of notification to Effective Date Date of Date(s) of identified Date of revised service
need/request for an the contractor OR (F2101, item 4) Implementation need/request for a plan
increase in service case manager (Service Delivery decrease in service
hours or change that (F2067 or equivalent) Documentation) hours
results in no delivery
of personal care tasks
a. Immediate increase in hours:
i. If requested by the contractor, did the contractor’s documentation include:
• evidence that the contractor discussed the reason for the request of immediate
increase in hours with the case manager? NA
• the date the contractor received approval from the case manager? NA
• the name of the case manager who approved the change? NA
• the effective date of change, and NA
• the number of hours authorized? NA
ii. Did the contractor implement the service plan change on the date negotiated with the
NA
case manager? NA
b. Increase in service hours or no delivery of personal care tasks:
i. If requested by the contractor, was the case manager notified in writing within seven
days from the date of request/identification of need; and NA
ii. Did the notification include:
• date the provider agency learned of the need for the change;
NA
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 185
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
18 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• reason II. ATTENDANT REQUIREMENTS
STANDARD for the change;
NA
• type of change (including the number of service hours) and:
• signature and date of the provider agency representative?
iii. For any increase in service hours requested by the contractor, individual or case manager, did the contractor
implement the change within the required timeframe?
• Was the service plan change implemented on the Begin Date (F2101, item 4) or
five days after the contractor’s date stamp on F2101, whichever is later; or NA
• If delayed, did the contractor document, by the next working day, the failure to
implement the service plan change on the effective date to include the reason and NA
new implementation date? NA
c. Decrease in service hours:
i. Did the contractor develop a new service plan within 21 days from the date of the
individual’s request or identification of need for a service plan change? NA
VII.1. If a service plan change for PAS was identified or requested, did the contractor
meet all requirements?
• If the contractor requested an increase in hours or no delivery of personal care tasks -
select “Y” if a. i-ii or b. i-iii are “Y” NA
• If the case manager requested an increase in hours or no delivery of personal care
tasks - select “Y” if a. ii or b. iii are “Y”
• Select “Y” if a decrease in service hours was requested/identified and c. is “Y”
STANDARD IX. BILLING
Compare the Units of Service tables to the Contract Monitoring Claims Report for the last six months of
service delivery within the review period.
OVERARCHING QUESTION For
the last six months of service delivery to the individual within the review
period,:
i. Were the number of units documented equal to or greater than the
number of units paid? Y or N
ii. Were the number of units paid equal to or less than the number of
IX.1a authorized units? (If No, did the increase meet the criteria of a temporary Not Calculated in
increase)? Y or N Score
• If overarching question IX.1a.i and IX.1a.ii are "Y", mark IX.1a"Y" and skip
overarching question IX.1b and mark Standard IX.1 "Y".
• If either overarching question IX.1a.i or IX.1a.ii is“N”, mark IX.1a "N" and
continue to overarching question IX.1b.
OVERARCHING QUESTION Did
the contractor provide evidence that the contractor negative billed the
over-billed amount due to DADS prior to the date of the Entrance
Not Calculated in
Conference?
IX.1b Score
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 186
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
18 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
IX.1b
• If overarching question IX.1b is “Y”, mark
STANDARD II. ATTENDANT REQUIREMENTS Standard IX.1 “Y”.
• If overarching question IX.1b is “N”, mark Standard IX.1 “N”. Complete
Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for
Payment.
IX. 1. DADS did not identify a financial error?
• Select “Y”, if the contractor does not owe an Amount Due to DADS per the Demand
for Payment Notice (Column L)
• Select “Y”, if the contractor provides evidence that the contractor negative billed the
amount due to DADS prior to the date of the entrance Conference.
• Select “N”, if the contractor owes an Amount Due to DADS per the Demand for
Payment Notice (Column L)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 187
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
19 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
II.1 Complete the Attendants Requirements Table below.
Column A: Enter the name(s) of each attendant that provided direct care to the individual during the last six
months of service delivery to the individual.
Review the contractor’s supporting documentation to answer Columns B, C and G.
Column B: Select “Y” if the attendant is at least 18 years of age or, if under 18 years of age, is a high school
graduate or is enrolled in a vocational educational program and has demonstrated competency to perform the
tasks assigned by the supervisor.
Column C: Select “NA” if Family Care. PHC/CAS- Select “Y” if the attendant is not the individual’s legal parent,
foster parent or spouse of a parent (if a minor- under the age of 18 years) or spouse (if an adult- 18 yrs or older)
Column G: For each attendant review F2101. If hired prior to 6/1/2010, select "NA". If the case manager did NOT
designate the attendant as “Do Not Hire,” select “Y”. If listed as “Do Not Hire”, select “N”. If “N” identify the number
of units provided by the attendant and paid by DADS for the last two months of service to the individual. If DADS
paid for services provided by the attendant, complete the Demand for Payment Notice columns A-H from Contract
Monitoring Claims Report, enter the number of verified units provided by the “DNH” attendant in Column J.
A. B. C. G.
Name of Attendant Attendant Attendant Attendant is
Meets the Meets the NOT
Age Relationship designated
Requirement Requirement COLUMNS LEFT BLANK as "Do Not
INTENTIONALLY Hire"
If hired on or
after
6/1/2010
`
II.1 Does each of the individual’s attendants meet the required qualifications?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 188
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
19 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• Select “Y” if ATTENDANT REQUIREMENTS
STANDARD II.for each row, all responses in column B are "Y" and all responses in
columns C and G are “Y” or "NA" (note: column C will only be NA for Family Care)
• Select “N” if for any row, a response in columns B, C or G is “N”
ORIENTATION CHECKLIST
A. B. C. D. E. F. G.
Name of Individual’s Attendant Date of First Service Date of Orientation Orientation Orientation Provided Orientation Elements not
to Individual Conducted in On or Before First Included All included in the
Person with Date of Service to the Required Orientation
Review service delivery documentation for (Review service delivery (Refer to Participation of the Individual Elements (Enter the
the last six months of service delivery within documentation for the documentation of corresponding
Individual or
review period to determine if
the review period and enter the name of first date of service to the
Attendant Attendant Met elements that were
each attendant that provided care to the sample individual was within Orientations Requirements for not addressed)
individual- NA for a Supervisor providing the last six months of conducted during the Orientation Without
personal assistance services service delivery. If the review period)
unlicensed attendant began
Participation of the
providing services to the Individual
sample individual during the
last six months of service
delivery, enter the first date
of service and complete
columns C - G. If the
unlicensed attendant worked
with the sample individual
prior to the last six months
of service delivery, select
“N” and leave columns C –
G blank.)
Last Six Months
Begin: End:
Last Name: First Name; Answer Date:
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 189
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
19 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Attendant Requirements for Orientation without Participation of the Individual (telephone/verbal): Meet the requirements of a Home health Aide*; have six continuous months of experience
delivering attendant care; has been oriented to the individual and the service plan has not changed; or has previously provided services to the individual.
Required elements:
1. Name of the individual for whom the attendant is to provide care
2. Name of the attendant
3. Date of the attendant orientation
4. Orientation conducted in person with the individual or without the participation of the individual
5. How the individual’s condition affects the performance of tasks
6. Tasks to be performed
7. Service schedule
8. Number of hours of service the attendant is to provide
9. Total number of hours the individual is authorized to receive
10. Safety and emergency procedures, including universal precautions
11. Specific situations about which the attendant should notify the contractor (e.g., changes in the individual’s needs; incidents that affect the individual’s condition; hospitalization;
absence or relocation from home; attendant’s inability to work; and suspicion/allegation of abuse, neglect or exploitation of the individual).
12. Signature of the Supervisor who conducted the orientation
13. Signature of the attendant, if present
14. Signature of the individual, if present
*A Home Health Aide must:
o have a minimum of six months experience in delivering personal care tasks in family care, primary home care, personal assistance services, client managed personal attendant
services; or
o be listed on the DADS Nurses Aide Registry with an employable “Active’ status.
II. 3. Was each attendant who began providing care to the individual during the last
six months of service delivery within the review period, oriented, as required, on or
before the first date of service delivery?
• Select “NA” if the individual’s attendant(s) began providing care to the individual prior
to the review period.
• Select “Y” if column B is “Y” and columns D., E and F. are “Y”
• Select “N” if column B is “Y” and column D., E and/or F is “N”.
STANDARD III. PRE-INITIATION ACTIVITIES
OVERARCHING QUESTION Did
the individual's pre-initiation activities occur during the review period?
III.1 • If overarching question III.1 is “N”, select “NA” for Standard III.1-3. Not Calculated in
Continue to Standard IV.1. Score
• If overarching question III.1 is “Y”, verify pre-initiation activities were
completed as required.
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 190
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
19 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Date of Referral Date of Referral Negotiated Date Stamp on Date of
(F2101, item 1) (F2101, item 25) Service Initiation F2101 Notification for
Date Intake
(Routine) (Expedited/Transf (Expedited/Transf (Retroactive)
er) er)
Date of Evaluation:
a. Routine Referral
i) Is the date of the evaluation within 14 calendar days after the date of referral or the date
the contractor received F-2101 as indicated by a date stamp- whichever is later; or
ii) If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the evaluation?
b. Expedited Referral (transfers are reviewed as an expedited referral)
i) Is the date of the evaluation on or before the date negotiated between the case
manager and contractor, which must be less than 14 days after the oral request; or
ii) If a delay, did the contractor notify the case manager of any failure to complete the
evaluation before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i) Is the date of the evaluation on or before the date of notification to DADS for intake?
d. Does the evaluation include the individual’s self-report of the dates and reasons for any
hospitalizations within 3 months prior to the evaluation were addressed?
e. Does the evaluation identify assistance needed to achieve activities of daily living,
including any assistive devices or medical equipment used by the person?
III.1. Did the contractor complete an evaluation of the individual as required?
o Select “Y” if a, b, or c is “Y” and d and e are “Y”
o Select “N” if a, b, or c is “N” and d and/or e is “N”
Date of Initial Service Delivery Plan:
a. Routine Referral
i. Was the initial service delivery plan completed within 14 calendar days after the referral
date or the date the contractor received F- 2101 as indicated by a date stamp- whichever
is later; or
ii. If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the service plan?
b. Expedited Referral (transfers are reviewed as an expedited referral)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 191
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
19 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
i. Is the date of the service delivery plan on or before the date negotiated between the
case manager and contractor, which must be less than 14 days after the oral request; or
ii If a delay, did the contractor notify the case manager of any failure to complete the
service delivery plan before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i. Was the service plan complete prior to the date of notification to DADS for intake?
d. The service plan is agreed upon and was signed by the individual and the contractor
e. The service plan identifies the location of service delivery
f. The service plan identifies the tasks the individual will receive (includes at least one
personal care task, unless FC)
g. The service plan identifies the total weekly hours authorized
h. The service plan identifies the service schedule which includes as necessary, based
on the individual’s needs, certain time periods for the delivery of specified tasks
i. The service plan identifies the frequency of supervisory visits
j. The service plan includes the statement that the contractor is responsible for providing
the tasks allowable in the PHC program (47.41) and agreed to on the service plan.
III. 2. Did the contractor develop an initial service delivery plan as required?
• Select “Y” if a, b, or c is “Y” and d - j are “Y”
• Select “N” if a, b, or c is “N” and/or d – j is “N”
OVERARCHING QUESTION Does
the individual receive family care or did the individual transfer from one
PHC contractor to another PHC, transfer from PHC to CAS or transfer from
Not Calculated in
CAS to PHC during the review period?
III.3 Score
• If overarching question III.3 is “Y”, select “NA” for Standard III.3. Continue
to Standard IV.1.
• If overarching question III.3 is “N”, verify the contractor met the
requirements for the individual’s practitioner’s statement.
Date of Practitioner’s Statement:
a. Routine Referral
i. Did the contractor obtain and submit to DADS a complete practitioner’s statement
within 14 calendar days after the date of referral or the date the contractor received F-
2101 as indicated by a date stamp- whichever is later. Review the contractor's fax, email
or other documentation that verifies the practitioner's statement was submitted to DADS
within the required timeframe; or
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 192
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
19 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. If a delay, II. ATTENDANT REQUIREMENTS
STANDARDdid the contractor document by due date the reason for the delay, an
anticipated date of completion or reason why a completion date cannot be anticipated;
and a description of the contractor’s efforts to obtain the practitioner’s statement?
b. Expedited Referral
i. Did the contractor send a complete practitioner’s statement to DADS within seven (7)
work days after service initiation? Review the contractor's fax, email or other
documentation that verifies the practitioner's statement was submitted to DADS within the
required timeframe.
c. Retroactive
i. Was the practitioner’s statement completed on or before the date of notification to
DADS for intake?
III. 3. Did the contractor meet the requirements for the individual’s practitioner’s
statement?
• Select “Y” if a, b, or c (as applicable) is “Y”
• Select “N” if a, b, or c ( as applicable) is “N”
Potential Billing Error:
If III.3 is “N”, review the Contract Monitoring Claims Report Payment Report for the billing periods within the 12
month review period prior to the date of the practitioner’s statement to determine if DADS paid for services prior to
the date of the practitioner’s statement. If DADS paid for services prior to the date of the practitioner’s statement,
complete Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for Payment. Enter “0” in Column J -
Units Verified for units paid prior to the date of the practitioner’s statement.
STANDARD IV. SERVICE INITIATION
OVERARCHING QUESTION Did
the individual enter services during the review period?
• If overarching question IV.1 is “N”, select “NA” for Standard IV.1. Continue Not Calculated in
IV.1
to Standard V.1. Score
• If overarching question IV.1 is “Y”, verify the contractor met the
requirements for service initiation.
a. Family Care- First Date of Service:
i. Routine Referral-Did services begin within 14 days after the referral date or
within 14 days after the date the contractor date stamped DADS’ authorization
form; or
ii. Transfer- Did services begin on the date negotiated between the case manager
and the contractor?
b. Primary Home Care or Community Attendant Services- First Date of Service:
i. Routine Referral- Did services begin within seven days after the date the
contractor’s receipt of DADS’ Authorization form?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 193
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
19 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. Transfer- Did services begin on the date negotiated between the case manager
STANDARD II. ATTENDANT REQUIREMENTS
and the contractor?
c. If a delay in service initiation did the contractor document the reason for the delay,
either an anticipated date of initiation or specific reasons why the contractor cannot
anticipate a date and a description of the contractor’s efforts to initiate services?
d. Did the contractor send notice of service initiation to the case manager within 14 days
after initiating services?
IV. 1. Were services initiated as required?
• Select “Y” if a is “Y”, b is “NA”, c is “NA” and d is “Y”
• Select “Y” if a is “NA”, b is “Y”, c is “NA” and d is “Y”
• Select “Y” if a or b is “N”, c is “Y” and d is “Y”
• Select “N” if a or b is “N”, c is “N” and d is “Y”
• Select “N” if d is “N”
VI. SERVICE DELIVERY
Complete UNITS OF SERVICE Tables for the last six months of service within the review
VI.1
period then answer VI.1.
a. Priority status- Does the number of documented hours/units of service equal the
number of authorized hours/units; or
Non-Priority status- Does the number of documented hours/units of service indicate that
there were no service interruptions exceeding 14 consecutive days?
b. If a is “N” was the reason for the failure to provide all service hours one of the
following:
• the individual’s revised service plan identified a need for an ongoing decrease in
hours;
• the individual requested that services not be provided;
• the individual requested fewer hours of service than reflected in the service
schedule;
• the individual requested that a specific attendant not provide services;
• the individual was not at home when the service was scheduled;
• services were not delivered for other reasons beyond the control of the provider
agency; or
• services were suspended.
- The individual temporarily or permanently left the contracted services delivery area;
- The individual moved to a location where services could not be provided under the PHC program;
- The individual died;
- The individual was admitted to an institution (hospital, nursing facility, state school, state hospital, or
ICF-MR facility);
- The individual requested that services end;
- DADS denied the individual’s Medicaid eligibility (not applicable to FC);
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 194
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
19 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
- The individual or someone in the individual’s home exhibited reckless behavior, which may have
STANDARD II. ATTENDANT REQUIREMENTS
resulted in imminent danger to the health and safety of the individual, the attendant, or another person;
- The individual or someone else in the individual’s home engaged in discrimination against a provider
agency or DADS employee in violation of applicable law;
- The individual refused services for more than 30 consecutive days.
VI. 1. Were personal assistance service hours provided in accordance with the
individual’s service plans or as required?
• Select “Y” if a is “Y” or a is “N” and b is “Y”
• Select “N” if a and b are “N”
STANDARD VII. SERVICE PLAN CHANGE
• Review the individual’s record for the 12 month review period to determine if a service plan change
was identified and requested.
VII.1.
• Select “NA” if a service plan change was not identified/requested. Continue to Standard VIII.
• If a service plan change was identified/requested, complete the table below.
Date(s) of /identified Date of notification to Effective Date Date of Date(s) of identified Date of revised service
need/request for an the contractor OR (F2101, item 4) Implementation need/request for a plan
increase in service case manager (Service Delivery decrease in service
hours or change that (F2067 or equivalent) Documentation) hours
results in no delivery
of personal care tasks
a. Immediate increase in hours:
i. If requested by the contractor, did the contractor’s documentation include:
• evidence that the contractor discussed the reason for the request of immediate
increase in hours with the case manager? NA
• the date the contractor received approval from the case manager? NA
• the name of the case manager who approved the change? NA
• the effective date of change, and NA
• the number of hours authorized? NA
ii. Did the contractor implement the service plan change on the date negotiated with the
NA
case manager? NA
b. Increase in service hours or no delivery of personal care tasks:
i. If requested by the contractor, was the case manager notified in writing within seven
days from the date of request/identification of need; and NA
ii. Did the notification include:
• date the provider agency learned of the need for the change;
NA
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 195
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
19 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• reason II. ATTENDANT REQUIREMENTS
STANDARD for the change;
NA
• type of change (including the number of service hours) and:
• signature and date of the provider agency representative?
iii. For any increase in service hours requested by the contractor, individual or case manager, did the contractor
implement the change within the required timeframe?
• Was the service plan change implemented on the Begin Date (F2101, item 4) or
five days after the contractor’s date stamp on F2101, whichever is later; or NA
• If delayed, did the contractor document, by the next working day, the failure to
implement the service plan change on the effective date to include the reason and NA
new implementation date? NA
c. Decrease in service hours:
i. Did the contractor develop a new service plan within 21 days from the date of the
individual’s request or identification of need for a service plan change? NA
VII.1. If a service plan change for PAS was identified or requested, did the contractor
meet all requirements?
• If the contractor requested an increase in hours or no delivery of personal care tasks -
select “Y” if a. i-ii or b. i-iii are “Y” NA
• If the case manager requested an increase in hours or no delivery of personal care
tasks - select “Y” if a. ii or b. iii are “Y”
• Select “Y” if a decrease in service hours was requested/identified and c. is “Y”
STANDARD IX. BILLING
Compare the Units of Service tables to the Contract Monitoring Claims Report for the last six months of
service delivery within the review period.
OVERARCHING QUESTION For
the last six months of service delivery to the individual within the review
period,:
i. Were the number of units documented equal to or greater than the
number of units paid? Y or N
ii. Were the number of units paid equal to or less than the number of
IX.1a authorized units? (If No, did the increase meet the criteria of a temporary Not Calculated in
increase)? Y or N Score
• If overarching question IX.1a.i and IX.1a.ii are "Y", mark IX.1a"Y" and skip
overarching question IX.1b and mark Standard IX.1 "Y".
• If either overarching question IX.1a.i or IX.1a.ii is“N”, mark IX.1a "N" and
continue to overarching question IX.1b.
OVERARCHING QUESTION Did
the contractor provide evidence that the contractor negative billed the
over-billed amount due to DADS prior to the date of the Entrance
Not Calculated in
Conference?
IX.1b Score
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 196
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
19 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
IX.1b
• If overarching question IX.1b is “Y”, mark
STANDARD II. ATTENDANT REQUIREMENTS Standard IX.1 “Y”.
• If overarching question IX.1b is “N”, mark Standard IX.1 “N”. Complete
Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for
Payment.
IX. 1. DADS did not identify a financial error?
• Select “Y”, if the contractor does not owe an Amount Due to DADS per the Demand
for Payment Notice (Column L)
• Select “Y”, if the contractor provides evidence that the contractor negative billed the
amount due to DADS prior to the date of the entrance Conference.
• Select “N”, if the contractor owes an Amount Due to DADS per the Demand for
Payment Notice (Column L)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 197
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
20 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
II.1 Complete the Attendants Requirements Table below.
Column A: Enter the name(s) of each attendant that provided direct care to the individual during the last six
months of service delivery to the individual.
Review the contractor’s supporting documentation to answer Columns B, C and G.
Column B: Select “Y” if the attendant is at least 18 years of age or, if under 18 years of age, is a high school
graduate or is enrolled in a vocational educational program and has demonstrated competency to perform the
tasks assigned by the supervisor.
Column C: Select “NA” if Family Care. PHC/CAS- Select “Y” if the attendant is not the individual’s legal parent,
foster parent or spouse of a parent (if a minor- under the age of 18 years) or spouse (if an adult- 18 yrs or older)
Column G: For each attendant review F2101. If hired prior to 6/1/2010, select "NA". If the case manager did NOT
designate the attendant as “Do Not Hire,” select “Y”. If listed as “Do Not Hire”, select “N”. If “N” identify the number
of units provided by the attendant and paid by DADS for the last two months of service to the individual. If DADS
paid for services provided by the attendant, complete the Demand for Payment Notice columns A-H from Contract
Monitoring Claims Report, enter the number of verified units provided by the “DNH” attendant in Column J.
A. B. C. G.
Name of Attendant Attendant Attendant Attendant is
Meets the Meets the NOT
Age Relationship designated
Requirement Requirement COLUMNS LEFT BLANK as "Do Not
INTENTIONALLY Hire"
If hired on or
after
6/1/2010
`
II.1 Does each of the individual’s attendants meet the required qualifications?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 198
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
20 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• Select “Y” if ATTENDANT REQUIREMENTS
STANDARD II.for each row, all responses in column B are "Y" and all responses in
columns C and G are “Y” or "NA" (note: column C will only be NA for Family Care)
• Select “N” if for any row, a response in columns B, C or G is “N”
ORIENTATION CHECKLIST
A. B. C. D. E. F. G.
Name of Individual’s Attendant Date of First Service Date of Orientation Orientation Orientation Provided Orientation Elements not
to Individual Conducted in On or Before First Included All included in the
Person with Date of Service to the Required Orientation
Review service delivery documentation for (Review service delivery (Refer to Participation of the Individual Elements (Enter the
the last six months of service delivery within documentation for the documentation of corresponding
Individual or
review period to determine if
the review period and enter the name of first date of service to the
Attendant Attendant Met elements that were
each attendant that provided care to the sample individual was within Orientations Requirements for not addressed)
individual- NA for a Supervisor providing the last six months of conducted during the Orientation Without
personal assistance services service delivery. If the review period)
unlicensed attendant began
Participation of the
providing services to the Individual
sample individual during the
last six months of service
delivery, enter the first date
of service and complete
columns C - G. If the
unlicensed attendant worked
with the sample individual
prior to the last six months
of service delivery, select
“N” and leave columns C –
G blank.)
Last Six Months
Begin: End:
Last Name: First Name; Answer Date:
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 199
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
20 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Attendant Requirements for Orientation without Participation of the Individual (telephone/verbal): Meet the requirements of a Home health Aide*; have six continuous months of experience
delivering attendant care; has been oriented to the individual and the service plan has not changed; or has previously provided services to the individual.
Required elements:
1. Name of the individual for whom the attendant is to provide care
2. Name of the attendant
3. Date of the attendant orientation
4. Orientation conducted in person with the individual or without the participation of the individual
5. How the individual’s condition affects the performance of tasks
6. Tasks to be performed
7. Service schedule
8. Number of hours of service the attendant is to provide
9. Total number of hours the individual is authorized to receive
10. Safety and emergency procedures, including universal precautions
11. Specific situations about which the attendant should notify the contractor (e.g., changes in the individual’s needs; incidents that affect the individual’s condition; hospitalization;
absence or relocation from home; attendant’s inability to work; and suspicion/allegation of abuse, neglect or exploitation of the individual).
12. Signature of the Supervisor who conducted the orientation
13. Signature of the attendant, if present
14. Signature of the individual, if present
*A Home Health Aide must:
o have a minimum of six months experience in delivering personal care tasks in family care, primary home care, personal assistance services, client managed personal attendant
services; or
o be listed on the DADS Nurses Aide Registry with an employable “Active’ status.
II. 3. Was each attendant who began providing care to the individual during the last
six months of service delivery within the review period, oriented, as required, on or
before the first date of service delivery?
• Select “NA” if the individual’s attendant(s) began providing care to the individual prior
to the review period.
• Select “Y” if column B is “Y” and columns D., E and F. are “Y”
• Select “N” if column B is “Y” and column D., E and/or F is “N”.
STANDARD III. PRE-INITIATION ACTIVITIES
OVERARCHING QUESTION Did
the individual's pre-initiation activities occur during the review period?
III.1 • If overarching question III.1 is “N”, select “NA” for Standard III.1-3. Not Calculated in
Continue to Standard IV.1. Score
• If overarching question III.1 is “Y”, verify pre-initiation activities were
completed as required.
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 200
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
20 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Date of Referral Date of Referral Negotiated Date Stamp on Date of
(F2101, item 1) (F2101, item 25) Service Initiation F2101 Notification for
Date Intake
(Routine) (Expedited/Transf (Expedited/Transf (Retroactive)
er) er)
Date of Evaluation:
a. Routine Referral
i) Is the date of the evaluation within 14 calendar days after the date of referral or the date
the contractor received F-2101 as indicated by a date stamp- whichever is later; or
ii) If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the evaluation?
b. Expedited Referral (transfers are reviewed as an expedited referral)
i) Is the date of the evaluation on or before the date negotiated between the case
manager and contractor, which must be less than 14 days after the oral request; or
ii) If a delay, did the contractor notify the case manager of any failure to complete the
evaluation before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i) Is the date of the evaluation on or before the date of notification to DADS for intake?
d. Does the evaluation include the individual’s self-report of the dates and reasons for any
hospitalizations within 3 months prior to the evaluation were addressed?
e. Does the evaluation identify assistance needed to achieve activities of daily living,
including any assistive devices or medical equipment used by the person?
III.1. Did the contractor complete an evaluation of the individual as required?
o Select “Y” if a, b, or c is “Y” and d and e are “Y”
o Select “N” if a, b, or c is “N” and d and/or e is “N”
Date of Initial Service Delivery Plan:
a. Routine Referral
i. Was the initial service delivery plan completed within 14 calendar days after the referral
date or the date the contractor received F- 2101 as indicated by a date stamp- whichever
is later; or
ii. If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the service plan?
b. Expedited Referral (transfers are reviewed as an expedited referral)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 201
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
20 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
i. Is the date of the service delivery plan on or before the date negotiated between the
case manager and contractor, which must be less than 14 days after the oral request; or
ii If a delay, did the contractor notify the case manager of any failure to complete the
service delivery plan before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i. Was the service plan complete prior to the date of notification to DADS for intake?
d. The service plan is agreed upon and was signed by the individual and the contractor
e. The service plan identifies the location of service delivery
f. The service plan identifies the tasks the individual will receive (includes at least one
personal care task, unless FC)
g. The service plan identifies the total weekly hours authorized
h. The service plan identifies the service schedule which includes as necessary, based
on the individual’s needs, certain time periods for the delivery of specified tasks
i. The service plan identifies the frequency of supervisory visits
j. The service plan includes the statement that the contractor is responsible for providing
the tasks allowable in the PHC program (47.41) and agreed to on the service plan.
III. 2. Did the contractor develop an initial service delivery plan as required?
• Select “Y” if a, b, or c is “Y” and d - j are “Y”
• Select “N” if a, b, or c is “N” and/or d – j is “N”
OVERARCHING QUESTION Does
the individual receive family care or did the individual transfer from one
PHC contractor to another PHC, transfer from PHC to CAS or transfer from
Not Calculated in
CAS to PHC during the review period?
III.3 Score
• If overarching question III.3 is “Y”, select “NA” for Standard III.3. Continue
to Standard IV.1.
• If overarching question III.3 is “N”, verify the contractor met the
requirements for the individual’s practitioner’s statement.
Date of Practitioner’s Statement:
a. Routine Referral
i. Did the contractor obtain and submit to DADS a complete practitioner’s statement
within 14 calendar days after the date of referral or the date the contractor received F-
2101 as indicated by a date stamp- whichever is later. Review the contractor's fax, email
or other documentation that verifies the practitioner's statement was submitted to DADS
within the required timeframe; or
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 202
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
20 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. If a delay, II. ATTENDANT REQUIREMENTS
STANDARDdid the contractor document by due date the reason for the delay, an
anticipated date of completion or reason why a completion date cannot be anticipated;
and a description of the contractor’s efforts to obtain the practitioner’s statement?
b. Expedited Referral
i. Did the contractor send a complete practitioner’s statement to DADS within seven (7)
work days after service initiation? Review the contractor's fax, email or other
documentation that verifies the practitioner's statement was submitted to DADS within the
required timeframe.
c. Retroactive
i. Was the practitioner’s statement completed on or before the date of notification to
DADS for intake?
III. 3. Did the contractor meet the requirements for the individual’s practitioner’s
statement?
• Select “Y” if a, b, or c (as applicable) is “Y”
• Select “N” if a, b, or c ( as applicable) is “N”
Potential Billing Error:
If III.3 is “N”, review the Contract Monitoring Claims Report Payment Report for the billing periods within the 12
month review period prior to the date of the practitioner’s statement to determine if DADS paid for services prior to
the date of the practitioner’s statement. If DADS paid for services prior to the date of the practitioner’s statement,
complete Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for Payment. Enter “0” in Column J -
Units Verified for units paid prior to the date of the practitioner’s statement.
STANDARD IV. SERVICE INITIATION
OVERARCHING QUESTION Did
the individual enter services during the review period?
• If overarching question IV.1 is “N”, select “NA” for Standard IV.1. Continue Not Calculated in
IV.1
to Standard V.1. Score
• If overarching question IV.1 is “Y”, verify the contractor met the
requirements for service initiation.
a. Family Care- First Date of Service:
i. Routine Referral-Did services begin within 14 days after the referral date or
within 14 days after the date the contractor date stamped DADS’ authorization
form; or
ii. Transfer- Did services begin on the date negotiated between the case manager
and the contractor?
b. Primary Home Care or Community Attendant Services- First Date of Service:
i. Routine Referral- Did services begin within seven days after the date the
contractor’s receipt of DADS’ Authorization form?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 203
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
20 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. Transfer- Did services begin on the date negotiated between the case manager
STANDARD II. ATTENDANT REQUIREMENTS
and the contractor?
c. If a delay in service initiation did the contractor document the reason for the delay,
either an anticipated date of initiation or specific reasons why the contractor cannot
anticipate a date and a description of the contractor’s efforts to initiate services?
d. Did the contractor send notice of service initiation to the case manager within 14 days
after initiating services?
IV. 1. Were services initiated as required?
• Select “Y” if a is “Y”, b is “NA”, c is “NA” and d is “Y”
• Select “Y” if a is “NA”, b is “Y”, c is “NA” and d is “Y”
• Select “Y” if a or b is “N”, c is “Y” and d is “Y”
• Select “N” if a or b is “N”, c is “N” and d is “Y”
• Select “N” if d is “N”
VI. SERVICE DELIVERY
Complete UNITS OF SERVICE Tables for the last six months of service within the review
VI.1
period then answer VI.1.
a. Priority status- Does the number of documented hours/units of service equal the
number of authorized hours/units; or
Non-Priority status- Does the number of documented hours/units of service indicate that
there were no service interruptions exceeding 14 consecutive days?
b. If a is “N” was the reason for the failure to provide all service hours one of the
following:
• the individual’s revised service plan identified a need for an ongoing decrease in
hours;
• the individual requested that services not be provided;
• the individual requested fewer hours of service than reflected in the service
schedule;
• the individual requested that a specific attendant not provide services;
• the individual was not at home when the service was scheduled;
• services were not delivered for other reasons beyond the control of the provider
agency; or
• services were suspended.
- The individual temporarily or permanently left the contracted services delivery area;
- The individual moved to a location where services could not be provided under the PHC program;
- The individual died;
- The individual was admitted to an institution (hospital, nursing facility, state school, state hospital, or
ICF-MR facility);
- The individual requested that services end;
- DADS denied the individual’s Medicaid eligibility (not applicable to FC);
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 204
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
20 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
- The individual or someone in the individual’s home exhibited reckless behavior, which may have
STANDARD II. ATTENDANT REQUIREMENTS
resulted in imminent danger to the health and safety of the individual, the attendant, or another person;
- The individual or someone else in the individual’s home engaged in discrimination against a provider
agency or DADS employee in violation of applicable law;
- The individual refused services for more than 30 consecutive days.
VI. 1. Were personal assistance service hours provided in accordance with the
individual’s service plans or as required?
• Select “Y” if a is “Y” or a is “N” and b is “Y”
• Select “N” if a and b are “N”
STANDARD VII. SERVICE PLAN CHANGE
• Review the individual’s record for the 12 month review period to determine if a service plan change
was identified and requested.
VII.1.
• Select “NA” if a service plan change was not identified/requested. Continue to Standard VIII.
• If a service plan change was identified/requested, complete the table below.
Date(s) of /identified Date of notification to Effective Date Date of Date(s) of identified Date of revised service
need/request for an the contractor OR (F2101, item 4) Implementation need/request for a plan
increase in service case manager (Service Delivery decrease in service
hours or change that (F2067 or equivalent) Documentation) hours
results in no delivery
of personal care tasks
a. Immediate increase in hours:
i. If requested by the contractor, did the contractor’s documentation include:
• evidence that the contractor discussed the reason for the request of immediate
increase in hours with the case manager? NA
• the date the contractor received approval from the case manager? NA
• the name of the case manager who approved the change? NA
• the effective date of change, and NA
• the number of hours authorized? NA
ii. Did the contractor implement the service plan change on the date negotiated with the
NA
case manager? NA
b. Increase in service hours or no delivery of personal care tasks:
i. If requested by the contractor, was the case manager notified in writing within seven
days from the date of request/identification of need; and NA
ii. Did the notification include:
• date the provider agency learned of the need for the change;
NA
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 205
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
20 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• reason II. ATTENDANT REQUIREMENTS
STANDARD for the change;
NA
• type of change (including the number of service hours) and:
• signature and date of the provider agency representative?
iii. For any increase in service hours requested by the contractor, individual or case manager, did the contractor
implement the change within the required timeframe?
• Was the service plan change implemented on the Begin Date (F2101, item 4) or
five days after the contractor’s date stamp on F2101, whichever is later; or NA
• If delayed, did the contractor document, by the next working day, the failure to
implement the service plan change on the effective date to include the reason and NA
new implementation date? NA
c. Decrease in service hours:
i. Did the contractor develop a new service plan within 21 days from the date of the
individual’s request or identification of need for a service plan change? NA
VII.1. If a service plan change for PAS was identified or requested, did the contractor
meet all requirements?
• If the contractor requested an increase in hours or no delivery of personal care tasks -
select “Y” if a. i-ii or b. i-iii are “Y” NA
• If the case manager requested an increase in hours or no delivery of personal care
tasks - select “Y” if a. ii or b. iii are “Y”
• Select “Y” if a decrease in service hours was requested/identified and c. is “Y”
STANDARD IX. BILLING
Compare the Units of Service tables to the Contract Monitoring Claims Report for the last six months of
service delivery within the review period.
OVERARCHING QUESTION For
the last six months of service delivery to the individual within the review
period,:
i. Were the number of units documented equal to or greater than the
number of units paid? Y or N
ii. Were the number of units paid equal to or less than the number of
IX.1a authorized units? (If No, did the increase meet the criteria of a temporary Not Calculated in
increase)? Y or N Score
• If overarching question IX.1a.i and IX.1a.ii are "Y", mark IX.1a"Y" and skip
overarching question IX.1b and mark Standard IX.1 "Y".
• If either overarching question IX.1a.i or IX.1a.ii is“N”, mark IX.1a "N" and
continue to overarching question IX.1b.
OVERARCHING QUESTION Did
the contractor provide evidence that the contractor negative billed the
over-billed amount due to DADS prior to the date of the Entrance
Not Calculated in
Conference?
IX.1b Score
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 206
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
20 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
IX.1b
• If overarching question IX.1b is “Y”, mark
STANDARD II. ATTENDANT REQUIREMENTS Standard IX.1 “Y”.
• If overarching question IX.1b is “N”, mark Standard IX.1 “N”. Complete
Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for
Payment.
IX. 1. DADS did not identify a financial error?
• Select “Y”, if the contractor does not owe an Amount Due to DADS per the Demand
for Payment Notice (Column L)
• Select “Y”, if the contractor provides evidence that the contractor negative billed the
amount due to DADS prior to the date of the entrance Conference.
• Select “N”, if the contractor owes an Amount Due to DADS per the Demand for
Payment Notice (Column L)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 207
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
21 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
II.1 Complete the Attendants Requirements Table below.
Column A: Enter the name(s) of each attendant that provided direct care to the individual during the last six
months of service delivery to the individual.
Review the contractor’s supporting documentation to answer Columns B, C and G.
Column B: Select “Y” if the attendant is at least 18 years of age or, if under 18 years of age, is a high school
graduate or is enrolled in a vocational educational program and has demonstrated competency to perform the
tasks assigned by the supervisor.
Column C: Select “NA” if Family Care. PHC/CAS- Select “Y” if the attendant is not the individual’s legal parent,
foster parent or spouse of a parent (if a minor- under the age of 18 years) or spouse (if an adult- 18 yrs or older)
Column G: For each attendant review F2101. If hired prior to 6/1/2010, select "NA". If the case manager did NOT
designate the attendant as “Do Not Hire,” select “Y”. If listed as “Do Not Hire”, select “N”. If “N” identify the number
of units provided by the attendant and paid by DADS for the last two months of service to the individual. If DADS
paid for services provided by the attendant, complete the Demand for Payment Notice columns A-H from Contract
Monitoring Claims Report, enter the number of verified units provided by the “DNH” attendant in Column J.
A. B. C. G.
Name of Attendant Attendant Attendant Attendant is
Meets the Meets the NOT
Age Relationship designated
Requirement Requirement COLUMNS LEFT BLANK as "Do Not
INTENTIONALLY Hire"
If hired on or
after
6/1/2010
`
II.1 Does each of the individual’s attendants meet the required qualifications?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 208
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
21 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• Select “Y” if ATTENDANT REQUIREMENTS
STANDARD II.for each row, all responses in column B are "Y" and all responses in
columns C and G are “Y” or "NA" (note: column C will only be NA for Family Care)
• Select “N” if for any row, a response in columns B, C or G is “N”
ORIENTATION CHECKLIST
A. B. C. D. E. F. G.
Name of Individual’s Attendant Date of First Service Date of Orientation Orientation Orientation Provided Orientation Elements not
to Individual Conducted in On or Before First Included All included in the
Person with Date of Service to the Required Orientation
Review service delivery documentation for (Review service delivery (Refer to Participation of the Individual Elements (Enter the
the last six months of service delivery within documentation for the documentation of corresponding
Individual or
review period to determine if
the review period and enter the name of first date of service to the
Attendant Attendant Met elements that were
each attendant that provided care to the sample individual was within Orientations Requirements for not addressed)
individual- NA for a Supervisor providing the last six months of conducted during the Orientation Without
personal assistance services service delivery. If the review period)
unlicensed attendant began
Participation of the
providing services to the Individual
sample individual during the
last six months of service
delivery, enter the first date
of service and complete
columns C - G. If the
unlicensed attendant worked
with the sample individual
prior to the last six months
of service delivery, select
“N” and leave columns C –
G blank.)
Last Six Months
Begin: End:
Last Name: First Name; Answer Date:
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 209
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
21 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Attendant Requirements for Orientation without Participation of the Individual (telephone/verbal): Meet the requirements of a Home health Aide*; have six continuous months of experience
delivering attendant care; has been oriented to the individual and the service plan has not changed; or has previously provided services to the individual.
Required elements:
1. Name of the individual for whom the attendant is to provide care
2. Name of the attendant
3. Date of the attendant orientation
4. Orientation conducted in person with the individual or without the participation of the individual
5. How the individual’s condition affects the performance of tasks
6. Tasks to be performed
7. Service schedule
8. Number of hours of service the attendant is to provide
9. Total number of hours the individual is authorized to receive
10. Safety and emergency procedures, including universal precautions
11. Specific situations about which the attendant should notify the contractor (e.g., changes in the individual’s needs; incidents that affect the individual’s condition; hospitalization;
absence or relocation from home; attendant’s inability to work; and suspicion/allegation of abuse, neglect or exploitation of the individual).
12. Signature of the Supervisor who conducted the orientation
13. Signature of the attendant, if present
14. Signature of the individual, if present
*A Home Health Aide must:
o have a minimum of six months experience in delivering personal care tasks in family care, primary home care, personal assistance services, client managed personal attendant
services; or
o be listed on the DADS Nurses Aide Registry with an employable “Active’ status.
II. 3. Was each attendant who began providing care to the individual during the last
six months of service delivery within the review period, oriented, as required, on or
before the first date of service delivery?
• Select “NA” if the individual’s attendant(s) began providing care to the individual prior
to the review period.
• Select “Y” if column B is “Y” and columns D., E and F. are “Y”
• Select “N” if column B is “Y” and column D., E and/or F is “N”.
STANDARD III. PRE-INITIATION ACTIVITIES
OVERARCHING QUESTION Did
the individual's pre-initiation activities occur during the review period?
III.1 • If overarching question III.1 is “N”, select “NA” for Standard III.1-3. Not Calculated in
Continue to Standard IV.1. Score
• If overarching question III.1 is “Y”, verify pre-initiation activities were
completed as required.
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 210
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
21 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Date of Referral Date of Referral Negotiated Date Stamp on Date of
(F2101, item 1) (F2101, item 25) Service Initiation F2101 Notification for
Date Intake
(Routine) (Expedited/Transf (Expedited/Transf (Retroactive)
er) er)
Date of Evaluation:
a. Routine Referral
i) Is the date of the evaluation within 14 calendar days after the date of referral or the date
the contractor received F-2101 as indicated by a date stamp- whichever is later; or
ii) If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the evaluation?
b. Expedited Referral (transfers are reviewed as an expedited referral)
i) Is the date of the evaluation on or before the date negotiated between the case
manager and contractor, which must be less than 14 days after the oral request; or
ii) If a delay, did the contractor notify the case manager of any failure to complete the
evaluation before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i) Is the date of the evaluation on or before the date of notification to DADS for intake?
d. Does the evaluation include the individual’s self-report of the dates and reasons for any
hospitalizations within 3 months prior to the evaluation were addressed?
e. Does the evaluation identify assistance needed to achieve activities of daily living,
including any assistive devices or medical equipment used by the person?
III.1. Did the contractor complete an evaluation of the individual as required?
o Select “Y” if a, b, or c is “Y” and d and e are “Y”
o Select “N” if a, b, or c is “N” and d and/or e is “N”
Date of Initial Service Delivery Plan:
a. Routine Referral
i. Was the initial service delivery plan completed within 14 calendar days after the referral
date or the date the contractor received F- 2101 as indicated by a date stamp- whichever
is later; or
ii. If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the service plan?
b. Expedited Referral (transfers are reviewed as an expedited referral)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 211
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
21 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
i. Is the date of the service delivery plan on or before the date negotiated between the
case manager and contractor, which must be less than 14 days after the oral request; or
ii If a delay, did the contractor notify the case manager of any failure to complete the
service delivery plan before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i. Was the service plan complete prior to the date of notification to DADS for intake?
d. The service plan is agreed upon and was signed by the individual and the contractor
e. The service plan identifies the location of service delivery
f. The service plan identifies the tasks the individual will receive (includes at least one
personal care task, unless FC)
g. The service plan identifies the total weekly hours authorized
h. The service plan identifies the service schedule which includes as necessary, based
on the individual’s needs, certain time periods for the delivery of specified tasks
i. The service plan identifies the frequency of supervisory visits
j. The service plan includes the statement that the contractor is responsible for providing
the tasks allowable in the PHC program (47.41) and agreed to on the service plan.
III. 2. Did the contractor develop an initial service delivery plan as required?
• Select “Y” if a, b, or c is “Y” and d - j are “Y”
• Select “N” if a, b, or c is “N” and/or d – j is “N”
OVERARCHING QUESTION Does
the individual receive family care or did the individual transfer from one
PHC contractor to another PHC, transfer from PHC to CAS or transfer from
Not Calculated in
CAS to PHC during the review period?
III.3 Score
• If overarching question III.3 is “Y”, select “NA” for Standard III.3. Continue
to Standard IV.1.
• If overarching question III.3 is “N”, verify the contractor met the
requirements for the individual’s practitioner’s statement.
Date of Practitioner’s Statement:
a. Routine Referral
i. Did the contractor obtain and submit to DADS a complete practitioner’s statement
within 14 calendar days after the date of referral or the date the contractor received F-
2101 as indicated by a date stamp- whichever is later. Review the contractor's fax, email
or other documentation that verifies the practitioner's statement was submitted to DADS
within the required timeframe; or
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 212
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
21 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. If a delay, II. ATTENDANT REQUIREMENTS
STANDARDdid the contractor document by due date the reason for the delay, an
anticipated date of completion or reason why a completion date cannot be anticipated;
and a description of the contractor’s efforts to obtain the practitioner’s statement?
b. Expedited Referral
i. Did the contractor send a complete practitioner’s statement to DADS within seven (7)
work days after service initiation? Review the contractor's fax, email or other
documentation that verifies the practitioner's statement was submitted to DADS within the
required timeframe.
c. Retroactive
i. Was the practitioner’s statement completed on or before the date of notification to
DADS for intake?
III. 3. Did the contractor meet the requirements for the individual’s practitioner’s
statement?
• Select “Y” if a, b, or c (as applicable) is “Y”
• Select “N” if a, b, or c ( as applicable) is “N”
Potential Billing Error:
If III.3 is “N”, review the Contract Monitoring Claims Report Payment Report for the billing periods within the 12
month review period prior to the date of the practitioner’s statement to determine if DADS paid for services prior to
the date of the practitioner’s statement. If DADS paid for services prior to the date of the practitioner’s statement,
complete Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for Payment. Enter “0” in Column J -
Units Verified for units paid prior to the date of the practitioner’s statement.
STANDARD IV. SERVICE INITIATION
OVERARCHING QUESTION Did
the individual enter services during the review period?
• If overarching question IV.1 is “N”, select “NA” for Standard IV.1. Continue Not Calculated in
IV.1
to Standard V.1. Score
• If overarching question IV.1 is “Y”, verify the contractor met the
requirements for service initiation.
a. Family Care- First Date of Service:
i. Routine Referral-Did services begin within 14 days after the referral date or
within 14 days after the date the contractor date stamped DADS’ authorization
form; or
ii. Transfer- Did services begin on the date negotiated between the case manager
and the contractor?
b. Primary Home Care or Community Attendant Services- First Date of Service:
i. Routine Referral- Did services begin within seven days after the date the
contractor’s receipt of DADS’ Authorization form?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 213
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
21 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. Transfer- Did services begin on the date negotiated between the case manager
STANDARD II. ATTENDANT REQUIREMENTS
and the contractor?
c. If a delay in service initiation did the contractor document the reason for the delay,
either an anticipated date of initiation or specific reasons why the contractor cannot
anticipate a date and a description of the contractor’s efforts to initiate services?
d. Did the contractor send notice of service initiation to the case manager within 14 days
after initiating services?
IV. 1. Were services initiated as required?
• Select “Y” if a is “Y”, b is “NA”, c is “NA” and d is “Y”
• Select “Y” if a is “NA”, b is “Y”, c is “NA” and d is “Y”
• Select “Y” if a or b is “N”, c is “Y” and d is “Y”
• Select “N” if a or b is “N”, c is “N” and d is “Y”
• Select “N” if d is “N”
VI. SERVICE DELIVERY
Complete UNITS OF SERVICE Tables for the last six months of service within the review
VI.1
period then answer VI.1.
a. Priority status- Does the number of documented hours/units of service equal the
number of authorized hours/units; or
Non-Priority status- Does the number of documented hours/units of service indicate that
there were no service interruptions exceeding 14 consecutive days?
b. If a is “N” was the reason for the failure to provide all service hours one of the
following:
• the individual’s revised service plan identified a need for an ongoing decrease in
hours;
• the individual requested that services not be provided;
• the individual requested fewer hours of service than reflected in the service
schedule;
• the individual requested that a specific attendant not provide services;
• the individual was not at home when the service was scheduled;
• services were not delivered for other reasons beyond the control of the provider
agency; or
• services were suspended.
- The individual temporarily or permanently left the contracted services delivery area;
- The individual moved to a location where services could not be provided under the PHC program;
- The individual died;
- The individual was admitted to an institution (hospital, nursing facility, state school, state hospital, or
ICF-MR facility);
- The individual requested that services end;
- DADS denied the individual’s Medicaid eligibility (not applicable to FC);
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 214
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
21 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
- The individual or someone in the individual’s home exhibited reckless behavior, which may have
STANDARD II. ATTENDANT REQUIREMENTS
resulted in imminent danger to the health and safety of the individual, the attendant, or another person;
- The individual or someone else in the individual’s home engaged in discrimination against a provider
agency or DADS employee in violation of applicable law;
- The individual refused services for more than 30 consecutive days.
VI. 1. Were personal assistance service hours provided in accordance with the
individual’s service plans or as required?
• Select “Y” if a is “Y” or a is “N” and b is “Y”
• Select “N” if a and b are “N”
STANDARD VII. SERVICE PLAN CHANGE
• Review the individual’s record for the 12 month review period to determine if a service plan change
was identified and requested.
VII.1.
• Select “NA” if a service plan change was not identified/requested. Continue to Standard VIII.
• If a service plan change was identified/requested, complete the table below.
Date(s) of /identified Date of notification to Effective Date Date of Date(s) of identified Date of revised service
need/request for an the contractor OR (F2101, item 4) Implementation need/request for a plan
increase in service case manager (Service Delivery decrease in service
hours or change that (F2067 or equivalent) Documentation) hours
results in no delivery
of personal care tasks
a. Immediate increase in hours:
i. If requested by the contractor, did the contractor’s documentation include:
• evidence that the contractor discussed the reason for the request of immediate
increase in hours with the case manager? NA
• the date the contractor received approval from the case manager? NA
• the name of the case manager who approved the change? NA
• the effective date of change, and NA
• the number of hours authorized? NA
ii. Did the contractor implement the service plan change on the date negotiated with the
NA
case manager? NA
b. Increase in service hours or no delivery of personal care tasks:
i. If requested by the contractor, was the case manager notified in writing within seven
days from the date of request/identification of need; and NA
ii. Did the notification include:
• date the provider agency learned of the need for the change;
NA
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 215
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
21 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• reason II. ATTENDANT REQUIREMENTS
STANDARD for the change;
NA
• type of change (including the number of service hours) and:
• signature and date of the provider agency representative?
iii. For any increase in service hours requested by the contractor, individual or case manager, did the contractor
implement the change within the required timeframe?
• Was the service plan change implemented on the Begin Date (F2101, item 4) or
five days after the contractor’s date stamp on F2101, whichever is later; or NA
• If delayed, did the contractor document, by the next working day, the failure to
implement the service plan change on the effective date to include the reason and NA
new implementation date? NA
c. Decrease in service hours:
i. Did the contractor develop a new service plan within 21 days from the date of the
individual’s request or identification of need for a service plan change? NA
VII.1. If a service plan change for PAS was identified or requested, did the contractor
meet all requirements?
• If the contractor requested an increase in hours or no delivery of personal care tasks -
select “Y” if a. i-ii or b. i-iii are “Y” NA
• If the case manager requested an increase in hours or no delivery of personal care
tasks - select “Y” if a. ii or b. iii are “Y”
• Select “Y” if a decrease in service hours was requested/identified and c. is “Y”
STANDARD IX. BILLING
Compare the Units of Service tables to the Contract Monitoring Claims Report for the last six months of
service delivery within the review period.
OVERARCHING QUESTION For
the last six months of service delivery to the individual within the review
period,:
i. Were the number of units documented equal to or greater than the
number of units paid? Y or N
ii. Were the number of units paid equal to or less than the number of
IX.1a authorized units? (If No, did the increase meet the criteria of a temporary Not Calculated in
increase)? Y or N Score
• If overarching question IX.1a.i and IX.1a.ii are "Y", mark IX.1a"Y" and skip
overarching question IX.1b and mark Standard IX.1 "Y".
• If either overarching question IX.1a.i or IX.1a.ii is“N”, mark IX.1a "N" and
continue to overarching question IX.1b.
OVERARCHING QUESTION Did
the contractor provide evidence that the contractor negative billed the
over-billed amount due to DADS prior to the date of the Entrance
Not Calculated in
Conference?
IX.1b Score
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 216
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
21 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
IX.1b
• If overarching question IX.1b is “Y”, mark
STANDARD II. ATTENDANT REQUIREMENTS Standard IX.1 “Y”.
• If overarching question IX.1b is “N”, mark Standard IX.1 “N”. Complete
Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for
Payment.
IX. 1. DADS did not identify a financial error?
• Select “Y”, if the contractor does not owe an Amount Due to DADS per the Demand
for Payment Notice (Column L)
• Select “Y”, if the contractor provides evidence that the contractor negative billed the
amount due to DADS prior to the date of the entrance Conference.
• Select “N”, if the contractor owes an Amount Due to DADS per the Demand for
Payment Notice (Column L)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 217
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
22 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
II.1 Complete the Attendants Requirements Table below.
Column A: Enter the name(s) of each attendant that provided direct care to the individual during the last six
months of service delivery to the individual.
Review the contractor’s supporting documentation to answer Columns B, C and G.
Column B: Select “Y” if the attendant is at least 18 years of age or, if under 18 years of age, is a high school
graduate or is enrolled in a vocational educational program and has demonstrated competency to perform the
tasks assigned by the supervisor.
Column C: Select “NA” if Family Care. PHC/CAS- Select “Y” if the attendant is not the individual’s legal parent,
foster parent or spouse of a parent (if a minor- under the age of 18 years) or spouse (if an adult- 18 yrs or older)
Column G: For each attendant review F2101. If hired prior to 6/1/2010, select "NA". If the case manager did NOT
designate the attendant as “Do Not Hire,” select “Y”. If listed as “Do Not Hire”, select “N”. If “N” identify the number
of units provided by the attendant and paid by DADS for the last two months of service to the individual. If DADS
paid for services provided by the attendant, complete the Demand for Payment Notice columns A-H from Contract
Monitoring Claims Report, enter the number of verified units provided by the “DNH” attendant in Column J.
A. B. C. G.
Name of Attendant Attendant Attendant Attendant is
Meets the Meets the NOT
Age Relationship designated
Requirement Requirement COLUMNS LEFT BLANK as "Do Not
INTENTIONALLY Hire"
If hired on or
after
6/1/2010
`
II.1 Does each of the individual’s attendants meet the required qualifications?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 218
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
22 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• Select “Y” if ATTENDANT REQUIREMENTS
STANDARD II.for each row, all responses in column B are "Y" and all responses in
columns C and G are “Y” or "NA" (note: column C will only be NA for Family Care)
• Select “N” if for any row, a response in columns B, C or G is “N”
ORIENTATION CHECKLIST
A. B. C. D. E. F. G.
Name of Individual’s Attendant Date of First Service Date of Orientation Orientation Orientation Provided Orientation Elements not
to Individual Conducted in On or Before First Included All included in the
Person with Date of Service to the Required Orientation
Review service delivery documentation for (Review service delivery (Refer to Participation of the Individual Elements (Enter the
the last six months of service delivery within documentation for the documentation of corresponding
Individual or
review period to determine if
the review period and enter the name of first date of service to the
Attendant Attendant Met elements that were
each attendant that provided care to the sample individual was within Orientations Requirements for not addressed)
individual- NA for a Supervisor providing the last six months of conducted during the Orientation Without
personal assistance services service delivery. If the review period)
unlicensed attendant began
Participation of the
providing services to the Individual
sample individual during the
last six months of service
delivery, enter the first date
of service and complete
columns C - G. If the
unlicensed attendant worked
with the sample individual
prior to the last six months
of service delivery, select
“N” and leave columns C –
G blank.)
Last Six Months
Begin: End:
Last Name: First Name; Answer Date:
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 219
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
22 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Attendant Requirements for Orientation without Participation of the Individual (telephone/verbal): Meet the requirements of a Home health Aide*; have six continuous months of experience
delivering attendant care; has been oriented to the individual and the service plan has not changed; or has previously provided services to the individual.
Required elements:
1. Name of the individual for whom the attendant is to provide care
2. Name of the attendant
3. Date of the attendant orientation
4. Orientation conducted in person with the individual or without the participation of the individual
5. How the individual’s condition affects the performance of tasks
6. Tasks to be performed
7. Service schedule
8. Number of hours of service the attendant is to provide
9. Total number of hours the individual is authorized to receive
10. Safety and emergency procedures, including universal precautions
11. Specific situations about which the attendant should notify the contractor (e.g., changes in the individual’s needs; incidents that affect the individual’s condition; hospitalization;
absence or relocation from home; attendant’s inability to work; and suspicion/allegation of abuse, neglect or exploitation of the individual).
12. Signature of the Supervisor who conducted the orientation
13. Signature of the attendant, if present
14. Signature of the individual, if present
*A Home Health Aide must:
o have a minimum of six months experience in delivering personal care tasks in family care, primary home care, personal assistance services, client managed personal attendant
services; or
o be listed on the DADS Nurses Aide Registry with an employable “Active’ status.
II. 3. Was each attendant who began providing care to the individual during the last
six months of service delivery within the review period, oriented, as required, on or
before the first date of service delivery?
• Select “NA” if the individual’s attendant(s) began providing care to the individual prior
to the review period.
• Select “Y” if column B is “Y” and columns D., E and F. are “Y”
• Select “N” if column B is “Y” and column D., E and/or F is “N”.
STANDARD III. PRE-INITIATION ACTIVITIES
OVERARCHING QUESTION Did
the individual's pre-initiation activities occur during the review period?
III.1 • If overarching question III.1 is “N”, select “NA” for Standard III.1-3. Not Calculated in
Continue to Standard IV.1. Score
• If overarching question III.1 is “Y”, verify pre-initiation activities were
completed as required.
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 220
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
22 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Date of Referral Date of Referral Negotiated Date Stamp on Date of
(F2101, item 1) (F2101, item 25) Service Initiation F2101 Notification for
Date Intake
(Routine) (Expedited/Transf (Expedited/Transf (Retroactive)
er) er)
Date of Evaluation:
a. Routine Referral
i) Is the date of the evaluation within 14 calendar days after the date of referral or the date
the contractor received F-2101 as indicated by a date stamp- whichever is later; or
ii) If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the evaluation?
b. Expedited Referral (transfers are reviewed as an expedited referral)
i) Is the date of the evaluation on or before the date negotiated between the case
manager and contractor, which must be less than 14 days after the oral request; or
ii) If a delay, did the contractor notify the case manager of any failure to complete the
evaluation before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i) Is the date of the evaluation on or before the date of notification to DADS for intake?
d. Does the evaluation include the individual’s self-report of the dates and reasons for any
hospitalizations within 3 months prior to the evaluation were addressed?
e. Does the evaluation identify assistance needed to achieve activities of daily living,
including any assistive devices or medical equipment used by the person?
III.1. Did the contractor complete an evaluation of the individual as required?
o Select “Y” if a, b, or c is “Y” and d and e are “Y”
o Select “N” if a, b, or c is “N” and d and/or e is “N”
Date of Initial Service Delivery Plan:
a. Routine Referral
i. Was the initial service delivery plan completed within 14 calendar days after the referral
date or the date the contractor received F- 2101 as indicated by a date stamp- whichever
is later; or
ii. If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the service plan?
b. Expedited Referral (transfers are reviewed as an expedited referral)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 221
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
22 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
i. Is the date of the service delivery plan on or before the date negotiated between the
case manager and contractor, which must be less than 14 days after the oral request; or
ii If a delay, did the contractor notify the case manager of any failure to complete the
service delivery plan before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i. Was the service plan complete prior to the date of notification to DADS for intake?
d. The service plan is agreed upon and was signed by the individual and the contractor
e. The service plan identifies the location of service delivery
f. The service plan identifies the tasks the individual will receive (includes at least one
personal care task, unless FC)
g. The service plan identifies the total weekly hours authorized
h. The service plan identifies the service schedule which includes as necessary, based
on the individual’s needs, certain time periods for the delivery of specified tasks
i. The service plan identifies the frequency of supervisory visits
j. The service plan includes the statement that the contractor is responsible for providing
the tasks allowable in the PHC program (47.41) and agreed to on the service plan.
III. 2. Did the contractor develop an initial service delivery plan as required?
• Select “Y” if a, b, or c is “Y” and d - j are “Y”
• Select “N” if a, b, or c is “N” and/or d – j is “N”
OVERARCHING QUESTION Does
the individual receive family care or did the individual transfer from one
PHC contractor to another PHC, transfer from PHC to CAS or transfer from
Not Calculated in
CAS to PHC during the review period?
III.3 Score
• If overarching question III.3 is “Y”, select “NA” for Standard III.3. Continue
to Standard IV.1.
• If overarching question III.3 is “N”, verify the contractor met the
requirements for the individual’s practitioner’s statement.
Date of Practitioner’s Statement:
a. Routine Referral
i. Did the contractor obtain and submit to DADS a complete practitioner’s statement
within 14 calendar days after the date of referral or the date the contractor received F-
2101 as indicated by a date stamp- whichever is later. Review the contractor's fax, email
or other documentation that verifies the practitioner's statement was submitted to DADS
within the required timeframe; or
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 222
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
22 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. If a delay, II. ATTENDANT REQUIREMENTS
STANDARDdid the contractor document by due date the reason for the delay, an
anticipated date of completion or reason why a completion date cannot be anticipated;
and a description of the contractor’s efforts to obtain the practitioner’s statement?
b. Expedited Referral
i. Did the contractor send a complete practitioner’s statement to DADS within seven (7)
work days after service initiation? Review the contractor's fax, email or other
documentation that verifies the practitioner's statement was submitted to DADS within the
required timeframe.
c. Retroactive
i. Was the practitioner’s statement completed on or before the date of notification to
DADS for intake?
III. 3. Did the contractor meet the requirements for the individual’s practitioner’s
statement?
• Select “Y” if a, b, or c (as applicable) is “Y”
• Select “N” if a, b, or c ( as applicable) is “N”
Potential Billing Error:
If III.3 is “N”, review the Contract Monitoring Claims Report Payment Report for the billing periods within the 12
month review period prior to the date of the practitioner’s statement to determine if DADS paid for services prior to
the date of the practitioner’s statement. If DADS paid for services prior to the date of the practitioner’s statement,
complete Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for Payment. Enter “0” in Column J -
Units Verified for units paid prior to the date of the practitioner’s statement.
STANDARD IV. SERVICE INITIATION
OVERARCHING QUESTION Did
the individual enter services during the review period?
• If overarching question IV.1 is “N”, select “NA” for Standard IV.1. Continue Not Calculated in
IV.1
to Standard V.1. Score
• If overarching question IV.1 is “Y”, verify the contractor met the
requirements for service initiation.
a. Family Care- First Date of Service:
i. Routine Referral-Did services begin within 14 days after the referral date or
within 14 days after the date the contractor date stamped DADS’ authorization
form; or
ii. Transfer- Did services begin on the date negotiated between the case manager
and the contractor?
b. Primary Home Care or Community Attendant Services- First Date of Service:
i. Routine Referral- Did services begin within seven days after the date the
contractor’s receipt of DADS’ Authorization form?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 223
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
22 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. Transfer- Did services begin on the date negotiated between the case manager
STANDARD II. ATTENDANT REQUIREMENTS
and the contractor?
c. If a delay in service initiation did the contractor document the reason for the delay,
either an anticipated date of initiation or specific reasons why the contractor cannot
anticipate a date and a description of the contractor’s efforts to initiate services?
d. Did the contractor send notice of service initiation to the case manager within 14 days
after initiating services?
IV. 1. Were services initiated as required?
• Select “Y” if a is “Y”, b is “NA”, c is “NA” and d is “Y”
• Select “Y” if a is “NA”, b is “Y”, c is “NA” and d is “Y”
• Select “Y” if a or b is “N”, c is “Y” and d is “Y”
• Select “N” if a or b is “N”, c is “N” and d is “Y”
• Select “N” if d is “N”
VI. SERVICE DELIVERY
Complete UNITS OF SERVICE Tables for the last six months of service within the review
VI.1
period then answer VI.1.
a. Priority status- Does the number of documented hours/units of service equal the
number of authorized hours/units; or
Non-Priority status- Does the number of documented hours/units of service indicate that
there were no service interruptions exceeding 14 consecutive days?
b. If a is “N” was the reason for the failure to provide all service hours one of the
following:
• the individual’s revised service plan identified a need for an ongoing decrease in
hours;
• the individual requested that services not be provided;
• the individual requested fewer hours of service than reflected in the service
schedule;
• the individual requested that a specific attendant not provide services;
• the individual was not at home when the service was scheduled;
• services were not delivered for other reasons beyond the control of the provider
agency; or
• services were suspended.
- The individual temporarily or permanently left the contracted services delivery area;
- The individual moved to a location where services could not be provided under the PHC program;
- The individual died;
- The individual was admitted to an institution (hospital, nursing facility, state school, state hospital, or
ICF-MR facility);
- The individual requested that services end;
- DADS denied the individual’s Medicaid eligibility (not applicable to FC);
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 224
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
22 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
- The individual or someone in the individual’s home exhibited reckless behavior, which may have
STANDARD II. ATTENDANT REQUIREMENTS
resulted in imminent danger to the health and safety of the individual, the attendant, or another person;
- The individual or someone else in the individual’s home engaged in discrimination against a provider
agency or DADS employee in violation of applicable law;
- The individual refused services for more than 30 consecutive days.
VI. 1. Were personal assistance service hours provided in accordance with the
individual’s service plans or as required?
• Select “Y” if a is “Y” or a is “N” and b is “Y”
• Select “N” if a and b are “N”
STANDARD VII. SERVICE PLAN CHANGE
• Review the individual’s record for the 12 month review period to determine if a service plan change
was identified and requested.
VII.1.
• Select “NA” if a service plan change was not identified/requested. Continue to Standard VIII.
• If a service plan change was identified/requested, complete the table below.
Date(s) of /identified Date of notification to Effective Date Date of Date(s) of identified Date of revised service
need/request for an the contractor OR (F2101, item 4) Implementation need/request for a plan
increase in service case manager (Service Delivery decrease in service
hours or change that (F2067 or equivalent) Documentation) hours
results in no delivery
of personal care tasks
a. Immediate increase in hours:
i. If requested by the contractor, did the contractor’s documentation include:
• evidence that the contractor discussed the reason for the request of immediate
increase in hours with the case manager? NA
• the date the contractor received approval from the case manager? NA
• the name of the case manager who approved the change? NA
• the effective date of change, and NA
• the number of hours authorized? NA
ii. Did the contractor implement the service plan change on the date negotiated with the
NA
case manager? NA
b. Increase in service hours or no delivery of personal care tasks:
i. If requested by the contractor, was the case manager notified in writing within seven
days from the date of request/identification of need; and NA
ii. Did the notification include:
• date the provider agency learned of the need for the change;
NA
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 225
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
22 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• reason II. ATTENDANT REQUIREMENTS
STANDARD for the change;
NA
• type of change (including the number of service hours) and:
• signature and date of the provider agency representative?
iii. For any increase in service hours requested by the contractor, individual or case manager, did the contractor
implement the change within the required timeframe?
• Was the service plan change implemented on the Begin Date (F2101, item 4) or
five days after the contractor’s date stamp on F2101, whichever is later; or NA
• If delayed, did the contractor document, by the next working day, the failure to
implement the service plan change on the effective date to include the reason and NA
new implementation date? NA
c. Decrease in service hours:
i. Did the contractor develop a new service plan within 21 days from the date of the
individual’s request or identification of need for a service plan change? NA
VII.1. If a service plan change for PAS was identified or requested, did the contractor
meet all requirements?
• If the contractor requested an increase in hours or no delivery of personal care tasks -
select “Y” if a. i-ii or b. i-iii are “Y” NA
• If the case manager requested an increase in hours or no delivery of personal care
tasks - select “Y” if a. ii or b. iii are “Y”
• Select “Y” if a decrease in service hours was requested/identified and c. is “Y”
STANDARD IX. BILLING
Compare the Units of Service tables to the Contract Monitoring Claims Report for the last six months of
service delivery within the review period.
OVERARCHING QUESTION For
the last six months of service delivery to the individual within the review
period,:
i. Were the number of units documented equal to or greater than the
number of units paid? Y or N
ii. Were the number of units paid equal to or less than the number of
IX.1a authorized units? (If No, did the increase meet the criteria of a temporary Not Calculated in
increase)? Y or N Score
• If overarching question IX.1a.i and IX.1a.ii are "Y", mark IX.1a"Y" and skip
overarching question IX.1b and mark Standard IX.1 "Y".
• If either overarching question IX.1a.i or IX.1a.ii is“N”, mark IX.1a "N" and
continue to overarching question IX.1b.
OVERARCHING QUESTION Did
the contractor provide evidence that the contractor negative billed the
over-billed amount due to DADS prior to the date of the Entrance
Not Calculated in
Conference?
IX.1b Score
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 226
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
22 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
IX.1b
• If overarching question IX.1b is “Y”, mark
STANDARD II. ATTENDANT REQUIREMENTS Standard IX.1 “Y”.
• If overarching question IX.1b is “N”, mark Standard IX.1 “N”. Complete
Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for
Payment.
IX. 1. DADS did not identify a financial error?
• Select “Y”, if the contractor does not owe an Amount Due to DADS per the Demand
for Payment Notice (Column L)
• Select “Y”, if the contractor provides evidence that the contractor negative billed the
amount due to DADS prior to the date of the entrance Conference.
• Select “N”, if the contractor owes an Amount Due to DADS per the Demand for
Payment Notice (Column L)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 227
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
23 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
II.1 Complete the Attendants Requirements Table below.
Column A: Enter the name(s) of each attendant that provided direct care to the individual during the last six
months of service delivery to the individual.
Review the contractor’s supporting documentation to answer Columns B, C and G.
Column B: Select “Y” if the attendant is at least 18 years of age or, if under 18 years of age, is a high school
graduate or is enrolled in a vocational educational program and has demonstrated competency to perform the
tasks assigned by the supervisor.
Column C: Select “NA” if Family Care. PHC/CAS- Select “Y” if the attendant is not the individual’s legal parent,
foster parent or spouse of a parent (if a minor- under the age of 18 years) or spouse (if an adult- 18 yrs or older)
Column G: For each attendant review F2101. If hired prior to 6/1/2010, select "NA". If the case manager did NOT
designate the attendant as “Do Not Hire,” select “Y”. If listed as “Do Not Hire”, select “N”. If “N” identify the number
of units provided by the attendant and paid by DADS for the last two months of service to the individual. If DADS
paid for services provided by the attendant, complete the Demand for Payment Notice columns A-H from Contract
Monitoring Claims Report, enter the number of verified units provided by the “DNH” attendant in Column J.
A. B. C. G.
Name of Attendant Attendant Attendant Attendant is
Meets the Meets the NOT
Age Relationship designated
Requirement Requirement COLUMNS LEFT BLANK as "Do Not
INTENTIONALLY Hire"
If hired on or
after
6/1/2010
`
II.1 Does each of the individual’s attendants meet the required qualifications?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 228
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
23 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• Select “Y” if ATTENDANT REQUIREMENTS
STANDARD II.for each row, all responses in column B are "Y" and all responses in
columns C and G are “Y” or "NA" (note: column C will only be NA for Family Care)
• Select “N” if for any row, a response in columns B, C or G is “N”
ORIENTATION CHECKLIST
A. B. C. D. E. F. G.
Name of Individual’s Attendant Date of First Service Date of Orientation Orientation Orientation Provided Orientation Elements not
to Individual Conducted in On or Before First Included All included in the
Person with Date of Service to the Required Orientation
Review service delivery documentation for (Review service delivery (Refer to Participation of the Individual Elements (Enter the
the last six months of service delivery within documentation for the documentation of corresponding
Individual or
review period to determine if
the review period and enter the name of first date of service to the
Attendant Attendant Met elements that were
each attendant that provided care to the sample individual was within Orientations Requirements for not addressed)
individual- NA for a Supervisor providing the last six months of conducted during the Orientation Without
personal assistance services service delivery. If the review period)
unlicensed attendant began
Participation of the
providing services to the Individual
sample individual during the
last six months of service
delivery, enter the first date
of service and complete
columns C - G. If the
unlicensed attendant worked
with the sample individual
prior to the last six months
of service delivery, select
“N” and leave columns C –
G blank.)
Last Six Months
Begin: End:
Last Name: First Name; Answer Date:
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 229
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
23 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Attendant Requirements for Orientation without Participation of the Individual (telephone/verbal): Meet the requirements of a Home health Aide*; have six continuous months of experience
delivering attendant care; has been oriented to the individual and the service plan has not changed; or has previously provided services to the individual.
Required elements:
1. Name of the individual for whom the attendant is to provide care
2. Name of the attendant
3. Date of the attendant orientation
4. Orientation conducted in person with the individual or without the participation of the individual
5. How the individual’s condition affects the performance of tasks
6. Tasks to be performed
7. Service schedule
8. Number of hours of service the attendant is to provide
9. Total number of hours the individual is authorized to receive
10. Safety and emergency procedures, including universal precautions
11. Specific situations about which the attendant should notify the contractor (e.g., changes in the individual’s needs; incidents that affect the individual’s condition; hospitalization;
absence or relocation from home; attendant’s inability to work; and suspicion/allegation of abuse, neglect or exploitation of the individual).
12. Signature of the Supervisor who conducted the orientation
13. Signature of the attendant, if present
14. Signature of the individual, if present
*A Home Health Aide must:
o have a minimum of six months experience in delivering personal care tasks in family care, primary home care, personal assistance services, client managed personal attendant
services; or
o be listed on the DADS Nurses Aide Registry with an employable “Active’ status.
II. 3. Was each attendant who began providing care to the individual during the last
six months of service delivery within the review period, oriented, as required, on or
before the first date of service delivery?
• Select “NA” if the individual’s attendant(s) began providing care to the individual prior
to the review period.
• Select “Y” if column B is “Y” and columns D., E and F. are “Y”
• Select “N” if column B is “Y” and column D., E and/or F is “N”.
STANDARD III. PRE-INITIATION ACTIVITIES
OVERARCHING QUESTION Did
the individual's pre-initiation activities occur during the review period?
III.1 • If overarching question III.1 is “N”, select “NA” for Standard III.1-3. Not Calculated in
Continue to Standard IV.1. Score
• If overarching question III.1 is “Y”, verify pre-initiation activities were
completed as required.
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 230
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
23 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Date of Referral Date of Referral Negotiated Date Stamp on Date of
(F2101, item 1) (F2101, item 25) Service Initiation F2101 Notification for
Date Intake
(Routine) (Expedited/Transf (Expedited/Transf (Retroactive)
er) er)
Date of Evaluation:
a. Routine Referral
i) Is the date of the evaluation within 14 calendar days after the date of referral or the date
the contractor received F-2101 as indicated by a date stamp- whichever is later; or
ii) If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the evaluation?
b. Expedited Referral (transfers are reviewed as an expedited referral)
i) Is the date of the evaluation on or before the date negotiated between the case
manager and contractor, which must be less than 14 days after the oral request; or
ii) If a delay, did the contractor notify the case manager of any failure to complete the
evaluation before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i) Is the date of the evaluation on or before the date of notification to DADS for intake?
d. Does the evaluation include the individual’s self-report of the dates and reasons for any
hospitalizations within 3 months prior to the evaluation were addressed?
e. Does the evaluation identify assistance needed to achieve activities of daily living,
including any assistive devices or medical equipment used by the person?
III.1. Did the contractor complete an evaluation of the individual as required?
o Select “Y” if a, b, or c is “Y” and d and e are “Y”
o Select “N” if a, b, or c is “N” and d and/or e is “N”
Date of Initial Service Delivery Plan:
a. Routine Referral
i. Was the initial service delivery plan completed within 14 calendar days after the referral
date or the date the contractor received F- 2101 as indicated by a date stamp- whichever
is later; or
ii. If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the service plan?
b. Expedited Referral (transfers are reviewed as an expedited referral)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 231
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
23 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
i. Is the date of the service delivery plan on or before the date negotiated between the
case manager and contractor, which must be less than 14 days after the oral request; or
ii If a delay, did the contractor notify the case manager of any failure to complete the
service delivery plan before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i. Was the service plan complete prior to the date of notification to DADS for intake?
d. The service plan is agreed upon and was signed by the individual and the contractor
e. The service plan identifies the location of service delivery
f. The service plan identifies the tasks the individual will receive (includes at least one
personal care task, unless FC)
g. The service plan identifies the total weekly hours authorized
h. The service plan identifies the service schedule which includes as necessary, based
on the individual’s needs, certain time periods for the delivery of specified tasks
i. The service plan identifies the frequency of supervisory visits
j. The service plan includes the statement that the contractor is responsible for providing
the tasks allowable in the PHC program (47.41) and agreed to on the service plan.
III. 2. Did the contractor develop an initial service delivery plan as required?
• Select “Y” if a, b, or c is “Y” and d - j are “Y”
• Select “N” if a, b, or c is “N” and/or d – j is “N”
OVERARCHING QUESTION Does
the individual receive family care or did the individual transfer from one
PHC contractor to another PHC, transfer from PHC to CAS or transfer from
Not Calculated in
CAS to PHC during the review period?
III.3 Score
• If overarching question III.3 is “Y”, select “NA” for Standard III.3. Continue
to Standard IV.1.
• If overarching question III.3 is “N”, verify the contractor met the
requirements for the individual’s practitioner’s statement.
Date of Practitioner’s Statement:
a. Routine Referral
i. Did the contractor obtain and submit to DADS a complete practitioner’s statement
within 14 calendar days after the date of referral or the date the contractor received F-
2101 as indicated by a date stamp- whichever is later. Review the contractor's fax, email
or other documentation that verifies the practitioner's statement was submitted to DADS
within the required timeframe; or
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 232
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
23 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. If a delay, II. ATTENDANT REQUIREMENTS
STANDARDdid the contractor document by due date the reason for the delay, an
anticipated date of completion or reason why a completion date cannot be anticipated;
and a description of the contractor’s efforts to obtain the practitioner’s statement?
b. Expedited Referral
i. Did the contractor send a complete practitioner’s statement to DADS within seven (7)
work days after service initiation? Review the contractor's fax, email or other
documentation that verifies the practitioner's statement was submitted to DADS within the
required timeframe.
c. Retroactive
i. Was the practitioner’s statement completed on or before the date of notification to
DADS for intake?
III. 3. Did the contractor meet the requirements for the individual’s practitioner’s
statement?
• Select “Y” if a, b, or c (as applicable) is “Y”
• Select “N” if a, b, or c ( as applicable) is “N”
Potential Billing Error:
If III.3 is “N”, review the Contract Monitoring Claims Report Payment Report for the billing periods within the 12
month review period prior to the date of the practitioner’s statement to determine if DADS paid for services prior to
the date of the practitioner’s statement. If DADS paid for services prior to the date of the practitioner’s statement,
complete Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for Payment. Enter “0” in Column J -
Units Verified for units paid prior to the date of the practitioner’s statement.
STANDARD IV. SERVICE INITIATION
OVERARCHING QUESTION Did
the individual enter services during the review period?
• If overarching question IV.1 is “N”, select “NA” for Standard IV.1. Continue Not Calculated in
IV.1
to Standard V.1. Score
• If overarching question IV.1 is “Y”, verify the contractor met the
requirements for service initiation.
a. Family Care- First Date of Service:
i. Routine Referral-Did services begin within 14 days after the referral date or
within 14 days after the date the contractor date stamped DADS’ authorization
form; or
ii. Transfer- Did services begin on the date negotiated between the case manager
and the contractor?
b. Primary Home Care or Community Attendant Services- First Date of Service:
i. Routine Referral- Did services begin within seven days after the date the
contractor’s receipt of DADS’ Authorization form?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 233
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
23 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. Transfer- Did services begin on the date negotiated between the case manager
STANDARD II. ATTENDANT REQUIREMENTS
and the contractor?
c. If a delay in service initiation did the contractor document the reason for the delay,
either an anticipated date of initiation or specific reasons why the contractor cannot
anticipate a date and a description of the contractor’s efforts to initiate services?
d. Did the contractor send notice of service initiation to the case manager within 14 days
after initiating services?
IV. 1. Were services initiated as required?
• Select “Y” if a is “Y”, b is “NA”, c is “NA” and d is “Y”
• Select “Y” if a is “NA”, b is “Y”, c is “NA” and d is “Y”
• Select “Y” if a or b is “N”, c is “Y” and d is “Y”
• Select “N” if a or b is “N”, c is “N” and d is “Y”
• Select “N” if d is “N”
VI. SERVICE DELIVERY
Complete UNITS OF SERVICE Tables for the last six months of service within the review
VI.1
period then answer VI.1.
a. Priority status- Does the number of documented hours/units of service equal the
number of authorized hours/units; or
Non-Priority status- Does the number of documented hours/units of service indicate that
there were no service interruptions exceeding 14 consecutive days?
b. If a is “N” was the reason for the failure to provide all service hours one of the
following:
• the individual’s revised service plan identified a need for an ongoing decrease in
hours;
• the individual requested that services not be provided;
• the individual requested fewer hours of service than reflected in the service
schedule;
• the individual requested that a specific attendant not provide services;
• the individual was not at home when the service was scheduled;
• services were not delivered for other reasons beyond the control of the provider
agency; or
• services were suspended.
- The individual temporarily or permanently left the contracted services delivery area;
- The individual moved to a location where services could not be provided under the PHC program;
- The individual died;
- The individual was admitted to an institution (hospital, nursing facility, state school, state hospital, or
ICF-MR facility);
- The individual requested that services end;
- DADS denied the individual’s Medicaid eligibility (not applicable to FC);
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 234
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
23 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
- The individual or someone in the individual’s home exhibited reckless behavior, which may have
STANDARD II. ATTENDANT REQUIREMENTS
resulted in imminent danger to the health and safety of the individual, the attendant, or another person;
- The individual or someone else in the individual’s home engaged in discrimination against a provider
agency or DADS employee in violation of applicable law;
- The individual refused services for more than 30 consecutive days.
VI. 1. Were personal assistance service hours provided in accordance with the
individual’s service plans or as required?
• Select “Y” if a is “Y” or a is “N” and b is “Y”
• Select “N” if a and b are “N”
STANDARD VII. SERVICE PLAN CHANGE
• Review the individual’s record for the 12 month review period to determine if a service plan change
was identified and requested.
VII.1.
• Select “NA” if a service plan change was not identified/requested. Continue to Standard VIII.
• If a service plan change was identified/requested, complete the table below.
Date(s) of /identified Date of notification to Effective Date Date of Date(s) of identified Date of revised service
need/request for an the contractor OR (F2101, item 4) Implementation need/request for a plan
increase in service case manager (Service Delivery decrease in service
hours or change that (F2067 or equivalent) Documentation) hours
results in no delivery
of personal care tasks
a. Immediate increase in hours:
i. If requested by the contractor, did the contractor’s documentation include:
• evidence that the contractor discussed the reason for the request of immediate
increase in hours with the case manager? NA
• the date the contractor received approval from the case manager? NA
• the name of the case manager who approved the change? NA
• the effective date of change, and NA
• the number of hours authorized? NA
ii. Did the contractor implement the service plan change on the date negotiated with the
NA
case manager? NA
b. Increase in service hours or no delivery of personal care tasks:
i. If requested by the contractor, was the case manager notified in writing within seven
days from the date of request/identification of need; and NA
ii. Did the notification include:
• date the provider agency learned of the need for the change;
NA
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 235
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
23 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• reason II. ATTENDANT REQUIREMENTS
STANDARD for the change;
NA
• type of change (including the number of service hours) and:
• signature and date of the provider agency representative?
iii. For any increase in service hours requested by the contractor, individual or case manager, did the contractor
implement the change within the required timeframe?
• Was the service plan change implemented on the Begin Date (F2101, item 4) or
five days after the contractor’s date stamp on F2101, whichever is later; or NA
• If delayed, did the contractor document, by the next working day, the failure to
implement the service plan change on the effective date to include the reason and NA
new implementation date? NA
c. Decrease in service hours:
i. Did the contractor develop a new service plan within 21 days from the date of the
individual’s request or identification of need for a service plan change? NA
VII.1. If a service plan change for PAS was identified or requested, did the contractor
meet all requirements?
• If the contractor requested an increase in hours or no delivery of personal care tasks -
select “Y” if a. i-ii or b. i-iii are “Y” NA
• If the case manager requested an increase in hours or no delivery of personal care
tasks - select “Y” if a. ii or b. iii are “Y”
• Select “Y” if a decrease in service hours was requested/identified and c. is “Y”
STANDARD IX. BILLING
Compare the Units of Service tables to the Contract Monitoring Claims Report for the last six months of
service delivery within the review period.
OVERARCHING QUESTION For
the last six months of service delivery to the individual within the review
period,:
i. Were the number of units documented equal to or greater than the
number of units paid? Y or N
ii. Were the number of units paid equal to or less than the number of
IX.1a authorized units? (If No, did the increase meet the criteria of a temporary Not Calculated in
increase)? Y or N Score
• If overarching question IX.1a.i and IX.1a.ii are "Y", mark IX.1a"Y" and skip
overarching question IX.1b and mark Standard IX.1 "Y".
• If either overarching question IX.1a.i or IX.1a.ii is“N”, mark IX.1a "N" and
continue to overarching question IX.1b.
OVERARCHING QUESTION Did
the contractor provide evidence that the contractor negative billed the
over-billed amount due to DADS prior to the date of the Entrance
Not Calculated in
Conference?
IX.1b Score
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 236
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
23 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
IX.1b
• If overarching question IX.1b is “Y”, mark
STANDARD II. ATTENDANT REQUIREMENTS Standard IX.1 “Y”.
• If overarching question IX.1b is “N”, mark Standard IX.1 “N”. Complete
Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for
Payment.
IX. 1. DADS did not identify a financial error?
• Select “Y”, if the contractor does not owe an Amount Due to DADS per the Demand
for Payment Notice (Column L)
• Select “Y”, if the contractor provides evidence that the contractor negative billed the
amount due to DADS prior to the date of the entrance Conference.
• Select “N”, if the contractor owes an Amount Due to DADS per the Demand for
Payment Notice (Column L)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 237
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
24 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
II.1 Complete the Attendants Requirements Table below.
Column A: Enter the name(s) of each attendant that provided direct care to the individual during the last six
months of service delivery to the individual.
Review the contractor’s supporting documentation to answer Columns B, C and G.
Column B: Select “Y” if the attendant is at least 18 years of age or, if under 18 years of age, is a high school
graduate or is enrolled in a vocational educational program and has demonstrated competency to perform the
tasks assigned by the supervisor.
Column C: Select “NA” if Family Care. PHC/CAS- Select “Y” if the attendant is not the individual’s legal parent,
foster parent or spouse of a parent (if a minor- under the age of 18 years) or spouse (if an adult- 18 yrs or older)
Column G: For each attendant review F2101. If hired prior to 6/1/2010, select "NA". If the case manager did NOT
designate the attendant as “Do Not Hire,” select “Y”. If listed as “Do Not Hire”, select “N”. If “N” identify the number
of units provided by the attendant and paid by DADS for the last two months of service to the individual. If DADS
paid for services provided by the attendant, complete the Demand for Payment Notice columns A-H from Contract
Monitoring Claims Report, enter the number of verified units provided by the “DNH” attendant in Column J.
A. B. C. G.
Name of Attendant Attendant Attendant Attendant is
Meets the Meets the NOT
Age Relationship designated
Requirement Requirement COLUMNS LEFT BLANK as "Do Not
INTENTIONALLY Hire"
If hired on or
after
6/1/2010
`
II.1 Does each of the individual’s attendants meet the required qualifications?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 238
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
24 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
• Select “Y” if ATTENDANT REQUIREMENTS
STANDARD II.for each row, all responses in column B are "Y" and all responses in
columns C and G are “Y” or "NA" (note: column C will only be NA for Family Care)
• Select “N” if for any row, a response in columns B, C or G is “N”
ORIENTATION CHECKLIST
A. B. C. D. E. F. G.
Name of Individual’s Attendant Date of First Service Date of Orientation Orientation Orientation Provided Orientation Elements not
to Individual Conducted in On or Before First Included All included in the
Person with Date of Service to the Required Orientation
Review service delivery documentation for (Review service delivery (Refer to Participation of the Individual Elements (Enter the
the last six months of service delivery within documentation for the documentation of corresponding
Individual or
review period to determine if
the review period and enter the name of first date of service to the
Attendant Attendant Met elements that were
each attendant that provided care to the sample individual was within Orientations Requirements for not addressed)
individual- NA for a Supervisor providing the last six months of conducted during the Orientation Without
personal assistance services service delivery. If the review period)
unlicensed attendant began
Participation of the
providing services to the Individual
sample individual during the
last six months of service
delivery, enter the first date
of service and complete
columns C - G. If the
unlicensed attendant worked
with the sample individual
prior to the last six months
of service delivery, select
“N” and leave columns C –
G blank.)
Last Six Months
Begin: End:
Last Name: First Name; Answer Date:
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 239
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
24 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Attendant Requirements for Orientation without Participation of the Individual (telephone/verbal): Meet the requirements of a Home health Aide*; have six continuous months of experience
delivering attendant care; has been oriented to the individual and the service plan has not changed; or has previously provided services to the individual.
Required elements:
1. Name of the individual for whom the attendant is to provide care
2. Name of the attendant
3. Date of the attendant orientation
4. Orientation conducted in person with the individual or without the participation of the individual
5. How the individual’s condition affects the performance of tasks
6. Tasks to be performed
7. Service schedule
8. Number of hours of service the attendant is to provide
9. Total number of hours the individual is authorized to receive
10. Safety and emergency procedures, including universal precautions
11. Specific situations about which the attendant should notify the contractor (e.g., changes in the individual’s needs; incidents that affect the individual’s condition; hospitalization;
absence or relocation from home; attendant’s inability to work; and suspicion/allegation of abuse, neglect or exploitation of the individual).
12. Signature of the Supervisor who conducted the orientation
13. Signature of the attendant, if present
14. Signature of the individual, if present
*A Home Health Aide must:
o have a minimum of six months experience in delivering personal care tasks in family care, primary home care, personal assistance services, client managed personal attendant
services; or
o be listed on the DADS Nurses Aide Registry with an employable “Active’ status.
II. 3. Was each attendant who began providing care to the individual during the last
six months of service delivery within the review period, oriented, as required, on or
before the first date of service delivery?
• Select “NA” if the individual’s attendant(s) began providing care to the individual prior
to the review period.
• Select “Y” if column B is “Y” and columns D., E and F. are “Y”
• Select “N” if column B is “Y” and column D., E and/or F is “N”.
STANDARD III. PRE-INITIATION ACTIVITIES
OVERARCHING QUESTION Did
the individual's pre-initiation activities occur during the review period?
III.1 • If overarching question III.1 is “N”, select “NA” for Standard III.1-3. Not Calculated in
Continue to Standard IV.1. Score
• If overarching question III.1 is “Y”, verify pre-initiation activities were
completed as required.
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 240
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
24 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
Date of Referral Date of Referral Negotiated Date Stamp on Date of
(F2101, item 1) (F2101, item 25) Service Initiation F2101 Notification for
Date Intake
(Routine) (Expedited/Transf (Expedited/Transf (Retroactive)
er) er)
Date of Evaluation:
a. Routine Referral
i) Is the date of the evaluation within 14 calendar days after the date of referral or the date
the contractor received F-2101 as indicated by a date stamp- whichever is later; or
ii) If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the evaluation?
b. Expedited Referral (transfers are reviewed as an expedited referral)
i) Is the date of the evaluation on or before the date negotiated between the case
manager and contractor, which must be less than 14 days after the oral request; or
ii) If a delay, did the contractor notify the case manager of any failure to complete the
evaluation before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i) Is the date of the evaluation on or before the date of notification to DADS for intake?
d. Does the evaluation include the individual’s self-report of the dates and reasons for any
hospitalizations within 3 months prior to the evaluation were addressed?
e. Does the evaluation identify assistance needed to achieve activities of daily living,
including any assistive devices or medical equipment used by the person?
III.1. Did the contractor complete an evaluation of the individual as required?
o Select “Y” if a, b, or c is “Y” and d and e are “Y”
o Select “N” if a, b, or c is “N” and d and/or e is “N”
Date of Initial Service Delivery Plan:
a. Routine Referral
i. Was the initial service delivery plan completed within 14 calendar days after the referral
date or the date the contractor received F- 2101 as indicated by a date stamp- whichever
is later; or
ii. If a delay, did the contractor document the reason for the delay, an anticipated date of
completion or reason why a completion date cannot be anticipated; and a description of
the contractor’s efforts to complete the service plan?
b. Expedited Referral (transfers are reviewed as an expedited referral)
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 241
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
24 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
STANDARD II. ATTENDANT REQUIREMENTS
i. Is the date of the service delivery plan on or before the date negotiated between the
case manager and contractor, which must be less than 14 days after the oral request; or
ii If a delay, did the contractor notify the case manager of any failure to complete the
service delivery plan before the negotiated date for completion of pre-initiation activities?
c. Retroactive
i. Was the service plan complete prior to the date of notification to DADS for intake?
d. The service plan is agreed upon and was signed by the individual and the contractor
e. The service plan identifies the location of service delivery
f. The service plan identifies the tasks the individual will receive (includes at least one
personal care task, unless FC)
g. The service plan identifies the total weekly hours authorized
h. The service plan identifies the service schedule which includes as necessary, based
on the individual’s needs, certain time periods for the delivery of specified tasks
i. The service plan identifies the frequency of supervisory visits
j. The service plan includes the statement that the contractor is responsible for providing
the tasks allowable in the PHC program (47.41) and agreed to on the service plan.
III. 2. Did the contractor develop an initial service delivery plan as required?
• Select “Y” if a, b, or c is “Y” and d - j are “Y”
• Select “N” if a, b, or c is “N” and/or d – j is “N”
OVERARCHING QUESTION Does
the individual receive family care or did the individual transfer from one
PHC contractor to another PHC, transfer from PHC to CAS or transfer from
Not Calculated in
CAS to PHC during the review period?
III.3 Score
• If overarching question III.3 is “Y”, select “NA” for Standard III.3. Continue
to Standard IV.1.
• If overarching question III.3 is “N”, verify the contractor met the
requirements for the individual’s practitioner’s statement.
Date of Practitioner’s Statement:
a. Routine Referral
i. Did the contractor obtain and submit to DADS a complete practitioner’s statement
within 14 calendar days after the date of referral or the date the contractor received F-
2101 as indicated by a date stamp- whichever is later. Review the contractor's fax, email
or other documentation that verifies the practitioner's statement was submitted to DADS
within the required timeframe; or
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 242
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
24 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. If a delay, II. ATTENDANT REQUIREMENTS
STANDARDdid the contractor document by due date the reason for the delay, an
anticipated date of completion or reason why a completion date cannot be anticipated;
and a description of the contractor’s efforts to obtain the practitioner’s statement?
b. Expedited Referral
i. Did the contractor send a complete practitioner’s statement to DADS within seven (7)
work days after service initiation? Review the contractor's fax, email or other
documentation that verifies the practitioner's statement was submitted to DADS within the
required timeframe.
c. Retroactive
i. Was the practitioner’s statement completed on or before the date of notification to
DADS for intake?
III. 3. Did the contractor meet the requirements for the individual’s practitioner’s
statement?
• Select “Y” if a, b, or c (as applicable) is “Y”
• Select “N” if a, b, or c ( as applicable) is “N”
Potential Billing Error:
If III.3 is “N”, review the Contract Monitoring Claims Report Payment Report for the billing periods within the 12
month review period prior to the date of the practitioner’s statement to determine if DADS paid for services prior to
the date of the practitioner’s statement. If DADS paid for services prior to the date of the practitioner’s statement,
complete Columns A-L of the PHC/FC/CAS Monitoring Workbook - Demand for Payment. Enter “0” in Column J -
Units Verified for units paid prior to the date of the practitioner’s statement.
STANDARD IV. SERVICE INITIATION
OVERARCHING QUESTION Did
the individual enter services during the review period?
• If overarching question IV.1 is “N”, select “NA” for Standard IV.1. Continue Not Calculated in
IV.1
to Standard V.1. Score
• If overarching question IV.1 is “Y”, verify the contractor met the
requirements for service initiation.
a. Family Care- First Date of Service:
i. Routine Referral-Did services begin within 14 days after the referral date or
within 14 days after the date the contractor date stamped DADS’ authorization
form; or
ii. Transfer- Did services begin on the date negotiated between the case manager
and the contractor?
b. Primary Home Care or Community Attendant Services- First Date of Service:
i. Routine Referral- Did services begin within seven days after the date the
contractor’s receipt of DADS’ Authorization form?
Texas Department of Aging Form TBD
PRIMARY HOME CARE/FAMILY CARE/
and Disability Services Page 243
COMMUNITY ATTENDANT SERVICES
INDIVIDUAL WORKPAPER
Sample Contract Number Contract Type: Dates of Review Begin: 01/00/1900
Number
24 Period End: 01/00/1900
Last: Date Completed
Completed By
First:
ii. Transfer- Did services begin on the date negotiated between the case manager
STANDARD II. ATTENDANT REQUIREMENTS
and the contractor?
c. If a delay in service initiation did the contractor document the reason for the delay,
either an anticipated date of initiation or specific reasons why the contractor cannot
anticipate a date and a description of the contractor’s efforts to initiate services?
d. Did the contractor send notice of service initiation to the case manager within 14 days
after initiating services?
IV. 1. Were services initiated as required?
• Select “Y” if a is “Y”, b is “NA”, c is “NA” and d is “Y”
• Select “Y” if a is “NA”, b is “Y”, c is “NA” and d is “Y”
• Select “Y” if a or b is “N”, c is “Y” and d is “Y”
• Select “N” if a or b is “N”, c is “N” and d is “Y”
• Select “N” if d is “N”
VI. SERVICE DELIVERY
Complete UNITS OF SERVICE Tables for the last six months of service within the review
VI.1
period then answer VI.1.
a. Priority status- Does the number of documented hours/units of service equal the
number of authorized hours/units; or
Non-Priority status- Does the number of documented hours/units of service indicate that
there were no service interruptions exceeding 14 consecutive days?
b. If a is “N” was the reason for the failure to provide all service hours one of the
following:
• the individual’s revised service plan identified a need for an ongoing decrease in
hours;
• the individual requested that services not be provided;
• the individual requested fewer hours of service than reflected in the service
schedule;
• the individual requested that a specific attendant not provide services;
• the individual was not at home when the service was scheduled;
• services were not delivered for other reasons beyond the control of the provider
agency; or
• services were suspended.
- The individual temporarily or permanently left the contracted services delivery area;
- The individual moved to a location where services could not be provided under the PHC program;
- The individual died;
- The individual was admitted to an institution (hospital, nursing facility, state school, state hospital, or
ICF-MR facility);
- The individual requested that services end;
- DADS denied the individual’s Medicaid eligibility (not applicable to FC);
Texas Department of Aging Form TBD