Authorization of Designated Person to Perform Listed Tasks

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Authorization of Designated Person to Perform Listed Tasks Powered By Docstoc
					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
                                                                                PRIMARY HOME CARE/FAMILY CARE/
and Disability Services                                                                                                                                    Page 244
                                                                                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:
            - 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 245
                                                                               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:
          • 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