Texas Department Of Aging
and Disability Services
Form TBD
Community Living Assistance Support Services (CLASS)
Case Management Agency (CMA)
Page 1
MONITORING WORKBOOK
Name of Legal Entity
Completed By
Review Level:
Full
Targeted
Review Type:
Formal
Follow Up
Date of Entrance (First day on-site)
Contract No.
Administrative
Complaint
Date of Exit (Last
day on-site)
Begin Date:
Revised Exit Date
End Date:
Dates of Monitoring Period
A response of “Yes” means the contractor has met the requirement. “No” means the contractor has not met the requirement. “N/A” means the requirement is not applicable. For any item marked as “No”
attach copies of supporting documents. All attachments should be numbered and indicate the applicable Standard and item.
STANDARD I. POLICIES AND PROCEDURES
1. Are complaints documented and investigated?
N/A
Y
N
N/A
Y
N
N/A
Y
N
Review the contractor’s CLASS complaint log or record of complaints reported during the 24-month monitoring period to verify each of the
following:







the date the CMA received the complaint;
the name of the person who filed the complaint;
a description of the nature of the complaint;
the name of the staff person who conducted the investigation of the complaint;
the names of persons contacted during the investigation of the complaint;
the outcome of the complaint; and
the date final action was taken by the CMA in response to the complaint
Reference: 40 TAC §45.707 CMA: Quality Management and Complaint Process (effective 3/21/2011)
2. Does the CMA have written policies and procedures that safeguard individuals against each of the following:





Infectious and communicable diseases
Conflicts of interest with CMA staff persons
Acts of financial impropriety
Abuse, neglect and exploitation; and
Deliberate damage of personal possessions
Reference: 40 TAC §45.702 Protection of Individual, Initial and Annual Explanations, and Offering Access to Other Services if Termination Presents a Threat to
Health and Safety (effective 3/21/2011)
3. Does the CMA have a quality assurance process to evaluate and improve the quality of case management provided
based in part on the survey results?


Request the contractor’s most recently completed annual satisfaction survey sent to all individuals, LARs and persons actively involved
with the individual; and
Ask the contractor for examples of how the survey results were used and what actions, if any, were taken to make improvements.
Note: Select “N/A” if the contract was effective within the previous 12 months.
Reference: CLASS Provider Manual Appendix I, Section 1300, Administrative Requirements (prior to 3/21/2011); 40 TAC §45.707 CMA: Quality Management and
Complaint Process
3 7 2012
A copy of the Workbook is given to the contractor’s representative at the exit conference
Texas Department Of Aging
and Disability Services
Form TBD
Community Living Assistance Support Services (CLASS)
Case Management Agency (CMA)
Page 2
MONITORING WORKBOOK
Name of Legal Entity
Contract No.
Completed By
Dates of Monitoring Period
A response of “Yes” means the contractor has met the requirement. “No” means the contractor has not met the requirement. “N/A” means the requirement is not applicable. For any item marked as “No”
attach copies of supporting documents. All attachments should be numbered and indicate the applicable Standard and item.
STANDARD I. POLICIES AND PROCEDURES (continued)
4. Does the CMA have a written process that ensures case managers are or can readily become familiar with individuals to
whom they are not ordinarily assigned, but to whom they may be required to provide case management?
N/A
Y
N
N/A
Y
N
N/A
Y
N
Reference: 40 TAC §45.705 CMA Service Delivery; CLASS Provider Manual, Section 2310, Enrollment (effective 6/13/2011)
5. Does the contractor have a written process for screening employees and contractors for exclusion from participation in
Medicare, Medicaid, the State Children’s Health Insurance 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 to HHSC-OIG any exclusion information discovered?
Reference: State Medicaid Director Letter, 09-001; Information Letter 09-33; Information Letter 10-20; Information Letter 11-07;Information Letter 11-102 (CMS)
6. Does the contractor conduct pre-employment/pre-contracting and monthly screening of employees and subcontractors against the federal and state LEIE? Documentation must include all elements below:
Review the documentation of the checks conducted for the last month of 24-month monitoring period.

date of the federal and state database searches;

first and last names and date of birth of all employees and sub-contractors subject to LEIE search requirements;

whether or not the employee/sub-contractor appeared in the federal/state LEIE databases;

date any excluded employee/sub-contractor was self-reported to HHSC-OIG;

copy of the self-report; and

name(s) and signatures of staff responsible for completing the pre-employment and pre-contracting monthly searches.
Reference: State Medicaid Director Letter, 09-001; Information Letter 09-33; Information Letter 10-20; Information Letter 11-07; Information Letter 11-102 (CMS)
Comments:
Total Yes
STANDARD I. POLICIES AND PROCEDURES
3 7 2012
A copy of the Workbook is given to the contractor’s representative at the exit conference
Total No
Texas Department Of Aging
and Disability Services
Form TBD
Community Living Assistance Support Services (CLASS)
Case Management Agency (CMA)
Page 3
MONITORING WORKBOOK
Name of Legal Entity
Contract No.
Completed By
Dates of Monitoring Period
A response of “Y” means the contractor has met the requirement. “N” means the contractor has not met the requirement. “N/A” 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 II. STAFF QUALIFICATIONS/TRAINING
(Complete the Staff Qualifications/Training Table to answers items II. 1-3)
1. Did staff hired during the monitoring period meet the
A
B
required qualifications?
C
D
E
F
G
H
I
J
K
L
M
N
O
R
S
T
U
V
W
X
Y
Z
AA
BB
CC
DD
See STAFF QUALIFICATIONS/TRAINING TABLE
P
Q
Reference: CLASS Provider Manual, Appendix 1, Section 1403, Staff
Requirements (prior to 3/21/2011); 40 TAC §45.703 CMA,Qualifications of CMA
Staff Persons (effective 3/21/2011)
Comments:
Number Yes
2. For each staff hired during the monitoring period was
a background check, resulting in no bars to
employment, conducted within the required
timeframe?
A
B
C
D
E
F
G
P
Q
R
S
T
U
V
H
Number No
I
J
K
L
M
N
O
X
Y
Z
AA
BB
CC
DD
See the STAFF QUALIFICATIONS/TRAINING TABLE
W
Reference: CLASS Provider Manual, Section 3700, Criminal History Checks
(prior to 3/21/2011); CLASS Provider Manual, Appendix VIII Criminal History
Check of Employees in Certain Agencies/Facilities Serving the Elderly or
Persons with Disabilities (prior to 3/21/2011); 40 TAC §45.703 Qualifications of
CMA Staff Persons; 40 TAC §93 Employee Misconduct Registry; Chapter 250
Health and Safety Code §250.003 Nurse Aide Registry and Criminal History
Checks of Employees and Applicants for Employment in Certain Facilities
Serving the Elderly or Persons with Disabilities
Comments:
3 7 2012
A copy of the Workbook is given to the contractor’s representative at the exit conference
Number Yes
Number No
Texas Department Of Aging
and Disability Services
Form TBD
Community Living Assistance Support Services (CLASS)
Case Management Agency (CMA)
Page 4
MONITORING WORKBOOK
Name of Legal Entity
Contract No.
Completed By
Dates of Monitoring Period
A response of “Y” means the contractor has met the requirement. “N” means the contractor has not met the requirement. “N/A” 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 II. STAFF QUALIFICATIONS/TRAINING (continued)
(Complete the Staff Qualifications/Training Table to answers items II. 1-3)
3. Did staff receive training within the required time
A
B
frames?
C
D
E
F
G
R
S
T
U
V
H
I
J
K
L
M
N
O
X
Y
Z
AA
BB
CC
DD
See the STAFF QUALIFICATIONS/TRAINING TABLE
Reference: CLASS Provider Manual, Section 3400 Provider Training
Requirements (prior to 6/13/2011); CLASS Provider Manual, Section 3410
Case Management and Direct Services Agencies (prior to 6/13/2011); CLASS
Provider Manual, Section 2121 Initial Training (effective 1/13/2012); CLASS
Provider Manual, Section 2122 Annual Training (effective 5/1/2012); 40 TAC
§45.704 Training of CMA Staff Persons; Information Letter 09-110
Comments:
P
Q
W
Number Yes
Number No
Total Yes
Total No
STANDARD II. STAFF QUALIFICATIONS/TRAINING
STANDARD III. CASE MANAGEMENT
(See Individual Work Papers for items III. 1-16)
1. Did the CMA conduct the initial face-to-face as
required?
Reference: IL 09-110 (prior to 3/21/2011); CLASS Provider Manual Section
4300 (prior to 3/21/2011); 40 TAC §45.212 Process for Enrollment of an
Individual; CLASS Provider Manual Section 2310, Enrollment; 40 TAC §45.217
CDS Option; 40 TAC §49.18 Client Rights and Responsibilities
1
2
3
4
5
6
16
17
18
19
20
21
7
22
8
9
10
11
12
13
14
15
23
24
25
26
27
28
29
30
Comments:
3 7 2012
Number Yes
A copy of the Workbook is given to the contractor’s representative at the exit conference
Number No
Texas Department Of Aging
and Disability Services
Form TBD
Community Living Assistance Support Services (CLASS)
Case Management Agency (CMA)
Page 5
MONITORING WORKBOOK
Name of Legal Entity
Contract No.
Completed By
Dates of Monitoring Period
A response of “Y” means the contractor has met the requirement. “N” means the contractor has not met the requirement. “N/A” 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 III. CASE MANAGEMENT
(See Individual Work Papers for items III. 1-16)
2. Did the CMA complete the Pre-Enrollment
activities as required?
1
2
3
4
5
6
7
16
17
18
19
20
21
22
8
9
10
11
12
13
14
15
23
24
25
26
27
28
29
30
Reference: CLASS Provider Manual Section 4200, Appendix 1-1502 (prior to
3/21/2011); 40 TAC §45.212 Process for Enrollment of an Individual; CLASS
Provider Manual Section 2310, Enrollment; 40 TAC §45.217 CDS Option
Comments:
Did the CMA conduct the initial SPT as
required?
3.
Number Yes
1
2
3
4
5
6
16
17
18
19
20
21
7
22
8
9
10
11
12
13
14
15
23
24
25
26
27
28
29
30
Reference: IL 2008-11 (prior to 3/21/2011); 40 TAC §45.214 Development of
Enrollment IPC; 40 TAC §45.103 Definitions; CLASS Provider Manual Section
2300, Service Planning
Comments:
3 7 2012
Number No
A copy of the Workbook is given to the contractor’s representative at the exit conference
Number Yes
Number No
Texas Department Of Aging
and Disability Services
Form TBD
Community Living Assistance Support Services (CLASS)
Case Management Agency (CMA)
Page 6
MONITORING WORKBOOK
Name of Legal Entity
Contract No.
Completed By
Dates of Monitoring Period
A response of “Y” means the contractor has met the requirement. “N” means the contractor has not met the requirement. “N/A” 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 III. CASE MANAGEMENT (continued)
(See Individual Work Papers for Items III. 1-16)
4. Did the CMA complete the SPT enrollment
activities as required?
1
2
3
4
5
6
16
17
18
19
20
21
7
22
8
9
10
11
12
13
14
15
23
24
25
26
27
28
29
30
Reference: CLASS Provider Manual Section 4400, Corrective Action Plans
(prior to 3/21/2011); 40 TAC §45.214 Development of Enrollment IPC; 40 TAC
§45.103 Definitions; CLASS Provider Manual Section 2300, Service Planning
Comments:
5. Did the CMA conduct the renewal SPT as
required?
Number Yes
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: CLASS Provider Manual Section 4400, Individual Service Plan;
CLASS Provider Manual Section 4600, Individual Program Plan; CLASS
Provider Manual Section 4340, Interdisciplinary Team (prior to 3/21/2011);
CLASS Provider Manual, Form 3621, CLASS - Individual Plan of Care,
Instructions; CLASS Provider Manual, Non-Waiver Services, Instructions;
CLASS Provider Manual, Form 8606, Individual Program Plan (IPP) - CLASS
and CWP Instructions; CLASS Provider Manual, Form 3596 CLASS Habilitation Plan, Instructions; CLASS Provider Manual, Form 3597 CLASS Habilitation Training Plan, Instructions (prior to 6/13/2011); 40 TAC §45.223
Renewal and Revision of an IPC(effective 3/21/2011); CLASS Provider Manual
Section 2320 Renewal (effective 6/13/2011)
Comments:
3 7 2012
Number No
A copy of the Workbook is given to the contractor’s representative at the exit conference
Number Yes
Number No
Texas Department Of Aging
and Disability Services
Form TBD
Community Living Assistance Support Services (CLASS)
Case Management Agency (CMA)
Page 7
MONITORING WORKBOOK
Name of Legal Entity
Contract No.
Completed By
Dates of Monitoring Period
A response of “Y” means the contractor has met the requirement. “N” means the contractor has not met the requirement. “N/A” 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 III. CASE MANAGEMENT (continued)
(See Individual Work Papers for Items III. 1-16)
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
6. Did the CMA complete the SPT renewal activities
as required?
Reference: CLASS Provider Manual Section 4400, Individual Service Plan (prior to
6/13/2011); 40 TAC §45.223 Renewal and Revision of an IPC; CLASS Provider
Manual Section 2320 Renewal
Comments:
7. Did the CMA conduct the SPT revision(s) as
required?
Reference: CLASS Provider Manual, Section 4711, DHS Approval of Updated
ISP; CLASS Provider Manual, Section 4400, Individual Service Plan; CLASS
Provider Manual, Section 4600, Individual Program Plan; CLASS Provider
Manual, Form 8606 , Individual Program Plan (IPP) Instructions (prior to
6/13/11); 40 TAC §45.223 Renewal and Revision of an IPC; CLASS Provider
Manual Section 2330 Revision
Comments:
3 7 2012
Number Yes
Number No
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
A copy of the Workbook is given to the contractor’s representative at the exit conference
Number Yes
Number No
Texas Department Of Aging
and Disability Services
Form TBD
Community Living Assistance Support Services (CLASS)
Case Management Agency (CMA)
Page 8
MONITORING WORKBOOK
Name of Legal Entity
Contract No.
Completed By
Dates of Monitoring Period
A response of “Y” means the contractor has met the requirement. “N” means the contractor has not met the requirement. “N/A” 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 III. CASE MANAGEMENT (continued)
(See Individual Work Papers for Items III. 1-16)
8. Were the SPT revision activities completed 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: CLASS Provider Manual Section 4400, Individual Service Plan (prior to
6/13/2011); 40 TAC §45.223 Renewal and Revision of an IPC; CLASS Provider
Manual Section 2330, Revision and 2331 Immediate Jeopardy
Comments:
9. Were IPP quarterly reviews completed as
required?
Reference: CLASS Provider Manual, Section 4700, Service Delivery
Verification and Evaluation; CLASS Provider Manual, Section 4710, ISP/IPP
Review and Updates; CLASS Provider Manual, Appendix I Section 1503,
Individual Service Plan; and CLASS Provider Manual, Form 3595, IPP
Quarterly Review, Instructions (prior to 6/13/2011); 40 TAC §45.223 Renewal
and Revision of an IPC; CLASS Provider Manual Section 2350 Quarterly
Review
Comments:
3 7 2012
Number Yes
Number No
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
A copy of the Workbook is given to the contractor’s representative at the exit conference
Number Yes
Number No
Texas Department Of Aging
and Disability Services
Form TBD
Community Living Assistance Support Services (CLASS)
Case Management Agency (CMA)
Page 9
MONITORING WORKBOOK
Name of Legal Entity
Contract No.
Completed By
Dates of Monitoring Period
A response of “Y” means the contractor has met the requirement. “N” means the contractor has not met the requirement. “N/A” 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 III. CASE MANAGEMENT (continued)
(See Individual Work Papers for Items III. 1-16)
10. Did the CMA verify the individual’s Medicaid
Eligibility 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 §45.302 Mandatory Participation; CLASS Provider Manual
Section 2200, Eligibility
Comments:
Number Yes
11. Were transfer activities completed as
required?
Number No
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: CLASS Provider Manual, Transfer Procedures, Section 4930 (prior
to 6/13/2011); 40 TAC §45.401 Coordination of Transfers (effective 3/21/2011);
CLASS Provider Manual 2340 Transfer (effective 6/13/2011)
Comments:
3 7 2012
Number Yes
A copy of the Workbook is given to the contractor’s representative at the exit conference
Number No
Texas Department Of Aging
and Disability Services
Form TBD
Community Living Assistance Support Services (CLASS)
Case Management Agency (CMA)
Page 10
MONITORING WORKBOOK
Name of Legal Entity
Contract No.
Completed By
Dates of Monitoring Period
A response of “Y” means the contractor has met the requirement. “N” means the contractor has not met the requirement. “N/A” 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 III. CASE MANAGEMENT (continued)
(See Individual Work Papers for Items III. 1-16)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Reference: CLASS Provider Manual, Section 4940, Denials, Reductions,
Suspensions, and Terminations (prior to 3/21/2011); 40 TAC §45.403 Denial of a
CLASS Program Service; 40 TAC §45.410 Requirement to Submit Fair Hearing
Request Summary to DADS; CLASS Provider Manual Section 2410 Denial
(effective 6/13/2011)
Comments:
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
13. Did the CMA suspend services to the individual
as required?
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Reference: CLASS Provider Manual, Section 4940, Denials, Reductions,
Suspensions, and Terminations (prior to 3/21/2011); 40 TAC §45.404 Suspension
of CLASS Program Services; 40 TAC §45.410 Requirement to Submit Fair
Hearing Request Summary to DADS; CLASS Provider Manual Section 2430
Suspension
Comments:
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
12. Did the CMA send notice of denial of program
service to the individual as required?
14. Did the CMA send notification of reduction as
required?
Reference: CLASS Provider Manual, Section 4940, Denials, Reductions,
Suspensions, and Terminations (prior to 3/21/2011); 40 TAC §45.405
Reduction of a CLASS Program Service; 40 TAC §45.410 Requirement to
Submit Fair Hearing Request Summary to DADS; CLASS Provider Manual
2420 Reduction
Comments:
3 7 2012
Number Yes
Number No
Number Yes
Number No
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
A copy of the Workbook is given to the contractor’s representative at the exit conference
Number Yes
Number No
Texas Department Of Aging
and Disability Services
Form TBD
Community Living Assistance Support Services (CLASS)
Case Management Agency (CMA)
Page 11
MONITORING WORKBOOK
Name of Legal Entity
Contract No.
Completed By
Dates of Monitoring Period
A response of “Y” means the contractor has met the requirement. “N” means the contractor has not met the requirement. “N/A” 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 III. CASE MANAGEMENT (continued)
(See Individual Work Papers for Items III. 1-16)
15. Did the CMA send notification of termination 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: CLASS Provider Manual, Section 4940, Denials, Reductions,
Suspensions, and Terminations(prior to 3/21/2011); 40 TAC §45.406 Termination of
CLASS Program Services With Advance Notice Because of Ineligibility or Leave from the
State or Because DSAs Cannot Ensure Health and Safety;40 TAC §45.407 Termination
of CLASS Program Services With Advance Notice Because of Non-compliance With
Mandatory Participation Requirements; 40 TAC §45.408 Termination of CLASS Program
Services Without Advance Notice; 40 TAC §45.409 Termination of CLASS Program
Services Without Advance Notice Because of Behavior Causing Immediate Jeopardy
Termination of a CLASS Program Service; 40 TAC §45.410 Requirement to Submit Fair
Hearing Request Summary to DADS; CLASS Provider Manual 2440, Termination;
CLASS Provider Manual 2441, Termination with Advance Notice; CLASS Provider
Manual 2442, Termination without Advance Notice
Comments:
Number Yes
16. Did the Case Manager manage the crisis 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: CLASS Provider Manual, Section 4720, Crisis Intervention (prior to
3/21/2011)
Comments:
STANDARD III. CASE MANAGEMENT
3 7 2012
Number No
A copy of the Workbook is given to the contractor’s representative at the exit conference
Number Yes
Number No
Total Yes
Total No
Texas Department Of Aging
and Disability Services
Form TBD
Community Living Assistance Support Services (CLASS)
Case Management Agency (CMA)
Page 12
MONITORING WORKBOOK
Name of Legal Entity
Contract No.
Completed By
Dates of Monitoring Period
A response of “Y” means the contractor has met the requirement. “N” means the contractor has not met the requirement. “N/A” 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 IV. BILLING
(See Monitoring Workbook-Demand for Payment Notice for item IV.1)
1. DADS did not identify a financial, or if applicable,
administrative 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
26
27
28
29
30
Reference: 40 TAC §45.401 Administrative Errors (prior to 3/21/2011); 40 TAC
§45.403 Financial Errors (prior to 3/21/2011); 40 TAC §45.901 Administrative
Errors (effective 3/21/2011); 40 TAC §45.902 Financial Errors(effective 3/21/2011);
40 TAC §45.706 CMA Recordkeeping (effective 3/21/2011)
Comments:
Total Yes
STANDARD IV. BILLING
3 7 2012
A copy of the Workbook is given to the contractor’s representative at the exit conference
Total No
Texas Department Of Aging
and Disability Services
Form TBD
Community Living Assistance Support Services (CLASS)
Case Management Agency (CMA)
Page 13
MONITORING WORKBOOK
Name of Legal Entity
Completed By
Review Level:
Full
Targeted
Dates of Review Period
Review Type:
Contract No.
Formal
Administrative
Begin Date:
End Date:
Follow Up
Complaint
Date of Entrance (First day on-site)
Date of Exit (Last day on-site)
A.
Total Yes
COMPLIANCE SCORE
Standard I
POLICIES AND PROCEDURES
Standard II
STAFF QUALIFICATIONS/TRAINING
Standard III
CASE MANAGEMENT
Standard IV
BILLING
Overall Total
Financial Errors
AMOUNT DUE TO DADS
Amount
$
(Demand for Payment Notice-Sum Columns L and N)
Administrative Errors
Amount
$
TOTAL $
3 7 2012
A copy of the Workbook is given to the contractor’s representative at the exit conference
B.
Total No
C.
Total
(A + B)
D.
Score
(A/C x 100)
Texas Department Of Aging
and Disability Services
Form TBD
Community Living Assistance Support Services (CLASS)
Case Management Agency (CMA)
Page 14
MONITORING WORKBOOK
DEMAND FOR PAYMENT NOTICE
Name of Legal Entity
Contract No.
Completed By
Dates of Monitoring Period
Complete the Demand for Payment Notice for all disallowed Units of Service.
Complete columns A-H by entering the original payment information from the Contract
Monitoring Claims Report (for each individual listed below, enter “N” for IV. 1)
Complete columns I - N to determine the amount due to DADS
Date of Exit (Last day on-site)
H/G
Units of
Service
Tables
(G-J)
(IxK)
H x .12
(if M is “Y”)
A
B
C
D
E
F
G
H
I
J
K
L
M
N
Client ID
Number
Last
Initial
First
Initial
Svc
Code
Svc Begin
Date
Svc End
Date
No. of
Units
Amount
Paid
Unit
Rate
Units
Verified
Units Pd
in Error
Amt.
Due
to
DADS
(Admin)
Y/N
Amt. Due
to DADS
(Financial)
To offset the amount(s) due to DADS the contractor must submit negative bills (by individual) as indicated above within 60 calendar days from the date of
exit conference or if applicable, the date the contractor receives Form 5997.
3 7 2012
A copy of the Workbook is given to the contractor’s representative at the exit conference