Section 3000, Protocol and Contract Monitoring Guidance

Revision 13-1; Effective November 1, 2013

 

Purpose

The purpose of the monitoring review is to determine compliance with the:

 

3100 Pre-Monitoring Activities

Revision 13-1; Effective November 1, 2013

 

Contract monitoring reviews are conducted using a team approach. At least two members of the Department of Aging and Disability Services (DADS) Oversight and Community Support (OCS) Unit participate in the pre-monitoring activities and the field monitoring reviews.

The review team:

  1. Designates a team leader for the monitoring review.
  2. Determines when to send the letter announcing the contract monitoring review. The quarterly notice letter is sent at the beginning of the quarter for contract reviews which fall within the upcoming quarter. The contract monitoring entrance letter is sent 30 calendar days in advance of the monitoring review.
  3. Determines the review period to be covered during the monitoring visit. Review periods will be based on the last review period and may range from 10 months to 14 months. The initial review period for new contracts is six months.
  4. Determines the sample for review. The sample number of cases reviewed for each monitoring review is 15 cases or 30 percent of all DADS wards served by the contractor, whichever number is greater. If a contractor serves less than 15 DADS wards, the total number of wards served will be included in the sample. The sample includes established guardianship of the person cases, newly referred guardianship of person cases, closed cases and may include guardian of the estate cases for the identified review period. The sample is drawn from the Guardianship Online Database (GOLD) system and the Monthly Wards Served report. The Monthly Wards Served report is maintained by the contractor; it identifies wards served by the contractor. The contractor provides this report to the DADS contract manager within 10 calendar days after the entrance letter is received by the contractor. A random sample is then drawn utilizing information gathered from the GOLD reports and the Monthly Wards Served report. Ten percent or more of the wards sampled for the review may be interviewed or observed.
  5. Prepares the monitoring visit review packets.
  6. Reviews the findings of the previous contract monitoring visit, as well as any follow-up actions as a result of the visit. The team reviews any complaints and results of investigations which have been conducted since the last monitoring visit. The review team ensures the contractor remained in compliance with the previous plan of correction and followed DADS rules and regulations and requirements regarding the investigation and resolution of complaints.

 

3200 Sampling Methodology

Revision 13-1; Effective November 1, 2013

 

Purpose

The sampling methodology to be used for Department of Aging and Disability Services (DADS) guardianship contractors includes:

Specific Methodology

 

3300 Expanded Sample

Revision 13-1; Effective November 1, 2013

 

During the monitoring review, if the review team identifies significant findings which impact the health and safety or financial standing of the wards, the monitoring team may expand the sample up to 100 percent.

Before expanding the sample, the team leader contacts the Oversight and Community Support unit manager to discuss the findings or issues identified. If the unit manager agrees, a decision is made to expand the sample, including how much to expand the sample. DADS state office identifies the additional names for the sample using the randomizer for individuals not selected in the initial sample.

The team leader notifies the contractor of the need to expand the sample and provides an estimate of the amount of time required to complete the review. After the expanded sample is selected, the team leader works with the contractor to obtain the needed records and information.

 

3400 Entrance Conference

Revision 13-1; Effective November 1, 2013

 

The monitoring team holds an entrance conference with the contractor’s representative and any staff members the contractor chooses to include. The entrance conference may be conducted in person, by webinar or conference call. During the entrance conference, the following activities occur:

  1. The team leader explains the purpose of the review, the monitoring process, the sampling methodology and review period.
  2. The team leader obtains the name of the contact person who will be available to the review team throughout the visit.
  3. The team leader gives an estimated amount of time required to complete the monitoring review.
  4. The team leader provides the contractor with the sample list of the wards’ names selected to be reviewed and requests the contact person, such as a supervisor, certified guardian or other staff be available during the monitoring review to respond to any inquiries by the monitoring team. The contact person or other individuals identified may be available in person or by telephone.
  5. The team leader discusses the use of interviews and observations as part of the determination for compliance. After a sample of wards for interviews and observations is determined, the team leader may coordinate some or all of the visits with the contractor. The contractor or certified guardian may coordinate the visits with the wards and facility staff.
  6. Time is allotted for questions and comments from the contractor and others at the entrance conference and throughout the review.
  7. The team leader stresses ongoing communication during the review. If questions arise or information is missing during the course of the review, the team leader requests the information from the contact person. Every effort is made to obtain information prior to the exit conference.

 

3500 General Information

Revision 13-1; Effective November 1, 2013

 

The annual review process focuses on outcomes and compliance with the Department of Aging and Disability Services (DADS) rules, state regulations, and other applicable standards and statutes. The benchmarks contractors must meet are located in this handbook. The guardianship rules are found in the Texas Administrative Code, Title 40, Part I, Chapter 10. Texas Probate Code, Texas Estates Code and other applicable statutes and standards governing guardianship practice. The review team determines if the contractor met or did not meet a benchmark based upon the rules and this handbook. The benchmarks are a subsection of a broader area called guardianship principles. The contractor must meet both benchmarks and guardianship principles.

Observations and Interviews

Observations and interviews are used to determine whether a benchmark is met or unmet. The review team conducts interviews with wards, collaterals, certified guardians, volunteers, managers, facility staff, employees of the court or others, as determined to be appropriate, to obtain information and determine compliance with the benchmarks. The review team observes wards in their place of residence, school, place of employment or day program location to determine if wards’ needs are being met, the cleanliness of the environment and other circumstances identified in the wards’ service plans.

Determination if a Benchmark is Met or Unmet

Information collected during record reviews, observations and interviews about the wards selected in the sample is used to determine the contractor's overall compliance with guardianship rules and benchmarks. Benchmarks may be determined as met or unmet based upon significant findings identified during the monitoring visit. However, one incident or one case could result in an unmet determination. The compliance determination is based upon the severity of the incident and the actions taken by the contractor.

The following guardianship principles and benchmarks provide guidance to the review team to determine whether a benchmark is met or unmet. Determination is significantly based on professional judgment and the requirements of each benchmark, rules, statutes, and standards governing guardianship practice. The team looks for significant findings to determine if the benchmark is met; however, one significant finding, as opposed to a pattern or trend, can result in a determination of an unmet benchmark.

 

3600 Determining if a Guardianship Principle is Met or Unmet

Revision 13-1; Effective November 1, 2013

 

A guardianship principle is the overall category for a set of benchmarks. There are eight guardianship principles each contracted guardianship provider must meet.

The guardianship principles are:

  1. Ensure all legal requirements are completed in compliance with policies, procedures and applicable codes and statutes.
  2. Ensure case management responsibilities are performed in compliance with court orders, policies and procedures.
  3. Ensure service related activities are completed, documented and maintained in accordance with policies and procedures.
  4. Ensure fiduciary responsibilities are performed in compliance with court orders, policies and procedures, and avoid the appearance of impropriety.
  5. Ensure the health and safety of DADS wards by making appropriate medical decisions and reporting allegations of abuse, neglect and exploitation to the appropriate investigative authority.
  6. Develop and implement a Quality Assurance (QA) Plan to ensure compliance with standards, policies, procedures, training requirements, and applicable codes and statutes.
  7. Ensure payment from DADS is accepted as payment in full for services rendered under the contract.
  8. Ensure DADS is notified of ward status updates and ward deaths. Ensure notifications are provided to the OCS contract manager and administrative assistant in a timely manner.

The benchmarks under each guardianship principle are evaluated before a decision is made as to whether the guardianship principle is met or unmet. The review team reviews each benchmark based upon evidence collected during the monitoring visit. After the review team makes a determination as to whether each benchmark is met or unmet, the review team determines if each guardianship principle is met or unmet. Each guardianship principle has a number of benchmarks which must be met. Depending on the significance of the findings, a decision is made as to whether the guardianship principle is met or unmet. If benchmarks are met, guardianship principles are met. Failure to meet a guardianship principle results in an action. The action may be a corrective action plan or may be a recommendation for a sanction as described in Texas Administrative Code (TAC), Title 40, Part 1, Chapter 10 Subchapter E, Rule § 10.507 of the guardianship rules or the DADS guardianship contract. Depending on the guardianship principle deemed to be unmet and outcomes which negatively impact the wards, a sanction may be recommended.

Failure to meet guardianship principles which significantly impact a ward’s safety and health may result in the recommendation for a sanction resulting in an action.

Exit Conference

The purpose of the exit conference is to share the findings with the contracted provider. During the exit conference, the following activities occur:

Plan of Correction

The contract manager contacts the contractor to discuss any significant findings. If there are issues or concerns the contractor does not agree with, those must be discussed with the contract manager at that time. The statement of findings is emailed to the contractor. The contractor submits a plan of correction (POC) based on discussions with the contract manager and the statement of findings. The POC must stipulate actions the contractor will take to correct the findings, the persons responsible for the correction and the date the correction will be completed. An email will be sent to the contracted provider indicating when the POC is due. In the email with the Statement of Findings, a deadline to submit a POC is identified. If additional corrective measures are required, the deadline may be extended at the discretion of the DADS contract manager. The POC is submitted to the monitoring team lead and, if necessary, may be returned to the contractor for changes or additions, or may be accepted as written.

Follow-up Reviews

Based upon the types of findings cited during the review, DADS may conduct a desk review or may conduct an on-site follow-up review. On-site follow-up reviews may or may not be announced, but will not occur before the accepted date of the POC. If it is determined an on-site follow-up visit will occur, the contract manager pulls a sample of cases to determine whether the findings have been corrected and if the benchmarks and guardianship principles are met. The size and type of cases included in the follow-up sample will be based on the previously cited findings and approved by the OCS unit manager. A follow-up POC will be submitted to the contractor outlining what findings have been corrected or not corrected.

Failure to correct cited findings may result in further actions, as stated in TAC, Title 40, Part 1, Chapter 10, Subchapter E, Rule §10.507 of the DADS guardianship rules and the DADS guardianship contract.

Readiness and Courtesy Reviews

A readiness review is conducted for new guardianship contractors within 30 days of the contract start date. A courtesy review is conducted for new guardianship contractors before the annual compliance review, generally six months after the contract start date. The contract manager performs a readiness review and courtesy review to determine the contractor’s readiness for a compliance monitoring review and to provide technical support, as needed.

 

3700 Guardianship Principles and Benchmarks

Revision 13-1; Effective November 1, 2013

 

The review team determines the contractor's compliance with each guardianship principle and benchmark based on the Department of Aging and Disability Services (DADS) guardianship rules, this handbook, Texas Probate Code, Texas Estates Code, and other applicable statutes and standards governing guardianship practice. The guardianship principle is a general category. Under each guardianship principle are the benchmarks that must be met.

Failure to meet a guardianship principle could result in a sanction action towards the contractor. The contractor must comply with eight guardianship principles.

The guardianship principles are:

  1. Legal requirements — Ensure all legal requirements are completed in compliance with policies, procedures and applicable codes.
  2. Case management requirements — Ensure case management responsibilities are performed in compliance with court orders, policies and procedures.
  3. Documentation requirements — Ensure service related activities are completed, documented and maintained in accordance with policies and procedures.
  4. Financial requirements — Ensure fiduciary responsibilities are performed in compliance with court orders, policies and procedures, and avoid the appearance of impropriety.
  5. Health and safety requirements — Ensure the health and safety of DADS wards by making appropriate medical decisions and reporting allegations of abuse, neglect and exploitation to the appropriate investigative authority.
  6. Quality assurance requirements — Develop and implement a Quality Assurance (QA) Plan to ensure compliance with standards, policies, procedures, training requirements and applicable codes.
  7. Payment for services requirements — Ensure payment from DADS is accepted as payment in full for services rendered under the contract.
  8. Ward status and updates — Ensure DADS is notified of ward status updates and ward deaths. Ensure notification is provided to the Oversight and Community Support (OCS) contract manager and OCS administrative assistant in a timely manner.

Benchmarks are evaluated for compliance through record reviews, observations and interviews to determine if the guardianship principles are met or unmet. Not all benchmarks are equal in weight. It is possible for one benchmark or several benchmarks within a principle to not be met but the guardianship principle to be met. Failure to meet any guardianship principles or a number of guardianship principles may result in the need for follow-up action or action that could negatively affect the contract.

Guardianship Principle 1:

Ensure legal requirements are completed in compliance with policies, procedures and applicable codes.

Benchmark 1:

Complete ongoing legal activities in compliance with policies, procedures and applicable codes. The contractor must ensure all legal documents for guardianship are file marked or certified copies are filed in the ward’s case record. The contractor must ensure the certified guardian performs the legal duties and responsibilities, as outlined in the orders for the guardianship.

How to determine met or unmet:

The team reviews the ward’s records to determine:

The outcome for this benchmark is:

Documentation reflects all actions by the contractor met the ward's needs within the order of guardianship. All legal documents are file marked or certified. Guardianships are maintained in good standing with the court, guardianship letters remain current, and the ward’s estate is managed to his/her benefit (if applicable).

Benchmark 2:

Final legal activities are completed in compliance with policies, procedures and applicable codes.

How to determine met or unmet:

The team conducts a review of the ward’s records to determine:

The review team conducts interviews, as needed, to clarify information or research missing information. Based upon review of the records and interviews, the team determines if the standard is met or unmet.

The outcome for this benchmark is:

Guardianships are closed within time frames established by the Probate or Estates Code. The ward’s property was delivered to the former ward or appropriate person.

Guardianship Principle 2:

Ensure case management responsibilities are performed in compliance with court orders, policies and procedures.

Benchmark 1:

Arrange for care of, and services to, the ward based upon the identified needs. Services will enhance the ward's quality of life. Ensure the ward has access to basic care and services, including:

How to determine met or unmet:

The team reviews the ward's records to determine:

The review team conducts interviews with the certified guardian, staff who work with the wards in their living environments, staff who work with the wards in other environments (individuals in all environments such as a day activity program, vocational setting, etc.) and other collaterals who have contact with the wards to determine if needs have been met. The review team may observe a ward to determine:

The team conducts record reviews, interviews and observations to determine if this benchmark is met. Focus is placed on the identified needs of the wards and how those needs are being met. Observations are an important component of this benchmark to determine if the needs of the wards are being met and also if the wards are living in safe and clean environments.

The outcome for this benchmark is:

The ward's needs are being met and efforts are made to enhance the ward's quality of life.

Benchmark 2:

Ensure monthly face-to-face contact with each ward.

How to determine met or unmet:

The team conducts a review of the documentation to determine:

The review team observes wards to determine:

The review team conducts interviews with the certified guardian and collaterals to determine knowledge of the ward, the ward’s needs, and the follow-up to identified needs and issues. The review team conducts interviews to clarify documentation, or if documentation is not available, determines the status of the case.

The review team makes a determination as to whether the benchmark is met based upon documentation, interviews and observations. The review team looks for significant instances which may adversely impact the ward. Best guardianship practices, as outlined in statutes, applicable codes and professional judgment are used to determine if the benchmark is met or unmet.

The outcome for this benchmark is:

Staff observe wards in their various environments at least quarterly (unless the ward is in a situation where observations are not possible, such as jail) in order to identify unmet needs and promote quality of life.

Benchmark 3:

Ensure the confidentiality of all wards’ records and ensure case records are stored and maintained in a secure and confidential manner.

How to determine met or unmet:

The team conducts a review of the records to determine:

The review team observes and conducts interviews to determine if staff followed confidentiality policies and procedures. The team looks for significant confidentiality findings and makes a determination if the benchmark is met or unmet based upon documentation, interviews and observations.

The outcome for this benchmark:

The ward’s right to privacy is protected and the ward’s information is not shared unnecessarily.

Benchmark 4:

Complete ongoing casework activities according to policies, procedures and other best practices as outlined by the GCB or JBCC.

How to determine met or unmet:

The team reviews records of the wards to determine:

The review team observes wards and conducts interviews, as appropriate, to verify if the benchmark is met or unmet. The team may interview and observe the ward, individuals at the facility or placement of the ward, collaterals, court officials or others to ensure casework activities were completed. Based upon observation, interview and review of the documentation, the review team determines if the benchmark is met or unmet.

The outcome for this benchmark is:

Promotes quality of life, addresses the ward’s needs on an ongoing basis, and follows casework benchmarks to ensure the ward’s needs are met.

Benchmark 5:

Ensure services are provided by persons who can adequately communicate with the ward.

How to determine met or unmet:

The team conducts record reviews to determine:

The review team makes observations, conducts interviews with the certified guardian, service providers and the ward to determine:

The team conducts record reviews, interviews and observations to determine if this benchmark is met. The team observes the wards to determine if their communication needs are addressed in the service plan and if the certified guardian and service providers are able to communicate with the wards in order to meet their needs.

The outcome for this benchmark is:

Service providers are able to meet the communication needs of the wards.

Guardianship Principle 3:

Ensure service related activities are documented and maintained in accordance with policies and procedures.

Benchmark 1:

Ensure consultations and approvals are documented, as required by policy.

How to determine met or unmet:

The team conducts a review of records to determine:

The review team may not conduct observations for this benchmark, but conducts interviews, as needed, to determine why documents or documentation is missing and why consultation was not completed. Observations of the ward may be conducted if there are questions which cannot be answered other than by interviewing and observing the ward.

The review team makes a determination as to whether the benchmark is met or unmet based upon documentation, interviews and observations, as appropriate. The benchmark may be unmet if findings indicate a negative impact on the ward(s).

The outcome for this benchmark is:

Decisions are made in the best interest of the ward after appropriate consultation and consideration is given to alternatives and outcomes.

Benchmark 2:

Maintain wards’ records with appropriate documentation as required by policies, procedures, the Probate Code or the Estates Code, statute rules and regulations. Provide read-only access to records database systems maintained by contractor.

How to determine met or unmet:

The team conducts a review of the ward’s records to determine:

The review team may conduct interviews with the certified guardian, court officials and other collaterals to determine if the benchmark is met or unmet.

The outcome for this benchmark is:

Documentation is clear, concise and current. All contacts and events are documented in the record. The ward’s needs are being met.

Guardianship Principle 4:

Ensure fiduciary responsibilities are performed in compliance with court orders for guardian of the person and or guardian of the estate, policies and procedures, and to avoid any appearance of impropriety.

Benchmark 1:

Ensure financial responsibilities, as outlined in court orders or by expectation of the GCB or JBCC, as appropriate, are followed to maintain and protect the ward’s trust fund accounts and other accounts managed on behalf of the ward. Ensure trust fund statements are obtained and reviewed quarterly and registers with receipts are maintained in the ward’s case file. Ensure the ward’s finances are being maintained in a fiscally responsible and prudent manner. Ensure financial responsibilities are followed and maintained to protect the ward’s bank accounts, estate, trust accounts or other assets, as appropriate, if serving as guardian of the estate or as representative payee. Ensure all financial records are documented and maintained using commonly accepted accounting methods. Ensure all identified financial discrepancies are followed up on to resolution and any trust fund issues are reported to the appropriate investigative agency.

How to determine met or unmet:

The team conducts a review of the ward’s records to determine:

The review team conducts interviews to clarify documentation or establish facts concerning an audit trail. The review team determines the benchmark is met or unmet based upon documentation and interviews

The outcome for this benchmark is:

All financial practices adhere strictly to the rules, regulations and court order, and avoid any appearance of impropriety. All identified financial issues have a resolution. All trust fund discrepancies are reported to the appropriate investigative agency.

Guardianship Principle 5:

Ensure the health and safety of wards by making appropriate medical decisions and reporting allegations of abuse, neglect and exploitation to the appropriate investigative authority.

Benchmark 1:

Make medical decisions on behalf of the ward following policies, procedures, applicable codes and statutes while respecting the culture and wishes of the ward.

How to determine met or unmet:

The team conducts a review of records to determine:

The review team conducts interviews for missing, conflicting information or for clarification, as needed. If treatment has not been performed, the reviewer may observe the ward and review his or her medical records. The team determines if the benchmark is met or unmet based upon a review of records, interviews and observations, as needed.

The outcome for this benchmark is:

The ward’s medical needs are met and the ward is included in the decisions as much as possible.

Benchmark 2:

Report suspected abuse, neglect or exploitation to the appropriate agency. Contractors must notify the DADS contract manager within 24 hours of making the report and submit the Ward Status Update Form to the contract manager.

The team reviews the records of the wards to determine:

The team conducts a review of the wards’ records and talks to the certified guardian and/or the program director to obtain a list of individuals who have been alleged victims of abuse, neglect or exploitation within the review period. The team reviews the agency complaint log to verify the incident was documented, DADS was notified and there was follow-up. The team interviews office staff and wards to determine what actions were taken and if the ward was protected. Based upon review of the wards’ records, interviews and observations, the team determines if the benchmark is met or unmet.

The outcome for this benchmark: is:

Wards have access to a safe, clean environment, their rights are protected and reports have been made to the appropriate investigating authority.

Benchmark 3:

If the alleged perpetrator is the contractor's employee or volunteer, the contractor must:

How to determine met or unmet:

The team conducts record and documentation reviews to determine:

The review team conducts interviews with employees, wards and management staff to determine:

The review team determines if the benchmark is met based upon review of policies and procedures, documentation and interviews with staff from the contracting agency and staff from DADS or other investigative agencies. The review team may interview the wards affected by the alleged abuse, neglect or exploitation. The contractor ensures any employee or volunteer who was an alleged perpetrator had no contact with DADS wards during an investigation and if found not to be the perpetrator, was re-oriented prior to future contact with the DADS wards.

The outcome for this benchmark is:

The contractor reported allegations of abuse, neglect or exploitation within the required time frames to the Department of Family and Protective Services (DFPS) and law enforcement. The contractor took immediate steps to protect the wards, ensure the ward's health and safety, and arrange for needed services. Wards are protected from abuse, neglect and exploitation.

Guardianship Principle 6:

Develop and implement a Quality Assurance (QA) plan to ensure compliance with principles, benchmarks, policies, procedures, training requirements and applicable statutes, and administrative rules to monitor internal and external systems of operation.

Benchmark 1:

Develop and implement a QA system to ensure compliance with principles, benchmarks, policies, procedures, and the Probate or Estates Code, as applicable. The QA plan must be reviewed annually for improvement in the program’s operations and revised in accordance with best practices and acceptable benchmarks.

How to determine met and unmet:

The team reviews the contractor’s QA plan to determine:

The review team interviews the supervisor, certified guardians and other staff to ensure all are aware of the QA plan and the plan is followed. The team determines, based upon review and implementation of the plan and interviews, if the standard is met or unmet.

The outcome for this benchmark is:

A QA plan is implemented. Significant problems are identified and resolved.

Benchmark 2:

A complaint tracking system is used to ensure complaints are investigated and follow-up is conducted, as needed.

How to determine met or unmet:

The team reviews the complaint tracking system to determine:

The review team conducts interviews with the supervisor, certified guardian and other staff to ensure everyone is aware of the complaint procedures and log requirements. The team reviews documentation of the complaint investigations and determines if follow-up was completed or needed. Based upon interviews and review of the complaint system, the team determines if the benchmark is met or unmet.

The outcome for this benchmark is:

Complaints are tracked and investigated to protect wards. Problems are identified and addressed when appropriate.

Benchmark 3:

Ensure staff attend training, as required by the GCB or the JBCC and policy. Ensure new employees, certified guardians and/or volunteers receive an orientation, initial training and ongoing training. Ensure volunteers are trained, supervised and monitored and only provide life enhancement activities.

How to determine met or unmet:

The team reviews training records to determine:

The review team reviews documentation to determine if volunteers are providing life enrichment activities only or if they are performing duties of a certified guardian.

The review team interviews staff and volunteers to ensure staff participated in the training. The team reviews the records of wards, as well as the training documentation, sign-in sheets and meeting agendas to ensure compliance with policies and procedures and GCB or JBCC. Based upon documentation and interviews, the review team determines if the standard is met or unmet.

The outcome for this benchmark is:

Staff received mandated training. Deficiencies in training were identified. Staff demonstrate their ability to implement principles taught in training. Volunteers receive necessary training, as outlined in agency policy and by the GCB or the JBCC.

Benchmark 4:

Ensure qualified staff are certified by the GCB or the JBCC, as authorized in the Texas Government Code (TGC), §111.042. Ensure staff maintain guardianship certification, as required by TGC §111.042 and register with the county, as appropriate. Staff must remain certified and register with each county in which they serve as a certified guardian. An adequate number of qualified certified guardians must be maintained to provide guardianship services to wards served under the contract.

How to determine met or unmet:

The team conducts a review of personnel records to determine:

The team reviews personnel records, interviews the supervisor and interviews court authorities, as needed, to ensure compliance with the benchmarks. Based upon interviews and documentation, the team determines if the benchmark is met or unmet. The team reviews personnel records and the guardianship certification website to determine if the benchmark is met. If needed, the review team interviews certified guardians, other staff and management staff to determine if the benchmark is met.

The outcome for this benchmark is:

Staff hired to serve the wards are qualified as certified guardians and registration requirements were met.

Benchmark 5:

Ensure a request for a criminal background check was submitted to DADS for prospective employees or volunteers who may have access to a ward, the estate of a ward or the benefits of a DADS ward. An offer of employment or access to wards is contingent upon the prospective employee or volunteer successfully passing a criminal history check. Ensure a criminal background check was conducted by the contractor using the National Registered Sex Offenders website for any visitors requesting unsupervised visits with DADS wards.

The team reviews documentation of criminal background checks to determine:

The team reviews the list of completed criminal background checks and background check queries in each case file within the sample, as well as the personnel folders of newly hired employees or new volunteers to determine if the benchmark is met or unmet.

The outcome for this benchmark is:

Criminal background checks through DADS for all employees and volunteers who will have access to a DADS ward, the estate of the ward, or the benefits of the ward were completed. Criminal history checks were completed by the contractor on visitors to wards who requested unsupervised visits on the National Registered Sex Offenders Verification website.

Benchmark 6:

Develop and implement policies and procedures and ensure a plan is in place to disseminate new policies and procedures to staff.

How to determine met or unmet:

The team conducts a review of the wards’ records to determine:

The review team conducts interviews to determine what system and processes the contractor has in place for dissemination of policies and procedures, how staff implement new directions, and if staff understand the policies and procedures. The review team determines if the benchmark is met or unmet based upon record review and interviews. If applicable, the review team may use observations to ensure staff implement procedures correctly. Based upon interviews and review of the wards’ records, the review team determines if benchmarks are met or unmet.

The outcome for this benchmark:

Disseminate and implement new policies and procedures as established in policy.

Benchmark 7:

Develop and implement policies and procedures for employees to ensure they are not excluded from participation in Medicare, Medicaid, the Children’s Health Insurance Program, and all federal health care programs to include:

Prior to hiring and on monthly basis:

How to determine met or unmet:

The review team determines if the benchmark is met, based upon a review of policies and procedures, documentation and interviews with staff.

The outcome for this benchmark is:

A system is in place to ensure employees are screened initially and then monthly for exclusion from participation in Medicare, Medicaid, the Children’s Health Insurance Program and all federal health care programs. Identified exclusions are immediately reported to HHSC/OIG and verifying documentation is available.

Benchmark 8:

Agents, employees and volunteers of the contractor, or their immediate family and friends, may not purchase the ward's property directly or through a third party.

How to determine met or unmet:

The team conducts a review of the ward's financial and legal records, as appropriate, regarding the sale of property to determine:

The review team may conduct interviews with staff and the ward to determine:

The team conducts reviews of the ward’s records, documentation of sale of property and interviews to determine if the benchmark is met. The review team conducts interviews to ensure property was not sold to the contractor, its agents, employees or volunteers, or their immediate family members or friends.

Guardianship Principle 7:

Ensure payment from DADS is accepted as payment in full for services rendered under the contract.

Benchmark 1:

The contractor must accept payment from DADS as payment in full for services rendered to the ward by the contractor. The contractor must not duplicate billing or be in receipt of other funds. The contractor must maintain reports submitted to DADS to verify the identity of wards served on a monthly basis. The contractor must thoroughly review financial agreements with DADS wards’ providers to ensure providers are not billing for unapproved expenses, as outlined by applicable policies, rules and statutes.

How to determine met or unmet:

The team reviews financial records, wards' records and payment background to determine:

The team conducts a review of the financial and payment records to determine if this benchmark is met. The review team determines payment received from DADS and wards was not funded through other sources. The review team determines if provider financial/room and board agreements fall within the scope of applicable provider policies, rules and other statutes.

The outcome for this benchmark is:

Payment from DADS is payment in full. Provider financial/room and board agreements adhere to policies, rules and other applicable statutes.

Benchmark 2:

The contractor must not seek or accept reimbursement from a DADS ward for whom it provides purchased services. The contractor must not collect:

How to determine met or unmet:

The team conducts a review of financial records and ward’s records to determine:

The team reviews financial records and the wards' records, and may conduct interviews to determine if this benchmark is met. The team reviews records and interviews wards to ensure the contractor does not seek reimbursement from the wards for services.

The outcome for this benchmark is:

The contractor does not seek or accept reimbursement from a DADS ward for services provided. The contractor does not collect payment from the wards for guardianship-related services.

Benchmark 3:

The contractor must not use DADS funds or DADS reimbursed staff time to provide guardianship or other services to an individual who was not referred by DADS.

How to determine met or unmet:

The team conducts a review of the financial records and a review of the wards’ records to determine:

The team reviews financial records and may interview staff to determine if this benchmark is met. The review team determines if DADS funds were used to pay for staff time for services to wards not contracted for guardianship services through DADS.

The outcome for this benchmark is:

The contractor does not use DADS funds or DADS reimbursed staff time to provide services to individuals who were not referred by DADS.

Benchmark 4:

The contractor must provide DADS staff access to the results of audits, including audits performed on DADS wards and contractor independent financial audits conducted annually.

How to determine met or unmet:

The review team requests audits performed by and for the contractor. The review team reviews the audits to ensure compliance with DADS rules.

The outcome for this benchmark is:

The contractor provides DADS staff access to the results of audits performed on DADS wards, as requested.

Guardianship Principle 8:

Ensure DADS is notified of a ward’s status and change in status. Ensure the Ward Status Update Form is completed and submitted to the DADS OCS contract manager and/or the OCS administrative assistant in a timely manner.

Benchmark 1:

The contractor must complete and submit the Ward Status Update Form to the OCS contract manager to notify of any significant status updates. The contractor must complete and submit the death notification form to the OCS contract manager and the OCS administrative assistant when a ward passes away. The contractor must complete and submit a Ward Status Update Form when the following occurs: reports/allegations of abuse, neglect and exploitation against or by the ward; incarceration, media issue and other significant updates affecting DADS wards.

How to determine met or unmet:

Outcome for this benchmark:

The DADS contract manager and administrative assistant were notified of status changes, ward updates and ward deaths in a timely manner.

Determining if Benchmarks are Met or Unmet:

After the team has completed its review of the contracted agency, the team reviews its findings, goes through each benchmark and determines, based upon the findings, if the benchmark was met or unmet.