Effective Date: 
1/2018

Documents

Instructions

Updated: 1/2018

Purpose

To document the corrective action plan (CAP) developed by the employer or designated representative (DR) at the request of a case manager, service coordinator, financial management services agency (FMSA), service planning team or Texas Health and Human Services Commission (HHSC) representative.

Procedure

When to Prepare

The employer or DR completes this form upon written request from a case manager, service coordinator, FMSA, service planning team or HHSC to submit a corrective action plan.

Note: An employer or DR may request assistance in the development or implementation of a corrective action plan. Refer to Texas Administrative Code (TAC), Title 40, Part 1, Chapter 41, §41.221 and §41.319 for corrective action plan rules.

Number of Copies

Original and at least two copies.

Transmittal

The employer or DR keeps a signed copy in the file for the individual or member receiving services through the CDS option and sends a copy to the person, agency or service planning team requesting the corrective action plan. The employer or DR must send a copy to the case manager or service coordinator. Other service planning team members receive copies, as applicable.

Form Retention

The employer or DR, the case manager or service coordinator and the FMSA keep this form while in effect and for five years thereafter.

Detailed Instructions

Individual/Member Name — Enter the name of the individual or member receiving services.

Program — Enter the program name.

Employer — Enter the employer's name. If the individual or member receiving services is the employer, enter the individual's or member's name again.

Designated Representative — Enter the designated representative's name, if applicable.

Support Advisor — Enter the support advisor's name, if applicable.

Corrective Action Plan Requested By — Enter the name of the person who requested the corrective action plan.

Position — Enter the position of the person who requested the corrective action plan.

Agency — Enter the name of the agency of the person who requested the corrective action plan.

Date of Request — Enter the date of the written request.

Due Date — Enter the corrective action plan due date, which is 10 days after the date of the request.

Reason(s) for Requested Corrective Actions — State the reason(s) a corrective action plan is being requested.

Note: A written corrective action plan may be required from an employer or DR if the employer or DR:

  • hires an ineligible service provider;
  • submits incomplete, inaccurate or late documentation of service delivery;
  • does not follow the budget;
  • does not comply with program requirements related to the CDS option; or
  • does not meet other employer responsibilities.

Corrective Action Plan* — State how the employer or DR will correct the problem.

Specific Action(s) to Be Taken* — Enter the specific action to be taken to implement the corrective action plan.

Responsible Person* — Enter the name of the person responsible for each action.

Due Date* — Enter the date by which the action must be completed.

* This form field is expandable. You are not limited to the space provided. The box will expand to accommodate up to 2,000 characters. All of the text you enter will show when the form is printed.

Plan Approval — An individual's service planning team must approve the corrective action plan.

Completion of Corrective Action Plan — Whoever requested the corrective action plan signs and enters the due date, indicates if the due date was/was not met and whether corrective actions were/were not completed, and enters any comments.*

* The comments field is expandable up to 2,000 characters.

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