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Effective Date: 
7/2014

Documents

Instructions

Updated: 7/2014

Purpose

To provide Texas Works advisors with a method for reviewing D&A/GLA facilities.

Procedure

When to Prepare

Advisors complete Form H1845 when conducting a six-month review of D&A/GLA facilities.

Number of Copies

The advisor completes one original and two copies.

Transmittal

Provide one copy each to the local office supervisor and the program manager in charge of the D&A/GLA facility. Retain the original in the facility case file.

Form Retention

Maintain the form in the facility case file for five years from the date of review.

Detailed Instructions

Part I — General Facility Information

Date of Visit — Enter the date of the facility review.

Conducted By — Enter the name of the person conducting the facility review.

Facility Name — Enter the name of the D&A/GLA facility being reviewed.

Authorized Representative (AR) — Enter the name of the facility AR.

Facility Address — Enter the physical address of the D&A/GLA facility being reviewed.

Type of Facility — Enter either D&A or GLA.

Number of Residents — Enter the number of residents currently residing at the facility if this is a GLA facility. Leave blank if the facility under review is a D&A facility.

GLA Proof of Certification — Enter the name of the state agency that certified this facility if this is a GLA facility. Leave blank if the facility under review is a D&A facility.

Authorization — Enter the authorization source of the D&A as either United States Department of Agriculture (USDA) (to accept Supplemental Nutrition Assistance Program (SNAP) benefits) or licensed by the Department of State Health Services (DSHS). Leave blank if the facility under review is a GLA facility.

Valid? — Enter Yes or No for valid authorization or license. Leave blank if the facility under review is a GLA facility.

Part II — Current Facility Residents

General Instructions — Using the most recent Form H1852, List of Resident Participants in the Supplemental Nutrition Assistance Program (SNAP), and current Texas Health and Human Services Commission (HHSC) records, randomly select six individuals who are reportedly residing at the facility.

Review Number — Enter the review number, one to six.

Case Name — Enter the name of the person to be reviewed.

Eligibility Determination Group (EDG) Number — Enter the person’s D&A/GLA SNAP EDG number.

Admission Date — Enter the date the person entered the facility, as shown on facility records.

Is person currently a resident? — Check Yes or No, as verified by personal contact or by current facility records.

Residency Verification — Check In Person or Facility Records to document how the previous question was verified.

Discharge Date — If the person is no longer a resident of the facility, verify the date of discharge per facility records and enter this date.

Form H1019 Date — If the person is no longer a resident of the facility, check office records and enter the date Form H1019, Report of Change, or Form H1019-S, Report of Change (Spanish), was received by the local office. If Form H1019 or Form H1019-S has not been received, enter None.

Former resident? — Check Yes if the person no longer resides at the facility and complete Part III – Former Facility Residents. Check No if the person still resides at the facility.

Part III — Former Facility Residents

General Instructions — Using Form H1852, submitted by the facility, randomly select six individuals who have reportedly moved since the last D&A/GLA facility review. Include any "current residents" no longer residing in the facility as part of the six.

Review Number — Enter the review number, one to six.

Case Name — Enter the case name of the former resident being reviewed.

EDG Number — Enter the former resident’s D&A/GLA SNAP EDG number.

Admission Date — Enter the date the former resident entered the facility, based on facility records.

Discharge Date — Enter the date the former resident was discharged from the D&A/GLA facility, as shown on facility records.

Form H1019 Date — Enter the date Form H1019 or Form H1019-S was received in the local office reporting the person was no longer residing at the facility.

Form H1852 Listed Months — List the months this person was reported active on Form H1852, beginning with the first month after the month of admission.

EBT Account Transactions — Using the Administrative Terminal Application (ATA), obtain a printout of all account activity for the SNAP EDG beginning with the month of discharge through the month the AR was removed from the account.

Was the person’s SNAP account accessed after the date of discharge? — Check Yes or No, based on the ATA account activity report for this case.

Review Number — Enter the review number of a former resident whose account was accessed after the date of discharge.

Date Accessed — Using the ATA account activity report, enter the first date after the discharge date this account was accessed by the facility.

Time Accessed — Using the ATA account activity report, enter the time the account was accessed after the resident left the facility.

Amount Used — Using the ATA account activity report, enter the amount of benefits used for this transaction.

Additional Documentation — Document a summary of findings for this account. Include any discrepancies identified during this review. Attach additional pages if necessary.

Part IV — Review Summary

Summary of Review — Document a summary of all findings for this review.

Date this review provided to supervisor — Enter the date a copy of this report was provided to the local office supervisor in charge of the D&A/GLA facility.

Date this review provided to program manager — Enter the date a copy of this report was provided to the program manager in charge of the D&A/GLA facility.

Negative findings in this review? — Check Yes or No.

Date escalated to state office — Enter the date the program manager sent the negative findings of this report to state office.

By whom — Enter the name of the program manager notifying state office.