Revision 17-1; Effective November 1, 2017
Federal regulations require the Texas Health and Human Services Commission (HHSC) to assure necessary safeguards are taken to protect the health, safety and welfare of individuals in the Community Living Assistance and Support (CLASS) program. HHSC conducts contract and fiscal compliance monitoring reviews to ensure providers meet all requirements for participation in the CLASS program.
Revision 17-1; Effective November 1, 2017
A contract and fiscal compliance monitoring review is a systematic review of a contractor's financial, personnel and individual service records to determine compliance with CLASS program and contract requirements.
- CLASS program providers are monitored during the 14th or 15th month of the provisional contract term. Depending upon the results of the formal provisional monitoring, HHSC will monitor the CLASS program provider within 13 to 24 months from the exit date of the formal provisional monitoring and, at a minimum, every 24 months thereafter.
HHSC randomly selects a sample that includes 5% of the individuals being served by the contracted provider before the review. A minimum of four individuals will be reviewed unless the program provider is serving three or fewer individuals. If the program provider is serving three or fewer individuals, HHSC will review all of the individuals being served HHSC does not provide the sample list before the entrance conference.
HHSC will conduct a contract monitoring review onsite at the physical location identified in the contract. HHSC notifies the program provider of an onsite monitoring review with written notice at least 14 calendar days before the review, which includes:
- the date and time HHSC staff plan to arrive at the review site and conduct the entrance conference;
- the number of HHSC staff to conduct the review;
- the approximate number of days necessary to complete the review;
- location at which HHSC will conduct the review; and
- the time period to be reviewed.
The program provider must provide:
- specific records necessary for the review, as requested by HHSC;
- adequate work space for the number of HHSC staff specified in the notification;
- lighting, heating and cooling consistent with that provided to provider staff; and
- copies or access for HHSC staff to make copies of documents during the course of the review.
HHSC staff conducts an entrance conference at the beginning of the monitoring review to discuss:
- the purpose of the visit;
- what will be reviewed;
- estimated length of time it will take to conduct the review;
- records needed to complete the review; and
- the program provider's contact person during the review.
The provider's documentation is reviewed for program and fiscal compliance. If any financial errors are found, HHSC may require the provider to submit documentation of negative billing to correct these errors.
Upon completion of the monitoring review, HHSC staff conducts an exit conference to:
- review findings identified during the monitoring review;
- provide the compliance score;
- provide fiscal monitoring results;
- explain if a corrective action plan (CAP) is required or if the findings will be forwarded to the Sanction Action Review Committee (SARC);
- discuss the need for an immediate corrective action plan, if applicable;
- inform the provider of its right to an administrative review of the methodology employed by the review team if the provider agency has reason to suspect the monitoring review was not conducted in accordance with HHSC policies and procedures; and
- inform the provider of the right to a formal appeal of recoupment.
A provider must attain a minimum compliance level of 90% or above. If a provider attains an overall compliance level of 90% or more, but scores less than 90% on any individual standard, the provider is required to submit a CAP for the standards for which it scored less than 90%. If the overall compliance score is below 90%, HHSC determines the provider to be out of compliance and may submit a referral to the SARC.
HHSC, at its discretion and upon the SARC recommendation, may apply the following sanctions, including:
- referral hold;
- vendor hold; and
- contract termination.