Revision 13-1; Effective November 1, 2013

 

Purpose

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

  • Department of Aging and Disability Services (DADS) rules and regulations;
  • Texas Guardianship Certification Board (GCB) or the Judicial Branch Certification Commission (JBCC) [effective Jan. 1, 2014], as appropriate;
  • Texas Probate Code or the Texas Estates Code, as applicable; and
  • Texas Administrative Code, and any other applicable statutes or codes.

 

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:

  • annual reviews; and
  • follow-up reviews, as needed.

Specific Methodology

  • 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 by the contactor will be included in the sample. A larger sample may be drawn if during the monitoring visits significant findings are identified indicating non-compliance with DADS rules, contract requirements or statutes. If a sample is expanded, the sample may include up to 100 percent of the contractor's cases.
  • The sample includes a representation of the types of wards served by the contractor.
  • After the list of wards served by the contractor is identified, the list is alphabetized and applied to a randomizer to ensure a random sample is obtained.
  • If, after identifying the sample, each category is not represented, the team continues developing a sample using the randomizer until each group served by the contractor is represented.
  • The sample is emailed to the contractor 14 calendar days (excluding holidays) before the scheduled review.

 

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:

  • The issues and findings identified during the monitoring review are shared with the contractor.
  • The contractor may provide missing documents and information related to issues addressed by the review team before or during the exit conference.
  • The team leader addresses questions and provides clarification, as needed.
  • The team leader identifies issues to be addressed in the Statement of Findings and discusses those at the exit conference.
  • The contractor must provide all missing documentation by close of business the next working day.
  • Supporting documentation will not be accepted after that day.

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:

  • Was an application for permanent guardianship of person/estate filed within 30 days of the acceptance date of the referral from DADS?
  • Were copies of letters of guardianship and the guardianship oath submitted to the DADS contract manager?
  • If an application was not filed with the appropriate court within 30 days, was an extension requested through the DADS contract manager?
  • Were files marked or certified copies of all documents in the ward’s records?
  • Were there current and accurate letters of guardianship in the ward’s records?
  • If letters were not in the record, not current or not accurate, was an explanation provided and was it documented in the file?
  • Was the annual report filed within 60 days of the anniversary of the qualification date?
  • Was the annual report approved by the court and the order approving the annual report in the file? If not, was there documentation explaining why?

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:

  • Was a final report of the person filed with the court within 60 days of the ward’s death, restoration of capacity, the qualification of successor guardian or within 90 days of a decision to close due to exhaustion of funds?
  • Was the final accounting approved by the court?
  • Was a final report/application to close filed with the court within 60 days of the ward’s death, restoration of capacity, the qualification of successor guardian or within 90 days of a decision to close due to exhaustion of funds?
  • Was the final report/application to close approved by the court?
  • Were appropriate orders and any other documents in the ward’s records (receipts, bank statements, etc.)?
  • Were court orders followed regarding the disposition of the property?
  • Were receipts from the recipient of the property filed with the court, if required?

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:

  • a safe, clean environment;
  • assistance in performing basic life functions;
  • regular, nutritious meals;
  • any needed medical, psychiatric, habilitation or other services; and
  • adequate supervision.

How to determine met or unmet:

The team reviews the ward's records to determine:

  • What needs were identified in the service plan?
  • What preferences did the ward have for services?
  • Was the service plan completed 90 days after taking the oath?
  • Was the service plan updated within the 60 days of the annual anniversary date and when significant changes occurred such as, but not limited to, medical concerns or behavioral problems?
  • Did staff or individuals providing services to the ward know the ward's needs and what was in the ward's service plan?
  • Where is the ward living and is it documented?
  • Are there any special needs that should be addressed in the ward's living environment?
  • Does the ward have any special nutritional or medical needs?
  • Was the placement evaluated prior to placing the ward in the facility?
  • Was the ward placed in a licensed, certified or regulated facility?
  • Was the facility rating and licensing reviewed as part of the initial service plan and reviewed annually with the service plan update?
  • Were services provided as outlined in the order of guardianship?
  • Was there documentation indicating the ward participated in the service plan?
  • Was the ward’s cultural diversity taken into consideration?
  • Was there documented evidence of building a support system for the ward to include family, friends and other appropriate collaterals?
  • Were medical care and other services provided based on the needs of the ward?
  • Were consents appropriately signed and available?
  • Was a service plan developed which included all needed services?
  • Were all case actions documented within the required time frames?
  • Were all requirements met, as outlined in the Texas Probate Code, Texas Estates Code, Texas Administrative Code and other applicable codes regarding the guardianship?
  • Did the certified guardian have physical possession of the ward?
  • Was there adequate food, clothing and shelter?
  • Were staff working at the ward's placement aware of the guardianship?
  • Has the guardian pursued all potential benefits to which the ward may be entitled?

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:

  • Does the ward live in a safe and clean environment?
  • Does the ward receive help with skills for daily living?
  • Did the service plan address all the ward's needs?
  • Are services being provided to meet the nutritional, medical, psychiatric, rehabilitative or other needs?
  • Is there adequate staffing and supervision to meet the ward's needs?

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:

  • Were contacts made and documented according to minimum requirements as outlined by the Guardianship Certification Board (GCB) or the Judicial Branch Certification Commission (JBCC)?
  • Were time frames met for contacts?
  • When contacts were made, were changes in the ward’s needs identified and updated in the service plan?
  • Did documentation provide a comprehensive view of the ward’s current status and reflect current events taking place in the ward’s life?
  • Were monthly face-to-face status contacts documented in the record?
  • Did the documentation present a sequential record of events occurring in the ward’s life?
  • Did documentation discuss all of the following main areas: physical, mental, legal, social, environmental and medical?
  • Did the certified guardian speak to caregivers, service providers, teachers or family members during monthly visits?
  • Did the certified guardian review the ward’s records when available at the ward’s placement?
  • Was the initial face-to-face visit with the ward within 10 calendar days of receiving the referral?
  • If the visit was not made within the required time frame, was the reason documented?
  • If there was a delay in completing the visit, was the delay documented?
  • Were face-to-face visits conducted in alternate placement locations at least quarterly?
  • Was a photo of the ward taken within 90 days of the contractor qualification date?
  • Was the photo dated and located on the first page of the case file?
  • Was a new photo taken two years after the first one and every two years thereafter?

The review team observes wards to determine:

  • Were contacts made appropriately?
  • Are collaterals aware of the identity and contact information for the certified guardian assigned to the ward?
  • Was appropriate action taken by the assigned certified guardian when problems were identified?
  • Were all problems identified and addressed?

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:

  • Was a ward’s information misfiled in another ward’s record?
  • Were Health Insurance Portability and Accountability Act (HIPAA) standards followed?

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:

  • Did the annual or updated service plan reflect the needs of the ward?
  • Was the annual service plan updated within 60 days after the original anniversary date?
  • Were placement standings checked and are copies in the file?
  • Did the record contain the guardianship demographic face sheet?
  • Was the face sheet located in the beginning of the file?
  • Was the face sheet information current and accurate?
  • Did the certified guardian take action when financial, medical or other needs/issues pertaining to the wards were identified?
  • Did the certified guardian use self-determination methods when working with the ward and his or her choices?

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:

  • Did the certified guardian ensure the providers of services were able to communicate with the ward?
  • If the ward uses sign language, speaks a foreign language or has other communication needs, such as a language board, was this information in the service plan and was the certified guardian able to secure service providers to communicate with the ward?
  • If there was difficulty in meeting the ward's communication needs, how was it addressed in the service plan?

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

  • Is the certified guardian able to communicate with the ward?
  • What communication needs does the ward have and how are the needs addressed?
  • Are service providers able to communicate with the ward?
  • If the ward needs augmented communication devices, have the items been provided? If not, have they been ordered?
  • Did the certified guardian refer, or arrange for, the ward to receive an assessment to determine a need for therapy, treatment or an augmented communication device to assist the ward with communication?
  • As the ward's communication needs change, are the changes addressed in the service plan and recognized by the certified guardian and the service providers?

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:

  • Were approvals and consultation documented by staff in the areas of medical, financial, placement, legal and other decisions affecting the ward?
  • Examples include, but are not limited to:
    • Extraordinary medical procedures
    • Sale of property
    • Purchase of burial plan
    • Obtaining a Do Not Resuscitate (DNR) form
    • Filing for guardianship
  • Were approvals and consultations clearly documented in the ward’s case file?

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:

  • Was appropriate documentation completed according to policy, procedures and minimum standards, as outlined by the GCB or the JBCC?
  • Was documentation accurate, timely and complete?
  • Were contacts with wards, collaterals and service providers documented in the narrative section of the ward’s file, within 10 working days after the activity, as outlined in TAC §10.403(g)(4)?
  • Did the certified guardian document all contacts and the ward’s activities?
  • Were all time frames met?

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:

  • Is there a clear audit trail for financial and trust fund expenditures?
  • Are all monies properly accounted for and receipts available?
  • Were the ward’s finances managed in a manner that prevented insufficient funds or unnecessary charges?
  • Were all financial policies and procedures followed?
  • Were the ward’s bills paid on time? If not, is there clear documentation as to why?
  • Were there inconsistencies in the ward’s representative payee and trust fund records?
  • Were the inconsistencies identified?
  • Was there follow-up to correct the issues?
  • Does documentation indicate the problems identified were resolved?
  • If avoidable late fees or other financial penalties were incurred by the ward due to the representative payee’s actions, did the guardian ensure the ward was reimbursed?
  • Is the ward’s Medicaid eligibility protected by ensuring the ward does not exceed allowable resource limits?
  • Did the guardian ensure the ward’s income and benefits are used only for the ward’s benefit?
  • Were financial/room and board agreements with providers signed by the certified guardian?
  • Do provider financial/room and board agreements signed by the guardian fall within the scope of applicable provider policies, rules and other statutes?
  • Is there evidence to suggest the certified guardian reviewed quarterly trust fund statements in a timely manner and are quarterly trust fund statements in the case file?

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:

  • Did the guardian consider the ward’s input and desires concerning the treatment?
  • Was the ward’s cultural background/preference respected?
  • Were the appropriate preventative and medically necessary services sought?
  • Did the certified guardian seek consultations, as needed, to make the necessary decision?
  • Did the certified guardian give oral and written consent to treatments?

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:

  • Did the contractor take actions if a ward was an alleged victim of abuse, neglect or exploitation?
  • Did the contractor report allegations to the regulating authority in a timely manner?
  • Did the contractor maintain contact with the regulating authority until the case was closed?
  • Did the contractor notify the DADS contract manager about the allegations and action taken?
  • Were measures taken to protect the ward during the investigation?
  • Did the contractor notify the contract manager and complete the Ward Status Update Form?
  • Was the completed Ward Status Update Form available in the ward’s case file?

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:

  • remove the employee or volunteer from contact with DADS wards until allegations have been investigated and an outcome has been determined;
  • take appropriate action, including pressing criminal charges, if an allegation of abuse, neglect or exploitation is found to be valid;
  • document the findings; and
  • re-orient the employee or volunteer before they begin working again with DADS wards if the investigation or the appeal process determines the employee or volunteer was not the perpetrator.

How to determine met or unmet:

The team conducts record and documentation reviews to determine:

  • Were there allegations of abuse, neglect or exploitation made concerning an employee or volunteer of the contractor?
  • Were policies and procedures followed after the allegation was made?
  • Did the contractor remove the employee or volunteer from working with DADS wards?
  • Does documentation of re-orientation exist if the alleged perpetrator was found not to be the perpetrator?

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

  • Were alleged perpetrators removed as soon as allegations were made?
  • Did the contractor contact the proper investigative authority and press criminal charges when necessary?
  • Was the ward protected from abuse, neglect or exploitation?
  • Was the DADS contract manager notified of the allegation of abuse, neglect or exploitation?
  • Did the contractor work with staff to ensure all allegations were reported and necessary steps were taken to ensure abuse, neglect and exploitation do not happen again?

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:

  • Does the plan ensure the certified guardian’s ward’s records and actions are reviewed for compliance with principles and benchmarks, policies, procedures, training requirements, applicable statutes and administrative rules?
  • Is the plan followed as written?
  • Is documentation present in each ward’s case record indicating a QA record review was completed at least annually?
  • Does the documentation of the review indicate missing documents or incomplete actions?
  • Were problems identified during the contractor’s QA process addressed by the certified guardian or the supervisor?
  • Did the supervisor follow-up on issues identified during the review of the certified guardian’s performance?
  • Is corrective action completed?
  • Are staff counseled, as needed, for performance issues, as described in the QA plan and is this documented?
  • Does the QA plan outline the certified guardian’s supervisor responsibility to conduct face-to-face visits with 30 percent of DADS wards served under the contract?
  • Is documentation present indicating 30 percent of DADS wards served were seen face-to-face by the supervisor?
  • Is the QA plan updated, as needed?

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:

  • Is a complaint tracking system in place?
  • Was a complaint investigation conducted, as required?
  • Was follow-up completed if an alleged complaint was substantiated?
  • Does the system track the following: (a) date the complaint was made, (b) name of the complainant, (c) complainant contact information, (d) nature of the complaint, (e) investigative notes, (f) outcome of complaint, and (g) method and date by which complainant was notified?
  • Were referrals made to appropriate sources, if indicated, upon completion of the complaint investigation?
  • Are staff aware of the complaint procedures?

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:

  • Did staff and volunteers attend and complete required training?
  • Were sign-in sheets and training or meeting agendas available?
  • Did staff request additional training, if needed?
  • Did the supervisor request additional training, as needed, for staff?

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:

  • Are staff, who are required to be certified or registered, certified or registered?
  • Are certified staff registered in each county in which they function?
  • Are staff certification or registration documents up-to-date?
  • Are the certified guardians following all rules and regulations of the GCB, JBCC or appropriate registration authority?

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:

  • Was a criminal background check obtained through DADS on all prospective employees and volunteers before an offer of employment or approval to provide volunteer services was made?
  • Was the criminal background check obtained before employees or volunteers began working with DADS wards?
  • Were criminal background checks completed annually for all staff and volunteers who provide services to DADS wards?
  • Were criminal history checks conducted by the contractor through the National Registered Sex Offenders website, http://www.nsopw.gov/en-us/Search/Verification, on visitors who requested unsupervised visits with DADS wards?
  • Are background search queries, which returned no results, available in the ward’s case record indicating a background check was completed on visitors requesting unsupervised visits with DADS wards?
  • If background search queries returned negative results, the contractor must have documentation substantiating why an unsupervised visit was approved in the ward’s case record.

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:

  • Do staff use current policies and procedures as they conduct business?
  • Are the steps to disseminate new policies and procedures identified in policies and procedures?
  • Are staff aware of all policies and procedures?
  • Is there a system in place for distribution of, and training on, all new policies and procedures?
  • Are policies and procedures available at contractor site locations?

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:

  • Conduct a search of the federal Health and Human Services Office of Inspector General (OIG) List of Excluded Individuals and Entities (LEIE) website and the Texas Health and Human Services Commission (HHSC) OIG LEIE website; and
  • Immediately report to the HHSC/OIG office any exclusion information discovered.

How to determine met or unmet:

  • Is there a system in place to ensure employees and potential employees of the contractor are screened at employment, and then monthly, to determine if they are excluded from participation in Medicare, Medicaid, the Children’s Health Insurance Program and all federal health care programs?
  • Were monthly checks completed and is verifying documentation available?
  • Were any individuals identified as being excluded? Was this information reported immediately to the HHSC/OIG?
  • Was the information related to exclusion documented?

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:

  • Was property sold?
  • Was it sold at auction?
  • Who sold the property?
  • Who bought the property?
  • Were any of the individuals who bought the property a family member or friend of the contractor, its agents, employees or volunteers?

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

  • Was property of the ward bought by an employee, employee's family member, friend or volunteer of the contractor?
  • What does the contractor do to ensure the ward's property is not sold to employees, volunteers or their immediate family members or friends?
  • How is property sold? If sold through an auction, is it published in the newspaper?
  • Did the contractor obtain a bill of sale for the property sold?

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:

  • Did the contractor receive reimbursement for services for DADS wards from any other source?
  • Does the contractor maintain a monthly billing list for claims submitted through the Texas Medicaid & Healthcare Partnership (TMHP) Claims Management System?
  • Does the contractor maintain monthly reports submitted to DADS verifying wards served on a monthly basis and timely submit those to DADS?
  • Was this area audited by the contractor to ensure compliance with DADS rules?
  • Were financial/room and board agreements with providers signed by the certified guardian?

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:

  • payment from a ward;
  • a percentage of the Social Security or Supplemental Security Income (SSI) check specified in the Omnibus Reconciliation Act of 1990;
  • payment authorized by the court in accordance with Texas Probate Code §665 or Estates Code §1155.002 and §1155.003, as appropriate; or
  • any reimbursement for legal fees or other expenses incurred in providing services under this contract.

How to determine met or unmet:

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

  • Did the contractor seek payment from a DADS ward for guardianship services?
  • Did the contractor receive reimbursement from a ward's funds for services provided?
  • Did the contractor receive payment from a DADS ward?
  • Did the contractor receive a percentage of the ward's SSI?
  • Did the contractor charge the ward for reimbursement of legal fees or payment authorized by the court?
  • Does the contractor collect fees? If yes, what are the fees used for and who pays the fees?
  • Have the wards paid the contractor for any services? If yes, does the contractor have a receipt?
  • If the ward says the contractor has been paid, what services were paid with the ward's money?

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:

  • Were staff providing services to non-DADS wards utilizing funding provided by DADS?
  • Did the contractor charge DADS for services provided to wards who were not referred by DADS?

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:

  • Were the contract manager and administrative assistant notified of the ward’s location or address change?
  • Did the contractor receive expressed written permission from the DADS contract manager if a ward was transferred to an area not served by the contractor?
  • Was the completed Ward Status Update Form in the ward’s file for each move?
  • Were the contract manager and administrative assistant notified of a ward’s death?
  • Was the death notification form completed timely?
  • Was the completed death notification form in the ward’s file?
  • Was the Ward Status Update Form completed for a report of abuse, neglect and exploitation and was the form available in the case file?

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.