Chapter 10, Reporting and Quality Assurance

Revision 23-1 Effective Nov. 13, 2023

Each service provider must develop a written quality assurance program for review of program activities that evaluate compliance with the independent living services rules and the Independent Living Services Standards for Providers. That system must, at a minimum, include regular reviews of case service records, entry in the Independent Living Services (ILS) Data Reporting System, eligibility determinations, and adherence to purchasing procedures. A minimum of 10 percent of all case service records must be reviewed annually by staff members who are not directly involved in the delivery of services under this funding source.

The ILS Data Reporting System is used for the service providers to gather, track, and monitor program performance and financial data. Each service provider is required to enter data into this system by the fifth of the month for the preceding month and per the training and instructions provided in the system user manual.

Other reporting requirements are addressed in the approved work plan and standard assurances, as part of contract requirements.

The written quality assurance review system must include:

• conducting annual self-evaluations;
• obtaining consumer satisfaction surveys;
• completing case reviews;
• supervising program staff members;
• monitoring vendors or contractors for purchased goods and services;
• maintaining records to track and measure performance compared to targets established in the approved work plan;
• making process improvements; and
• implementing corrective actions in response to HHSC monitoring reviews.

10.1 Annual Self-Evaluation

Revision 23-1 Effective Nov. 13, 2023

Entities must collect data and review to track performance. When data shows improvements are necessary to enhance the entity's performance and consumer satisfaction, an action plan must be created and monitored until improvement is made to a successful level measured by goals in the action plan.

10.1.1 Consumer Satisfaction Surveys

Revision 23-1 Effective Nov. 13, 2023

Consumer satisfaction measures input from people about benefits received from provider services.
Each provider may develop its own survey instrument and procedure. However, at a minimum, the survey instrument must use a Likert scale and include the following statements:

• I was treated in a friendly, caring, and respectful manner by the staff of [insert provider name].
• Services were provided in a timely manner.
• The services met my needs.
• I was satisfied with the services provided.

Likert Scale

All people must be given the chance to respond to the consumer satisfaction survey.

The provider must calculate an average rating on the Likert scale for each of the four required statements.

The results of the consumer satisfaction must be submitted to HHSC ILS Program annually, 45 days after the end of the state fiscal year. The results must also be available to HHSC by request.

10.2 Required Reports

Revision 23-1 Effective Nov. 13, 2023

A service provider that receives funding under the contract must submit program and financial reports, as described below. The service provider’s records must support all the data reported, including information entered in the Independent Living Services Data Reporting System and recorded on fiscal reports matching amounts in accounting records.

10.2.1 Form 3153 Complaint and Inquiries Report

Revision 23-1 Effective Nov. 13, 2023

The service provider must submit Form 3153, Complaint and Inquiries Report, to the provider inbox by the fifth day of each month. Service providers must record all complaints received for the contract, whether verbal or written, and enter them in the report. The status of previous complaints, general inquiries about the program, and legislative inquiries are also recorded. Corrective action may be implemented by HHSC to resolve a complaint if determined necessary.

10.2.2 Program Reports

Revision 23-1 Effective Nov. 13, 2023

The service provider must enter or upload data into the Independent Living Services (ILS) Data Reporting System by the fifth day of the following month per the user guide instructions. The ILS Data Reporting System captures program performance and financial data about each ILS Program contract, including data on:

• waiting lists;
• monthly consumer participation;
• goals met (successful) and unsuccessful case closures; and
• purchases service records.

HHSC will use information in this data reporting system to monitor the ILS Program contracts. The database will provide information for the following:

• Key performance measures, including:
  • the number of people receiving independent living services; and
  • the number of people who achieve independent living goals.
• Work plan targets, including:
  • number of people served who are blind or visually impaired; and
  • the minimum percent of the approved budget to be spent on purchased goods and services, including complex rehabilitation technology.

On a monthly basis, and by the fifth day after the end of the previous month, service providers are required to enter individual success stories into the Independent Living Services Data Reporting System. These success stories should include examples of people served with different disabilities, including those who are deaf or hard of hearing and blind or visually impaired.

The results of the consumer satisfaction surveys must be submitted annually to HHSC within 45 days of the end of the state fiscal year.

10.2.3 Financial Reports

Revision 23-1 Effective Nov. 13, 2023

The service provider must complete financial reports for the Independent Living Services Program contract, to include the contract Budget Workbook, Form 3000, Budget Revision Request, Form 3008, Cost Share Collections/Refund Report, and Form 3001, Quarterly Financial Report. When a financial report is completed, it should be saved separately, named appropriately, and submitted to the contract manager per the instructions.

10.2.3.1 Budget Workbook

Revision 23-1 Effective Nov. 13, 2023

The Budget Workbook is an Excel template distributed by HHSC to the service provider annually to record service provider projected budget use for the upcoming fiscal year. The service provider records their estimated expenses in each category based on the annual contract award and submits it to the HHSC provider mailbox. The budget workbook approved by HHSC serves as the initial budget. HHSC must be notified of all deviations from the line items of the Budget Workbook within three business days, especially those changes related to personnel, including adding or eliminating positions, adjustments of more than 25% of a staff’s time to the grant or merit increases.

10.2.3.2 Form 3000, Budget Revision Request

Revision 23-1 Effective Nov. 13, 2023

The service provider submits Form 3000, Budget Revision Request to the HHSC provider mailbox to request funds be moved from one category or another. The budget is not considered revised until approved by HHSC. Expenses incurred which exceed the approved budget in a category will be deemed unallowable. Revisions submitted after the deadline, provided annually by HHSC in writing, will not be accepted. See 7.3, Contract Work Plan and Budget for more information on budget revisions.

10.2.3.3 Form 3008, Cost Share Report

Revision 23-1 Effective Nov. 13, 2023

Submit Form 3008, Cost Share Collections/Refund Report monthly to the HHSC provider mailbox along with the Request for Advance or Reimbursement (RAR). The purpose of the report is to document the amount of cost share collected from people, refunds from a vendor, and the amount applied to each purchased services category. Refunds made to a person due to a lower amount of cost share than initially charged are not captured on this report. Those refunds are recorded as reductions in the individual participation entries in the ILS Data Reporting System. Whether the service provider uses accrual or cash-based accounting, the cost share amounts listed each month on the Cost Share Report should match the monthly individual participation amounts recorded in the ILS Data Reporting System.

10.2.3.4 Form 3001, Quarterly Financial Report

Revision 23-1 Effective Nov. 13, 2023

Form 3001, Quarterly Financial Report, is submitted to the HHSC provider mailbox within 30 days after the end of each quarter and within 45 days after the end of the state fiscal year. This report reflects actual, unrounded expenses and program income incurred from the beginning of the fiscal year through the last month of the quarter being reported. Amounts recorded in purchased services categories on the quarterly financial report should not include any deductions for applied cost share. Purchased services category amounts must match the service records entered in the ILS Data Reporting System.

10.2.4 HHSC Request for Advance or Reimbursement (RAR)

Revision 23-1 Effective Nov. 13, 2023

As described under 8.6.1, Request for Payment, the RAR is used to request funds for contract costs.

• Cost Reimbursement – Service providers classified as cost reimbursement are reimbursed for allowable incurred costs. Monthly expenses are reported using the HHSC Request for Advance or Reimbursement (RAR). The RAR must be submitted by the 10th day of the month following the month the expenses were incurred or paid. Service providers classified as cost reimbursement are not eligible to receive advance payments.
• Advance Payment – Service providers classified as advance payment, may request advance payments. Advance payment for operating funds for no more than 90 days in advance may be requested each quarter. If advanced funds are not expended during the quarter of the request, they must be adjusted on the next request. Advance requests will be made using the RAR. The RAR must be submitted for a quarterly advance request and each month to record expenses. Service providers classified as advance payment must submit the RAR by the fifth day of each month, even if the service provider would not be owed money for that month. The service provider can receive advance funds meaning funds received before the expense is incurred, for an amount equal to 90 days of operating funds or less, if the contract requirements are met.

In the case of a request for reimbursement, the costs should reflect allowable costs for the period billed.

10.2.5 Audit Requirements

Revision 23-1 Effective Nov. 13, 2023

Per contract assurances, all service providers must obtain an annual financial audit. It must be conducted by an independent auditor in compliance with Generally Accepted Auditing Standards (GAAS), as published by the American Institute of Certified Public Accountants.

The service provider must arrange for a financial and compliance audit (Single Audit), if required, per 45 CFR Part 75.500-75.521.

If a Single Audit is not required, the service provider obtains an annual audit of its financial statements.

Each year, the HHSC Single Audit Unit notifies service providers they must submit a determination form to the single audit portal to identify whether a single audit or annual audit is required. All audit reports must be submitted to the single audit portal within nine months after the end of the service provider’s fiscal year or within one month after the service provider receives the audit report, whichever is less. Direct questions related to audit requirements, or the single audit portal to Single_audit_report@hhs.texas.gov.

Audits must be charged to the fiscal year that the audit was conducted rather than the fiscal year being reviewed in the audit.