Revision 20-1; Effective September 1, 2019

Contract monitoring reviews are conducted using a team approach. At least two members of the Texas Health and Human Services Commission (HHSC) Oversight and Community Support (OCS) Unit participate in the pre-monitoring activities and the field monitoring reviews.

The review team:

• Designates a team leader for the monitoring review.
• Determines when to send the letter announcing the contract monitoring review. The contract monitoring entrance letter is sent 30 calendar days in advance of the monitoring review and will include a meeting time for the on-site visit to ensure space is available to meet with contract staff and conduct exit.
• 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.
• Determines the sample for review, as outlined below. The sample is emailed to the contractor’s executive director or designee 14 calendar days (excluding holidays) before the scheduled review. 
• Prepares the monitoring visit review packets.
• Reviews the findings and plan of correction from the previous contract monitoring visit, as well as any follow-up actions as a result of the visit.
• Reviews any complaints and results of investigations which have been conducted since the last monitoring visit.

Revision 20-1; Effective September 1, 2019

Purpose

The sampling methodology to be used for Texas Health and Human Services Commission (HHSC) guardianship contractors includes:

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

Specific Methodology

The sample number of cases reviewed for each monitoring review is 20 percent with a minimum of 15 cases and maximum of 20 cases of HHSC wards served by the contractor, whichever number is greater. If a contractor serves less than 15 HHSC wards, the total number of wards served by the contactor will be included in the sample. The sample includes established guardianship of the person cases, newly referred guardianship of the person cases and closed cases for the identified review period. The sample is drawn from the Guardianship Online Database (GOLD) system. A random sample is drawn utilizing information gathered from the GOLD reports. After the list of wards served by the contractor is compiled from GOLD, 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 forwarded to the contractor 14 calendar days before the review begins. A larger sample may be drawn if during the monitoring visits significant findings are identified indicating noncompliance with HHSC rules, policies, procedures or statutes. If a sample is expanded, the sample may include up to 100 percent of the wards served by the contractor.

Revision 20-1; Effective September 1, 2019

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. HHSC 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.

Revision 22-1; Effective Nov. 1, 2022

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, virtually or by TEAMS meeting. During the entrance conference, the following activities occur:

• The team leader explains the purpose of the review, the monitoring process, the sampling methodology and review period.
• The team leader obtains the name of the contact person who will be available to the review team throughout the desk review and on-site visit to respond to inquiries from the monitoring team.
• The team leader gives an estimated amount of time required to complete the monitoring review.
• The team leader provides the contractor with the sample list of the wards’ names selected to be reviewed. The contact person or other individuals identified must be available by phone or email the days the desk review is conducted.
• The team lead provides the contractor a comprehensive list of missing documentation, findings and general inquires at the end of each day of the desk review. The contractor can respond to the daily inquiries throughout the review.
• The team leader discusses the use of visits, interviews and observations as part of the determination for compliance. After a sample of wards for visits, interviews and observations is determined, the team leader may coordinate some or all the visits with the contractor. The contractor may coordinate the visits with the wards and facility staff.
• Time is allotted for questions and comments from the contractor and others at the entrance conference and throughout the review.
• The team leader stresses ongoing communication during the review. If questions arise or information is missing during the review, the team leader requests the information from the contact person. Every effort is made to obtain information prior to the exit conference.

Revision 22-1; Effective Nov. 1, 2022

The annual review process focuses on outcomes and compliance with the HHSC rules, state regulations, and other applicable standards and statutes. The benchmarks contractors must meet are in this handbook. The guardianship rules are found in the Texas Administrative Code, Title 26, Part 1, Chapter 361, 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 on 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. The review team ensures the contractor remained in compliance with the previous plan of correction and followed HHSC rules, regulations, requirements and policies.

Observations and Interviews

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. 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.

Exit Conference

The purpose of the exit conference is to share observations and potential findings with contractor staff. During the exit conference, the following activities occur:

• The team shares commendations and strengths identified throughout the review.
• The team discusses noted areas of concern and potential findings identified during the monitoring review.
• The contractor, or designee, may provide missing documents and information related to areas addressed by the review team before or during the exit conference. The contractor will have until close of the next business day to provide follow-up documentation. Documentation will not be reviewed beyond that date. Under limited circumstances, extensions may be granted with approval from the Oversight and Community Support (OCS) unit manager.

Plan of Correction

The statement of findings is documented in the Guardianship Online Database (GOLD) by the OCS team lead. A team approach with state office management staff is taken in drafting the statement of findings. The statement of findings report is forwarded via email to the contractor for review, along with a deadline to submit the plan of correction (POC). The team lead contacts the contractor to discuss any significant findings.

The contractor will address the findings in the POC form supplied by the team lead. The POC must stipulate actions the contractor will take to correct the findings, the persons responsible for implementing the plan and the date the plan will be implemented. If additional corrective measures are required, the deadline may be extended at the discretion of the HHSC OCS team lead with the guidance of the OCS unit manager. Once the POC has been received, the team lead will document in GOLD and run the final POC report to be approved by the OCS unit manager. The approved and final report will be forwarded to the contractor to close the review.

Follow-up Reviews

Based on the types of significant findings (Legal, Financial and Health and Safety) cited during the review, HHSC may conduct a follow-up 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 assigned team lead pulls a sample of cases to determine whether the significant 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 significant findings and approved by the OCS unit manager. A follow-up Statement of Findings (SOF) will be entered in GOLD. An SOF report will be generated and sent to the contractor. The contractor is not required to submit a response for a follow-up review; however, action(s) for noncompliance, directed by HHSC program management, may be taken.

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.

Revision 22-1; Effective Nov. 1, 2022

Information collected during record reviews, observations, and interviews about the wards selected in the sample is used to determine the unit'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.

Determination is based on requirements of each benchmark, rules, statutes, policies and standards governing guardianship practice. The team looks for significant findings to determine if the benchmark is met.

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:

• Legal
• Case Management
• Documentation
• Financial
• Health and Safety
• Quality Assurance
• Reimbursement for Services
• Ward Status Updates

The benchmarks under each guardianship principle are evaluated to determine if the principle is met or unmet. The review team reviews each benchmark based upon evidence collected during the monitoring visit. Each guardianship principle has several 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 26, Part 1, Chapter 361 of the guardianship rules or the HHSC 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.

Revision 22-1; Effective Nov. 1, 2022

The review team determines the contractor's compliance with each guardianship principle and benchmark based on the HHSC guardianship rules, this handbook, 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 — Ensure all legal requirements are completed in compliance with policies, procedures and applicable codes.
2. Case Management — Ensure case management responsibilities are performed in compliance with court orders, policies and procedures.
3. Documentation — Ensure service-related activities are completed, documented and maintained in accordance with policies and procedures.
4. Financial — Ensure fiduciary responsibilities are performed in compliance with court orders, policies and procedures, and avoid the appearance of impropriety.
5. Health and Safety — Ensure the health and safety of HHSC wards by making appropriate medical decisions and reporting allegations of abuse, neglect and exploitation to the appropriate investigative authority, and conducting background checks on staff and visitors.
6. Quality Assurance — Develop and implement a Quality Assurance (QA) Plan to ensure compliance with standards, policies, procedures, training requirements and applicable codes.
7. Reimbursement for Services — Ensure payment from HHSC is accepted as payment in full for services rendered under the contract.
8. Ward Status Updates — Ensure HHSC 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. Failure to meet any guardianship principles or several guardianship principles may result in the need for follow-up action or action that could negatively affect the contract.

3710 Guardianship Principle 1: Legal

Revision 22-1; Effective Nov. 1, 2022

Ensure legal requirements are completed in compliance with policies, procedures and applicable codes.

Benchmark 1: Initial and Ongoing

Complete initial and ongoing legal activities in compliance with policies, procedures and applicable codes. The contractor must ensure all legal documents for guardianship are file marked, as appropriate, and 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:

• Was a guardianship application filed within 30 days of the acceptance date of the referral from HHSC?
• Were copies of letters of guardianship and the guardianship oath submitted to the HHSC contract manager?
• If an application was not filed with the appropriate court within 30 days, was an extension requested through the HHSC contract manager?
• Were file 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, as required. Guardianships are maintained in good standing with the court, and guardianship letters remain current and accurate.

Benchmark 2: Final

Final legal activities are completed in compliance with policies, procedures and applicable codes.

How to determine met or unmet:

• Was a Final Report/Application to Close and Discharge filed with the court within 60 days of the ward’s death, restoration of capacity or the qualification of successor guardian?
• Was the Final Report/Application to Close and Discharge approved by the court?
• Were appropriate orders and any other documents in the ward’s records (receipts, bank statements, etc.) if required by the court?
• 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 outcome for this benchmark is:

Guardianships are closed within time frames established by the Estates Code. The ward’s property was delivered to the appropriate person.

3720 Guardianship Principle 2: Case Management

Revision 22-1; Effective Nov. 2022

Ensure case management responsibilities are performed in compliance with court orders, policies and procedures.

Benchmark 1: Service Planning

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:

• Did the annual or updated service plan reflect the needs of the ward?
• What needs or goals were identified in the service plan?
• What preferences did the ward have for services?
• Was the service plan completed within 90 days of qualification?
• 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?
• Is the current residence of the ward documented in the case file?
• 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, including a licensing review, and annually thereafter?
• Was the ward placed in a licensed, certified or regulated facility?
• Was there documentation in the case record indicating the ward participated in the service planning?
• 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?
• Were all requirements met, as outlined in the 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 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?

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.

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: Monthly Status Contacts

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 Judicial Branch Certification Commission (JBCC)?
• Were time frames met for contacts?
• When contacts were made, were significant 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 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?
• Were face-to-face visits conducted in the home environment at least quarterly and rotated between regular locations of the ward?

The review team observes wards to determine:

• Were monthly status contacts made appropriately?
• Are provider staff 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?
• Does the ward live in a safe and clean environment?
• Is there adequate staffing and supervision to meet the ward's needs?

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 determines 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 alternate environments at least quarterly.

Benchmark 3: Confidentiality

Ensure the confidentiality of all wards’ records and ensure personal 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 maintained in a confidential manner?
• 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 determines 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: Case Work Activities

Complete ongoing casework activities according to policies, procedures and other best practices as outlined by the JBCC.

How to determine met or unmet:

The team reviews records of the wards to determine:

• Were placement standings checked and are copies in the file?
• Did the record contain the demographic face sheet in the beginning of the file and was the information current and accurate?
• Did the certified guardian act when financial, medical or other needs or 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?
• Was a photo of the ward taken and uploaded within 90 days of the date of qualification and every two years thereafter?

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: Communication

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:

• Can the certified guardian and service providers communicate with the ward?
• What communication needs does the ward have and how are the needs addressed?
• 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 speech 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 outcome for this benchmark is:

Service providers meet the communication needs of the wards. The team observes the wards to determine if their communication needs are addressed in the service plan and if the guardianship specialist and service providers communicate with the wards to meet their needs.

3730 Guardianship Principle 3: Documentation

Revision 22-1; Effective Nov. 1, 2022

Ensure service-related activities are documented and maintained in accordance with policies and procedures.

Benchmark 1: Consultation

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
• 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 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 determines 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: Case Documentation

Maintain wards’ records with appropriate documentation as required by policies, procedures, 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 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 26 TAC Section 361.153(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 professional, clear, concise and current. All contacts and events are documented in the record. The ward’s needs are being met.

3740 Guardianship Principle 4: Financial and Estate Management

Revision 22-1; Effective Nov. 1, 2022

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: Financial Management

Ensure financial responsibilities for all wards served, as outlined in court orders or by expectation of the 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 and receipts are obtained, reviewed quarterly and 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, trust accounts or other assets, as appropriate. Ensure all financial records are documented and maintained using commonly accepted accounting methods. Ensure all identified financial discrepancies are resolved 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 trust fund records? If so, were they 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?
• Do provider financial and room and board agreements negotiated by the guardian fall within the scope of applicable provider policies, rules and other statutes?
• Is there evidence the certified guardian reviewed quarterly trust fund statements in a timely manner and are quarterly trust fund statements in the case record?

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.

Benchmark 4: Purchasing Wards Property is Prohibited

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 with court permission and according to procedures outlined in the court order?
• 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 the 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.

The outcome for this benchmark is:

The ward’s property is protected and managed consistent with powers granted in the court order and duties and responsibilities set forth in the Texas Estates Code, policy and procedure, and standards.

3750 Guardianship Principle 5: Health and Safety

Revision 22-1; Effective Nov. 1, 2022

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: Medical Decisions

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 and 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 or written consent to treatments?

The review team conducts interviews for missing or 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: Reporting to Investigations Agencies

Report suspected abuse, neglect, or exploitation to the appropriate agency. Contractors must notify the HHSC 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 within 24 hours?
• Did the contractor maintain contact with the regulating authority until the investigation was closed?
• Did the contractor notify the HHSC 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 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, HHSC 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: Allegations Against Contractor Staff

If the alleged perpetrator is the contractor's employee or volunteer, the contractor must:

• remove the employee or volunteer from contact with HHSC wards until allegations have been investigated and an outcome has been determined;
• take appropriate action, including contacting law enforcement, if an allegation of abuse, neglect or exploitation is found to be valid;
• document the findings in the case record; and
• re-orient the employee or volunteer before they begin working again with HHSC 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 and interviews with contractor employees, wards and provider staff 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 HHSC wards?
• Does documentation of re-orientation exist if the alleged perpetrator was found not to be the perpetrator?
• Were alleged perpetrators removed as soon as allegations were made?
• Did the contractor contact the proper investigative authority when necessary?
• Was the ward protected from abuse, neglect or exploitation?
• Was the HHSC 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 HHSC 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 HHSC wards during an investigation and if found not to be the perpetrator, was re-oriented prior to future contact with the HHSC 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.

Benchmark 4: Background Checks

Ensure a request for a background check was submitted to HHSC for prospective employees or volunteers who may have access to a ward, or the benefits of an HHSC ward. An offer of employment or access to wards is contingent upon the prospective employee or volunteer successfully passing a background check. Ensure a background check was conducted by the contractor using the National Registered Sex Offenders website for any visitors requesting unsupervised visits with HHSC wards.

The team reviews documentation of background checks to determine:

• Was a background check obtained through HHSC on all prospective employees and volunteers before an offer of employment or approval to provide volunteer services was made?
• Was the background check obtained before employees or volunteers began working with HHSC wards?
• Were background checks completed annually for all staff and volunteers who provide services to HHSC wards?
• Were background 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 HHSC 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 HHSC 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 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:

Background checks through HHSC for all employees and volunteers who will have access to an HHSC ward, or the benefits of the ward, were completed. Background checks on the National Registered Sex Offenders Verification website were completed by the contractor on visitors to wards who requested unsupervised visits.

3760 Guardianship Principle 6: Quality Assurance

Revision 22-1; Effective Nov. 1, 2022

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: Contractor QA Plan

Develop and implement a QA plan to ensure compliance with principles, benchmarks, policies, procedures, and the 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 on 100 percent of HHSC wards 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?
• Is corrective action completed?
• Does the QA plan outline the certified guardian’s supervisor responsibility to conduct face-to-face visits with 30 percent of HHSC wards served under the contract?
• Is documentation present indicating 30 percent of HHSC 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 staff are aware of the QA plan and determines if the QA 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: Complaint Tracking

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: Staff Training

Ensure staff attend training, as required by the JBCC and policy. Ensure new employees, provisional employees, certified guardians and 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 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: Guardian Certification

Ensure qualified staff are certified by the JBCC, as authorized in the Texas Government Code (TGC), Section 152.2015. Ensure staff maintain guardianship certification, as required by TGC Section 152.2015, and register with the county, as appropriate. Staff must remain certified and register with each county in which they serve as a certified guardian. Per JBCC requirement an adequate number of qualified certified guardians must be maintained to provide guardianship services to wards served under the contract. Ensure program registration is completed per JBCC requirements.

How to determine met or unmet:

The team conducts a review of personnel records to determine:

• Are staff certified, as required?
• Are staff certification or registration documents up to date?
• Are the certified guardians following all rules and regulations of the 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: Policies and Procedures

Develop and implement policies and procedures and ensure a plan is in place to disseminate new policies and procedures to staff. Copies of new policies and procedures will be requested quarterly from contractors by the lead caseworker conducting the review.

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 6: OIG List of Excluded Individuals and Entities

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.

3770 Guardianship Principle 7: Contractor Reimbursement

Revision 22-1; Effective Nov. 1, 2022

Ensure payment from HHSC is accepted as payment in full for services rendered under the contract.

Benchmark 1: Payment Requirements

The contractor must accept payment from HHSC 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 HHSC to verify the identity of wards served monthly. The contractor must thoroughly review financial agreements with HHSC 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 HHSC 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 HHSC verifying wards served monthly and timely submit those to HHSC?
• Was this area audited by the contractor to ensure compliance with HHSC rules?

The team conducts a review of the financial and payment records to determine if this benchmark is met. The review team verifies HHSC is the sole payment source for each ward served under the contract.

The outcome for this benchmark is:

Payment from HHSC is payment in full.

Benchmark 2: HHSC Payment in Full for Guardianship Services

The contractor must not seek or accept reimbursement from an HHSC 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 Estates Code Section 1155.002 and Section 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 an HHSC ward for guardianship services?
• Did the contractor receive reimbursement from a ward's funds for services provided?
• Did the contractor receive payment from an HHSC 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?

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 an HHSC ward for services provided. The contractor does not collect payment from the wards for guardianship-related services.

Benchmark 3: HHSC Allowable Costs

The contractor must not use HHSC funds or HHSC reimbursed staff time to provide guardianship or other services to an individual who was not referred by HHSC.

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-HHSC wards utilizing funding provided by HHSC?
• Did the contractor charge HHSC for services provided to wards who were not referred by HHSC?

The team reviews financial records and may interview staff to determine if this benchmark is met. The review team determines if HHSC funds were used to pay for staff time for services to wards not contracted for guardianship services through HHSC.

The outcome for this benchmark is:

The contractor does not use HHSC funds or HHSC reimbursed staff time to provide services to individuals who were not referred by HHSC.

Benchmark 4: Contractor Outside Audits

The contractor must provide HHSC staff access to the results of audits, including audits performed on HHSC 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 HHSC rules.

The outcome for this benchmark is:

The contractor provides HHSC staff access to the results of audits performed on HHSC wards, as requested.

3780 Guardianship Principle 8: Ward Status Update

Revision 22-1; Effective Nov. 1, 2022

Ensure HHSC is notified of a ward’s status and change in status. Ensure the Ward Status Update Form is completed and submitted to the HHSC OCS contract manager or the OCS administrative assistant in a timely manner.

Benchmark 1: Status Documentation

The contractor must complete and submit the Ward Status Update Form to the OCS contract manager and designee to notify of any significant status updates. The contractor must complete and submit a Ward Status Update Form when the following occurs: Death of ward, hospitalizations, reports or allegations of abuse, neglect and exploitation against or by the ward; elopements, law enforcement involvement, incarceration, media issue and other significant updates affecting HHSC wards.

How to determine met or unmet:

• Were the contract manager and designee notified of the ward’s location or address change?
• Did the contractor receive express written permission from the HHSC 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 designee 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 HHSC contract manager and designee 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.