3500, General Information

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.