Chapter 10: Reporting and Quality Assurance

Revision 19-1, Effective March 1, 2019

 

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. 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.

An ILS Data Reporting System was developed for the Independent Living Services Program to gather, track, and monitor program performance and financial data. Each service provider will be required to enter data into this system at least monthly and in accordance with 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 and/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

Entities must collect data and review to track performance. When data indicates 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

Consumer satisfaction measures input from consumers 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
1 Strongly disagree
2 Disagree
3 Neither agree nor disagree
4 Agree
5 Strongly agree

 

All consumers, both successful and unsuccessful, must be given the opportunity to respond.

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

 

10.2 Required Reports

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 of the data reported, including information entered into the Independent Living Services Data Reporting System and recorded on fiscal reports matching amounts in accounting records.

 

10.2.1 Program Reports

The service provider is required to enter or upload data into the Independent Living Services (ILS) Data Reporting System by the fifth day of the following month in accordance with 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;  
  • successful and unsuccessful case closures; and
  • consumer 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 consumers receiving independent living services;
    • the average number of people receiving an independent living service; and
    • the number of consumers who achieve independent living goals.
  • Work plan targets, including:
    • a certain percent of consumers served who are deaf or hard of hearing;
    • a certain percent of consumers 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 (also by the fifth day after the end of the previous month), service providers also will be required to enter consumer success stories into the Independent Living Services Data Reporting System. These consumer success stories should include examples of consumers served with different disabilities, including consumers who are deaf or hard of hearing and blind or visually impaired.

 

10.2.2 Financial Reports

The service provider is required to complete financial reports for the Independent Living Services Program contract, to include the original annual budget, Form 3001, Quarterly Financial Report, Form 3003, Quarterly Program Income Report, and Form 3000, Budget Revision Request. The Budget Workbook, based on an Excel template, is used for completing these quarterly or annual financial reports.

A service provider submits Form 3001 to the HHSC contract manager within 30 days after the end of the quarter. Form 3001 for the fourth quarter will be due within 45 days after the end of the year.

The financial reports are linked in the Budget Workbook to facilitate completion of the reports and to support ongoing budget oversight, including a comparison of actual-to-budgeted funds. When a financial report is completed, it should be saved separately, named appropriately, and submitted to the contract manager according to the instructions.

 

10.2.3 HHSC ILS Invoice Workbook

As described under 8.7.1: Request for Payment, the HHSC ILS Invoice Workbook is used to request funds for contract costs.

The HHSC ILS Invoice Workbook must be completed and submitted within five days after the end of the reporting month and must be approved before the advance is paid. The service provider can receive advance funds (that is, 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.

 

10.2.4 Audit Requirements

In accordance with contract assurances, all service providers are required to obtain an annual financial audit 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, in accordance with 2 Code of Federal Regulations (CFR), Part 200, Uniform Guidance, Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards and/or Uniform Grant Management Standards (UGMS) State of Texas Audit Circular.

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

The service provider will be given instructions for audit submission to the HHSC.