Form 8557, CLASS/DBMD Corrective Action Plan

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Documents

Effective Date: 6/2022

Instructions

Updated: 6/2022

Purpose

To provide a standardized method of completing a proposed corrective action plan that includes all required elements.

Procedure

When to Prepare

CLASS CMAs, DSAs and DBMD program providers must complete one Corrective Action Plan Form 8557 for each individual standard that scored less than 90 percent during a formal or intermittent monitoring review.  

CLASS CMAs, DSAs, and DBMD program providers must complete one Corrective Action Plan Form 8557 for each substantiated allegation and non-compliance that was cited during a complaint investigation. 

Form Retention

Keep this form in accordance with record retention requirements outlined in the Texas Administrative Code.

Detailed Instructions

Legal Entity: — Enter the name of the legal entity.

Contract No.: — Enter the legal entity’s contract number

Program Type: — Mark the appropriate box to indicate the program type (choose one option):

  • CLASS CMA
  • CLASS DSA
  • DBMD

Submitted by: — Enter the name of the legal entity’s staff member who is submitting the proposed corrective action plan.

Area Code and Phone No.: Enter the phone number of the legal entity’s staff member who is submitting the proposed corrective action plan.

Email Address: — Enter the email address of the legal entity’s staff member who is submitting the proposed corrective action plan.

Type of Review — Mark the appropriate box to indicate the type of review that was conducted (choose one option):

  • Formal
  • Intermittent
  • Complaint Investigation

Date of Exit: — Enter the date of the monitoring review exit as noted on the completed Form 5990 Exit Conference or the complaint investigation end date as noted on the completed Form 2175 Contractor Notification of Findings.

Instructions to the Program Provider: 

  1. Complete one Form 8557, Corrective Action Plan: 
    1. for each individual standard that scored less than 90% during the contract and fiscal compliance monitoring review.   
    2. for each substantiated allegation of non-compliance that was cited during a complaint investigation.
  2. All fields are required. Incomplete forms will be returned to the submitter for corrections.
  3. Submit the completed Form 8557 to the HHSC contract monitoring staff that conducted your monitoring review or complaint investigation.  Corrective action plans must be submitted within 10 business days after the date of the notice from HHSC. Failure to submit a completed corrective action plan may result in one or more contract sanctions.
  4. The program provider will be notified by letter from HHSC of corrective action plan approval or denial.

Non-compliance Description — Describe the non-compliance that HHSC identified during the monitoring review or complaint investigation which resulted in the requirement to submit a corrective action plan.  

You must include all non-compliance that was identified for the monitoring standard.  Refer to the notes provided to you by the monitoring team at the conclusion of the monitoring review or complaint investigation.  

Corrective Action — Describe the activities that will be performed across the contract to correct or prevent the non-compliance from reoccurring. (Do not just restate the Texas Administrative Code.)  

When determining the appropriate action, consider the steps necessary to achieve compliance. This may include quality assurance activities, policy updates, checklists, re-training, tracking sheets or a combination of these methods.  For additional guidance, review the “Best Practice Guidelines for Developing a Corrective Action Plan” document.    

Name of Person Responsible for Corrective Action: — Enter the name of the legal entity’s staff member who will be responsible for implementing the corrective action plan. 

Title of Person Responsible for Corrective Action: — Enter the title of the legal entity’s staff member who will be responsible for implementing the corrective action plan.  

Implementation Date: — Enter the date that the legal entity will implement the corrective action documented in the Corrective Action field.  If multiple activities are noted in the Corrective Action field, enter the implementation date of the last activity.

Provider Agency Staff: — The legal entity’s staff member who is responsible for implementing the corrective action plan must sign the form.

Date: — The legal entity’s staff member who is responsible for implementing the corrective action plan must enter the date they signed the form.

HHSC Provider Monitoring Staff Approval: — HHSC monitoring staff will sign the form, signifying approval of the proposed corrective action plan.

Date: — HHSC monitoring staff will enter the date they signed the form.

Additional Resource:

Best Practice Guidelines for Developing a Corrective Action Plan (PDF)

Contact Program Staff

For questions related to the form or form instructions, contact the CLASS/DBMD Provider Monitoring team via e-mail at: CAPM_CLASS_DBMD_Monitoring@hhs.texas.gov