Form 3153, Purchased Services Contract Monthly Complaint and Inquiries Report

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Documents

Effective Date: 4/2019

Instructions

Updated: 4/2019

Purpose

The service provider completes this form for the preceding month and emails it to IL_Provider_Inquiries@hhsc.state.tx.us by the fifth day of the month.

Definitions

Complaints – Any dissatisfaction expressed by the consumer, vendor or stakeholder.

Complaint Types

  • Service complaint – A consumer dissatisfaction with a good or service purchased, arranged or provided by the service provider.
  • Staff complaint – A consumer dissatisfaction with the service provider’s staff related to treatment or case decisions.
  • Services and staff complaint – A consumer dissatisfaction with both the service provider’s staff and the good or service purchased, arranged or provided.
  • Vendor complaint – A consumer dissatisfaction with the goods or services provided by a vendor or an arranged provider.
  • Other complaint – Any other type of consumer dissatisfaction related to the Independent Living Services (ILS) Purchased Services Program.

Completion date – The date that the inquiry or legislative inquiry responses were complete and no further action was necessary.

Inquiry – A request by a consumer for information about the ILS Purchased Services Program or services.

Inquiry types

  • ILS program services (includes the services offered in the ILS Purchased Services Program).
  • Eligibility requirements for the ILS Purchased Services Program.
  • Service delivery (includes consumer participation fees, length of services, wait for services).
  • Referral (from a state organization, community agency, stakeholder).

Legislative inquiry – Inquiries and complaints received from congressional or state legislative offices regarding the ILS Purchased Services Program.

Resolution date – The point at which a determination can be made as to whether a complaint should be substantiated and no further action is necessary.

Substantiated complaint – A complaint in which it is found the ILS Standards for Providers, purchased services contract and/or service provider policy was not followed.

Unsubstantiated complaint – A complaint where research clearly indicates an ILS Standards for Providers, purchased services contract or service provider policy was not violated or agency standards were met.

Detailed Instructions

Service Provider – Enter the name of the service provider.

Contract Number – Enter the contract number.

Reporting Month and Year – Enter the reporting month and year.

Report Date – Enter the report date.

 

Section I. Complaint Log Current Month

Complete each field for the preceding month using the definitions provided above.

Complainant Name – List each consumer or complainant name separately.

Complaint Date – Enter the date of the first contact by the complainant or consumer.

Resolution Date – Enter the date which a determination can be made about a complaint being substantiated or unsubstantiated.

Type of Complaint – Select the type of complaint from the drop-down menu using the definitions above.

Complaint Substantiated – Select Yes or No to record if the complaint was substantiated.

 

Section II. Complaints Pending from Previous Month(s)

Complete each field to include any unresolved complaints using the definitions provided above.

Complainant Name – List each consumer or complainant name separately.

Complaint Date – Enter the date of the first contact by the complainant or consumer.

Resolution Date – Enter the date which a determination was made about a complaint being substantiated or unsubstantiated.

Type of Complaint – Select the type of complaint from the drop-down menu using the definitions above.

Complaint Substantiated – Select Yes or No to record if the complaint was substantiated.

 

Section III. Inquiries Log

Complete each field, using the definitions provided above, for inquiries made about the ILS Purchased Services Program during the report month.

Contact Name – Enter the contact name.

Inquiry Date – Enter the date of the initial contact.

Completion Date – Enter the date that the inquiry responses were complete and no further action was necessary. 

Type of Inquiry – Select the type of inquiry from the drop-down menu using the definitions above.

 

Section IV. Legislative Inquiries Log

Complete each field, using the definitions provided above, for legislative inquiries made about the ILS Purchased Services Program during the report month.

Contact Name – Enter the contact name.

Legislator Name – Enter the legislator name.

Inquiry Date – Enter the date of the initial contact.

Completion Date – Enter the date that the legislative inquiry responses were complete and no further action was necessary. 

Reason for Inquiry – Enter the reason for the inquiry.

Signature – Complete the electronic signature of the executive director or designee and enter the date.

HHSC Use Only – HHSC staff enter the date received, month reported to the Office of the Ombudsman and sign the form.