Form 2314, Satisfaction and Service Monitoring

Instructions

Updated: 5/2015

Purpose

To document the individual's condition, status and the assessment of how well Community Care Services Eligibility (CCSE) services meet the individual’s needs. When the individual expresses dissatisfaction with a particular service or if the case manager identifies a concern with a particular service, the case manager’s action to be taken to resolve the issue is also recorded.

The information gathered and recorded on this form will be:

• used in both service planning and evaluation, and serve as a data entry document;
• used to record the individual's level of satisfaction with the current services and if services are meeting the individual's needs;
• used to document complaints received from the individual;
• used to document requests for changes in the service plan from the individual during the monitoring contact or requests for change of providers; and
• entered in a statewide database and used to monitor provider performance.

Procedure

When to Prepare

Texas Health and Human Services Commission (HHSC) staff complete Form 2314 at required monitoring contacts including the 3/30-day, 60-day, 90-day, 6-month and annual contacts. Form 2314 may be used to document other contacts with the individual, including requests for changes in the service plan or complaints regarding service delivery, but it is not required. However, all contacts with the individual must be documented in the case record.

Form 2314 is a narrative form and intended to record relevant information as reported by the individual regarding his health status, living arrangements, caregiver assistance, service delivery and adequacy of the current service arrangement. The case manager completes Form 2314, as appropriate, during the interview with the individual. Use the information for entry into the Service Authorization System Wizard (SASW).

Number of Copies

Complete one Form 2314. After the information is entered into SASW for Form 2314, the worksheet may be discarded. A copy of Form 2314 created through SASW must be generated and retained in the case record. Additional copies may be required for any referrals deemed necessary.

Detailed Instructions

I. General Information

1. Name of Individual Receiving Services— Enter the individual's name.

2. Individual’s No.— Enter the individual's identification number. This is the Medicaid number or the individual number assigned through the Texas Integrated Eligibility Redesign System (TIERS) or SAS.

3. Person Contacted— Record the name of the person contacted.

4. Relationship (if other than the individual)— Enter the relationship the person contacted has with the individual.

5. Date Contacted —Record the date the contact was made.

6. Type of Contact— Check the box that indicates the manner in which the contact was made.

A. Telephone— Check this box if the contact was by telephone.

B. Home Visit— Check this box if the contact was by a home visit.

C. Other— Check this box if the contact was made in a place other than the home and specify the place (for example, hospital, nursing facility, etc.).

7. Reason for Contact— Check the appropriate box, indicating the type of monitoring visit.

A. 3-Day/30-Day— Check this box if the purpose of the monitoring contact was to perform a 3-day or 30-day contact.

B. 60-Day— Check this box if the purpose of the monitoring contact was to perform a 60-day contact.

C. 90-Day— Check this box if the purpose of the monitoring contact was to perform a 90-day contact.

D. 6-Month— Check this box if the purpose of the monitoring contact was to perform a 6-month contact.

E. Annual— Check this box if the purpose of the monitoring contact was to perform an annual contact.

F. Complaint— Check this box if the purpose of the contact was to document a complaint from the individual.

G. Other— Check this box if the purpose of the contact is other than described in situations A-F.

8. Type of Service— Check the appropriate box(es) to indicate what services are being monitoring at this contact: Community Attendant Services (CAS), Family Care (FC), Primary Home Care (PHC), Emergency Response Services (ERS), Day Activity and Health Services (DAHS), Residential Care (RC), Adult Foster Care (AFC) or Home-Delivered Meals (HDM). If HDM is being monitoring, check the appropriate box(es) to indicate what type of meals are being delivered: Hot, Frozen/Chilled or Shelf Stable.

II. — Overall Satisfaction on Services

Ask the individual about his overall satisfaction with CCSE services and with the provider authorized to deliver services. Record any dissatisfaction and document any comments from the individual.

III. — Monitoring Reminders

The primary purpose of each monitoring contact, whether it is a home visit or a telephone call, is to determine the adequacy of the current service plan and actual service delivery. Ask enough questions at each contact so the individual's current responses, together with the written case record, form a reasonable basis to determine the primary purpose. See the bullets for examples of specific questions that may be appropriate.

IV. Changes Requested at this Monitoring Contact

Record the changes that have been requested or identified at this monitoring contact.

V. Overall Satisfaction with Program

This section is completed to document the individual's overall satisfaction with the CCSE program. Document the individual's level of satisfaction after the resolution of any alleged dissatisfaction. Check the box that most accurately reflects the individual's overall degree of satisfaction with the service(s) being provided.

A — Outstanding
B — Very Good
C — Adequate
D — Needs Improvement
E — Poor

In the SAS Consumer Satisfaction window, document the individual's overall satisfaction by choosing a satisfaction level from the drop-down box.

VI. Document Identification

Case Manager's Name— Enter the name of the case manager completing the review. This item will not be entered into the database.

Dissatisfaction Codes

Codes marked with a plus sign (+) are to be used for an individual who only receives DAHS services.

A. Timing of Services

A1 — Start of nursing, attendant or other services delayed— Use this code to indicate the individual is currently receiving authorized services, but there was a delay in service initiation.

A2 — Schedule for service delivery not being followed— Use this code when the service provider frequently fails to meet agreed-upon schedule.

A3 — Supplies/equipment not delivered promptly— Use this code when supplies or equipment are not delivered promptly.

A4 — Client wants schedule change— Use this code when the individual indicates that the agency is not responding to his request for a schedule change.

A5 — Approved service not being provided— Use this code when the individual indicates he is no longer receiving authorized services.

A6+ — The facility is not open— Use this code when the DAHS facility is not open at times the individual needs to attend the facility.

A7 — Other specify in comments section.— Use this code to record any observation by the individual regarding timing of services which is not covered above.

B. Amount of Service

B1 — Wants hours increased— Use this code when the individual believes that the number of hours authorized for the service is inadequate to meet his needs.

B2 — Wants hours decreased— Use this code when the individual believes he no longer needs as many hours of an authorized service to meet his needs.

B3 — Wants additional tasks/services/supplies/adaptive aids— Use this code when the individual has expressed a need for a task, service, supply, or adaptive aid that was not authorized in his service plan (may or may not want an increase in hours).

B4 — Wants fewer tasks/services/supplies— Use this code when the individual believes he no longer needs a task, service, supply, or adaptive aid that was authorized in his service plan (may or may not want a decrease in hours). See Code C6 to address unwanted adaptive aids.

B5— Needs hours increased— Use this code when the individual believes that the number of hours authorized for the service is inadequate to meet his needs.

B6 — Needs hours decreased— Use this code when the individual believes he no longer needs as many hours of an authorized service to meet his needs.

B7 — Needs additional tasks/services/supplies/adaptive aids— Use this code when the individual has expressed a need for a task, service, supply or adaptive aid that was not authorized in his service plan (may or may not want an increase in hours).

B8— Needs fewer tasks/services/supplies— Use this code when the individual believes he no longer needs a task, service, supply or adaptive aid that was authorized in his service plan (may or may not want a decrease in hours). See action code C6 to address other unwanted adaptive aids.

B9 — Other specify in comments section— Use this code to record any observation by the individual regarding the amount of services which is not covered above.

B10 — Wants to add this service/program— Use this code when the individual has expressed a need for another service or program that is not on his service plan.

C. Quality Issues (Related to the Service)

C1 — No service provider— Use this code when the provider agency does not have a contract for a needed service (for example, a home and community support services agency does not have an occupational therapist who serves the service area where the individual resides).

C2 — No regular service provider currently assigned to case— Use this code when the individual is receiving authorized services, but does not have a regular service provider.

C3 — Service provider's absences or failure to adhere to work schedule causing problems— Use this code when the individual indicates the service provider's absences or failure to adhere to work schedule causes problems.

C4 — Provider not delivering all tasks/services or delivery is not as scheduled— Use this code when the individual indicates the service provider is not performing assigned tasks, not providing authorized services or is not performing tasks according to schedule.

C5 — Poor work performance— Use this code when the individual indicates the service provider is performing assigned tasks according to schedule, but the quality of the work is poor.

C6 — Adaptive aid or minor home modification does not meet the client's needs— Use this code when, the adaptive aid or minor home modification either (1) does not meet the specifications of the assessment, or (2) the assessment does not accurately reflect the individual's needs.

C7 — Supplies/DME/minor home modifications are of poor quality or are not as ordered,— Use this code when medical supplies, adaptive aids or minor home modifications are of poor quality, insufficient supply, poor workmanship, wrong size, etc.

C8 — Lack of or dissatisfaction with activities provided— Use this code when the individual is not satisfied with AFC, AL, RC or DAHS services.

C9 — Service lacks medical necessity— Use this code when adaptive aids or minor home modifications were authorized or delivered without a validated medical necessity.

C10— Other specify in comments section— Use this code to record any individual observation regarding quality issues related to the service which is not covered above.

C11— Other specify in comments section— Use this code to record any other quality or compliance issues such as the individual appears to be overly sedated while telling you he cannot remember what medicines he is taking.

D. Quality Issues (Relating to Provider Staff)

D1 — Provider staff/contractors do not treat client with respect/dignity— Use this code when the individual indicates the provider’s staff or contractors do not treat him with respect or dignity.

D2 — Service provider is verbally abusive— Use this code when the individual indicates the service provider is or was verbally abusive to him.

D3 — Service provider is physically abusive— Use this code when the individual indicates the service provider is or was physically abusive to him. The case manager should consider citing action codes AP Referral to APS, LI Referral to Regulatory or CM Referral to Contract Manager, if he believes the complaint may be valid.

D4 — Service provider is sexually abusive— Use this code when the individual indicates the service provider is or was sexually abusive to him. The case manager should consider citing action codes AP, LI and/or CM if he believes the complaint may be valid.

D5 — Service provider staff behavior places client/belongings in jeopardy— Use this code when the individual indicates the service provider behaves in a manner that the individual feels he or his belongings are in jeopardy of harm or damage. The case manager should consider citing action codes AP, LI and/or CM if he believes the complaint may be valid.

D6 — Client does not know how to contact provider for help/does not have telephone number(s)— Use this code when the individual reports he does not know how to contact the provider or does not have the provider’s telephone number.

D7 — Provider agency staff do not respond to client's request for information or assistance— Use this code when the individual indicates the provider agency does not respond to his requests for information or assistance.

D8 — Client independence/self-determination not honored— Use this code when the individual believes his independence or ability to direct his care is not honored.

D9 — Provider did not discuss changes in attendant or schedule with client— Use this code when the individual indicates the provider agency did not discuss with him changes in his service providers or the schedule.

D10 — The client feels that staff are not responsive to his needs— Use this code when the individual indicates the staff are not responsive to his needs.

D11 — The client feels uncomfortable in expressing his opinions or dissatisfaction for fear of losing his service— Use this code when the individual states he feels uncomfortable in expressing his opinions or dissatisfaction without fear of losing his service(s).

D12+ — The client feels pressured from the facility to attend the facility for longer hours or on additional days— Use this code when the individual indicates he feels pressured from the DAHS facility to attend the facility for longer hours or increase the number of days he attends the facility.

D13 — The facility does not have appropriate staff available— Use this code when the individual indicates the staff are not available.

D14 — Other specify in comments section— Use this code to record any observation from the individual regarding quality issues related to provider staff which is not covered above.

E. Quality Issues (Related to Training)

E1 — Provider staff not oriented to general job/program requirements— Use this code when the individual indicates the service provider has no knowledge of non-service related job requirements (that is, calling in absences, negotiating schedule changes, completing time sheets, body positioning to avoid injury, while transferring the individual, etc.).

E2 — Provider staff not oriented to service-related job/program requirements— Use this code when the individual indicates the service provider is not familiar with the service plan or with the specifics of job assignments as it relates to the individual. For example, the provider is not aware that for the individual, bathing means that the provider is supposed to be present while the individual is bathing in case assistance is needed.

E3 — Service provider does not know how to perform authorized task(s)— Use this code when the individual indicates the service provider does not know how to perform tasks (for example, service provider does not know how to cook).

E4 — Service provider did not provide adequate orientation on program/services to client/family— Use this code when the individual indicates that the service provider is unable to explain what the service provider can or cannot do, does not know how to deal with problematic situations, cannot relate to the individual or his family of their rights and responsibilities, etc.

E5 — Other specify in comments section— Use this code to record any observation from the individual regarding quality issues related to provider training and orientation which is not covered by E1-E4. Only the first 50 characters will be retained by the database so comments should be brief.

F. Quality Issues (Related to Meals/Snacks)

F1 — Meals schedule not being followed— Use this code when the individual indicates he is not receiving his meals regularly.

F2 — Quantity and/or variety of food not adequate— Use this code when the individual indicates he is not receiving enough food or if the meals are consistently the same.

F3 — Menu plan not adequate to meet basic nutritional requirements— Use this code when the individual indicates that a balanced diet is not being provided.

F4 — Nutritional special diets not met— Use this code when the individual has a special diet plan but it is not being provided.

F5 — Quality of meal not adequate— Use this code when the individual indicates the quality of the meal is poor.

F6 — Other specify in comments section— Use this code to record any observation from the individual regarding quality issues related to food, snacks, or both, which are not covered by F1-F5. Only the first 50 characters will be retained by the database so comments should be brief.

G. DAHS Facility Issues (Other)

G1+ — The client has been approached by another facility to transfer— Use this code when the individual indicates a staff from a different DAHS facility recommended he transfer to their facility.

G2+ — The client wants to transfer to a closer facility— Use this code when the individual indicates he wants to attend a DAHS facility which is closer to his home.

G3+ — The client wants to transfer to a new facility— Use this code when the individual indicates he wants to transfer to another DAHS facility because it is new.

G4+ — The client wants to follow facility's staff to the new facility— Use this code when the individual indicates he wants to change DAHS facilities because the staff whom he has become accustomed are moving to another DAHS facility and the individual wants to go with them.

G5+ — Other specify in comments section— Use this code to record any observation from the individual regarding a DAHS facility which is not covered above.

Action Codes

• AP — Referral to Adult Protective Services
• BD — Referral to BNE (The BNE is now the Board of Nursing)
• CF — Contact family
• CI — Client ineligible
• CM — Referral to Contract Manager
• CW — Referral to Caseworker
• ED — Educate client
• FC — File formal complaint
• LI — Referral to TDH Licensure (Use this code when a referral to Regulatory is made.)
• NO — No action needed
• PA — Referral to provider agency
• RN — Referral to regional nurse
• SP — Change service plan
• SU — Referral to supervisor (Use this code when a referral is made to the case manager's supervisor.)
• TR — Client transfer to another provider agency