Form 3853, Contract Evaluation Summary

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Documents

Effective Date: 6/2016

Instructions

Updated: 8/2015

Purpose

To serve as the primary document to summarize finding of standards compliance monitoring for the Community Care for the Aged and Disabled (CCAD) programs, and Deaf-Blind with Multiple Disabilities (DBMD).

Procedure

When to Prepare

HHSC staff who conduct the monitoring complete the form after all cases have been read.

Number of Copies

Complete an original and one copy.

Transmittal

During or after the exit conference, a copy of the form is given to the contractor representative. HHSC staff retain the original for agency records.

Form Retention

Retain a copy of this form in the contract file.

Detailed Instructions

Completed By — Enter the first and last name of the team lead.

Name of Legal Entity — Enter the name of the entity as it appears on the contract.

Contract No. — Enter the nine-digit contract number.

Contract Begin Date — Enter the begin date of the contract.

Contract End Date — Enter the end date of the contract.

Review Type — Indicate the type of review being conducted.

Review Level — Check Full or Targeted.

Date of Entrance — Enter the start date of the review.

Date of Exit — Enter the end date of the review.

Date of Revised Exit — Enter the date of the revised exit.

Dates of Monitoring Period — Enter the monitoring period begin and end dates.

Evaluation of Standards

Standards — Enter the number and name of each contract standard used for this review. For each standard, complete columns A through E as follows:

  • Column A (number N/A) — From the monitoring form completed during the review, add the number of "N/As" recorded for each standard. Enter this number in Column A.
  • Column B (number Met) — From the monitoring form reviewed, add the number of "Mets" recorded for each standard. Enter this number in this column.
  • Column C (number Not Met) — From the monitoring form completed during the review, add the number of "Not Mets" recorded for each standard. Enter this number in this column.
  • Column D Total (B+C) — For each standard, add the number of "Mets" in Column B and the number of "Not Mets" in Column C. Enter this number in this column.
  • Column E, % Met, (B/D x 100%) — For each standard, divide the number of "Mets" in Column B by the total number in Column D and multiply the amount by 100%. Enter this percentage in this column.

Totals — For Columns A through D, add the numbers in the column (down) and enter the total for each column.

Overall Compliance % — Divide the total of Column B [down] (Met) by the total of Column D [down](Total). This percentage (B/D) is the cumulative level of compliance for the contractor. Round to the hundredth's decimal place. E.g. 67.66%