Current through Reg. 50, No. 13; March 28, 2025
(a) HHSC
conducts contract and fiscal monitoring on site or by desk review:
(1) to determine if:
(A) a contractor is in compliance with its
contract, which requires compliance with applicable federal and state laws,
rules, and regulations, provider manuals and handbooks, billing guidelines, and
communications promulgated by HHSC, including information letters; or
(B) a contractor is in compliance with a
corrective action plan as described in § 49.522 of this chapter (relating
to Corrective Action Plan) or an immediate protection plan as described in
§ 49.511 of this chapter (relating to Immediate Protection and Immediate
Protection Plan);
(2) for
purposes described in paragraph (1)(A) of this subsection, at least once during
the term of a provisional contract and periodically after the effective date of
a standard contract, on a schedule determined by HHSC;
(3) by evaluating standards in accordance
with:
(A) for all contractors, a
program-specific HHSC contract and fiscal compliance monitoring tool;
and
(B) for contractors that have
an FMSA contract listed in § 49.101(a)(5) of this chapter (relating to
Application), a CDS tax monitoring tool; and
(4) at a location identified by HHSC, which
may include a location where the contractor conducts business or provides
contracted services.
(b)
To conduct contract and fiscal monitoring, HHSC:
(1) sends a written notice to a contractor
that includes the date the monitoring will begin and lists the records the
contractor must provide at the entrance conference described in paragraph (2)
of this subsection;
(2) conducts an
entrance conference with the contractor;
(3) performs other activities, which may
include:
(A) reviewing the contractor's
records;
(B) reviewing the
contractor's policies and procedures;
(C) reviewing consumer satisfaction
surveys;
(D) interviewing a person
with knowledge relevant to the contract, including an individual receiving
services or the contractor's employee; and
(E) observing an individual receiving
services;
(4) conducts an
exit conference with the contractor, at which HHSC reports the compliance score
for each standard reviewed and an overall compliance score; and
(5) notifies the contractor, in writing, of
the results of the monitoring.
(c) A contractor must provide records listed
in the notice described in subsection (b)(1) of this section to HHSC at the
entrance conference described in subsection (b)(2) of this section. If a
contractor does not provide records in accordance with this subsection, HHSC
conducts contract monitoring with any records provided.
(d) If HHSC determines that a contractor's
compliance score for a standard on a monitoring tool described in subsection
(a)(3) of this section is less than 90 percent, HHSC requires the contractor to
submit an acceptable corrective action plan to HHSC in accordance with §
49.522 of this chapter.
(e) If HHSC
determines that a contractor's overall compliance score on a monitoring tool
described in subsection (a)(3) of this section is less than 90 percent, HHSC
considers the contractor out of substantial compliance with the contract and
may:
(1) determine that a contractor does not
qualify for a standard contract;
(2) impose an action or sanction in
accordance with Subchapter E of this chapter (relating to Enforcement by HHSC
and Termination by Contractor);
(3)
conduct additional monitoring in accordance with this section; or
(4) take a combination of the actions
described in paragraphs (1) - (3) of this subsection.
(f) If, during a contract and fiscal
monitoring, HHSC determines that the contractor is not protecting an
individual's health and safety, HHSC may require the contractor to:
(1) immediately protect the individual's
health and safety; and
(2) submit
an immediate protection plan in accordance with § 49.511 of this
chapter.
