STDC concurs with the finding regarding incomplete intake documentation due to the absence of case worker signatures on multiple client intake forms under the Area Agency on Aging (AAA) programs. While client eligibility and demographic information were present, the lack of formal sign-off by the as...
STDC concurs with the finding regarding incomplete intake documentation due to the absence of case worker signatures on multiple client intake forms under the Area Agency on Aging (AAA) programs. While client eligibility and demographic information were present, the lack of formal sign-off by the assigned case worker represents a lapse in documentation compliance and internal control.
STDC management acknowledges the importance of complete and accurate documentation to uphold program integrity and compliance with the Older Americans Act. We are fully committed to strengthening internal controls, reinforcing training, and implementing procedural safeguards to ensure that all eligibility determinations and service authorizations are properly reviewed and documented.
To address this, STDC will reinforce existing policies requiring case worker authorization of client intakes, implement a formal quality assurance checkpoint before service initiation, and provide refresher training to all intake and case management staff. These steps will ensure compliance with documentation standards required under the Older Americans Act and STDC’s own internal procedures.
Corrective Action Plan
Finding Number: 2023-04
Planned Completion Date: July 31, 2025
Responsible Official: Aging and Disability Services Director
Corrective Actions:
1. Reinforce Policy Compliance through Staff Training
The Aging and Disability Services Director will conduct mandatory refresher training for all intake and case management staff. The training will emphasize the importance of complete documentation, specifically the requirement to sign and date all applicable forms, including:
o Intake Forms 2270 and 2276
o Rights and Responsibilities Form 2275
o Client Information Release Form 2277
o Care Plan
o Caregiver Assessment
o Consumer Needs Evaluation (CNE)
o Evaluation of the Home (Housing Assessment)
Staff training shall be verified for completion using: training attendance logs, training agenda, and post-training quiz results.
2. Implement a Secondary Review Process (Quality Assurance Checkpoint)
The Aging and Disability Services Director will establish a secondary quality assurance review by the Contract Manager or other designated staff prior to initiating services. The reviewer will confirm that all required forms are fully completed and include both client and case worker signatures.
3. Update Intake Documentation Checklist and Procedures-Attached
The Aging and Disability Services Director will revise the internal Required Documentation Checklist to include a checkbox for verifying the presence of AAA staff signatures and dates on all applicable forms. The updated checklist will be implemented in all new client intake files.
CASE FILE CHECKLIST
1. Referral and Screening
The referral and screening process begins with the Information, Referral, and Assistance (I&R/A) staff, who receive the client’s initial inquiry or service request. Once initial details are collected, the referral is assigned to a designated AAA case manager for follow-up.
Screening
The case manager reviews the client’s records to verify information gathered during the referral. This step helps determine eligibility (typically for individuals aged 60 and over) and whether the client qualifies for AAA services or should be referred externally.
The screening must include:
o Medical history
o Employment background
o Home environment
o Self-care ability
o Socioeconomic and financial status
o Services received in the past
o General demographics and needs
o Past and current health conditions
o Physical, emotional, and cognitive functioning
o Living arrangements and home safety
o Health insurance coverage and benefits
Referral and screening documentation must be included in the client’s file to support coordination, follow-up, and accountability.
2. Intake – Form 2270 (Applicable to Caregiver Support Coordination)
This form is required and must be completed by AAA staff or the case manager to collect demographic information necessary to determine eligibility. The form must include:
o Initial Intake Completion – Form 2270
o Client Rights and Responsibilities (read and checked off as explained)
o Part I – Recipient Identification
o Part II – Services Requested
o Part III – Emergency Contact Information
o Part IV – Relationship to Care Recipient
o Part V – Care Recipient Identification
AAA staff signature and date
3. Intake – Form 2276 (Applicable to Care Coordination Support)
This form is required and must be completed by AAA staff or the case manager to collect demographic information necessary to determine eligibility. The form must include:
o Initial Intake Completion – Form 2276
o Client Rights and Responsibilities (read and checked off as explained)
o Part I – Recipient Identification
o Part II – Services Requested
o Part III – Emergency Contact Information
o Part IV – If referred, enter referred by; if not, leave blank
o AAA staff signature and date
Forms must be fully and accurately completed and include the printed name or signature of the AAA staff completing the intake, along with the date.
4. Client Rights and Responsibilities – Form 2275
This form is provided and explained to the client. A copy must be given to the client. The form must include:
o Explanation of client rights and responsibilities
o Client signature and date
Must be signed and dated by the participant/client.
5. Client Information Release – Form 2277
This form serves as authorization to release client information to support assessment, service arrangement, and coordination of care. The form must include:
o Individual’s name and WellSky ID
o Completion of Parts A, B, and C
o Client signature and date in Part C
A copy must be provided to the client.
6. Care Plan (15–25 minutes – form attached)
The care plan is developed collaboratively with the client and/or caregiver and is based on preferences, identified needs, and available resources. It outlines specific services to be provided and desired outcomes. The Care Plan Form must include:
o Complete client information
o Type of service (e.g., Respite, Homemaker, Personal Assistance, or other services such as Residential Repair, Health Maintenance, or ERS)
o Number of units or hours per day/week (if applicable)
o Duration of services
o Objectives and care-related goals
o Self-care resources
o Desired results and measurable outcomes
The form must be signed and dated by the client and/or caregiver and AAA staff/Care Coordinator.
7. Caregiver Assessment – AIAAA CAQ E 3.0 (15–25 minutes – form attached)
Only applicable for Caregiver Support Coordination case files.
This assessment identifies caregiver needs, strengths, limitations, and stressors to support effective care planning. The form must include:
o Complete caregiver information
o Caregiver needs and profile
o Skills and training assessment
o Caregiver stress interview
o Priority status
o Optional targeting categories
o Additional notes, if applicable
Must include the printed name or signature of the AAA staff completing the assessment and the date of completion.
7. Consumer Needs Evaluation (CNE) (form attached)
The CNE documents the client’s impairment level and helps determine eligibility for services. The evaluation must include:
o Completion of Parts I–V
o Classification of impairment level (low, moderate, or high), based on functional needs
o Consideration of mobility, self-care, cognitive ability, and support systems
The form must be signed and dated by the AAA staff member completing the evaluation.
8. Comprehensive Assessment & Statement of Need (form attached)
This assessment provides a holistic view of the client’s condition and support needs. The form must include:
o Complete client information
o Documentation of physical, mental, and medical conditions
o Identification of mobility limitations
o Functional/physical status – check all that apply
o List of current services or treatments being received
o Family caregiver support
o Medication listing, if applicable
AAA staff must complete and check all relevant sections to ensure full and accurate documentation.
9. Evaluation of the Home (Housing Assessment – if applicable)
Required for requests related to residential repairs or identifying health/safety concerns in the home. The form must include:
o Residential status
o Client name and address
o List of items needing repair
The form must be signed and dated by the homeowner/tenant (if applicable) and the AAA staff completing the evaluation.