Preparing and submitting the Texas Department of Aging Home and Community Support Services Agencies (HCSSA) Form 2020 is a critical step for agencies operating within the state, signaling their readiness for the initial survey or inspection required for licensure in various categories of home and community-based services. This comprehensive form, updated in August 2006, serves a pivotal role for agencies desiring to offer Personal Assistance Services (PAS), Licensed and Certified (L&C) services, Licensed Home Health (LHH) services, including those with or without dialysis, and Hospice care. By completing this document, agencies provide detailed information including the agency's name, address, hours of operation, and contact details, along with patient information such as names, services provided, and the attending physician's details. Moreover, the form requires acknowledgment of the agency's compliance with specific services provision like skilled nursing, home health aide, and various therapies, as well as adherence to required patient counts for those applying under certain licensure categories. Notably, the form also stipulates requirements for agencies seeking initial licensure for hospice or L&C (Medicare) survey, emphasizing the necessity of having served a minimum number of clients and the successful transmission of the Outcome Assessment Information Set (OASIS) test, among other prerequisites. This document, which must be mailed or faxed to the designated regional program manager, embodies the agency's formal declaration of readiness and request for the state's initial licensure survey. It is a testament to an agency's operational capability and commitment to meeting the state's regulations for providing quality home and community support services.
| Question | Answer |
|---|---|
| Form Name | Form 2020 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | mas 2020 form pdf, form2020, what is a 2020 form, medanswering forms 2020 |
Texas Department of Aging |
Home and Community Support Services Agencies (HCSSA) |
Form 2020 |
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and Disability Services |
August 2006 |
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Notification of Readiness for Initial Survey |
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Instructions
Complete all information in each of the boxes. Mail or fax the form to your regional program manager.
Name of Regional Program Manager
I acknowledge by my signature below that the agency is ready for its initial survey. The agency is requesting initial survey for the following categories:
Personal Assistance Services (PAS)
Licensed and Certified (L&C)
Licensed Home Health (LHH)
L&C with Dialysis
LHH with Dialysis
Hospice
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Agencies requesting an initial L&C (Medicare) survey must have provided skilled nursing services and must have provided, or be prepared to provide, at least one more of the following services:
Skilled Nursing
Home Health Aide
Physical Therapy
Occupational Therapy
Speech Therapy
Medical Social Worker
These abbreviations are used in this document: HIC No. – Health Insurance Claim Number; OASIS – Outcome Assessment Information Set.
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License No. |
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Agency Address (Street, City, State, ZIP Code) |
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Days and Hours of Operation |
Area Code and Telephone No. |
Fax Area Code and No. |
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Date Attended Presurvey |
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Administrator |
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Supervising Nurse |
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Patient Name |
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Area Code and Telephone No. |
HIC No. or Social Security No. |
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Address (Street, City, State, ZIP Code) |
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Date Admitted |
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Services Provided |
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Patient Name |
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Area Code and Telephone No. |
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Patient Name |
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Area Code and Telephone No. |
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Address (Street, City, State, ZIP Code) |
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Date Admitted |
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Patient Name |
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Area Code and Telephone No. |
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Address (Street, City, State, ZIP Code) |
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Date Admitted |
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Patient Name |
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Area Code and Telephone No. |
HIC No. or Social Security No. |
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Address (Street, City, State, ZIP Code) |
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Date Admitted |
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Form 2020 |
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Patient Name |
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Area Code and Telephone No. |
HIC No. or Social Security No. |
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Address (Street, City, State, ZIP Code) |
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Patient Name |
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Area Code and Telephone No. |
HIC No. or Social Security No. |
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Address (Street, City, State, ZIP Code) |
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Date Admitted |
Physician |
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Patient Name |
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Area Code and Telephone No. |
HIC No. or Social Security No. |
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Address (Street, City, State, ZIP Code) |
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Patient Name |
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Area Code and Telephone No. |
HIC No. or Social Security No. |
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Address (Street, City, State, ZIP Code) |
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Date Admitted |
Physician |
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10. |
Patient Name |
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Area Code and Telephone No. |
HIC No. or Social Security No. |
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Address (Street, City, State, ZIP Code) |
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Date Admitted |
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Important Notice: Agencies requesting LHH or PAS licensure must have provided services to at least one client at the time this notice is sent. An agency is not required to admit a client in each category authorized under a license. An agency seeking licensure to provide LHH services or
The information below applies only to agencies requesting initial hospice or L&C (Medicare) survey. If applying for licensure in both the hospice and L&C categories, two separate certification surveys and
a. Form |
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Hospice agencies must have accepted patients (who are not required to be Medicare beneficiaries), be prepared to provide all
b.services necessary to meet the hospice conditions of participation, and must demonstrate the operational capability of all facets of operation.
c. OASIS test successfully transmitted on |
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Agencies requesting the L&C category must have provided skilled care to 10 patients and have at least seven patients actively receiving skilled care at the time of the initial certification (Medicare) survey. The agency will notify the Texas
d.Department of Aging and Disability Services regional program manager immediately if its active patient census falls below seven at any time after this notice is sent. If the agency is requesting a licensure category for LHH and/or PAS, it must have provided services to at least one patient at the time this notice was sent.
e.Attach a copy of the final validation report (OASIS) to this form when it is mailed or faxed to your regional program manager.
Signature |
Date |