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Select n if any of the amounts in columns w z and ac

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·Select “N” if any of the amounts in Columns W, Z and AC are in parentheses and thecorresponding columns X, AA and AD are “N”.·If “N”, and the contractor has not provided evidence of correction, enter the room & board and/orco-pay and/or bed hold refund amount due in the RC Monitoring Workbook- AL/RC Individuals’ FundsSummary.If the contractor corrected the room & board and/or co-pay and/or bed hold refund amountdue at any time prior to the exit, do not enter the amount on the Individual Funds Summary.Documentthis correction in the Notes tab.oReview F2067s/F3251 Daily Census Record (or equivalent) for the monitoring period to determine if the individual washospitalized during the monitoring period.(B) No.DaysHospitalized(C)IndividualResponsibilityPortion of Bed HoldCharge(E)Numberof Days inMonth(F) Co-Pay Amount Dueto theIndividual[(D/E)*B] - (C*B)(G) Date of PaymentResulting inRefund/Credit, ifapplicable(H) DaRefundappl
Texas Departmentof Aging andDisability ServicesRESIDENTIAL CARE (RC)INDIVIDUAL WORK PAPERForm TBDPage 681Contract NumberContract Type:Dates of Review PeriodDates of Fiscal Review25Begin:End:Completed ByLast:Date CompletedFirst:SampleNumberFirstMonthSecondMonthFrom:To:CCAD ONLYNAXI.5.oIf overarching question X.6 is “Y”, complete the table belowDate of Death/DischargeUnused Room & BoardProrated Co-PayAmount DueDate of RefundAmount DueDate oXI.4.If the individual was hospitalized during the monitoring period, was a refund orcredit for the prorated co-payment amount made to the individual within 70 days afterthe date of receipt of the payment that resulted in the refund or credit?·If “N”, enter the co-pay refund amount due in the RC Monitoring Workbook- AL/RC Individuals’Funds Summary.If the contractor corrected the co-pay at any time prior to the exit, do not enter theamount on the Individual Funds Summary.Document this correction in the Notes tab.oReview F2067s (or equivalent) and/or F3251 Daily Census Record (or equivalent) for the last month of service delivery withinthe monitoring period to determine if the individual died or was discharged.oIf individual died or discharged during the monitoring period, complete the table belowAmount Refunded (ifany)Amount Refunded (ifany)
Texas Departmentof Aging andDisability ServicesRESIDENTIAL CARE (RC)INDIVIDUAL WORK PAPERForm TBDPage 682Contract NumberContract Type:Dates of Review PeriodDates of Fiscal Review25Begin:End:Completed ByLast:Date CompletedFirst:SampleNumberFirstMonthSecondMonthc. The correct amount was refunded:NAi. Unused room and board refund was equal to the unused room and board amount dueii. Co-pay refund, if applicable, was equal to the co pay amount dueNA(Refer to column “Z”,AL/RCReimbursementSpreadsheet)(Refer to column “W”,AL/RC ReimbursementSpreadsheet)a. Date of refund of unused room and board and, if applicable, co-payment was within 10 workdays ofawareness of death/dischargeb. Unused room and board and, if applicable, co-payment refund were made to individual or theindividual’s representative/beneficiary or escheated to the STATE OF TEXASXI. 5. If the individual was discharged or died during the monitoring period was theunused room and board and prorated co-payment, if applicable, refunded/reimbursedas required?

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Disability Services

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