Form 2314, Satisfaction and Service Monitoring

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Effective Date

10/2014
2314.pdf

Instructions

Updated: 3/2026

Purpose

To document the person’s condition, status and the assessment of how well Community Care Services Eligibility (CCSE) services meet the person’s needs. When the person expresses dissatisfaction with a particular service or if the caseworker identifies a concern with a particular service, the caseworker’s action to be taken to resolve the issue is also recorded.

The information gathered and recorded on this form will be:

  • used in both service planning and evaluation, and serve as a data entry document;
  • used to:
    • record the person’s level of satisfaction with the current services and if services are meeting the person’s needs;
    • document complaints received from the person;
    • document requests for changes in the service plan from the person during the monitoring contact or requests for change of providers; and
  • entered in a statewide database and used to monitor provider performance.

Procedure

When to Prepare

Texas Health and Human Services Commission (HHSC) staff complete Form 2314 at required monitoring contacts including the 3/30-day, 60-day, 90-day, 6-month and annual contacts. 

Form 2314 is a narrative form and intended to record relevant information as reported by the person about their:

  • health status,
  • living arrangements,
  • caregiver assistance,
  • service delivery, and
  • adequacy of the current service arrangement. 

The caseworker completes Form 2314, as appropriate, during the interview with the person. Use the information for entry into the Service Authorization System Online (SASO).

Number of Copies

Complete one Form 2314. After the information is entered into SASO for Form 2314, the worksheet may be discarded. A copy of Form 2314 created through SASO must be generated and retained in the case record. More copies may be required for any referrals deemed necessary.

Detailed Instructions

I. General Information

1. Name of Individual Receiving Services— Enter the person’s name.

2. Individual’s No. — Enter the person’s identification number. This is the Medicaid number or the individual number assigned through the Texas Integrated Eligibility Redesign System (TIERS) or SASO.

3. Person Contacted — Enter the name of the person contacted.

4. Relationship, if other than the person receiving services — Enter the relationship the person contacted has with the person receiving services.

5. Date Contacted —Enter the date the contact was made.

6. Type of Contact — Check to indicate how the contact was made.

A. Telephone — Check if the contact was by phone.

B. Home Visit — Check if the contact was by a home visit.

C. Other — Check if the contact was made in a place other than the home and specify the place, for example, a hospital or nursing facility.

7. Reason for Contact — Check the appropriate box to indicate the type of monitoring visit.

A. 3-Day or 30-Day — Check if the monitoring contact was to perform a 3-day or 30-day contact.

B. 60-Day — Check if the monitoring contact was to perform a 60-day contact.

C. 90-Day — Check if the monitoring contact was to perform a 90-day contact.

D. 6-Month — Check if the monitoring contact was to perform a 6-month contact.

E. Annual — Check if the monitoring contact was to perform an annual contact.

F. Complaint — Check if the contact was to document a complaint from the person.

G. Other — Check if the contact is other than described in situations A-F.

8. Type of Service — Check the appropriate box(es) to indicate what services are being monitoring at this contact:

  • Community Attendant Services (CAS),
  • Family Care (FC),
  • Primary Home Care (PHC),
  • Emergency Response Services (ERS),
  • Day Activity and Health Services (DAHS),
  • Residential Care (RC),
  • Adult Foster Care (AFC) or
  • Home-Delivered Meals (HDM). 

If HDM is being monitoring, check the appropriate box(es) to indicate the type of meals being delivered: Hot, Frozen, Chilled or Shelf Stable.

II. — Overall Satisfaction on Services

Ask the person about their overall satisfaction with CCSE services and with the provider authorized to deliver services. Record any dissatisfaction and document any comments from the person.

III. — Monitoring Reminders

The primary purpose of each monitoring contact, whether it is a home visit or a phone call, is to determine the adequacy of the current service plan and actual service delivery. Ask enough questions at each contact so the person’s current responses, together with the written case record, form a reasonable basis to determine the primary purpose. Review the bullets for examples of specific questions that may be appropriate.

IV. Changes Requested at this Monitoring Contact

Enter the changes that have been requested or identified at this monitoring contact.

V. Overall Satisfaction with Program

Complete this section to document the person’s overall satisfaction with the CCSE program. Document the person’s level of satisfaction after the resolution of any alleged dissatisfaction. Check the box that most accurately reflects the person’s overall degree of satisfaction with the service(s) being provided.

A — Outstanding
B — Very Good
C — Adequate
D — Needs Improvement
E — Poor

In the SASO Consumer Satisfaction window, document the person’s overall satisfaction by choosing a satisfaction level from the drop-down box.

VI. Document Identification

Caseworker’s Name — Enter the name of the caseworker completing the review. This item will not be entered into the database.

Dissatisfaction Codes

Codes marked with a plus sign are to be used for a person who only receives DAHS services.

A. Timing of Services

A1 — Start of nursing, attendant or other services delayed— Use this code to indicate the person is currently receiving authorized services, but there was a delay in service initiation.

A2 — Schedule for service delivery not being followed— Use this code when the service provider frequently fails to meet agreed-upon schedule.

A3 — Supplies or equipment not delivered promptly— Use this code when supplies or equipment are not delivered promptly.

A4 — Person wants schedule change— Use this code when the person indicates that the agency is not responding to their request for a schedule change.

A5 — Approved service not being provided— Use this code when the person indicates they are  no longer receiving authorized services.

A6+ — The facility is not open— Use this code when the DAHS facility is not open at times the person needs to attend the facility.

A7 — Other specify in comments section.— Use this code to record any observation by the person regarding timing of services which is not covered above.

B. Amount of Service

B1 — Wants hours increased— Use this code when the person believes that the number of hours authorized for the service is inadequate to meet their needs.

B2 — Wants hours decreased— Use this code when the person believes they no longer need as many hours of an authorized service to meet their needs.

B3 — Wants additional tasks, services, supplies,  and adaptive aids— Use this code when the person has expressed a need for a task, service, supply, or adaptive aid that was not authorized in their service plan may or may not want an increase in hours.

B4 — Wants fewer tasks, services.  And supplies— Use this code when the person believes they no longer need a task, service, supply, or adaptive aid that was authorized in their service plan may or may not want a decrease in hours. Review Code C6 to address unwanted adaptive aids.

B5— Needs hours increased— Use this code when the person believes that the number of hours authorized for the service is inadequate to meet their needs.

B6 — Needs hours decreased— Use this code when the person believes they no longer need as many hours of an authorized service to meet their needs.

B7 — Needs additional tasks, services , supplies. And adaptive aids— Use this code when the person has expressed a need for a task, service, supply or adaptive aid that was not authorized in their service plan may or may not want an increase in hours.

B8— Needs fewer tasks, services, and supplies— Use this code when the person believes they no longer needs a task, service, supply or adaptive aid that was authorized in their service plan may or may not want a decrease in hours. Review action code C6 to address other unwanted adaptive aids.

B9 — Other specify in comments section— Use this code to record any observation by the person regarding the amount of services which is not covered above.

B10 — Wants to add this service or program— Use this code when the person has expressed a need for another service or program that is not on their service plan.

C. Quality Issues  Related to the Service

C1 — No service provider— Use this code when the provider agency does not have a contract for a needed service for example, a home and community support services agency does not have an occupational therapist who serves the service area where the person resides.

C2 — No regular service provider currently assigned to case— Use this code when the person is receiving authorized services, but does not have a regular service provider.

C3 — Service provider's absences or failure to adhere to work schedule causing problems— Use this code when the person indicates the service provider's absences or failure to adhere to work schedule causes problems.

C4 — Provider not delivering all tasks or services or delivery is not as scheduled— Use this code when the person indicates the service provider is not performing assigned tasks, not providing authorized services or is not performing tasks according to schedule.

C5 — Poor work performance— Use this code when the person indicates the service provider is performing assigned tasks according to schedule, but the quality of the work is poor.

C6 — Adaptive aid or minor home modification does not meet the person’s needs— Use this code when, the adaptive aid or minor home modification either (1) does not meet the specifications of the assessment, or (2) the assessment does not accurately reflect the person’s needs.

C7 — Supplies, DME, minor home modifications are of poor quality or are not as ordered,— Use this code when medical supplies, adaptive aids or minor home modifications are of poor quality, insufficient supply, poor workmanship, wrong size, etc.

C8 — Lack of or dissatisfaction with activities provided— Use this code when the person is not satisfied with AFC, AL, RC or DAHS services.

C9 — Service lacks medical necessity— Use this code when adaptive aids or minor home modifications were authorized or delivered without a validated medical necessity.

C10— Other specify in comments section— Use this code to record any personal observation regarding quality issues related to the service which is not covered above.

C11— Other specify in comments section— Use this code to record any other quality or compliance issues such as the person appears to be overly sedated while telling you he cannot remember what medicines he is taking.

D. Quality Issues Relating to Provider Staff

D1 — Provider staff or contractors do not treat person with respect or dignity— Use this code when the person indicates the provider’s staff or contractors do not treat them with respect or dignity.

D2 — Service provider is verbally abusive— Use this code when the person indicates the service provider is or was verbally abusive to them.

D3 — Service provider is physically abusive— Use this code when the person indicates the service provider is or was physically abusive to them. The caseworker should consider citing action codes AP Referral to APS, LI Referral to Regulatory or CM Referral to Contract Manager, if they believes the complaint may be valid.

D4 — Service provider is sexually abusive— Use this code when the person indicates the service provider is or was sexually abusive to them. The caseworker should consider citing action codes AP, LI and/or CM if they believes the complaint may be valid.

D5 — Service provider staff behavior places the person’s belongings in jeopardy— Use this code when the person indicates the service provider behaves in a manner that the person feels they or their belongings are in jeopardy of harm or damage. The caseworker should consider citing action codes AP, LI and/or CM if they believes the complaint may be valid.

D6 — Person does not know how to contact provider for help or does not have phone number(s)— Use this code when the person reports they do not know how to contact the provider or does not have the provider’s phone number.

D7 — Provider agency staff do not respond to person’s request for information or assistance— Use this code when the person indicates the provider agency does not respond to their requests for information or assistance.

D8 —Personal independence or self-determination not honored— Use this code when the person believes their independence or ability to direct their care is not honored.

D9 — Provider did not discuss changes in attendant or schedule with person— Use this code when the person indicates the provider agency did not discuss with them changes in their service providers or the schedule.

D10 — The person feels that staff are not responsive to their needs— Use this code when the person indicates the staff are not responsive to their needs.

D11 — The person feels uncomfortable in expressing their opinions or dissatisfaction for fear of losing their service— Use this code when the person states they feels uncomfortable in expressing their opinions or dissatisfaction without fear of losing their service(s).

D12+ — The person feels pressured from the facility to attend the facility for longer hours or on additional days— Use this code when the person indicates they feel pressure from the DAHS facility to attend the facility for longer hours or increase the number of days they attend the facility.

D13 — The facility does not have appropriate staff available— Use this code when the person indicates the staff are not available.

D14 — Other specify in comments section— Use this code to record any observation from the person regarding quality issues related to provider staff which is not covered above.

E. Quality Issues Related to Training

E1 — Provider staff not oriented to general job or program requirements— Use this code when the person indicates the service provider has no knowledge of non-service related job requirements that is, calling in absences, negotiating schedule changes, completing time sheets, body positioning to avoid injury, while transferring the person, etc..

E2 — Provider staff not oriented to service-related job or program requirements— Use this code when the person indicates the service provider is not familiar with the service plan or with the specifics of job assignments as it relates to the person. For example, the provider is not aware that for the person, bathing means that the provider is supposed to be present while the person is bathing in case assistance is needed.

E3 — Service provider does not know how to perform authorized task(s)— Use this code when the person indicates the service provider does not know how to perform tasks for example, service provider does not know how to cook.

E4 — Service provider did not provide adequate orientation on program or services to person or family— Use this code when the person indicates that the service provider is unable to explain what the service provider can or cannot do, does not know how to deal with problematic situations, cannot relate to the person or their family of their rights and responsibilities, etc.

E5 — Other specify in comments section— Use this code to record any observation from the person regarding quality issues related to provider training and orientation which is not covered by E1-E4. Only the first 50 characters will be retained by the database so comments should be brief.

F. Quality Issues (Related to Meals/Snacks)

F1 — Meals schedule not being followed— Use this code when the person indicates they are not receiving their meals regularly.

F2 — Quantity or variety of food not adequate— Use this code when the person indicates they are not receiving enough food or if the meals are consistently the same.

F3 — Menu plan not adequate to meet basic nutritional requirements— Use this code when the person indicates that a balanced diet is not being provided.

F4 — Nutritional special diets not met— Use this code when the person has a special diet plan but it is not being provided.

F5 — Quality of meal not adequate— Use this code when the person indicates the quality of the meal is poor.

F6 — Other specify in comments section— Use this code to record any observation from the person regarding quality issues related to food, snacks, or both, which are not covered by F1-F5. Only the first 50 characters will be retained by the database so comments should be brief.

G. DAHS Facility Issues Other

G1+ — The person has been approached by another facility to transfer— Use this code when the person indicates a staff from a different DAHS facility recommended they transfer to their facility.

G2+ — The person wants to transfer to a closer facility— Use this code when the person indicates they want to attend a DAHS facility which is closer to their home.

G3+ — The person wants to transfer to a new facility— Use this code when the person indicates they want to transfer to another DAHS facility because it is new.

G4+ — The person wants to follow facility's staff to the new facility— Use this code when the person indicates they want to change DAHS facilities because the staff whom they has become accustomed are moving to another DAHS facility and the person wants to go with them.

G5+ — Other specify in comments section— Use this code to record any observation from the person regarding a DAHS facility which is not covered above.

Action Codes

  • AP — Referral to Adult Protective Services
  • BD — Referral to BNE The BNE is now the Board of Nursing
  • CF — Contact family
  • CI — Client ineligible
  • CM — Referral to Contract Manager
  • CW — Referral to Caseworker
  • ED — Educate client
  • FC — File formal complaint
  • LI — Referral to TDH Licensure Use this code when a referral to Regulatory is made.
  • NO — No action needed
  • PA — Referral to provider agency
  • RN — Referral to regional nurse
  • SP — Change service plan
  • SU — Referral to supervisor Use this code when a referral is made to the caseworker’s supervisor.
  • TR — Person transfer to another provider agency