Effective Date
Instructions
Updated: 12/2009
Purpose
This form is used by the Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IID) program and serves as the primary document for the purchase of an augmentative communication device (ACD) system made by the service provider for residents.
Procedure
When to Prepare
The service provider representative completes Section I (after the ACD system has been delivered) to assess the resident's satisfaction, identify any need for additional orientation or training hours and to document the resident's recommendations for resolution if dissatisfied with the purchase.
The service provider representative completes Section II (after the ACD system has been delivered) to determine if the ACD system meets the resident's needs and, if applicable, to document the resolution of problems that previously kept the ACD system from meeting the resident's needs.
If the resident is not satisfied with the ACD system, this form should be submitted again once the resolution has been completed.
Number of Copies
Complete one original for each ACD system delivered.
Transmittal
The service provider retains the original form with all fields completed.
Form Retention
The original form must be kept by the service provider for no less than five years and 90 days after purchase, or as long as the resident maintains ownership of the ACD system until all litigation, claims or audit findings are resolved, whichever is longer.
Detailed Instructions
ICF/IID Service Provider — Enter the name of the ICF/IID provider.
HHSC Contract Number — Enter the service provider's ICF/IID contract number.
Resident Name — Enter the resident's name.
Date of Purchase/Delivery — Enter the date on which the ACD system was delivered to the resident by the supplier.
Resident Address — Enter the resident's physical street address, including city, state and ZIP code.
Description of the Augmentative Communication Device (ACD) System — Enter the name and model number of the ACD system that was recommended by the therapist and ordered for the resident.
Invoice Cost of Item — The amount entered must not exceed the approved cost.
Section I — Resident Satisfaction
This section assesses the resident's level of satisfaction with the ACD system and indicates whether additional training or orientation is needed. The ICF/IID provider representative who assesses the resident's level of satisfaction after the ACD system has been delivered must complete this section. Resident satisfaction may not be assessed by the same person who is supplying the ACD system.
The provider representative assists the resident/LAR to indicate satisfaction or dissatisfaction by marking the appropriate box.
I am satisfied with the ACD system delivered. — Mark this box if the resident/LAR expresses satisfaction with the ACD system.
I am not satisfied with the ACD system delivered. Explain why and document the recommendation(s) for resolution: — Mark this box if the resident/LAR indicates dissatisfaction with the ACD system. Enter the stated reason for dissatisfaction and the resident's recommendation(s) for resolution. Attach additional pages, if needed.
I have received orientation/training in its use and do not require additional training. —Mark this box if the resident/LAR has received orientation/training in the use of the ACD system.
I am satisfied with the ACD system, but I need more training in its use. Document additional orientation/training needed and hours required: — Mark this box if the resident/LAR expresses satisfaction with the ACD system but needs more training in its use. Enter the number of hours of additional orientation/training the resident requests. Attach additional pages, if needed.
Signature–Resident/Legally Authorized Representative (LAR) and Date — The resident/LAR signs and dates the form.
Signature–ICF/IID Provider Representative and Date — The ICF/IID provider representative signs and dates the form after completing the fields.
Section II — ICF/IID Provider Determination
The provider representative marks the appropriate box.
The item meets the documented need(s) of the resident based on the recommendations for the ACD system documented by the Speech Therapist on Form 8728, ICF/IID Augmentative Communication Device (ACD) System Authorization. — Mark this box if the item meets the documented needs of the resident based on the recommendations made by the Speech Therapist on Form 8728.
The item does not meet the documented needs of the resident. Explain why and document recommendation(s) for resolution: — Mark this box if the item does not meet the needs of the resident based on the recommendations for the ACD system documented by the Speech Therapist on Form 8728. Document why the item does not meet the resident's needs and attach additional pages, if needed.
Signature–Provider Representative and Date — The provider representative who determines if the ACD system meets the needs of the resident must sign and date the form.
Provider Representative Printed Name and Title — Self-explanatory.
Note: The item cannot be billed until after the date it has been determined appropriate to meet the documented needs of the resident.