Source: https://hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/home-community-support-services-agencies-hcssa/report-change-hcssa-information
Timestamp: 2018-02-22 02:49:31
Document Index: 400027677

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Report Change of HCSSA Information | Texas Health and Human Services
Report Change of HCSSA Information
Home > Doing Business with HHS > Provider Portals > Long-term Care Providers > Home and Community Support Services Agencies (HCSSA) > Report Change of HCSSA Information
This page provides information and instructions for home and community support services agencies (HCSSAs) that must report changes to their:
agency name (legal entity or doing business as);
certification status;
management personnel (administrator, alternate administrator, or chief financial officer);
controlling person (stock transfers of 49 percent or less);
service areas; or
Changes must be submitted using the Home and Community Support Services Agency License Application (DADS Form 2021).
All certified agencies making any of the above changes must also submit updated information to the fiscal intermediary via the printed CMS 855A Home Health Enrollment Application (PDF format) OR the online Medicare Provider Enrollment, Chain, and Ownership System (PECOS).
Note: CMS may deactivate Medicare billing privileges if a Medicare-certified HCSSA does not report a change of information supplied on the Form CMS 855A Medicare Enrollment Application within 90 calendar days of when the change occurred. Changes that must be reported by a Medicare-certified HCSSA include, but are not limited to, a change in practice location, a change in any managing employee including the supervising nurse, and a change in billing services. A change in ownership or control must be reported within 30 calendar days.
As a result of Senate Bill (SB) 223 and House Bill (HB) 1720, 82nd Texas Legislature, Regular Session, 2011, effective July 1, 2012, all HCSSAs must pay a $30 standard fee when reporting to DADS one or more of the following changes:
change in agency name (legal entity or doing business as)
change in management personnel (administrator or chief financial officer)
change in controlling person
change in category of service
change in service area
No standard fee is required if the HCSSA only reports to DADS one or more of the following changes:
change in management personnel (alternate administrator)
If a HCSSA does not submit in a timely manner the Home and Community Support Services Agency License Application (DADS Form 2021) to report one or more changes listed above, the HCSSA must pay a late fee of $100. This late fee is in addition to the $30 fee if applicable.
No fee or late fee is required if the HCSSA only reports the following changes:
change in fax number or email address
change in certification status
DADS accepts a certified check, money order, company check or personal check made out to the Department of Aging and Disability Services in payment for a fee.
See the chart below for a crosswalk of change types, reporting timelines and schedule of fees.
Crosswalk of change types, reporting timelines and schedule of fees
Change in HCSSA Information
Possible Total Fees:
§Physical location (40 TAC §97.213) At least 30 days before relocation* Yes Yes $130
Mailing address, if different from physical address (40 TAC §97.214) No later than seven days after a change No Yes $100
Telephone number (40 TAC §97.214) No later than seven days after a change No Yes $100
Operating hours (40 TAC §97.214) No later than seven days after a change No Yes $100
Fax number or email address As soon as possible No No $0
HCSSA name (legal entity or doing business as) (40 TAC §97.215) No later than seven days after the effective date of the name change Yes Yes $130
Certification status (40 TAC §97.216) No later than five days after the HCSSA decides to voluntarily withdraw from the Medicare Program No No $0
Administrator, chief financial officer (40 TAC §97.218) No later than seven days after a change Yes Yes $130
Alternate administrator (40 TAC §97.218) No later than seven days after a change No Yes $100
Controlling person (40 TAC §97.218) No later than seven days after a change Yes Yes $130
Adding or deleting a category of service (40 TAC §97.219) At least 30 days before adding
At least 30 days before deleting Yes Yes $130
Expanding or reducing service areas (40 TAC §97.220) At least 30 days before expansion*
At least 10 days after reduction Yes Yes $130
Closure (40 TAC §97.217) Within five days before permanent closure No No $0
*unless an exemption is granted by DADS
For more information on reporting changes in application information and fees, refer to:
Texas Administrative Code, Title 40, Part 1, Chapter 97, Subchapter C, Division 2, Rule 97.208 Reporting Changes in Application Information and Fees
Changes in Physical Location or Mailing Address
A HCSSA must not transfer a license from one location to another without prior notice to DADS. Changes in physical address must be submitted in writing to DADS using DADS Form 2021 no later than 30 calendar days before the effective date of the change, unless DADS grants the HCSSA an exemption from the 30-day time frame as specified in 40 TAC §97.213(b).
Changes in mailing address must be submitted in writing to DADS using DADS Form 2021 no later than seven calendar days after the effective date of the change.
Make changes on Form 2021, Home and Community Support Services Agency License Application, pages 1 and 20.
Place an X on page 1, number 1, on the application next to "Update: Type of Update" and write in "mailing address change" and/or "physical address change" as well as the effective date. Include the HCSSA's license number in the appropriate box.
On page 1, complete:
number 3 (Name of Owner; New Address, if applicable; Tax ID Number),
number 4 (Name of Agency), and
number 5 (New Physical Address/Mailing Address).
On page 20 (Change of Information), complete, sign and date.
If you are required to submit a fee (standard and/or late fee), mail changes and applicable fees to Accounts Receivable in DADS state office:
If you are not required to submit a fee (standard and/or late fee), mail changes to Licensing and Credentialing in DADS state office:
Physical address (40 TAC §97.213) No later than 30 days before relocation* Yes Yes $130
Mailing address, if different than physical address (40 TAC §97.214) No later than seven days after a change No Yes $100
Texas Administrative Code, Title 40, Part 1, Chapter 97, Subchapter C, Division 2, Rule 97.213 Agency Relocation
Texas Administrative Code, Title 40, Part 1, Chapter 97, Subchapter C, Division 2, Rule 97.214 Notification Procedures for a Change in Agency Contact Information and Operating Hours
Changes in telephone number or operating hours
Changes in telephone number or operating hours must be submitted in writing to DADS using DADS Form 2021 no later than seven calendar days after the change.
Place an X on page 1, number 1, of the application next to "Update: Type of Update" and write "Change Phone or Operating Hours" as well as the effective date. Include the HCSSA's license number in the appropriate box.
number 3 (Name of Owner, Address, Tax ID Number),
number 4 (Agency name),
number 5 (Address), and
number 6 (Telephone No. and/or Operating Hours).
If you are required to submit a late fee, mail changes and applicable fee to Accounts Receivable in DADS state office:
If you are not required to submit a late fee, mail changes to Licensing and Credentialing in DADS state office:
Reporting Timeline (Calendar Days)
Telephone number and operating hours (40 TAC §97.214) No later than seven days after a change No Yes $100
Texas Administrative Code, Title 40, Part 1, Chapter 97, Subchapter C, Division 2, Rule 97.214 Notification Procedures for a Change in Agency Contact Information and Agency Operating Hours
Changes in fax number or email address
Changes in fax number or email should be submitted as soon as possible to ensure correct contact information is available to DADS staff.
Make changes on Form 2021, Home and Community Support Services Agency License Application, page 1.
Place an X on page 1, number 1, of the application next to "Update: Type of Update" and write "Change fax number or email address" as well as the effective date. Include the HCSSA's license number in the appropriate box.
number 6 (Fax No. and/or Agency E-mail Address).
Mail changes to Licensing and Credentialing in DADS state office:
Fax number and email address As soon as possible No No $0
Change in HCSSA name (legal entity or doing business as)
If a HCSSA intends to change its name (legal entity or doing business as) but does not undergo a change of ownership, the HCSSA must report the name change to DADS using DADS Form 2021 no later than seven calendar days after the effective date of the name change.
Make changes on DADS Form 2021, Home and Community Support Services Agency License Application, pages 1 and 20.
Place an X on page 1, number 1, next to "Update: Type of Update" and write in "Name Change" as well as the effective date. Include the HCSSA's license number in the appropriate box.
number 4 (New Name the Agency will be Doing Business As), and
number 5 (Address).
Attach a copy of the certificate of amendment from the Secretary of State (or other governmental authority).
Attach a copy of the assumed name certificate from the Secretary of State (or county if not filed with the Secretary of State).
Attach a copy of the HCSSA's current federal tax identification number. (This form comes from the federal Internal Revenue Service. IRS also refers to this number as the Employee Identification Number.)
Mail changes and applicable fees to Accounts Receivable in DADS state office:
HCSSA Name Change (legal entity or doing business as) (40 TAC §97.215) No later than seven days after the effective date of the name change Yes Yes $130
Texas Administrative Code, Title 40, Part 1, Chapter 97, Subchapter C, Division 2, Rule 97.215 Notification Procedures for Agency Name Change
If HCSSA decides to voluntarily withdraw from the Medicare Program, the HCSSA must notify DADS in writing no later than five calendar days after the decision to withdraw is made. A HCSSA should use DADS Form 2021 to provide written notice.
Make changes on DADS Form 2021, Home and Community Support Services Agency License Application, page 1.
Place an X on page 1, number 1, on the application next to "Update: Type of Update" and write in "Certification Status Change". Include the HCSSA's license number in the appropriate box.
Mail to Licensing and Credentialing in DADS state office:
Texas Administrative Code, Title 40, Part 1, Chapter 97, Subchapter C, Division 2, Rule 97.216 Change in Agency Certification Status
Changes in management personnel (administrator, alternate administrator or chief financial officer)
Changes in administrator, alternate administrator, or chief financial officer must be submitted in writing to DADS using DADS Form 2021 no later than seven calendar days after the date of change. Changes in staff will not be made until all documentation is received.
Place an X on page 1, number 1, of the application next to "Update: Type of Update" and write in "Management Changes" as well as the effective date. Include the HCSSA's license number in the appropriate box.
number 4 (Name the Agency will be Doing Business As),
number 6 (Management Information).
Attach a current resume that clearly reflects:
the qualifications for the new position according to the Texas Administrative Code, Title 40, Part 1, Chapter 97, §97.244 and §97.259;
the month, day and year of the new position;
all past employment history with start and termination dates;
CEU certificates, if applicable; and
RN license numbers, if applicable.
Complete and attach DADS Form 2022, Home and Community Support Services Agencies Licensure Criminal History Check
Administrator or chief financial officer (40 TAC §97.218) No later than seven days after a change Yes Yes $130
Texas Administrative Code, Title 40, Part 1, Chapter 97, Subchapter C Division 2 Rule 97.218 Agency Organizational Changes
Changes in Controlling Person (Stock Transfers of 49 Percent or Less)
Changes in controlling person as defined in 40 TAC §97.2 must be submitted in writing to DADS using DADS Form 2021 no later than seven calendar days after the date of change. Make changes on DADS Form 2021, Home and Community Support Services Agency License Application, pages 1, 2, 5, 9 and 20.
Place an X on page 1, number 1, next to "Stock Transfer" and enter the effective date of the change. Include the HCSSA's license number in the appropriate box.
number 4 (Name the Agency will be Doing Business As), and
On page 2, complete number 10a.
On page 5, complete number 12a, 12b and new ownership information.
On page 9, complete number 12b(iv) if there has been a change to the Board of Directors/Governing Body.
On page 20, (Change of Information), complete, sign and date.
Complete and attach DADS Form 2022, Home and Community Support Services Agencies Licensure Criminal History Check if applicable.
Attach copies of the legal and notarized documents pertaining to the stock transfer.
Adding or deleting service categories
To add or delete a category of service to its license, a HCSSA must submit written notice to DADS using DADS Form 2021 at least 30 calendar days before the addition or deletion of the category of service.
Make changes on DADS Form 2021, Home and Community Support Services Agency License Application, pages 1, 2 and 20.
Place an X on page 1, number 1, of the application next to "Update: Type of Update" and write in "Addition of category of service" or "Deletion of category of service" and indicate which categories of service are being added or deleted as well as the effective date. Include the HCSSA's license number in the appropriate box.
number 3 (Name of Owner, Address and Tax ID Number),
On page 2, complete number 9 (Category of Service); indicate which categories of services are being added or deleted.
Note: If adding Licensed and Certified Home Health (L&CHH), you must provide:
Certificates of L&CHH from the HCSSA presurvey computer-based training for the administrator, alternate administrator, supervising nurse and alternate supervising nurse.
Resumes for the administrator, alternate administrator, supervising nurse and alternate supervising nurse.
Two copies of the signed Health Insurance Benefit Agreement, CMS Form 1561, each with an original signature.
Completed Office of Civil Rights Forms.
In addition, you must complete and submit a printed Form CMS 855A Medicare Enrollment Application (PDF) OR the online Medicare Provider Enrollment, Chain, and Ownership System (PECOS) to the fiscal intermediary.
On page 20 (Change of Information), complete, sign, and date.
If adding a Hospice category to a current license:
Place an X on page 1, number 1, next to "Update: Type of Update" and write in "Hospice Addition" as well as the effective date. Include the HCSSA's license number in the appropriate box.
On page 2, complete number 9 (Category of Service); indicate Hospice Services.
Provide certificates for Hospice from the HCSSA presurvey computer-based training for the administrator, alternate administrator, supervising nurse and alternate supervising nurse for hospice services.
Provide resumes for the administrator, alternate administrator, supervising nurse and alternating supervising nurse.
Submit two copies of the signed Health Insurance Benefit Agreement, Form CMS 1561, each with an original signature.
Submit two copies of the Hospice Request for Certification in Medicare, Form CMS 417, with original signatures.
Submit completed Office of Civil Rights Forms.
In addition, you must complete and submit a printed Form CMS 855A Medicare Enrollment Application (PDF format) OR the online Medicare Provider Enrollment, Chain, and Ownership System (PECOS) to the fiscal intermediary.
Adding or deleting a category of service (40 TAC §97.219)
At least 30 days before adding
At least 30 days before deleting
Yes Yes $130
Texas Administrative Code, Title 40 Part 1 Chapter 97, Subchapter C, Division 2, Rule 97.219 Procedures for Adding or Deleting A Category to the License
Expanding or Reducing Service Areas
A HCSSA may expand its service area at any time during the licensure period by submitting written notice to DADS using DADS Form 2021 at least 30 calendar days before the expansion.
A HCSSA may reduce its service area at any time during the licensure period by submitting written notice to DADS using DADS Form 2021 no later than 10 calendar days after the reduction.
Make changes on DADS Form 2021, Home and Community Support Services Agency License Application, pages 1, 3, 4 and 20.
Place an X on page 1, number 1, next to "Update: Type of Update" and write in "Service Area Addition" or "Service Area Deletion" as well as the effective date. Include the HCSSA's license number in the appropriate box.
For changes: On pages 3 and 4, number 11, place a check mark for all current counties to be served. Note: If the HCSSA is Medicare-certified, the counties in the service area must be contiguous.
§Expanding or reducing service areas (40 TAC §97.220) At least 30 days before expansion*
No later than 10 days after reduction Yes Yes $130
Texas Administrative Code, Title 40, Part 1, Chapter 97, Subchapter C, Division 2, Rule 97.220 Service Areas
A HCSSA must notify DADS in writing within five calendar days before the permanent closure of the HCSSA, branch office or alternate delivery site.
Place an X on page 1, number 1, of the application next to "Update: Type of Update" and write in "Closure," as well as the effective date of the closure. Include the HCSSA's license number in the appropriate box.
Attach the following information: location of the client records, name and address of the client record custodian, a statement signed and dated by the owner(s) agreeing to the closure, a disposition of all active clients at the time of the closure, and the license.
For Medicare closure:
Place an ad in the local newspaper 15 days before closure. Submit a copy of the ad with your closure documents to the DADS state office.
Submit closure information to the fiscal intermediary through Form CMS 855A.
Notify the DADS state office that the HCSSA is closing by following the steps on this page.
Mail or fax changes to Licensing and Credentialing in DADS state office:
Fax: 512-438-2731
Texas Administrative Code, Title 40, Part 1, Chapter 97, Subchapter C, Division 2, Rule 97.217 Agency Closure Procedures and Voluntary Suspension of Operations