TX HHS Form 3040. Review Findings and Plan of Improvement

Form 3040 is an official corrective action document used within the Home and Community-Based Services Adult Mental Health (HCBS-AMH) program in Texas. The form is used by providers to formally respond to review findings issued by oversight authorities and to document a clear, structured plan for correcting identified issues and preventing their recurrence.

This form serves as written evidence that a provider understands the findings, takes responsibility for remediation, and has established concrete steps to achieve and maintain compliance.

Purpose of Form 3040

The primary purpose of Form 3040 is to document how an HCBS-AMH provider will address deficiencies identified during a review, audit, monitoring visit, or compliance assessment. It transforms review findings into an actionable improvement plan with defined responsibilities, timelines, and monitoring mechanisms.

The form is required to demonstrate accountability, quality improvement, and adherence to state program standards.

When This Form Must Be Submitted

Form 3040 must be completed and submitted when a provider receives formal findings that require corrective action. Common situations include:

• After a compliance review identifies deficiencies or concerns
• Following an on-site or desk review by program oversight staff
• When required as part of ongoing monitoring or quality assurance
• After repeated or unresolved issues are identified

The form is generally not required if no findings or areas needing improvement are identified during a review.

Who Is Responsible for Completing the Form

The form is typically completed by program leadership or designated compliance staff within the HCBS-AMH provider organization. This may include:

• Program directors or administrators
• Compliance or quality assurance managers
• Clinical supervisors or department heads

Each finding must identify the individual responsible for implementing the corrective actions.

Explanation of Each Key Section

Concerns and Areas Needing Improvement

This section summarizes each identified concern or deficiency. Findings should be addressed clearly and directly, reflecting the issues noted during the review.

Findings

The findings describe what was observed, what requirement was not met, and why corrective action is needed. Providers should ensure their response aligns with the original review language.

Remedies / Plan for Improvement

This section outlines the overall strategy for correcting the issue. It should explain how the provider intends to resolve the finding and prevent future occurrences.

Name and Title of Person Carrying Out Remedies

The provider must assign responsibility to a specific individual. This establishes accountability and ensures follow-through.

Timeline for Implementation

This section defines when corrective actions will be completed. Timelines should be realistic, measurable, and consistent with program expectations.

Actions to Correct the Finding

Here, the provider lists concrete steps that will directly address the deficiency.

Actions for Monitoring Compliance

This section explains how the provider will verify that corrections are implemented and maintained over time.

Actions to Identify Deficiencies

Providers describe internal checks, audits, or reviews that will help detect similar issues early.

Actions to Sustain Necessary Corrections

This part focuses on long-term solutions, such as policy updates, training, or workflow changes.

Actions to Evaluate and Monitor Ongoing Effectiveness

The provider explains how it will measure whether corrective actions remain effective beyond initial implementation.

Practical Tips for Completing Form 3040

• Address each finding separately and completely.
• Use clear, specific language rather than general statements.
• Assign responsibility to named individuals, not departments.
• Ensure timelines are achievable and documented.
• Align corrective actions with existing policies and procedures.

Common Mistakes to Avoid

• Providing vague or generic corrective actions
• Missing timelines or responsible parties
• Failing to address root causes
• Copying findings without explaining remedies
• Submitting the form after the required deadline

Legal and Regulatory Context

Form 3040 is required under Texas oversight and quality assurance requirements for HCBS-AMH providers. State regulations require providers to respond to findings with documented corrective action plans to protect service recipients, ensure program integrity, and maintain eligibility to operate within the program.

Failure to submit an adequate plan of improvement may result in follow-up reviews, increased monitoring, or enforcement actions.

Real-Life Situations Where This Form Is Used

• A provider is cited for incomplete client documentation during a compliance review.
• Staff training requirements are found to be inconsistently applied.
• Internal monitoring processes are identified as insufficient.
• Previous corrective actions did not fully resolve an issue.

Documents Commonly Submitted or Referenced with This Form

• Compliance review or monitoring reports
• Updated policies and procedures
• Training records or attendance logs
• Internal audit results
• Quality improvement plans

Frequently Asked Questions

Is Form 3040 mandatory after every review?

It is required only when findings or areas needing improvement are identified.

Can one form address multiple findings?

Yes, the form allows multiple findings to be documented separately.

Who reviews the completed form?

Oversight staff responsible for HCBS-AMH program compliance.

Can timelines be adjusted after submission?

Changes typically require approval or follow-up communication.

What happens if corrective actions are not completed?

Unresolved findings may lead to additional monitoring or enforcement.

How is ongoing compliance verified?

Through follow-up reviews, audits, or monitoring activities.

Related Forms

• HCBS-AMH Monitoring Review Reports
• Corrective Action Tracking Forms
• Provider Quality Improvement Plans
• Staff Training Documentation

Form Details

• Form Name: Review Findings and Plan of Improvement
• Form Number: 3040
• Program: HCBS Adult Mental Health (HCBS-AMH)
• State: Texas
• Revision Date: December 2018