Program-Specific Documents

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Program-Specific Documents

FAIR

FAIR Policy Manual (updated 8/7/2025)
- Attachment 1 — Confidentiality Agreement–Board Member, Instructions
- Attachment 2 — Confidentiality Agreement–Employees and Volunteers, Instructions
- Attachment 3 — SAEF (updated 3/19/2025), Instructions (updated 8/9/2024)
- Attachment 4 — FAIR Service Recipient Responsibility Agreement - Congregate; Instructions
- Attachment 4A — FAIR Service Recipient Responsibility Agreement - In-Home; Instructions
- Attachment 5 — Rights and Responsibilities Posting (updated 3/19/2025), Instruction
- Attachment 6 — Denial/Reduction on Services Letter (updated 4/1/19), Instructions (updated 4/1/19)
- Attachment 7 — Grievance Procedures Form (updated 10/23/24), Instructions (updated 4/1/19)
- Attachment 8 — Grievance Procedures Posting (updated 10/23/24), Instructions
- Attachment 9 — Personal Conduct Policy Form and Posting (updated 4/1/19); Form with Signature (updated 4/1/19), Instructions
- Attachment 10 — Board Certification, Instructions
- Attachment 11 — State Cost Share Chart (updated 1/29/26)
- Attachment 12 — FAIR State Cost Share Invoice, Instructions
- Attachment 13 — Approved Program Expenses (added 8/6/25)
- Attachment 14 — Activity Plan (updated 11/5/15), Instructions
- Attachment 15 — FAIR Congregate Respite Guidelines (updated 3/19/25)
- Attachment 16 — FAIR Sample Letter to Physician (updated 11/23/15), Instructions
- Attachment 17 — FAIR Job Description Congregate
- Attachment 18 — FAIR Job Description In-Home
- Attachment 19 — Personal History (updated 11/9/15), Instructions
- Attachment 20 — FAIR Worker Notes (updated 11/23/15); Instructions (updated 11/23/15)
- Attachment 21 — FAIR Supplemental Service Recording Log (added 11/23/15); Instructions (added 11/23/15)

In-Home Fiscal Forms

In-Home Invoice Template
FY2024 Budget Forms
Cost Share Accountability Form (revised 7/11/23)

Lighthouse

Lighthouse Policy Manual (updated 8/6/2025)
- Attachment 1 — Confidentiality Agreement–Board Member, Instructions
- Attachment 2 — Confidentiality Agreement–Employees and Volunteers, Instructions
- Attachment 3 — SAEF (updated 3/19/2025), Instructions (updated 8/9/2024)
- Attachment 4 — Rights and Responsibilities Form (updated 3/19/2025), Instruction
- Attachment 5 — Rights and Responsibilities Posting (updated 3/19/2025), Instruction
- Attachment 6 — Denial/Reduction of Services Letter (updated 4/1/19), Instructions (updated 4/1/19)
- Attachment 7 — Grievance Procedures Form (updated 10/23/24), Instructions (updated 4/1/19)
- Attachment 8 — Grievance Procedures Posting (updated 10/23/24), Instructions
- Attachment 9 — Personal Conduct Policy Form and Posting (updated 4/1/19); Form with Signature (updated 4/1/19), Instructions
- Attachment 10 — Board Certification, Instructions
- Attachment 11 — State Cost Share Chart (updated 1/29/26)
- Attachment 12 — Lighthouse State Cost Share Invoice, Instructions
- Attachment 13 — Approved Program Expenses (added 8/6/25)
- Attachment 14 — Lighthouse RN Assessment (updated 11/5/15), Instructions
- Attachment 15 — Lighthouse Plan of Care (updated 11/13/18), Instructions
- Attachment 16 — Lighthouse Eligibility Determination Form (updated 3/21/2025), Instructions
- Attachment 17 — Lighthouse Six-Month Call Log, Instructions
- Attachment 18 — Lighthouse Direct Care Worker Log, Instructions
Billing Worksheet (added 12/29/15)
Direct Care Worker Monitoring Tool (updated 8/15/17)
Program Monitoring Tool (updated 8/15/17)
Desktop Review Forms (updated 7/9/2025)

Medicaid Aged and Disabled Waiver

Case Management Agency Listing
Case Management Selection Forms (by county) - used for a Waiver member to choose a case management agency
Personal Attendant Agency Listing
Personal Attendant Selection Forms (by county) - used for a Waiver member to choose a homemaker agency
Bureau for Medical Services' Aged and Disabled Waiver Manual (effective 1/1/19)
NASMHPD OPD Language Guidelines (added 11/19/14)
Fingerprinting Locations in West Virginia (added 6/4/15)
Forms
- Medicaid Fraud Worksheet (added 2/20/14)
- Recipient Fraud Worksheet (added 5/28/19)
- Exploitation Agreement (added 9/11/14)
- Exploitation Agreement Directions (added 9/11/14)
- Member Expenditure Form (added 9/11/14)
- Member Expenditure Form Instructions (added 9/11/14)
- ADW Manuals and Forms, WV Bureau of Medical Services Website
- ADW Change Request Form (updated 7/2023)
Training
- Questions and Answers from Manual Training – October 2015 (added 5/24/16)
- Cultural Sensitivity Training (added 9/9/14)
Incident Management – managing risk or potential of risk of health and safety of Aged and Disabled Waiver clients
- WV IMS (added 9/7/18)
- U.S. Department of Justice, Elder Abuse Website (added 10/2/14)
- New Provider IMS Packet Part 1 (added 7/1/19)
- New Provider IMS Packet Part 2 (added 7/1/19)
Monitoring Tools - for use by the Bureau's nurse monitors
- Case Management Monitoring Tool Guide (updated 2/11/19)
- Personal Attendant Monitoring Tool Guide (updated 2/11/19)
- Personnel Files Monitoring Tool (updated 2/16/17)
- Continuing Certification Monitoring Tool (updated 12/12/17)
Quality Assurance Documents
- ADW Recipient User Guide: Version 6 (added 7/13/17)
- Aged and Disabled Waiver Quality Assurance and Improvement Advisory Council Vacancy Announcement and Membership Form
- Aged and Disabled Waiver Stakeholder Suggestion Form – an electronic document to be used for making comments and suggestions regarding the program
- Aged and Disabled Waiver Member Survey
- Aged and Disabled Waiver Case Manager Checklist – Is This Case Manager Right for Me? helpful considerations when choosing a case manager
- Aged and Disabled Waiver Homemaker Checklist – Is This Homemaker Right for Me? helpful considerations when choosing a homemaker
- Aged and Disabled Staff Management Toolkit
- Direct Care Worker Guide (added 1/6/14)
- Transportation Tool Kit (added 1/31/14)
- Aged and Disabled Waiver Provider Privacy Guide (added 3/24/14)
- Extreme Situations Guide (added 12/17/15)
Risk Management
Certification Affidavit and Continuing Certification Review

Medicaid Personal Care

Bureau for Medical Services' Personal Care Manual (updated 1/1/18)
Personal Care Forms, WV Bureau for Medical Services Website (updated 1/1/18)
Personal Care Agency Listing
Personal Care Selection Forms (by county)
Medicaid Fraud Worksheet (added 2/20/14)
Fingerprinting Locations in West Virginia (added 6/4/15)
Personal Care Program Changes - Request Form (updated 3/30/18)
Monitoring Tools – for use by the Bureau's nurse monitors
- Personnel Monitoring Tool (updated 9/15/22)
- Member Record Monitoring Tool (updated 9/15/22)
- Initial Site Monitoring Tool (updated 5/1/23)
Incident Management
- WV IMS (added 9/7/18)

Older Americans Act

Older Americans Act – 2020 Authorization
Older Americans Act Title III Services Policy Manual (effective 10/1/2024; updated 3/11/2025)
Older Americans Act Title III Policy Manual Comments (updated 10/1/2024)
- Attachment 1 — Confidentiality Agreement–Board Member, Instructions
- Attachment 2 — Confidentiality Agreement–Employees and Volunteers, Instructions
- Attachment 3 — SAEF (updated 3/19/2025), Instructions (updated 8/9/2024)
- Attachment 4 — Rights and Responsibilities Form (updated 3/19/2025), Instruction
- Attachment 5 — Rights and Responsibilities Posting (updated 3/19/2025), Instruction
- Attachment 6 — Denial/Reduction of Services Letter (updated 4/1/19), Instructions (updated 4/1/19)
- Attachment 7 — Grievance Procedures Form (updated 10/9/2024), Instructions (updated 4/1/19)
- Attachment 8 — Grievance Procedures Posting (updated 10/9/2024), Instruction
- Attachment 9 — Personal Conduct Policy Form and Posting (updated 4/1/19); Form with Signature (updated 4/1/19), Instructions
- Attachment 10 — Board Certification, Instructions
- Attachment 11 — Federal Cost Share Chart (updated 1/29/26)
- Attachment 12 — Federal State Cost Share Initial Notification (updated 1/9/17), Instructions
- Attachment 13 — Federal Cost Share Monthly Statement (updated 1/9/17), Instructions
- Attachment 14 — Federal Cost Share Accountability Form (updated 8/9/2024), Instructions
- Attachment 15 — Personal History (updated 11/9/15), Instructions
- Attachment 16 — Activity Plan (updated 11/5/15), Instructions
- Attachment 17 — Homemaker Plan of Care and Service Worksheet, Instructions
- Attachment 18 — Chore Plan of Care and Service Worksheet, Instructions
- Attachment 19 — Personal Care Plan of Care and Service Worksheet, Instructions
- Attachment 20 — Initial/Annual Home-Delivered Meals Assessment (updated 8/9/2024), Instructions (updated 8/9/2024)
- Attachment 21 — Title III-E Worker Notes (added 11/23/15), Instructions (added 11/23/15)
- Attachment 22 — Title III-E Supplemental Service Reporting Log (added 11/23/15), Instructions (added 11/23/15)
- Attachment 23 — Title IIID Programs Commonly Utilized by Providers (added 9/26/2024)
- Attachment 24 — Risk Assessment Worksheet (added 9/12/2024), Instructions (added 9/12/2024)
- Attachment 25 — Congregate Respite Guidelines (added 3/11/2025)
OAA Title III Nutrition Services Operation Manual (updated 10/1/2024)
SAEF ADL and IADL Scores (added 7/19/2024)
Title III Monitoring Tools (added 6/16/16)
- Administrative Monitoring Tool (updated 10/1/2024)
- Personnel Files Monitoring Tool (updated 10/1/2024)
- Title III-B Adult Day Care Service Monitoring Tool (updated 10/1/2024)
- Title III-B Assisted Transportation Service Delivery Monitoring Tool (updated 10/1/2024)
- Title III-B Chore Service Delivery Monitoring Tool (updated 10/1/2024)
- Title III-B Group Client Support Service Delivery Monitoring Tool (updated 10/1/2024)
- Title III-B Homemaker Service Delivery Monitoring Tool (updated 10/1/2024)
- Title III-B Individual Client Support Service Delivery Monitoring Tool (updated 10/1/2024)
- Title III-B Information and Assistance Service Delivery Monitoring Tool (updated 10/1/2024)
- Title III-B Outreach Service Delivery Monitoring Tool (updated 10/1/2024)
- Title III-B Personal Care Service Delivery Monitoring Tool (updated 10/1/2024)
- Title III-B Public Information/Education Service Delivery Monitoring Tool (updated 10/1/2024)
- Title III-B Transportation Service Delivery Monitoring Tool (updated 10/1/2024)
- Title III-C Congregate Meals Administrative Monitoring Tool (updated 2/14/25)
- Title III-C Congregate Meals Service Delivery Monitoring Tool (updated 10/1/2024)
- Title III-C Home Delivered Meals Administrative Monitoring Tool (updated 2/14/25)
- Title III-C Home Delivered Meals Service Delivery Monitoring Tool (updated 10/1/2024)
- Title III-D Evidence Based Service Delivery Monitoring Tool (updated 10/1/2024)
- Title III-E Caregiver of Older Adults Congregate Respite Monitoring Tool (added 10/1/2024)
- Title III-E Caregiver of Older Adults Information and Assistance Service Delivery Monitoring Tool (added 10/1/2024)
- Title III-E Caregiver of Older Adults In-Home Respite Monitoring Tool (added 10/1/2024)
- Title III-E Caregiver of Older Adults Public Information/Education Service Delivery Monitoring Tool (added 10/1/2024)
- Title III-E Caregiver of Older Adults Support Groups Monitoring Tool (added 10/1/2024)
- Title III-E Caregiver of Older Adults Training Monitoring Tool (added 10/1/2024)
- Title III-E Older Relative Caregivers Support Groups Monitoring Tool (added 10/1/2024)
- Title III-E Older Relative Caregivers Information and Assistance Service Delivery Monitoring Tool (added 10/1/2024)
- Title III-E Older Relative Caregivers Public Information/Education Service Delivery Monitoring Tool (added 10/1/2024)
- Plan of Correction Section I
- Plan of Correction Section II (updated 10/27/16)
- Plan of Correction Section III
Registered Dietician Approved Menus
Nutrition Education
- Cooking Demos

SAMS Assistance

SAEF (updated 3/19/2025)
SAEF Scoring and Required Questions Guide Sheet (updated 3/10/25)
Building a New Roster (added 10/18/21)
Deactivating a Consumer (updated 1/25/18)
Duplicate Consumer Merge Form (updated 5/17/17)
Reactivating a Consumer (updated 1/25/18)
How to Eliminate the Extra Line in the Consumer Listing Report (9/4/18)

Updated 1/29/26