West Virginia Bureau of Senior Services

FAIR

• FAIR Policy Manual  (updated 3/21/2025) 
  
  • 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 2/1/25)   
  • Attachment 12 — FAIR State Cost Share Invoice, Instructions  
  • Attachment 13 — FAIR Cost Share Accountability Form (updated 7/6/21)
  • 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 Supplenental Service Recording Log (added 11/23/15); Instructions(added 11/23/15)

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In-Home Fiscal Forms  

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

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Lighthouse

• Lighthouse Policy Manual   (updated 3/21/2025)   
  
  • 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 2/1/25)
  • Attachment 12 — Lighthouse State Cost Share Invoice, Instructions  
  • Attachment 13 — Lighthouse Cost Share Accountability Form (updated 7/6/21)
  • 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 4/29/2025)

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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
  
  
  • Depression is Not a Normal Part of Growing Older   (added 2/8/21)  
  • Mental Health Issues in the Aged and Disabled Waiver Program
  • Mental Health Toolkit: Guide for Working with Mental Health Issues
• Certification Affidavit and Continuing Certification Review
  
  
  • Certification Affidavit
  • Continuing Certification Review
  • Direct Care Personnel Document
  • Example Direct Care Personnel Worksheet  

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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)   

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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 2/1/25)
  • 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 
  
  Spring/Summer Menus  
  

            Week 1     Week 2     Week 3     Week 4     Week 5     Week 6

  Fall/Winter Menus  
            Week 1     Week 2     Week 3     Week 4     Week 5     Week 6 

  Holiday Menus  
            Holiday Recipes 

• Nutrition Education  
  
  Cooking Demos

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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 4/29/2025