Current through Reg. 49, No. 38; September 20, 2024
(a) A DSA must
ensure that for each direct service provided, except adaptive aids, dental
treatment, minor home modifications, CFC ERS, CFC support management, and a
direct service that is documented through an electronic visit verification
system, as listed in 1 TAC §
354.4005(b)
(relating to Applicability), a service provider:
(1) documents:
(A) the type of service provided;
(B) the date and the time the service begins
and ends;
(C) the type of contact
(phone or in-person);
(D) the name
of the person with whom the contact occurred;
(E) a description of the activity performed,
unless the activity is a non-delegated task provided by an unlicensed service
provider that is documented on an IPP;
(F) the signature and title of the service
provider; and
(G) the progress or
lack of progress in achieving a goal or outcome in the individual's IPP in
observable, measurable terms that directly relate to the specific goal or
outcome; and
(2)
completes an HHSC Documentation of Services Delivered form to document the
provision of a direct service that is supported by the documentation required
in paragraph (1) of this subsection.
(b) A DSA must ensure that, after a service
provider makes the last entry on an HHSC Documentation of Services Delivered
form, a staff person other than the service provider signs and dates the form
as a timekeeper as verification of the accuracy of the information on the form.
(c) A DSA must maintain a separate
record for each individual receiving CLASS Program services and CFC services
from the DSA. The individual's record must include:
(1) a copy of the individual's current IPC
and any other IPC authorized for the current IPC period;
(2) a copy of the individual's current IPP
and any other IPP developed for the current IPC period;
(3) a copy of the individual's current
PAS/HAB plan;
(4) if transportation
is included on the IPC as a habilitation activity or as an adaptive aid, a copy
of the individual's individual transportation plan;
(5) a copy of the individual's current ID/RC
Assessment;
(6) if the DSA was the
individual's DSA when the individual enrolled in the CLASS Program:
(A) the original ID/RC Assessment signed by a
physician; or
(B) the original
level of care form signed by a physician and was in use before the ID/RC
Assessment;
(7) a copy of
the current adaptive behavior screening assessment;
(8) a copy of the current HHSC CLASS/DBMD
Nursing Assessment form;
(9) a copy
of the current HHSC Related Conditions Eligibility Screening Instrument
form;
(10) any new or revised HHSC
Provider Agency Model Service Backup Plan form for the current IPC period;
(11) the documentation required by
subsection (a)(1) of this section;
(12) the completed HHSC Documentation of
Services Delivered forms signed and dated by a timekeeper as required by
subsection (b) of this section; and
(13) any other relevant documentation
concerning the individual.
