SECTION 259.313. CMA: Documentation of Services Delivered and Recordkeeping

(a) A CMA must ensure that when a case manager provides case management, the case manager:

(1) documents:

(A) the date of contact;

(B) a description of the case management activity performed;

(C) the progress or lack of progress in achieving goals or outcomes in the individual's IPP in observable, measurable terms that directly relate to the specific goal or outcomes addressed;

(D) the person with whom the contact occurred; and

(E) the signature and title of the case manager who provided the contact; and

(2) completes an HHSC Documentation of Services Delivered form to document the provision of case management that is supported by the documentation required in paragraph (1) of this subsection.

(b) A CMA must ensure that, after a case manager makes the last entry on an HHSC Documentation of Services Delivered form, a staff person other than the case manager who completed the form signs and dates the form as a timekeeper as verification of the accuracy of the information on the form.

(c) A CMA must maintain a separate record for each individual receiving case management from the CMA. An individual's record must include:

(1) the individual's current IPC and any other IPC authorized for the current IPC period;

(2) the individual's current IPP and any other IPP developed for the current IPC period;

(3) the individual's current HHSC IPP Addendum and any other HHSC IPP Addendum developed for the current IPC period;

(4) the individual's current ID/RC Assessment;

(5) the individual's current HHSC CLASS/DBMD Nursing Assessment form;

(6) the individual's HHSC Waiver Program Verification of Freedom of Choice form completed at enrollment documenting the individual's or LAR's choice of the CLASS Program over the ICF/IID Program;

(7) the individual's current HHSC Selection Determination form documenting the individual's or LAR's choice of a CMA and DSA;

(8) the documentation required by subsection (a)(1) of this section;

(9) the completed HHSC Documentation of Services Delivered forms signed and dated by a timekeeper as required by subsection (b) of this section; and

(10) any other relevant documentation concerning the individual.

Source Note: The provisions of this §259.313 adopted to be effective January 30, 2023, 48 TexReg 362