SECTION 260.209. Documentation of Services Delivered and Recordkeeping

(a) A program provider must ensure that for each service provided, except adaptive aids, dental treatment, minor home modifications, CFC ERS, CFC support management, licensed assisted living, licensed home health assisted living, and a service that is documented through an electronic visit verification system, as listed in 1 TAC §354.4005(b) (relating to Applicability), a service provider completes an HHSC DBMD Summary of Services Delivered form to document:

(1) the type of service provided;

(2) the date and the time the service begins and ends;

(3) the type of contact (phone or in-person);

(4) the name of the person with whom the contact occurred;

(5) a description of the service activity performed, unless the activity is a non-delegated task provided by an unlicensed service provider that is documented on the IPP; and

(6) the signature and title of the service provider.

(b) A program provider must ensure that, after a service provider makes the last entry on an HHSC DBMD Summary 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 program provider must ensure that an individual's record includes:

(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 ID/RC Assessment;

(4) if the program provider was the individual's program provider when the individual enrolled in the DBMD Program:

(A) the original ID/RC Assessment signed by a physician; or

(B) the original level of care form signed by a physician that was in use before the ID/RC Assessment;

(5) a copy of the current adaptive behavior screening assessment;

(6) a copy of the current Related Conditions Eligibility Screening Instrument;

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

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

(9) any other relevant documentation concerning the individual;

(10) documentation of 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 addressed, including:

(A) assessments, evaluations, and progress notes prepared by a service provider for review by a case manager in accordance with §260.77(a)(1)(E) of this chapter (relating to Renewal and Revision of an IPP and IPC);

(B) the IPP reviews for the current IPC period prepared by a case manager in accordance with §260.77(a)(2) of this chapter; and

(C) if the IPP includes day habilitation, transportation provided as a residential habilitation activity, and CFC PAS/HAB, the individual's progress or lack of progress in achieving the following outcomes:

(i) the ability to effectively communicate the individual's wants and needs to a service provider of day habilitation, transportation provided as a residential habilitation activity, or CFC PAS/HAB;

(ii) the ability to actively participate in ADLs and IADLs to the extent of the individual's ability;

(iii) the ability to implement the individual's choices;

(iv) the ability to access and participate in community activities; and

(v) the ability to move safely and efficiently within the setting in which the individual receives day habilitation, transportation provided as a residential habilitation activity, or CFC PAS/HAB;

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

(12) the individual's current HHSC Documentation of Provider Choice form documenting the individual's or LAR's choice of a program provider;

(13) if required by §260.213 of this subchapter (relating to Service Backup Plans), any new or revised HHSC Provider Agency Model Service Backup Plan form for nursing, intervener services, or CFC/PAS HAB for the current IPC period;

(14) if the IPC includes transportation provided as a residential habilitation activity or as an adaptive aid, a copy of the individual's transportation plan;

(15) if a protective device is used, the documentation required by §260.215 of this subchapter (relating to Protective Devices); and

(16) if a restraint is used, the documentation required by §260.217 of this subchapter (relating to Restraints).

Source Note: The provisions of this §260.209 adopted to be effective February 26, 2023, 48 TexReg 896