SECTION 303.504. Documentation Maintained by a LIDDA in a Designated Resident's Record

(a) A LIDDA must ensure a habilitation coordinator maintains the following documentation in a designated resident's record:

(1) all assessments used for service planning;

(2) all documentation of habilitation coordination contacts as described in §303.503(a) of this chapter (relating to Documenting Habilitation Coordination Contacts);

(3) documentation related to monitoring specialized services, including:

(A) the initiation and delivery of all specialized services provided for the designated resident, including reasons for delays and all follow-up activities;

(B) the designated resident's and LAR's satisfaction with all specialized services; and

(C) the designated resident's progress or lack of progress toward achieving goals and outcomes identified in the HSP, including whether the designated resident is maintaining progress toward achieving goals and outcomes from the designated resident's and LAR's perspectives;

(4) the current NF comprehensive care plan;

(5) the current HSP;

(6) all documents and forms used to:

(A) identify the designated resident's need for specialized services; and

(B) conduct SPT meetings, including written reports from SPT members who are providers of specialized services and completed forms related to assessing for habilitative needs;

(7) the completed HHSC forms that document discussions with the designated resident and LAR about the range of community living options and alternative services and supports available;

(8) all pertinent information related to the designated resident, such as guardianship paperwork and consents;

(9) the current plan of care; and

(10) an implementation plan for each IHSS that appears on the plan of care.

(b) For a designated resident who has refused habilitation coordination, a LIDDA must maintain the following documentation in a designated resident's record:

(1) all completed Refusal of Habilitation Coordination forms;

(2) documentation of the specialized services discussed in the initial IDT and any SPT or IDT specialized services review meeting; and

(3) the completed HHSC forms that document discussions with the designated resident and LAR about the range of community living options and alternative services and supports available.

Source Note: The provisions of this §303.504 adopted to be effective July 7, 2019, 44 TexReg 3265; amended to be effective September 1, 2021, 46 TexReg 5419