26 TAC § 259.363. DSA: Documentation of Services Delivered and Recordkeeping

(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.