Home and Community-based Services Handbook

Forms Table of Contents

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Number Title Date
0702Fax Cover Sheet for TxHmL and HCS 2/2012
1572Nursing Tasks Screening Tool2/2013
1572-SNursing Tasks Screening Tool (Spanish)2/2013
1573Residential Review Evidence of Correction for Results Less Than 90% 2/2013
1577Personal Care Services Selection12/2009
1581Consumer Directed Services Option Overview11/2013
1581-SConsumer Directed Services Option Overview (Spanish)11/2013
1582Consumer Directed Services Responsibilities11/2013
1582-SConsumer Directed Services Responsibilities (Spanish)11/2013
1583Employee Qualification Requirements12/2013
1583-SEmployee Qualification Requirements (Spanish)1/2014
1584Consumer Participation Choice4/2012
1584-SConsumer Participation Choice (Spanish)4/2012
1586Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option12/2013
1586-SAcknowledgment of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option (Spanish)11/2013
1588HCS Review Report9/2010
1592RN Delegation Checklist4/2012
1597Level of Care Redetermination Cover Sheet12/2013
1740Service Backup Plan9/2014
1740-SService Backup Plan (Spanish)9/2014
1741Corrective Action Plan8/2014
1741-SCorrective Action Plan (Spanish)8/2014
1742Service Backup Plan for HCS and TxHmL8/2013
1746HCS/TxHmL Exit Conference3/2014
1748HCS Entrance Conference3/2014
2067Case Information12/2012
2125Home and Community-based Services Implementation Plan10/2013
3605HCS Parent or Legally Authorized Representative (LAR) Contact Information for Individuals Under 22 Years of Age 6/2010
3605-SHCS Parent or Legally Authorized Representative (LAR) Contact Information for Individuals Under 22 Years of Age (Spanish)6/2010
3608Individual Plan of Care (IPC) - Home and Community-based Services7/2014
3608-SIndividual Plan of Care (IPC) - Home and Community-based Services (Spanish)7/2014
3609Waiver Survey and Certification Residential Checklist11/2013
3610Informal Review Request5/2014
3611Involuntary Termination of Consumer Directed Services (CDS) Individual Plan of Care (IPC) Cover Sheet (HCS and TxHmL)4/2014
3612Transfer Process Checklist4/2014
3615Request to Continue Suspension of Waiver Program Services4/2014
3616Request for Termination of Waiver Program Services4/2014
3617Request for Transfer of Waiver Program Services2/2012
4116-DentalDental Summary Sheet9/2011
4116-MHM-AAMinor Home Modification/Adaptive Aids Summary Sheet9/2011
4122Host/Companion Service Delivery Log4/2014
4122-SHost/Companion Service Delivery Log (Spanish)4/2014
5604HCS Program Provider Request for Life Safety Inspection4/2014
5606Life Safety Code Certification5/2014
5607Review of DFPS Reports and ANE Trends1/2014
5610HCS Fire Drills, Four-Person Home Inspections and Approvals6/2013
5611Personnel Checklist10/2014
8492Random Sample Review of Nursing On-Call Required Submission of Documentation10/2013
8493Notification to DADS Regarding a Death in HCS, TxHmL and DBMD Programs4/2012
8494Notification to DADS Regarding DFPS Investigation3/2012
8495Exclusion of Host Home/Companion Care (HH/CC) Provider from the Board of Nursing (BON) Definition of Unlicensed Person 5/2014
8509Unlicensed Personnel Tracking of Delegated Tasks6/2014
8574Administration of Medications by Unlicensed Personnel6/2014
8575Notification of Local Authority (LA) Reassignment4/2012
8576Individual Profile Information4/2012
8578Intellectual Disability/Related Condition Assessment2/2012
8579Notification of Service Coordinator (SC) Disagreement4/2012
8580Request for Variance of Supported Employment - Employer Requirements2/2012
8581Corrective Action Plan Form1/2008
8583HCS and TxHmL Program Contact Information 4/2012
8583-SHCS and TxHmL Program Contact Information (Spanish)4/2012
8584Nursing Comprehensive Assessment6/2014
8584-CDSComprehensive Nursing Assessment and Plan of Care - HCS Program8/2014
8584-CDS-SComprehensive Nursing Assessment and Plan of Care - HCS Program (Spanish)8/2014
8599Individual Plan of Care (IPC) Cover Sheet5/2012
8600Individual Plan of Care (IPC) Backdating Cover Sheet 2/2012
8601Verification of Freedom of Choice11/2010
8603Level of Need (LON) Review/Increase Cover Sheet4/2012
8647Service Coordination Assessment -- Intellectual Disability Services1/2012
8662Related Conditions Eligibility Screening Instrument2/2012
8665Person-Directed Plan9/2013
8665-IDIndividual Data9/2013