Home and Community-based Services Handbook

Forms Table of Contents

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0702Fax Cover Sheet for TxHmL and HCS
1572Nursing Tasks Screening Tool
1572-SNursing Tasks Screening Tool (Spanish)
1573Residential Review Evidence of Correction for Results Less Than 90%
1577Personal Care Services Selection
1581Consumer Directed Services Option Overview
1581-SConsumer Directed Services Option Overview (Spanish)
1582Consumer Directed Services Responsibilities
1582-SConsumer Directed Services Responsibilities (Spanish)
1583Employee Qualification Requirements
1583-SEmployee Qualification Requirements (Spanish)
1584Consumer Participation Choice
1584-SConsumer Participation Choice (Spanish)
1586Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option
1586-SAcknowledgment of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option (Spanish)
1588HCS Review Report
1592RN Delegation Checklist
1597Level of Care Redetermination Cover Sheet
1740Service Backup Plan
1740-SService Backup Plan (Spanish)
1741Corrective Action Plan
1741-SCorrective Action Plan (Spanish)
1742Service Backup Plan for HCS and TxHmL
1746HCS/TxHmL Exit Conference
1748HCS Entrance Conference
2067Case Information
2125Home and Community-based Services Implementation Plan
3605HCS Parent or Legally Authorized Representative (LAR) Contact Information for Individuals Under 22 Years of Age
3605-SHCS Parent or Legally Authorized Representative (LAR) Contact Information for Individuals Under 22 Years of Age (Spanish)
3608Individual Plan of Care (IPC) - Home and Community-based Services
3608-SIndividual Plan of Care (IPC) - Home and Community-based Services (Spanish)
3609Waiver Survey and Certification Residential Checklist
3610Informal Review Request
3611Involuntary Termination of Consumer Directed Services (CDS) Individual Plan of Care (IPC) Cover Sheet (HCS and TxHmL)
3612Transfer Process Checklist
3615Request to Continue Suspension of Waiver Program Services
3616Request for Termination of Waiver Program Services
3617Request for Transfer of Waiver Program Services
4116-DentalDental Summary Sheet
4116-MHM-AAMinor Home Modification/Adaptive Aids Summary Sheet
4122Host/Companion Service Delivery Log
4122-SHost/Companion Service Delivery Log (Spanish)
5035Request for Exception to Service Limit
5604HCS Program Provider Request for Life Safety Inspection
5606Life Safety Code Certification
5607Review of DFPS Reports and ANE Trends
5610HCS Fire Drills, Four-Person Home Inspections and Approvals
5611HCS Personnel Checklist
8492Random Sample Review of Nursing On-Call Required Submission of Documentation
8493Notification to DADS Regarding a Death in HCS, TxHmL and DBMD Programs
8494Notification to DADS Regarding DFPS Investigation
8495Exemption of Foster/Companion Care (FCC) Provider from the Board of Nursing (BON) Definition of Unlicensed Person
8509Unlicensed Personnel Tracking of Delegated Tasks
8574Administration of Medications by Unlicensed Personnel
8575Notification of Local Authority (LA) Reassignment
8576Individual Profile Information
8578Intellectual Disability/Related Condition Assessment
8579Notification of Service Coordinator (SC) Disagreement
8580Request for Variance of Supported Employment - Employer Requirements
8581Corrective Action Plan Form
8583HCS and TxHmL Program Contact Information
8583-SHCS and TxHmL Program Contact Information (Spanish)
8584Nursing Comprehensive Assessment
8584-CDSComprehensive Nursing Assessment and Plan of Care - HCS Program
8584-CDS-SComprehensive Nursing Assessment and Plan of Care - HCS Program (Spanish)
8599Individual Plan of Care (IPC) Cover Sheet
8600Individual Plan of Care (IPC) Backdating Cover Sheet
8601Verification of Freedom of Choice
8603Level of Need (LON) Review/Increase Cover Sheet
8647Service Coordination Assessment -- Intellectual Disability Services
8662Related Conditions Eligibility Screening Instrument
8665Person-Directed Plan
8665-IDIndividual Data