7800, Service Delivery Records

Revision 17-1; Effective November 1, 2017

The CMA will maintain individual records that contain information required by HHSC and CLASS for a period of six years. Documentation must be maintained in each individual's record to include:

• identifying information — name, sex, race, date of enrollment, citizenship, residence, marital status, Social Security number, Medicaid number;
• name, address and phone number of responsible or interested parties;
• financial information (income);
• incident reports;
• if the individual requires supported employment services and is not already employed, written verification of HHSC determination of eligibility or denial of supported employment services;
• if the individual requires employment assistance services, written verification of the HHSC determination of eligibility or denial of supported employment services unless CLASS employment assistance services are being provided while awaiting HHSC to develop an individual plan for employment (IPE) for the individual;
• case management activities to include the:
  • date of contact;
  • description of the case management provided;
  • progress or lack of progress in achieving goals or outcomes in observable, measurable terms that directly relate to the specific goal or objective addressed;
  • person with whom the contact occurred; and
  • case manager who provided the contact.
• if the individual is in school, the individual education plan (IEP) for the individual;
• discharge summaries; and
• additional required documentation:
  • individual's current IPC;
  • individual's current person-centered plan, IPP-A
  • individual's current IPP;
  • individual's current Intellectual Disability/Related Condition (ID/RC) Assessment; and
  • any other relevant documentation concerning the individual.

The DSA will maintain individual records that contain information required by HHSC and CLASS for a period of six years. Documentation must be maintained in each individual's record to include:

• identifying information — name, sex, race, date of enrollment, citizenship, residence, marital status, Social Security number, Medicaid number;
• name, address and phone number of responsible or interested parties;
• physicians' orders for medications and treatments, and any other medical records;
• consent statements for money management;
• evaluations of progress towards individual goals to include the:
  • type of CLASS program service provided;
  • date and the time the service begins and ends;
  • type of contact (phone or face-to-face);
  • name of the person with whom the contact occurred;
  • description of the activities performed, unless the activity performed is a non-delegated task that is provided by an unlicensed service provider and is documented on the IPP; and
  • signature and title of the service provider;
• incident reports;
• trust fund records;
• documentation that employment assistance or supported employment is not available to the individual under a program funded under §110 of the Rehabilitation Act of 1973 or under a program funded under the Individuals with Disabilities Education Act (20 U.S.C. §1401 et seq.); and
• these forms, as identified in Title 40 of the TAC §45.807:
  • a copy of the individual's current IPC;
  • a copy of the individual's current IPP-A;
  • a copy of the individual's current IPP;
  • a copy of the individual's current ID/RC Assessment;
  • a copy of the current adaptive behavior screening assessment;
  • a copy of the current HHSC CLASS/DBMD Nursing Assessment form
  • a copy of the current Related Conditions Eligibility Screening Instrument;
  • any new or revised Form 3628, Provider Agency Model Service Backup Plan, for the current IPC period; and
  • any other relevant documentation concerning the individual.

Evidence that employment assistance is not available to the individual under a program funded under §110 of the Rehabilitation Act of 1973 or under a program funded under the Individuals with Disabilities Education Act, must include documentation of the individual having applied for HHSC. Individuals receiving educational services through a school system must seek to have employment assistance or supported employment services included in the Individual Education Plan, when appropriate.

The requirement to document the service provided in an individual's record does not apply if the service/activity performed is a non-delegated task provided by an unlicensed service provider that is documented on the IPP.