Form 4119, Residential Support Services (RSS) and Supervised Living (SL) Service Delivery Log

Instructions

Updated: 8/2022

Purpose

Form 4119 is used by Texas Health and Human Services Commission (HHSC) staff and Home and Community-based Services (HCS) Waiver program providers to document a service event for the Residential Support Services and Supervised Living service component.

Procedure

When to Prepare

Form 4119 must be completed within 14 calendar days after the activity being documented is provided.

Form Retention

The program provider must maintain a copy of the completed Form 4119 in the individual's record.

General Instructions

• Form 4119 must be used for only one person.
• Form 4119 may be used for up to seven separate billable service events. Each billable service event must be entered on a separate column.
• Form 4119, or another form created for a similarly intended purpose, is considered a Medicaid document used for Medicaid purposes. As such, by using this form, you understand it is your responsibility to record accurate information, as this information may be subject to a court of law. Failure to record accurate information and/or deliberate falsification of documentation is strictly prohibited.

Detailed Instructions

Individual Name — Enter the individual's name.

Place of Service(s) — Enter the complete address where the billable activity occurred.

Local Case No./Case ID — Enter the person's local case number and CARE ID number.

Check One: — Mark either RSS or SL.

Date and Days of the Week — Enter the date (month, day, year) when the billable activity occurred.

Activities of Daily Living, Habilitation, Assisting With, Night Shift, Not in Home — Initial all items completed by the service provider. A minimum of one activity under "Night Shift" must be marked for a billable service event to have occurred in Residential Support Services. For people who receive SL service, no initials are necessary under "Night Shift."

Staff Signatures — Enter the signatures of the service provider(s) providing billable activities for the corresponding day of service.

Staff Initials — Enter the initial of the service provider(s) providing billable activities for the corresponding day of service.

Comments — Provide legible written documentation as needed or desired to provide further justification of the services provided. If providing documentation, enter the date in which the billable activity occurred and the staff initials.

Questions

Email providerfiscalcompliance@hhs.texas.gov about Form 4119 or instructions.