Form 3251,Residential Care Daily Census Record

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Documents

Effective Date: 2/2020

 

Instructions

Updated: 2/2020

 

Purpose

  • To provide a daily record of attendance for people enrolled in residential care.
  • To be used as a source document for fiscal, auditing, and service control (not all inclusive).

 

Procedure

When to Prepare

Facility enters the enrolled person’s daily activity each day. The facility may use Form 3251, or an alternate form of documentation, to document daily census for the Residential Care Program. The alternate documentation must include all the required elements listed in the residential care rules to be in compliance. The alternate documentation may be a multiple page document. HHSC approval is not required for alternate forms.

Number of Copies

Complete one original, in ink.

Transmittal

The facility keeps Form 3251.

Form Retention

Keep according to the terms of the contract.

 

Detailed Instructions

Name of Facility — Enter the name of the facility.

Vendor No.— Enter the facility’s vendor number.

Month and Year — Enter the calendar month and year services are provided. Only one month should be recorded on each form.

Enrolled Person’s Name — Enter the names of all the people residing in the facility in alphabetical order at the beginning of the service period (month). If services are initiated for a person during the month, enter the name at the end of the list.

Indicate the activity for each person in the square allowed for each day using the following symbols:

Checkmark – Present

A – Admission (first day to be billed for services)

PL – Personal Leave

HL – Hospital Leave

D – Discharge (should not bill for services on or after this date)

EC – Emergency Care

IEC – Ineligible Emergency Care (can bill under this plan for a maximum of five days from date of admission)

Monthly Totals — Enter the monthly total of each activity for each person at the end of the month. Use information to manage leave utilization according to the standards.

Facility Representative Signature and Date — Form 3251 must be signed and dated on or after the last day of the month.

 

CORRECTIONS TO FORM

To correct an error,

  • line through the error;
  • write the correct entry; and
  • initial the correction.

Do not use liquid paper or correction fluid. Original entries, corrections, and initials must be legible.