Form 1572, Nursing Tasks Screening Tool

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Effective Date: 5/2019


Updated: 2/2013


The Nursing Tasks Screening Tool for the Home and Community-based Services (HCS) and Texas Home Living (TxHmL) programs is used to determine if an RN nursing assessment must be completed when an individual or their legally authorized representative (LAR) have refused to include sufficient number of nursing units on their Individual Plan of Care (IPC) for an RN nursing assessment.


An RN nursing assessment must be completed for each individual when:

  • Nursing services are provided through the waiver;
  • Unlicensed staff perform nursing tasks; or
  • An LVN is providing on-call services.

The Nursing Tasks Screening Tool is only required when an individual or the individual's legally authorized representative (LAR) refuses a RN assessment.


The Nursing Tasks Screening Tool is to be completed by the selected program provider and individual or LAR at the time of enrollment to the program, at least annually, and when the health status of the participant changes if the individual or LAR refuses an RN nursing assessment.

Detailed Instructions

Name of Program Participant — Enter the first and last name of the individual.

Date — Enter the date that the screening tool is being completed.

A. Physician Delegation — Answer "Yes" or "No" to the question regarding physician delegation (physicians may delegate medical acts to an unlicensed person when the unlicensed person is able to carry out the act properly and safely. As the physician remains responsible for the medical act performed, delegation is made to a specific person and does not encompass any person who is caring for the individual. Writing an order for an individual's care does not constitute delegation to an unlicensed person). If the answer is "Yes," skip to Section C.

B. Medication Administration — Check "Yes" or "No" to the question regarding Medicaid administration. If the answer is "Yes," check all of the routes of medication administration that are currently used.

Special Procedures — Answer "Yes" or "No" to the questions regarding special procedures.

Eating — Answer "Yes" or "No" to the questions regarding eating.

Bathing — Answer "Yes" or "No" to the question regarding bathing.

Toileting — Answer "Yes" or "No" to the questions regarding toileting.

Mobility — Answer "Yes" or "No" to the questions regarding mobility.

C. Signature - Individual or LAR — The individual or the LAR signs here.

Signature - Program Provider Representative — The program provider representative signs here.

D. Program Provider Review — The program provider representative determines whether an RN assessment is required by reviewing the information on the form and checks the box that represents the representative's conclusion. The representative signs and enters his/her title and date of signature.