Form 1585, Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services

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Documents

Effective Date: 2/2016


Instructions

Updated: 9/2009

Purpose

  • To record the individual's or legally authorized representative's agreement to assume the responsibility for the training, directing and supervising of employees to provide some nursing tasks in Community Based Alternatives (CBA).

    Note: This option is not available for Primary Home Care, Community Attendant services, Family Care or Client Managed Personal Attendant Services (CMPAS).
  • To record the specific nursing tasks the individual or legally authorized representative will take responsibility for in training/supervising the attendant to perform.
  • To document that the home and community support services (HCSS) agency is no longer responsible for the designated nursing tasks.

Note: The following programs use Form 1733, Employer and Employee Acknowledgement of Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services, instead of Form 1585:

  • Community Living Assistance and Support Services (CLASS)
  • Deaf-Blind Multiple Disability Medicaid Waiver Program (DBMD)
  • Medically Dependent Children Program (MDCP)
  • Home and Community-based Services (HCS)
  • Texas Home Living Program (TxHmL)

Procedure

When to Prepare

Complete Form 1585 when the individual requesting services or individual receiving ongoing services or his legally authorized representative is assuming responsibility for any nursing tasks allowed under the Consumer Directed Services (CDS) option (§531.051 of the Government Code).

Number of Copies

Original of Page 1 and the original and three copies of Page 2.

Transmittal

The case manager/service coordinator will file the original of Page 2 in the case record. Give the individual or legally authorized representative the original Page 1 and a copy of Page 2. Send the CDS agency and the HCSS agency a copy of Page 2.

Form Retention

Keep the original of Page 2 for five years after the case is denied or closed.

Detailed Instructions

Review the information on the form carefully with the individual or legally authorized representative, if applicable.

Services to Be Delivered — The individual or legally authorized representative completes this section of the form listing the nursing tasks he or she will take responsibility for training and supervising the attendant to perform.

Individual Signature and Date — The individual signs and dates, assuming responsibility for the tasks listed above.

Legally Authorized Representative Signature and Date — If applicable, the legally authorized representative signs and dates, assuming responsibility for the tasks listed above.

Case Manager/Service Coordinator Signature and Date — The case manager/service coordinator signs and dates the form.