Form 1747, Acknowledgement of Nursing Requirements

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Documents

Effective Date: 6/2024

Instructions

Updated: 6/2024

Purpose

Form 1747 is used to annually:

  • record acknowledgement of nursing rules;
  • record proof of a licensed vocational nurse’s (LVN’s) or registered nurse’s (RN’s) understanding of responsibilities and documentation requirements while providing nursing under the consumer directed services (CDS) option; and
  • make sure LVNs who provide nursing services using the CDS option are appropriately supervised by:
    • a licensed physician,
    • an RN,
    • an advanced practice registered nurse (APRN), or
    • a physician’s assistant (PA).

Procedure

When to Prepare

Each nurse completes this form upon the person's initial enrollment in the CDS service delivery option and annually before providing care through the CDS service delivery option. If the nurse providing care is an LVN, the form is also used to document the supervision of the LVN. The CDS employer is responsible for making sure documentation is completed:

  • at least annually at the time of person service plan (ISP) or person plan of care (IPC) renewal;
  • if the CDS employer hires a new nurse at any time during their current ISP or IPC year; and
  • whenever the nurse employed by the CDS employer acquires a new supervisor.

Number of Copies

The original form plus two copies are required. The original completed Form 1747 is kept in the person's case record. A copy is kept in the home of the person receiving services, and a copy is sent to the financial management services agency (FMSA).

Transmittal

The CDS employer must send a copy of the completed or updated Form 1747 to the FMSA before any nurse (RN or LVN) can deliver, or continue to deliver, nursing services. The most current Form 1747 should be kept in the person's home.

Form Retention

The CDS employer must maintain a copy of the completed Form 1747 in the home of the person receiving nursing services. Originals or electronic copies of this form must be kept in the person's folder/electronic record for five years after services are terminated.

Detailed Instructions

Note: The form provides the citation for the Texas Board of Nursing rules that govern the practice of the nurse in the CDS setting.

Member’s Name – Enter the name of the member receiving nursing services through the CDS option.

Date of Birth – Enter the date of birth of the member receiving nursing services through the CDS option.

Medicaid Identification No. – Enter the Medicaid identification number associated with the person receiving nursing services through the CDS option.

Medicaid Waiver Program – Enter the Medicaid waiver program the member is or will be enrolled in at the time of service delivery.

CDS Employer’s Name – Enter the name of the CDS employer.

Service Plan Date – Enter the date of the member’s current service plan year.

Certification by nurse hired by a CLASS, HCS, MCDP, STAR+PLUS HCBS, or TxHmL CDS employer – The nurse hired by the CDS employer prints their name in the space provided to acknowledge documentation that must be obtained, completed, and kept in the home of the person.

Signature – The nurse hired by the CDS employer signs the form.

Credentials – Enter nursing credentials.

Date – Enter date the nurse certified they have received the information regarding the documents that must be obtained, completed, and kept in the home of the person.

If the certifying nurse above is an LVN, the following section must be completed.

I am supervised by – Select the credentials for the LVN’s supervisor: physician, physician’s assistant (PA), RN, or APRN.

Supervisor’s Name – Print the name of the LVN’s supervising physician, PA, RN, or APRN.

Supervisor’s License No. – Enter the supervisor’s medical license number.

Supervisor’s Street Address, City, State, Zip code) – Enter the supervisor’s address.

Supervisor’s Area Code and Phone No. – Enter the supervisor’s area code and phone number.

Signature – Physician, PA, RN, or APRN – Signature of the physician, PA,  RN, or APRN attesting to supervision of the LVN.  Electronic signatures with dates are accepted.

Date – Supervising physician, PA, RN, or APRN enters the date document is signed.

License No.– Enter the supervisor’s medical license number.

Financial Management Services Agency (FMSA) – Printed name of FMSA staff that received completed Form 1747.

Signature – Signature of receiving FMSA staff.

Date Received – FMSA enters the date the signed Form 1747 is received.