Form 6518, Record of Completion for Individual Specific Training, Instructions

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Effective Date
01/2022
6518.pdf (254.86 KB)

Instructions

Updated: 1/2022

Purpose

To provide a standardized record of completion for Deaf Blind with Multiple Disabilities (DBMD) individual specific training.

Procedure

When to Prepare

The DBMD program provider completes Form 6518 when providing specific training on the needs of an individual. Training must occur before providing services to the individual at least annually, and if the individual’s needs change.

Form Retention

Keep this form in accordance with record retention requirements outlined in the Texas Administrative Code.

Detailed Instructions

Individual's Name — Enter or print the individual's name.

Date Training Completed — Enter the date (month, day, year) that the service provider completed the training.

Name of the Service Provider — Enter or print the name of the service provider who completed the training.

Name of Trainer — Enter or print the name of the DBMD program provider staff member who conducted the training.

Service Provider Type (Check one or more) — Check the box(es) to indicate which service provider type is receiving the training. Specific training is required for all program provider staff, including subcontractors, who provide:

  • Community First Choice Personal Assistance Services Habilitation (PAS/Hab)
  • Day Habilitation
  • Employment Assistance
  • Intervener, I, II, III
  • Licensed Assisted Living (18 and 24 Hour)
  • Licensed Home Health Assisted Living
  • Respite (In-Home and Out-of-Home)
  • Supported Employment
  • Transportation – Residential Habilitation

Completed in the Individual’s Home — Mark Yes or No to indicate that training was or was not provided in the individual’s home.

Complete Physical Address of the Training Site — Provide the complete physical address where the specific training was conducted, including city, state and ZIP code.

Reason for Training — Mark the appropriate box to indicate the reason for the training (choose one option):

  • Initial Training – Select this option when:
    • The individual is new to the contract.
    • The service provider is a new employee.
    • The service provider will be providing services to the individual for the first time.
  • Annual Renewal – Select this option when the service provider is completing their required annual training.
  • Individual’s Needs Changed – Select this option at any time during the plan year when there has been a change to the individual’s needs.

Examples of changes to the individual’s needs: Sustained injuries, health deterioration, diet changes, new physical diagnosis, new adaptive equipment, etc.

Training included the full participation of the: – Mark the appropriate box to indicate who participated during the service provider training:

  • Individual
  • Individual’s Legally Authorized Representative
  • Actively Involved Person

Section 1: Specific Needs – Complete all items in this section.

Methods of communication — Mark the box to indicate that instruction has been provided to the service provider detailing the individual’s methods of communication. Describe if the individual uses American Sign Language, gestures, a communication board, etc.

Specific visual and audiological loss — Mark the box to indicate that instruction has been provided to the service provider detailing the individual’s specific visual and audiological loss. Describe if the individual has cochlear implants, needs staff to speak into one particular ear, needs tactile stimulation or uses Braille, etc.

Adaptive aids (if applicable) — Mark the box to indicate that instruction has been provided to the service provider detailing the individual’s use of adaptive aids. List the adaptive aids the individual uses and refer to Section 1000, Adaptive Aids/Vehicle Modification Services, of the DBMD Program Manual.

Managing challenging behavior

Prevention of aggressive behavior — Mark the box to indicate that instruction has been provided to the service provider detailing the individual’s aggressive behavior and preventative methods used to address the specific behavior.

De-escalation techniques — Mark the box to indicate that instruction has been provided to the service provider detailing the methods used to address and de-escalate a challenging behavior when prevention has failed.

Individual has a Behavioral Support Plan (BSP) — Mark Yes or No to indicate that the individual does or does not have an active behavior support plan.

Section 2: Protective Devices – Complete the appropriate items in this section.

Training on the individual’s protective device(s) has been completed (if any) — Mark the box to indicate that instruction has been provided to the service provider detailing the usage of the individual’s protective device(s).

List the protective device — List the protective item or device used by the individual. For a list of protective devices, refer to 40 TAC 42.103 Definitions.

Use of a protective device must be reported to — List the name of the DBMD program provider staff member that must be notified of protective device(s) usage. Notification must occur in accordance with 40 TAC 42.408 Protective Devices.

I understand that protective devices must not be used to modify or control an individual’s behavior, for disciplinary purposes, for convenience or as a substitute for an effective, less restrictive method. — Mark the box to indicate understanding of the statement.

Not Applicable (check if the individual does not use a protective device) — Mark the box to indicate that the individual does not use a protective device.

Section 3: Restraints — Complete the appropriate items in this section.

Training on restraints has been completed, including usage and reporting requirements — Mark the box to indicate that instruction has been provided to the service provider detailing the usage of a physician authorized restraint.

List the authorized restraint(s) — List the allowable restraint, as authorized by the physician.

Use of a restraint must be reported to — List the name of the DBMD program provider’s Registered Nurse (RN). Notification must occur in accordance with 40 TAC 42.409 Restraints. Program providers who provide licensed assisted living must comply with 26 TAC 553.267. Program providers must ensure that a six-bed ICF/IID that provides out-of-home respite services complies with 26 TAC 551.42.

Training includes the following documentation requirements: — Mark the box to indicate that documentation and reporting requirements were explained to the service provider. This training must be completed even if the individual does not have a physician’s order for restraint usage. Training must occur to ensure understanding if a restraint must be used during a behavioral emergency to protect the individual’s health and safety.

Documentation requirements include:

  • The use of the restraint; (document in the individual’s record that a restraint was used)
  • Time and date the restraint was used; (enter the time and month, day, year)
  • Name of the person administering the restraint; (name of the service provider who administered the restraint)
  • Type of restraint and duration used; (the actual restraint type and the duration of the restraint) and
  • If used in a behavioral emergency:
    • Events preceding the use of the restraint; (what events/actions occurred leading up to the necessary usage of a restraint)
    • Actions taken after the use of the restraint; (what did the service provider do after they administered the restraint) and
    • Types of interventions attempted before use of the restraint (what actions did the service provider take in an attempt to prevent or de-escalate the situation).

I understand that restraints must not be used for disciplinary purposes, retaliation, coercion, retribution, for the convenience of myself or another service provider or as a substitute for an effective, less restrictive method. — Mark the box to indicate understanding of the statement.

Not Applicable (check if the individual does not have a physician’s order for a restraint) — Mark the box to indicate that the individual does not have a physician’s order for a restraint.

Section 4: Delegated Tasks — Complete this section as applicable.

Training on delegated tasks has been completed by (document the name of the appropriate licensed medical professional who provided delegation training) on (document the date of the delegated training) and competency was verified. Documentation of the delegated training is maintained in the individual’s record and is available for review upon request. — Documentation must be maintained in accordance with 40 TAC 42.403 Training.

Section 5: Individual Needs Changes — Complete this section as applicable.

These changes should be reported to — List the name of the DBMD program provider staff member that must be notified when the individual’s needs change. Change(s) include, but may not be limited to:

  • Individual is hospitalized;
  • Changes in the individual’s needs or behavior; and
  • Individual is absent from the home or has moved.

Section 6: Additional Information — Complete this section as applicable.

If this training is being conducted as the result of a change in the individual’s needs, document the change(s) — Provide documentation of changes to the individual’s needs that required a training update.

Additional concerns (if any) — Provide any additional concerns, as necessary.

Additional comments (if any) — Provide any additional comments, as necessary.

Signature of Service Provider and Date — The service provider signs and dates the form. The service provider’s signature is a verification that they have received training on the specific needs of the individual and can demonstrate competency.

Signature of Trainer and Date — The trainer signs and dates the form. The trainer’s signature is a verification that instruction has been provided to the service provider on the specific needs of the individual.

Contact Program Staff

For questions related to the form or instructions, contact the CLASS/DBMD Provider Monitoring team via email at CAPM_CLASS_DBMD_Monitoring@hhs.texas.gov.

For questions related to DBMD program policies, contact the Long Term Services and Support (LTSS) Policy team via email at DBMDPolicy@hhs.texas.gov.