Documents
Instructions
Updated: 2/2023
Purpose
To provide a standardized record of completion for Deaf Blind with Multiple Disabilities (DBMD) Program Service Provider Training.
Procedure
When to Prepare
The DBMD program provider completes Form 6520 to document the completion of:
- DBMD Program Service Provider training;
- HHSC Deaf Blind with Multiple Disabilities Waiver Computer Based Training; and
- DBMD Program Case Management training.
Training must occur in accordance with the timeframes outlined in 26 TAC 250.205 Training and 26 TAC 260.515 Service Provider Qualifications.
Form Retention
Keep this form in accordance with record retention requirements outlined in the Texas Administrative Code. The DBMD Program Provider is not required to submit the forms to HHSC upon completion but must maintain the forms in personnel records and provide a copy to HHSC upon request.
Detailed Instructions
Name of the Service Provider — Enter or print the name of the service provider who completed the training.
Service Provider Date of Hire — Enter or print the date (month, day, year) of hire for the service provider.
Name of Trainer — Enter or print the name of the DBMD program provider staff member who conducted the training.
A program provider that develops and conducts its own trainings must ensure that the staff person who develops and conducts the training has successfully completed HHSC training on the specified topic. Documentation of the completion must be maintained in the personnel file of the staff person developing and conducting the specified training.
Date Training Completed — Enter the date (month, day, year) that the service provider completed the training.
Service Provider Type (Check one or more) — Check the box(es) to indicate which service provider type is receiving the training. DBMD Program Service Provider training is required for program directors and all program provider staff, including subcontractors, who provide:
- Case Management
- Community First Choice Personal Assistance Services Habilitation (PAS/Hab)
- Employment Assistance
- Individualized Skills and Socialization
- Intervener, I, II, III
- Licensed Assisted Living (18 and 24 Hour)
- Licensed Home Health Assisted Living
- Nursing (RN or LVN, Specialized RN or LVN)
- Respite (In-Home and Out-of-Home)
- Supported Employment
- Transportation – Residential Habilitation
Section 1: DBMD Program Service Provider Training – Complete all items in this section.
The training requirements listed in this section may also be fulfilled by completing the DBMD Provider Training located in the HHS Learning Portal. A certificate obtained from the HHS Learning portal must be maintained in the employee’s personnel record and must be available for review upon request.
Methods and Strategies for Communication — Mark the box to indicate that instruction has been provided to the service provider on the topic of Methods and Strategies for Communication or that the service provider completed the DBMD Provider Training.
Active Participation in Home and Community Life — Mark the box to indicate that instruction has been provided to the service provider on the topic of Active Participation in Home and Community Life or that the service provider completed the DBMD Provider Training.
Orientation and Mobility — Mark the box to indicate that instruction has been provided to the service provider on the topic of Orientation and Mobility or that the service provider completed the DBMD Provider Training.
Behavior as Communication — Mark the box to indicate that instruction has been provided to the service provider on the topic of Behavior as Communication or that the service provider completed the DBMD Provider Training.
Causes and Origins of Deafblindness — Mark the box to indicate that instruction has been provided to the service provider on the topic of Causes and Origins of Deafblindness or that the service provider completed the DBMD Provider Training.
Vision, Hearing, and the Functional Implications of Deafblindness — Mark the box to indicate that instruction has been provided to the service provider on the topic of Vision, Hearing, and the Functional Implications of Deafblindness or that the service provider completed the DBMD Provider Training.
Section 2: HHSC Deaf Blind with Multiple Disabilities Waiver Computer Based Training
The above-named program director or case manager completed the HHSC Deaf Blind with Multiple Disabilities Waiver Computer Based Training and received a score of at least 80 percent on the examination included in the training. The HHSC issued training certificate is maintained in the employee’s personnel record and is available for review upon request. – Mark the box to indicate that the case manager or program director completed the DBMD Waiver Computer Based Training and received a score of at least 80 percent.
The training requirements listed in this section may also be fulfilled by completing the DBMD Provider Training located in the HHS Learning Portal.
The HHSC training certificate issued after the case manager or program director achieves the required score must be maintained in the employee’s personnel record and must be available for review upon request.
Section 3: DBMD Program Case Management Training — Mark the box to indicate that DBMD Program and Case Management training was provided to the case manager or program director.
The training requirements listed in this section may also be fulfilled by completing the DBMD Provider Training located in the HHS Learning Portal. A certificate obtained from the HHS Learning portal must be maintained in the employee’s personal record and must be available for review upon request.
The training, if provided by the DBMD program provider, must have addressed the following elements:
The DBMD Program service delivery model, which includes:
- the role of the case manager and DBMD Program provider;
- the rule of the service planning team;
- person-centered planning; and
- the CDS option.
DBMD Program services, including how these services:
- complement other Medicaid services;
- supplement family supports and non-waiver services available in the individual’s community; and
- prevent institutionalization.
DBMD Program Process and Procedures for:
- eligibility and enrollment;
- service planning, service authorization and program plans;
- access to non-waiver resources; and
- complaint procedures and the fair hearing process.
Rules, Policies and Procedures about:
- preventing abuse, neglect, and exploitation of an individual;
- reporting abuse, neglect, and exploitation to local and state authorities; and
- financial improprieties involving the individual.
Signature of Service Provider and Date — The service provider signs and dates the form. The service provider’s signature is a confirmation that they have received training on the training topics documented on the form.
Signature of Trainer and Date — The trainer signs and dates the form. The trainer’s signature is a confirmation that instruction has been provided to the service provider on the training topics documented on the form. The trainer is also confirming that they have verified compliance of computer-based training requirements.
Signature of Person Providing Verification and Date — If computer-based training requirements were verified by someone other than the person providing the DBMD Program Service Provider training or the DBMD Case Management Training, that person signs and dates the form. The person’s signature is a confirmation that completion of those requirements was verified.
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.