(a) A CMA must ensure that when a case manager provides case management, the case manager:
(1) documents:
- (A) the date of contact;
- (B) a description of the case management activity performed;
- (C) the progress or lack of progress in achieving goals or outcomes in the individual's IPP in observable, measurable terms that directly relate to the specific goal or outcomes addressed;
- (D) the person with whom the contact occurred; and
- (E) the signature and title of the case manager who provided the contact; and
- (2) completes an HHSC Documentation of Services Delivered form to document the provision of case management that is supported by the documentation required in paragraph (1) of this subsection.
- (b) A CMA must ensure that, after a case manager makes the last entry on an HHSC Documentation of Services Delivered form, a staff person other than the case manager who completed the form signs and dates the form as a timekeeper as verification of the accuracy of the information on the form.
(c) A CMA must maintain a separate record for each individual receiving case management from the CMA. An individual's record must include:
- (1) the individual's current IPC and any other IPC authorized for the current IPC period;
- (2) the individual's current IPP and any other IPP developed for the current IPC period;
- (3) the individual's current HHSC IPP Addendum and any other HHSC IPP Addendum developed for the current IPC period;
- (4) the individual's current ID/RC Assessment;
- (5) the individual's current HHSC CLASS/DBMD Nursing Assessment form;
- (6) the individual's HHSC Waiver Program Verification of Freedom of Choice form completed at enrollment documenting the individual's or LAR's choice of the CLASS Program over the ICF/IID Program;
- (7) the individual's current HHSC Selection Determination form documenting the individual's or LAR's choice of a CMA and DSA;
- (8) the documentation required by subsection (a)(1) of this section;
- (9) the completed HHSC Documentation of Services Delivered forms signed and dated by a timekeeper as required by subsection (b) of this section; and
- (10) any other relevant documentation concerning the individual.
Source Note:The provisions of this §259.313 adopted to be effective January 30, 2023, 48 TexReg 362.