(a) A DSA must ensure that for each direct service provided, except adaptive aids, dental treatment, minor home modifications, CFC ERS, CFC support management, and a direct service that is documented through an electronic visit verification system, as listed in 1 TAC §354.4005(b) (relating to Applicability), a service provider:
  (1) documents:
    (A) the type of service provided;
    (B) the date and the time the service begins and ends;
    (C) the type of contact (phone or in-person);
    (D) the name of the person with whom the contact occurred;
    (E) a description of the activity performed, unless the activity is a non-delegated task provided by an unlicensed service provider that is documented on an IPP;
    (F) the signature and title of the service provider; and
    (G) the progress or lack of progress in achieving a goal or outcome in the individual's IPP in observable, measurable terms that directly relate to the specific goal or outcome; and
  (2) completes an HHSC Documentation of Services Delivered form to document the provision of a direct service that is supported by the documentation required in paragraph (1) of this subsection.
(b) A DSA must ensure that, after a service provider makes the last entry on an HHSC Documentation of Services Delivered form, a staff person other than the service provider signs and dates the form as a timekeeper as verification of the accuracy of the information on the form.
(c) A DSA must maintain a separate record for each individual receiving CLASS Program services and CFC services from the DSA. The individual's record must include:
  (1) a copy of the individual's current IPC and any other IPC authorized for the current IPC period;
  (2) a copy of the individual's current IPP and any other IPP developed for the current IPC period;
  (3) a copy of the individual's current PAS/HAB plan;
  (4) if transportation is included on the IPC as a habilitation activity or as an adaptive aid, a copy of the individual's individual transportation plan;
  (5) a copy of the individual's current ID/RC Assessment;
  (6) if the DSA was the individual's DSA when the individual enrolled in the CLASS Program:
    (A) the original ID/RC Assessment signed by a physician; or
    (B) the original level of care form signed by a physician and was in use before the ID/RC Assessment;
  (7) a copy of the current adaptive behavior screening assessment;
  (8) a copy of the current HHSC CLASS/DBMD Nursing Assessment form;
  (9) a copy of the current HHSC Related Conditions Eligibility Screening Instrument form;
  (10) any new or revised HHSC Provider Agency Model Service Backup Plan form for the current IPC period;
  (11) the documentation required by subsection (a)(1) of this section;
  (12) the completed HHSC Documentation of Services Delivered forms signed and dated by a timekeeper as required by subsection (b) of this section; and
  (13) any other relevant documentation concerning the individual.

Source Note: The provisions of this §259.363 adopted to be effective January 30, 2023, 48 TexReg 362