| (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.
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