| (a) A LIDDA must ensure a habilitation coordinator
maintains the following documentation in a designated resident's record:
(1) all assessments used for service planning;
(2) all documentation of habilitation coordination
contacts as described in §303.503(a) of this chapter (relating
to Documenting Habilitation Coordination Contacts);
(3) documentation related to monitoring specialized
services, including:
(A) the initiation and delivery of all specialized
services provided for the designated resident, including reasons for
delays and all follow-up activities;
(B) the designated resident's and LAR's satisfaction
with all specialized services; and
(C) the designated resident's progress or lack of progress
toward achieving goals and outcomes identified in the HSP, including
whether the designated resident is maintaining progress toward achieving
goals and outcomes from the designated resident's and LAR's perspectives;
(4) the current NF comprehensive care plan;
(5) the current HSP;
(6) all documents and forms used to:
(A) identify the designated resident's need for specialized
services; and
(B) conduct SPT meetings, including written reports
from SPT members who are providers of specialized services and completed
forms related to assessing for habilitative needs;
(7) the completed HHSC forms that document discussions
with the designated resident and LAR about the range of community
living options and alternative services and supports available;
(8) all pertinent information related to the designated
resident, such as guardianship paperwork and consents;
(9) the current plan of care; and
(10) an implementation plan for each IHSS that appears
on the plan of care.
(b) For a designated resident who has refused habilitation
coordination, a LIDDA must maintain the following documentation in
a designated resident's record:
(1) all completed Refusal
of Habilitation Coordination forms;
(2) documentation of the specialized services discussed
in the initial IDT and any SPT or IDT specialized services review
meeting; and
(3) the completed HHSC forms that document discussions
with the designated resident and LAR about the range of community
living options and alternative services and supports available.
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