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Effective Date: 
1/2018

Documents

Instructions

Updated: 1/2018

Purpose

To document that the employer and employee acknowledge that the employer may train and supervise the employee in the delivery of certain tasks and/or services without the involvement of a licensed nurse through Consumer Directed Services (CDS).

Note: the following programs use Texas Health and Human Services Commission (HHSC) Form 1733 instead of Form 1585, Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services (CDS):

  • Community Living Assistance and Support Services (CLASS)
  • Deaf Blind with Multiple Disabilities Medicaid Waiver Program (DBMD)
  • Medically Dependent Children Program (MDCP)
  • STAR+PLUS Home and Community Based Services (HCBS) program
  • Home and Community-based Services (HCS)
  • Texas Home Living Program (TxHmL)

Procedure

When to Prepare

The employer completes this form with each new employee at the time of hire.

Number of Copies

Original and one copy.

Transmittal

The employer keeps the original and gives a copy to the employee.

Form Retention

The employer must keep this form while in effect, plus five years after termination of the agreement or until all outstanding litigation, claims and audits are resolved.

Detailed Instructions

The employer reviews all information contained in this form with the employee before services are delivered to the individual.

Certification

The employer and the employee acknowledge that each has read and understands the information in this form. Each acknowledges that the employer may choose to train and supervise the employee to deliver the tasks and/or services.

Employee — The employee prints his or her name and signs and dates the form.

Employer — The employer prints his or her name and signs and dates the form.

Tasks

The employer specifically writes the tasks the employee will perform, with supervision of the employer, instead of a licensed nurse. If the employer is the legally authorized representative (LAR) of the individual or member receiving services, the LAR must check the tasks the employee may perform when the LAR is not present to supervise.