Form 3252, Title XX Residential Care Adult Foster Care Daily Service Delivery Record

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Documents

Effective Date: 4/2019

Instructions

Updated: 4/2019

Purpose

  • To provide a daily record of service delivery for residential care clients, Title XX RC clients and Adult Foster Care clients.
  • To be used as a source document for fiscal, auditing, and service control monitoring (not all inclusive).

Procedure

When to Prepare

The facility records service delivery each day services are provided. The facility may use Form 3252, or an alternate form of documentation, to document service delivery for the Residential Care and CCAD Title XX Residential Care Programs. The alternate documentation must include all the required elements listed in the assisted living and residential care rules to be in compliance. The alternate documentation may be a multiple page document. HHSC approval is not required for alternate forms.

Number of Copies

Complete one original, in ink.

Transmittal

Form 3252 is kept by the facility.

Form Retention

Keep Form 3252 according to the terms of the contract.

Additional Pages

The facility may attach additional pages to Form 3252 if necessary to meet other requirements. Indicate the total number of pages in the top right corner of Form 3252, as well as on the pages attached to Form 3252.

Detailed Instructions

Client Name — Enter the name of the client.

Vendor Number — Enter the facility’s vendor number.

Month and Year — Enter the calendar month and year services are provided. Only one month should be recorded on form.

Task(s) Assigned — Attendant checks all tasks listed on Form 3252 that are provided to a client. The facility may use a separate page to document the delivery of a specific task, and additional pages for additional tasks.

Comments — Enter any comments regarding the client.

Signature — Facility Representative/Date — Form 3252 must be signed and dated on or after the last day services were provided.

CORRECTIONS TO FORM

To correct an error,

  • line through the error,
  • write the correct entry, and
  • initial the correction.

Do not use liquid paper or correction fluid. Original entries, corrections, and initials must be legible.