This form is to be used to provide a daily census:
- for individuals receiving residential services in the Deaf Blind with Multiple Disabilities (DBMD) program.
- when the individual is on leave due to personal leave, hospital leave or institutional leave.
Per Texas Administrative Code (TAC) 42.630 (a) (8), a form developed by the program provider may be used in place of this form as long as the form captures all of the information addressed on the Daily Census Documentation form.
Each day must capture the specific service code (19, 19E, 19F) the individual received for each day of every month and year. For each day the individual is on leave (personal, hospital or institutional), the form should capture those activities with the appropriate code.
Each DBMD provider agency must keep the Daily Census Documentation form according to the record retention requirements found in Texas Administrative Code, Chapter 49 (related to Contracting for Community Care Services).
Individual's Name — Enter the full name of the individual receiving DBMD services.
Medicaid Number — Enter the Medicaid number of the individual.
Vendor Name — Enter the name of the DBMD provider agency providing the identified service(s).
Vendor Number — Enter the seven-digit number assigned to the DBMD provider agency providing the identified service(s).
Month and Year — Enter the month and year the service is provided. The form includes space for up to six months of entries.
Fields 1-31 — Enter the correct code in each numbered field to indicate the services provided:
- 19 = 24-Hour Assisted Living Services
- 19E = Licensed Home Health Assisted Living
- 19F = 18-Hour Assisted Living
- PL = Personal leave
- HL = Hospital leave
- IL = Institutional leave
Totals — Indicate the total for each code reflected in fields 1-31. If the value is "0," enter a "0" in the field.
Timekeeper Name — Enter the name of the timekeeper for the agency.
Signature – Timekeeper and Date — The timekeeper for the agency signs and dates the form. The timekeeper should verify the accuracy of the total hours.