The Texas 3599 form is a document used by the Texas Department of Aging and Disability Services to facilitate the orientation and supervisory visits of habilitation service providers. This form collects essential information regarding the individual's needs and the services provided, ensuring that appropriate care is delivered. By documenting the individual's functional limitations and the provider's performance, the Texas 3599 helps maintain a high standard of support for those in need.
The Texas 3599 form serves as a crucial document in the realm of community living assistance and support services, specifically designed for individuals who require habilitation services. It is utilized primarily during supervisory visits and orientation sessions for habilitation service providers. This form captures essential information, such as the individual's name, the frequency of visits, and the specific habilitation service provider involved. Additionally, it outlines the purpose of the visit, which includes assessing the individual's functional limitations and ensuring that the service provider is well-informed about the individual's health conditions and the tasks they are expected to perform. The form also includes sections for documenting health and safety concerns, reporting changes in the individual's needs or behavior, and evaluating the competence of the service provider in delivering both habilitation and medically related tasks. Furthermore, it facilitates communication between the individual, their legal authorized representative, and the service provider, ensuring that all parties are aligned in their understanding of the care being provided. Ultimately, the Texas 3599 form is a vital tool that helps maintain the quality and effectiveness of support services, promoting the well-being of individuals in need.
Texas Department of Aging
Community Living Assistance and Support Services (CLASS)
and Disability Services
Habilitation Service Provider Orientation/Supervisory Visits
Individual’s Name (please print)
Date
Frequency of supervisory visits Habilitation service provider name
Delegated habilitation service provider
Habilitation service provider
Special habilitation service provider orientation by telephone
Form 3599
September 2013
Purpose of Visit
PO SV
Describe the individual’s functional limitations that require a need for habilitation services. (Complete when orienting habilitation service
1. provider)
2. Orientation (complete when orienting habilitation service provider):
2-1
Habilitation service provider instructed about individual’s health condition and how it may affect provision of tasks.
Habilitation service provider instructed about tasks to be provided, work schedule and safety and emergency
2-2
procedures.
2-3
instructed to report to
(Print name and credentials)
(Telephone no.)
The following health and safety concerns (document concerns):
Note: In the event of an emergency, notify 911.
2-4 Habilitation service provider instructed to report the following to the supervisor as soon as possible:
Individual hospitalized
Other:
Changes in individual’s needs and behavior
Individual absent from home or moved
Habilitation service provider unable to work scheduled hours
Habilitation service provider schedules
Schedule 1
Type Of Service
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Weekly Total Habilitation Hours
Schedule 2
Page 2 / 09-2013
3.A. Tasks/Plan of Care: Indicate tasks to be performed (complete on every visit). During supervisory visit, ask individual or LAR what tasks are provided by the service provider. Observe or ask about performance: S = Satisfactory U = Unsatisfactory
Hygiene..............
Toileting.............
Dressing.............
Shopping ...........
Meal Preparation
Freq. Perform.
Feeding ..........................
Exercise .........................
Transfer/Ambulation......
Cleaning .........................
Community Assistance
Medically Related Tasks......
3.B. Is the habilitation service provider competent to provide habilitation tasks?
Yes
3.C. Is the habilitation service provider competent to provide delegated habilitation tasks?
3.D. Is the habilitation service provider competent to provide medically related tasks?
Complete the following for Supervisory Visits (N/A for habilitation service provider orientation only).
4.
Is the individual satisfied with the services provided by the habilitation service provider?
5.
Is the habilitation service provider following the schedule?
6.A.
Describe service delivery problems.
No
No No
N/A
6.B. Describe habilitation service provider training needs.
6.C. Describe corrective actions taken.
7. Does the individual continue to need services? ...........................................................................................................
8. Additional Comments:
Signature – Individual/LAR
Signature – Habilitation Service Provider
Signature – Supervisor
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