Form 3054 – Fill Out and Use This PDF

Form 3054 PDF Details

The Texas Department of Aging and Disability Services' Form 3054, also known as the Primary Home Care Service Delivery Record, plays a crucial role in the administration of home and community support services. Issued in August 2012, this form provides a structured method for documenting the services delivered to individuals by Home and Community Support Services Agencies. It encompasses a broad spectrum of personal care tasks stretching from bathing, dressing, and feeding to more specific tasks like grooming, laundry, and even shopping or escort services. Designed to be filled out by employees serving the individual, it asks for detailed entries including employee and individual names, identification numbers, the county, and a list of tasks assigned. Critical to both accountability and billing, the form also includes spaces to record each service occurrence by day, including time in, time out, and total daily hours, aiming to ensure an accurate reflection of the services provided. The form emphasizes the importance of honesty and accuracy in its completion, noting that billing for services not actually provided constitutes fraud. With spaces for signatures from both the employee and a timekeeper, it finalizes the acknowledgement of the work completed according to the schedule or authorized hours, thereby helping to maintain integrity and transparency in home-based care.