Form 4119 PDF Details

The Texas Department of Aging and Disability Services' Form 4119, updated in February 2012, serves a critical role in the administration of Home and Community-based Services (HCS) and Texas Home Living Services (TxHmL). Designed to meticulously log respite service delivery, this form captures a comprehensive snapshot of the care provided to individuals with disabilities, ensuring their needs are met in a holistic manner. It demands detailed records of daily living activities ranging from bathing, dressing, personal hygiene, to meal planning, housekeeping, and beyond. The form distinguishes between services provided during the day and those that extend into the night, specifically for individuals receiving Supported Living (SL) services, where nighttime checks are not required. It not only emphasizes the importance of aiding in activities of daily living but also underscores the necessity of fostering independence, community integration, developing socially valued behaviors, and participating in leisure activities. Staff are required to initial or check off completed tasks, document any incidents, and note observations, thereby offering a transparent and accountable record of services rendered. This rigorous documentation process facilitates effective communication among caregivers, service providers, and case managers, ensuring the individual's well-being and quality of life remain at the forefront of care provision.

QuestionAnswer
Form NameForm 4119
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namestexas health human services form 4119, texas aging and disability form 4119, form 4119 form, hhsc form 4119

Form Preview Example

Texas Department of Aging

Form 4119

and Disability Services

February 2012-E

Home and Community-based Services/Texas Home Living Services

Respite Service Delivery Log

Individual Name (First, Last)

Place of Service(s)

Local Case No./Case ID Week Of

Check One:

RSS

SL

At the end of your shift, mark (initial or check) all items that you completed with the individual. If there were any incidents, concerns or special events, please document on bottom of form. For individuals who receive SL service, no night initials or check marks are necessary.

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

mm/dd/yy

Activities of Daily Living

Bathing

Dressing

Personal Hygiene

Eating

Meal Planning

Meal Preparation

Housekeeping

Habitation

Improve Independent Living Skills

Community Integration

Develop Socially Valued Behaviors

Use of Natural Supports

Participate in Leisure Activities

IP Skill Development

Assisting With

Ambulation and Mobility

Reinforcing

Reinforcing Specialized Therapies

Transportation

Supervising Safety and Security

Night Shift

Supervising Safety and Security

Monitoring Health

Monitoring Personal Hygiene

Not in Home

Temporary Discharge

Active on Leave

Staff Initials

Staff Initials

Date

Staff Initials

Comments

Employee Signature

Initials

Staff ID

 

 

Employee Signature

Initials

Staff ID

 

 

 

 

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Best ways to complete texas health human services form 4119 portion 1

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texas health human services form 4119 completion process detailed (part 2)

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Simple tips to fill out texas health human services form 4119 part 3

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