Service Recipient Record Requirements

(1) The licensee shall ensure that each service recipient’s record includes at least the following information: (a) Name, address, telephone number, gender, and date of birth; (b) Date of service enrollment; (c) Name, address, and telephone number of an emergency contact person; (d) Written fee agreement. If the licensee charges fees for personal support services, a written agreement dated and signed by the service recipient or the service recipient’s MINIMUM PROGRAM REQUIREMENTS FOR PERSONAL SUPPORT CHAPTER 0940-05-38 SERVICES AGENCIES legal representative (conservator, parent, guardian or legal custodian) or person paying for services prior to the provision of services. The written agreement shall include at least the following information: 1. The fee or fees to be paid by the service recipient; 2. The services covered by such fees; and 3. Any additional charges for services not covered by the basic service fee. (e) Written acknowledgement that the service recipient or service recipient’s legal representative (conservator, parent, guardian or legal custodian) has been informed of the service recipient’s rights and responsibilities and the agency’s general rules affecting the service recipients; (f) A written service plan based on a needs assessment which indicates type, frequency, duration, and amount of personal support services provided to assist the service recipient in performing major life duties. (g) Consent for services by the service recipient or service recipient’s legal representative (conservator, parent, guardian, or legal custodian), surrogate decision maker under T.C.A. § 33-3-219 or attorney-in-fact under a durable power of attorney for health care, when applicable; (h) If applicable, address, phone number or e-mail address to reach the service recipient’s legal representative (conservator, parent, guardian or legal custodian) or surrogate decision maker under T.C.A. § 33-3-219 or attorney-in-fact under a durable power of attorney for health care; (i) Documentation of party responsible for payment of services; (j) A record of services actually delivered with dates and times documented; (k) Documentation of medical problems, illnesses and treatments, accidents, seizures, adverse incidents and follow-up, while the service recipient receives services; (l) Documentation of all funds received and disbursed on behalf of the service recipient; (m) An alternate plan for staffing in case of absence of the personal support services worker; (n) Written authorization by the service recipient or the service recipient’s authorized representative if the agency is providing medication assistance; (o) Written documentation that the service recipient has evaluated the quality of personal support services provided at least semi-annually. Each agency shall develop an evaluation form for the service recipient, or legal representative of the service recipient, to fill out and sign to acknowledge this requirement has occurred; (p) A written consumer notice outlining general service responsibilities as well as general notification of the agency’s responsibilities as an employer or contractor provided to service recipients before beginning service, which shall include, at a minimum the duties, responsibilities, obligations and legal liabilities of the personal support services agency; the personal support services worker; and the service recipient. The MINIMUM PROGRAM REQUIREMENTS FOR PERSONAL SUPPORT CHAPTER 0940-05-38 SERVICES AGENCIES description shall clearly set forth the service recipient’s responsibility, if any, for the following: 1. Day to day supervision of the personal support services worker; 2. Assigning duties to the personal support services worker; 3. Hiring, firing and discipline of the personal support services worker; 4. Provision of equipment or materials for use by the personal support services worker; 5. Performing a criminal background check on the personal support services worker; 6. Checking the personal support services worker’s references; and 7. Ensuring credentials and appropriate licensure/certification of a personal support services worker; and (q) Copy of legal document granting another individual or corporation authority to act as the service recipient’s legal representative/conservator/power of attorney/durable power of attorney for health care/mental health care.