Form 4122 is the weekly service delivery log for the Host Home/Companion Care service in Texas. Sereniq lets the host home provider document each day from the phone, sends every note through supervisor approval, and prints the Form 4122 facsimile by week, date range, or calendar month.
Sereniq prints HHSC Form 4122, the Host Home/Companion Care Service Delivery Log, from the daily notes a host home provider writes on the phone. Each note's checked activities become that day's initials on the Sunday-to-Saturday grid, and only supervisor-approved notes print. Print one week, a date range, or a calendar month.
What is HHSC Form 4122? Form 4122 is the Host Home/Companion Care Service Delivery Log. HHSC describes it as the form used by HHSC staff and Home and Community-based Services (HCS) waiver program providers to document a service event for the host home/companion care service component. The current revision is May 2022.
Who fills out Form 4122? The host home or companion care provider who lives with the individual fills it out, and the program provider keeps it. HHSC says the program provider must keep a copy of the completed form in the individual's record, and each form is for only one individual. Group homes use a different log: Residential Support and Supervised Living are documented on Form 4119 (see how to complete HHSC Form 4119 and Form 4119 software).
What does Form 4122 record? The header takes the individual's name, the location, the local case number, and the week. Below it is a grid with one column per day, Sunday through Saturday, and rows for Activities of Daily Living (bathing, dressing, personal hygiene, eating, meal planning, meal preparation, housekeeping), Habilitation (including IP skill development and community integration), Assisting With (including administration of medication, transportation, and monitoring health), and Not in Home (temporary discharge, active on leave). A daily initials row, a comments table, and the provider's printed name and signature close the form.
How often is Form 4122 completed? Daily, one week per sheet. The form tells the provider to initial, at the end of each day, every item they completed with the individual, and to write any incidents, concerns, or special events at the bottom. HHSC says one form covers up to seven billable service events and must be completed within 14 calendar days after the activity.
What are the common Form 4122 mistakes? Filling the week in from memory days later instead of at the end of each day. Missing the 14-day window. Putting two individuals on one form. Leaving a day blank when the individual was away, instead of marking temporary discharge or active on leave. Skipping the comments when something happened. Leaving the printed name or signature empty. Using Form 4119 for a host home, or Form 4122 for a group home.
How does Sereniq produce Form 4122? Sereniq gives the host home provider their own role, scoped to their one home, with no shift schedule and no clock-in. The provider writes one note per day in the iOS or Android app and checks the activities from the same list printed on Form 4122. AI can polish a rough note into clear, objective language, and the provider reviews it before it is saved. A supervisor then approves the note, and only approved notes print.
What does the Sereniq print look like? Sereniq fills each day's activity rows and the Host Home/Companion Care Initials row from the approved notes, puts each note's narrative in the comments table with its date and initials, and stamps the provider's own drawn signature in the signature block. Dates print as MM/DD/YYYY, each week starts on a new page, and a week that crosses into a new month prints as two sheets so one sheet never mixes two months. See every state form Sereniq renders on the forms and prints page, and how host homes run in Sereniq on the Host Home / Companion Care page. New to the Texas waiver programs? Start with what HCS is in Texas.
Texas program providers with Host Home/Companion Care placements, and the host home providers who fill out Form 4122 each week. Sereniq was born in Texas on HHSC forms and adapts forms and terminology to other states; Texas is live today.
Form 4122 is the Texas HHSC Host Home/Companion Care Service Delivery Log. HCS waiver program providers use it to document service events for the host home/companion care service component, one individual per form and up to seven service events per form.
The host home or companion care provider initials the activities they completed with the individual at the end of each day and signs the form. The program provider keeps a copy of the completed form in the individual’s record.
HHSC says Form 4122 must be completed within 14 calendar days after the activity it documents. In practice, the provider initials each day at the end of that day, and each sheet covers one Sunday to Saturday week.
Form 4119 is the service delivery log for Residential Support and Supervised Living in group homes. Form 4122 is the service delivery log for Host Home/Companion Care. Sereniq prints both and routes each individual to the right form.
Yes. The host home provider role can print its own weekly Form 4122. Supervisors approve the notes first, and only approved notes appear on the printed log.
Form 4122 has its own Administration of Medication row. Sereniq also offers the Form 3092 MAR at a host home as optional record keeping, so the provider can chart doses on the phone if the agency wants a medication grid.
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