How do you complete HHSC Form 4119?

What is HHSC Form 4119?

Form 4119 is the Texas HHSC Residential Support Services (RSS) and Supervised Living (SL) Service Delivery Log. HHSC staff and Home and Community-based Services (HCS) waiver providers use it to document a service event for the RSS and SL service components.

RSS and SL are the two HCS group home services. Both are delivered in a three-person or four-person residence that the provider owns or leases. The difference is staffing: for RSS, a staff member must be present and awake whenever the individual is home, while for SL, a staff member must be present during normal sleeping hours.

The current form is effective 5/2019, and HHSC updated its instructions in 8/2022. Questions about the form go to HHSC provider fiscal compliance.

Is Form 4119 required?

Not the form itself. The HCS Program Billing Requirements call Form 4119 an example form that may be used. A provider may document RSS or SL in any way that meets the written documentation rules, but those rules are required.

Form 4119 is the format HHSC publishes, so reviewers know it. Whatever format you use, it has to contain the same information and follow the same timing and signature rules.

Who fills out Form 4119?

The direct support professionals (DSPs) who delivered the billable service fill it out. HCS billing rules say a written service log must be completed by the service provider who provided the service and must carry that person's signature and title.

A supervisor can review the log, but cannot write it for someone else. Each staff member who provided billable activities on a day signs and initials for that day.

What goes in each section of Form 4119?

Form 4119 covers one individual. Across the top you enter who, where, and which service. Each column is one day, where staff initial the activities they completed and sign. A comments area holds any extra explanation.

For RSS, at least one activity under Night Shift must be marked for the day to count as a billable service event. For SL, no Night Shift initials are needed.

The billable activities for RSS and SL include help with daily living (bathing, dressing, hygiene, eating, meal planning, housekeeping), mobility, reinforcing therapies, help with medication or RN-delegated tasks, habilitation, transportation, and supervising safety and security. An activity outside that list is not billable.

• Individual Name: the individual's name
• Place of Service(s): the complete address where the billable activity happened
• Local Case No./Case ID: the local case number and CARE ID number
• Service type: mark RSS or SL
• Date and Days of the Week: the month, day, and year of each billable day
• Activities of Daily Living, Habilitation, Assisting With: initial every item the staff member completed
• Night Shift: at least one item marked for RSS; not needed for SL
• Staff Signatures and Staff Initials: each staff member who provided billable activities that day
• Comments: extra explanation, with the date of the activity and the staff initials

How often do you complete Form 4119, and what is the deadline?

Form 4119 must be completed within 14 calendar days after the activity is provided. One form holds up to seven separate billable service events, one per column, for one individual.

RSS and SL are billed by the day, and a claim cannot be for more than one unit per calendar day. So one Form 4119 usually covers up to a week for one individual, and a home with several individuals keeps one log per person.

The provider must keep a copy of the completed form in the individual's record.

What are the most common Form 4119 mistakes?

The most common mistakes are vague or copied entries, late logs, missing signatures, and a missing Night Shift mark on an RSS day. HHSC billing rules list specific content that is never acceptable as a description of activities.

HHSC does not accept ditto marks, references to other logs, statements such as "had a good day" or "no problem today", text photocopied from other logs, or a medication log in place of a description of activities. Corrections must follow the state's rule for correcting records.

The log must also describe any unusual incident, such as a seizure, illness, or behavioral outburst, and what staff did about it. If the individual was not available to receive services on a day, the log should explain why.

These details matter because HHSC recoups payment for any claim it cannot verify is supported by written documentation during a provider fiscal compliance review.

• Ditto marks or arrows instead of real entries
• Generic notes like "had a good day"
• Copying or photocopying entries from another log
• Signing more than 14 calendar days after the service
• An RSS day with no Night Shift activity marked
• Missing address, CARE ID, or service type
• An unusual incident that happened but is not written down

How do you document an individual who is away visiting family?

HCS billing rules let a provider claim RSS or SL for an individual on a visit with family or friends of at least a calendar day, for up to 14 consecutive days of the visit. The documentation must show the individual's name, the visit dates, and the date and signature of the RSS or SL staff member.

The Form 4119 activity grid includes a Not in Home item. Whatever format you use, the three elements above must be in the record.

How does Sereniq help with Form 4119?

Sereniq builds the Form 4119 from the notes DSPs already write on their phones. Administrators print it by week or by calendar month, instead of rebuilding the log from paper at the end of the week.

Each staff member draws their own signature once, and Sereniq places it only on the entries that person wrote. Supervisors can review and approve notes in the app, and Host Home providers get the matching Form 4122 log.