Form 1591 | Universal Rehabilitation Services

Provider Advocate Committee Acting as the Client's Responsible Adult

Requirements:

The Provider Advocate Committee (PAC) acts as the Client's Responsible Adult (CRA) only in situations in which the individual cannot make decisions regarding health care and does not have an identified adult who is willing and able to participate in decisions about the overall management of the individual's health care.

PAC may only approve the delegation of allowable task(s) by a Registered Nurse (RN) to unlicensed personnel as specified in TAC 22, Part II, §225.10 (1-12). PAC does NOT allow Health Maintenance Activities (HMAs) to be exempt from delegation.

PAC membership must consist of at least the assessing RN, the program provider's CEO/designee and a person employed by the provider who is responsible for Othername delivery oversight. PAC must review the decision for delegation on at least an annual basis or when changes in the individual's condition warrant a revision to a previously approved delegated task(s).

PAC met onand reviewed the proposed delegation of task(s) for. PAC has determined that the following task(s) are being delegated by, RN.

Delegated tasks:

PAC has determined that the task(s) meet all three of the BON criteria under TAC 22, Part II, §225.1(a)(1-3):

The individual is in an independent living environment (§225.1(a)(1));

PAC is acting as the individual's CRA (§225.1(a)(2)); and

The task(s) is for a stable or predictable condition (as defined by §225.4(11) and §225.1(a)(3)).

PAC has reviewed the RN's comprehensive assessment, the nursing plan for training and verification of competency of the unlicensed person(s) and the level of supervision and frequency of supervisory visits required.

PAC has determined that delegation of the above task(s) is appropriate and promotes safety for the individual. PAC approves the RN's delegation decision.

PAC has determined that delegation of the above task(s) is not appropriate and does not meet the BON requirement for RN delegation in TAC 22, Part II, §225. PAC does not approve the RN's delegation decision.

Explanation for denying delegation and alternative plan for care:

Name list

Print Name

Title

Date

Signature