TX HHS Form 2404. Documentation of Licensed Vocational Nurse Required Supervision

Form 2404 is an official compliance document used in the Texas Medically Dependent Children Program (MDCP) to confirm that a Licensed Vocational Nurse (LVN) is practicing under the legally required supervision of a Registered Nurse (RN), licensed physician, or physician assistant (PA). The form serves as written verification that supervision requirements under Texas law are met before or during the delivery of MDCP services.

Purpose of Form 2404

The primary purpose of Form 2404 is to document compliance with Texas supervision requirements for LVNs who provide services under MDCP. State law does not allow an LVN to practice independently, and this form creates a clear, auditable record identifying the supervising professional responsible for oversight.

The form helps ensure patient safety, professional accountability, and regulatory compliance for Medicaid-funded services.

When This Form Must Be Completed

Form 2404 must be completed in situations where an LVN provides or will provide services under the MDCP program. Common scenarios include:

• When an LVN begins providing MDCP services for a new client
• When an LVN starts work under a new MDCP contract
• When there is a change in supervising RN, physician, or PA
• During audits or compliance reviews

The form is not required for nurses who are not LVNs or for services outside the MDCP program.

Who Is Authorized to Complete the Form

Form 2404 is completed and signed by the Licensed Vocational Nurse. The supervising professional—RN, physician, or PA—must also sign the form to acknowledge their supervisory role.

Both parties are responsible for ensuring the information is accurate and current.

Explanation of Each Section of the Form

LVN Identification Information

This section includes the printed name of the LVN and the MDCP contract number. It identifies the nurse whose practice is being documented and links the supervision to a specific program contract.

Supervision Statement

The LVN certifies that they meet supervision requirements and identifies the supervising professional. The form allows the LVN to select one of three options:

• Supervision by a licensed physician
• Supervision by a Registered Nurse (RN)
• Supervision by a Physician Assistant (PA)

Supervising Professional Information

This section records the name, address, phone number, and license number of the supervising professional. This information establishes clear accountability and allows verification if needed.

Signatures and Dates

The LVN signs and dates the form to confirm the supervision arrangement. The supervising RN, physician, or PA must also sign and date the form, formally accepting supervisory responsibility.

Practical Tips for Completing Form 2404

• Verify license numbers before submitting the form.
• Ensure the supervising professional agrees to provide supervision.
• Update the form immediately if supervision changes.
• Keep a signed copy available for audits or reviews.

Common Mistakes to Avoid

• Leaving license numbers incomplete or incorrect
• Failing to obtain the supervisor’s signature
• Listing a supervisor who is not legally qualified
• Using outdated supervision information

Legal and Regulatory Context

Form 2404 is required under Section 301.353 of the Texas Occupations Code, which mandates that LVNs practice under appropriate supervision. The requirement is further detailed in the Texas Board of Nursing rules at 22 Texas Administrative Code §217.11 and related interpretive guidelines.

Failure to document proper supervision may result in compliance findings, payment issues, or professional disciplinary action.

Real-Life Examples of When This Form Is Used

• An LVN is hired to provide MDCP nursing services for a child at home.
• A supervising RN changes due to staffing updates.
• An MDCP provider undergoes a state compliance audit.
• An LVN renews or updates their MDCP contract.

Documents Commonly Associated with This Form

• MDCP service contracts
• Professional license verification records
• Nursing supervision agreements
• Provider credentialing documents

Frequently Asked Questions

Is Form 2404 required for every LVN in MDCP?

Yes, every LVN providing MDCP services must have documented supervision.

Can one supervisor oversee multiple LVNs?

Yes, if allowed under nursing rules and agreed upon.

Does the form need to be resubmitted if supervision changes?

Yes, a new form should be completed whenever supervision changes.

Is supervision required at all times?

Yes, LVN practice must always occur under appropriate supervision.

Who keeps the completed form?

The provider and LVN typically retain copies for compliance purposes.

Is this form a supervision agreement?

No, it documents compliance but does not replace contractual agreements.

Related Forms

• MDCP Provider Contract Forms
• Nursing Supervision Agreements
• Texas Board of Nursing Compliance Forms

Form Details

• Form Name: Documentation of Licensed Vocational Nurse Required Supervision
• Form Number: 2404
• Program: Medically Dependent Children Program (MDCP)
• State: Texas
• Revision Date: January 2009