TX HHS Form 3050. DAHS Health Assessment or Individual Service Plan

Form 3050 is a core medical and functional assessment used in Texas Day Activity and Health Services (DAHS) programs. The form helps a DAHS nurse document a participant’s physical condition, cognitive abilities, daily care needs, and the specific supports that the facility will provide. In practice, this document works as both a clinical snapshot and a personalized service plan, ensuring the participant receives appropriate care in a structured adult day health environment.

Although it is a state-standard form, every completed version reflects a person’s unique health profile, risks, and functional limitations. Mistakes or omissions can lead to inappropriate care, safety issues, or delays in eligibility, so careful and thoughtful completion is essential.

Purpose and When Form 3050 Is Required

DAHS facilities must complete Form 3050 at the start of care, during ongoing reassessments, or whenever a participant’s condition changes. It is mandatory for anyone receiving Medicaid-funded DAHS services in Texas.

The form is required because Texas Health and Human Services (HHS) mandates documentation of chronic medical conditions, functional limitations, and therapeutic needs before a participant can receive reimbursable services. It serves as the official record showing that DAHS is medically justified and clinically beneficial.

Who Can Complete the Form

The assessment must be performed and signed by a licensed nurse employed by or contracted with the DAHS facility. Participants or responsible parties also sign the form to confirm involvement in the assessment process. Individuals and family members may contribute information but cannot complete the document themselves.

Section-by-Section Explanation

Section I — Identification and Background Information

This section establishes the basics: participant name, Medicaid ID, date of birth, sex, living situation, DAHS facility information, and the reason for assessment (initial, change, or ongoing). Errors here often cause administrative delays, especially incorrect Medicaid numbers or mismatched names.

Section II — Assessment of Functional and Physical Status

This is the clinical heart of the form. The nurse documents symptoms or conditions observed within the last 30 days across multiple domains:

• Nutrition/Metabolism: issues with weight, swallowing, dentures, blood sugar, or intake patterns.
• Elimination: constipation, incontinence, or bowel/bladder programs.
• Cardiac/Respiratory: shortness of breath, oxygen use, chest pain, blood pressure fluctuations.
• Skin Condition: pressure ulcers, wounds, fragile skin, swelling.
• Mobility/Body Control: gait problems, paralysis, loss of dexterity, contractures, device use.
• Neurological Status: seizures, tremors, cognition issues, disorientation.
• Sensory Impairments: visual/hearing deficits, pain, glasses or hearing aids.
• Communication: speech limitations, difficulty expressing needs, comprehension issues.
• Behavioral Challenges: wandering, agitation, refusal to eat or medicate.
• Vital Signs: height, weight, blood sugar, blood pressure, pulse, and respiration.

Common mistakes include underreporting mild conditions (“he gets dizzy only sometimes”) or overlooking skin issues, which can be serious in adults with limited mobility.

Section III — Therapies and Treatments

This section identifies all therapies the participant currently receives from any provider—physical therapy, speech therapy, dialysis, respiratory therapy, chemotherapy, etc. Listing all services is crucial because DAHS must align its care with external medical treatment plans.

Section IV — Plan of Care at the DAHS Facility

This is the individualized service plan (ISP). It specifies what assistance the facility will provide for:

• Transfers
• Ambulation and mobility devices
• Eating and feeding aids
• Toileting, catheters, ostomy care
• Bathing and hygiene
• Dressing and grooming
• Medication self-administration support

Nurses must be specific about frequency and type of assistance. Vague entries (“help as needed”) may lead to compliance issues during audits.

Section V — Therapeutic Benefit

The nurse explains how DAHS participation will benefit the individual therapeutically. Examples include improved nutrition, structured medication support, social engagement to reduce cognitive decline, or supervised exercise.

Section VI — Participation in Assessment

This section documents who was involved in the assessment: the participant, family members, significant others, or a responsible party. Signatures confirm the assessment was done transparently and collaboratively.

Examples of Real-Life Situations Requiring Form 3050

• An older adult with diabetes starts attending DAHS for supervised meals and glucose monitoring after several recent blood sugar incidents.
• A stroke survivor needs help with transfers, bathing, and medication reminders during daytime hours when caregivers work.
• A participant with dementia shows new wandering behaviors, requiring a reassessment to update the care plan.
• A person receiving dialysis needs coordination between DAHS and their treatment schedule.

Documents Typically Attached

• Recent physician statements or care orders
• Medication lists
• Hospital discharge summaries (if applicable)
• Therapy plans from PT/OT/SLP
• Diagnostic reports related to chronic conditions

Practical Tips for Completing Form 3050

• Be specific about frequencies (“daily,” “twice daily,” “during meals”).
• Document even mild or occasional symptoms; they matter clinically.
• Ensure vital signs and weight are current.
• Attach all supporting documents to avoid service delays.
• Review mobility aids carefully—incorrect entries often lead to safety problems.

FAQ

• Is Form 3050 required for all DAHS participants? Yes, it is mandatory for anyone receiving Medicaid-funded services.
• How often is the form updated? At the start of care, annually, or when the participant’s condition changes.
• Who signs the form? The DAHS nurse and the participant or responsible party.
• Does this form replace a doctor’s assessment? No, it supplements physician documentation but does not replace it.
• Can family members fill in the medical sections? They may provide information, but only a licensed nurse completes the form.
• What happens if something is left blank? Missing details may delay approval or cause compliance issues.
• Are supporting medical documents required? Strongly recommended, especially for chronic or complex conditions.

Micro-FAQ (Short Answers)

• Purpose? To record medical, functional, and care needs for DAHS participants.
• Who files? A licensed DAHS nurse.
• When filed? Start of care, annually, or after health changes.
• Attachments? Medication lists, doctor notes, therapy plans.
• Submitted to? Kept by the DAHS facility and reviewed by Texas HHS.
• Legally required? Yes, for Medicaid-funded DAHS services.
• Participant signature? Required.
• Based on? Last 30 days of medical observation.
• Used for care planning? Yes, forms the core of the ISP.
• Risk if inaccurate? Incorrect care, safety issues, compliance problems.

Related Forms

• Form 3051 — DAHS Physician’s Orders
• Form 2064 — Physician’s Assessment
• Form 3055 — DAHS Individual Program Plan
• Texas Medicaid 1844 — Nursing Add-On Assessment

Form Details

• Form Name: Day Activity and Health Services (DAHS) Health Assessment / Individual Service Plan
• Form Number: 3050
• Region: Texas
• Edition Date: June 2017-E