TX HHS Form 3628. Provider Agency Model Service Backup Plan

The TX HHS Form 3628, Provider Agency Model Service Backup Plan, is a crucial document that helps solve the problem of ensuring continuity of service delivery in case of an absence or emergency. This form is typically used by provider agencies, such as Community Living Assistance Deaf Bind with Multiple Disabilities (CLASS) and Direct Services Agency, to develop a backup plan for their services.

The form requires key information, including the name of the individual program, type of service, date of service planning team meeting, and effective date of the backup plan. It also outlines specific strategies and sequences of service delivery in case of an absence or emergency. The form emphasizes the importance of having a resource person and specifies the actions to be taken in their absence.

This form is essential for provider agencies to ensure that their services are delivered continuously, even in the event of an unexpected absence. By completing this form, provider agencies can rest assured that they have a plan in place to minimize disruptions and maintain service quality. Key points to note include:

• The form is used by provider agencies to develop a backup plan for their services.
• The plan outlines specific strategies and sequences of service delivery in case of an absence or emergency.
• The form emphasizes the importance of having a resource person and specifies the actions to be taken in their absence.