TX HHS Form 8495. Exclusion of Host Home/Companion Care (HH/CC) Provider from the Board of Nursing (BON) Definition of Unlicensed Person
Form 8495 is a professional nursing determination used in Texas to document the exclusion of a Host Home or Companion Care (HH/CC) provider from the Board of Nursing (BON) definition of an unlicensed person. The form records a registered nurse’s assessment that a specific HH/CC provider meets strict regulatory criteria allowing them to assume certain health-related responsibilities without being classified as unlicensed nursing staff.
Purpose of Form 8495
The primary purpose of Form 8495 is to formally document a registered nurse’s decision that an HH/CC provider qualifies for exclusion from the BON definition of an unlicensed person. This determination allows the HH/CC provider to support an individual’s health care needs within clearly defined limits, under a nursing service plan and ongoing nurse oversight.
The form protects the individual receiving services, clarifies roles and responsibilities, and helps ensure compliance with nursing and long-term services regulations.
When This Form Is Required
Form 8495 must be completed when a registered nurse determines that an HH/CC provider meets all required criteria to function outside the BON definition of an unlicensed person. Common situations include:
- An individual receives services in a Host Home or Companion Care setting
- The HH/CC provider assists with health-related tasks under nurse guidance
- Nursing services are part of the individual’s service plan
- A regulatory or program requirement calls for formal nursing documentation
The form is not required if the HH/CC provider does not meet all exclusion criteria or if nursing services are not involved.
Who Is Authorized to Complete the Form
Form 8495 may only be completed and signed by a Registered Nurse (RN). The RN is responsible for conducting a comprehensive assessment, making the exclusion determination, and developing a nursing service plan.
The HH/CC provider and the individual receiving services do not complete the form themselves.
Explanation of Key Sections
Identification of the Individual and HH/CC Provider
This section identifies the individual receiving services and the HH/CC provider being evaluated. Accurate identification is essential for compliance and recordkeeping.
Assessment Criteria
The RN must affirm that all four regulatory criteria are met:
- The HH/CC provider meets the definition of a Client Responsible Adult (CRA) under Texas Administrative Code
- The relationship between the individual and HH/CC provider is stable and beneficial
- The HH/CC provider is willing and able to assume responsibility for the individual’s health care
- Adequate and appropriate supports are available to the HH/CC provider
All criteria must be satisfied for the exclusion to apply.
Exclusion Determination
This section documents the RN’s professional decision to exclude the HH/CC provider from the BON definition of an unlicensed person, based on the completed assessment.
Nursing Service Plan Requirement
The RN confirms that a nursing service plan has been developed. The plan requires the HH/CC provider to report changes in the individual’s condition or medical treatment, ensuring ongoing nurse oversight.
RN Signature and Credentials
The RN signs and dates the form and provides their printed name and credentials, formally accepting responsibility for the determination.
Practical Tips for Completing Form 8495
- Conduct and document a thorough, individualized assessment.
- Confirm that all four regulatory criteria are clearly met.
- Develop a detailed nursing service plan before signing the form.
- Explain reporting expectations to the HH/CC provider.
- Review and update the form annually, as required.
Common Mistakes to Avoid
- Completing the form without a comprehensive assessment
- Assuming exclusion applies automatically
- Failing to update the form annually
- Not maintaining a current nursing service plan
- Incomplete RN credentials or missing signature
Legal and Regulatory Context
Form 8495 is governed by Texas Administrative Code, Title 22, Part 11, Chapter 225, which defines nursing practice and the role of unlicensed persons. The Client Responsible Adult exception allows certain caregivers to assume health-related responsibilities when strict criteria and nurse oversight are in place.
An incorrect or unsupported exclusion may expose providers and programs to regulatory findings or enforcement actions.
Real-Life Examples of Use
- An RN evaluates a Host Home provider supporting an adult with complex medical needs.
- A Companion Care provider assists with health monitoring under a nursing service plan.
- A program documents compliance during a licensing or contract review.
Documents Commonly Associated with This Form
- Nursing service plan
- Comprehensive nursing assessment
- Individual service plan
- Host Home or Companion Care agreements
- Program compliance documentation
Frequently Asked Questions
Who can sign Form 8495?
Only a registered nurse may complete and sign the form.
Is this form a one-time requirement?
No, it must be reviewed and updated annually.
Does this allow the HH/CC provider to practice nursing?
No, it documents a limited exclusion under nurse oversight.
What happens if criteria are no longer met?
The exclusion no longer applies and the form must be reassessed.
Is the HH/CC provider required to report changes?
Yes, reporting changes is part of the nursing service plan.
Is this form required for all Host Home providers?
No, only when nursing-related responsibilities are involved.
Related Forms
- Nursing Service Plan Documentation
- Individual Service Plan
- Host Home/Companion Care Agreements
- Nursing Assessment Forms
Form Details
- Form Name: Exclusion of Host Home/Companion Care Provider from the Board of Nursing Definition of Unlicensed Person
- Form Number: 8495
- Issued By: Texas Health and Human Services
- State: Texas
- Revision Date: October 2014