Effective Date
Instructions
Updated: 5/2025
Note: The term person when used in this form refers to an individual per 26 Texas Administrative Code (TAC) Section 260.5.
Purpose
To provide a standardized record of completion for required DBMD Program Service Provider Training.
Procedure
When to Prepare
The DBMD program provider completes Form 6520 to document completion of:
- DBMD Program Service Provider training;
- HHSC Deaf Blind with Multiple Disabilities Waiver Computer Based Training; and
- DBMD Program Case Management training.
Training must occur per the timeframes outlined in 26 Texas Administrative Code (TAC) 260.205 Training and 26 TAC 260.515 Contracting to Provide Individualized Skills and Socialization.
Form Retention
Keep this form per record retention requirements outlined in the TAC. The DBMD program provider is not required to submit the forms to HHSC on completion but must maintain the forms in personnel records and provide a copy to HHSC on request.
Detailed Instructions
Service Provider’s Name — Enter or print the name of the service provider who completed the training.
Service Provider Hire Date — Enter or print the month, day and year of the service provider's hire.
Trainer’s Name — Enter or print the name of the DBMD program provider staff member who provided the training.
Date Training Completed — Enter the month, day and year the service provider completed the training.
Service Provider Type, check one or more — Indicate which service provider type is completing the training. DBMD Program Service Provider training is required for program directors and all program provider staff, including subcontractors, who provide:
- Case Management
- Community First Choice Personal Assistance Services Habilitation (PAS/Hab)
- Employment Assistance
- Employment Readiness
- Individualized Skills and Socialization
- Intervener, I, II, III
- Licensed Assisted Living, 18 and 24 Hour
- Licensed Home Health Assisted Living
- Nursing – RN or LVN, Specialized RN or LVN
- Respite, In-Home and Out-of-Home
- Supported Employment
- Transportation – Residential Habilitation
A program provider that develops and conducts its own trainings must make sure the staff person who develops and conducts the training has successfully completed HHSC training on the specified topic. Documentation of the completion must be maintained in the personnel file of the staff person developing and conducting the specified training.
Section 1: DBMD Program Service Provider Training — Complete all items in this section.
The training requirements listed in this section may be fulfilled by completing the DBMD Provider Training in the HHS Learning Portal. A certificate from the HHS Learning portal must be maintained in the employee’s personnel record and must be available for review on request.
Methods and Strategies for Communication — Mark to indicate instruction has been provided to the service provider on this topic or that the service provider completed the DBMD Provider Training.
Active Participation in Home and Community Life — Mark to indicate instruction has been provided to the service provider on this topic or that the service provider completed the DBMD Provider Training.
Orientation and Mobility — Mark to indicate instruction has been provided to the service provider on this topic or that the service provider completed the DBMD Provider Training.
Behavior as Communication — Mark to indicate instruction has been provided to the service provider on this topic or that the service provider completed the DBMD Provider Training.
Causes and Origins of Deafblindness — Mark to indicate instruction has been provided to the service provider on this topic or that the service provider completed the DBMD Provider Training.
Vision, Hearing and the Functional Implications of Deafblindness — Mark to indicate instruction has been provided to the service provider on this topic or that the service provider completed the DBMD Provider Training.
Section 2: HHSC Deaf Blind with Multiple Disabilities Waiver Computer-based Training
The above-named program director or case manager completed the HHSC Deaf Blind with Multiple Disabilities Waiver Computer-based Training and received a score of at least 80% on the examination included in the training. The HHSC-issued training certificate is maintained in the employee’s personnel record and is available for review on request. – Mark to indicate the case manager or program director completed this training and received a score of at least 80%.
The training requirements listed in this section may be fulfilled by completing the DBMD Provider Training in the HHS Learning Portal.
The HHSC training certificate issued after the case manager or program director achieves the required score must be maintained in the employee’s personnel record and must be available for review on request.
Section 3: DBMD Program Case Management Training — Mark to indicate this training was provided to the case manager or program director.
The training requirements listed in this section may be fulfilled by completing the DBMD Provider Training in the HHS Learning Portal. A certificate from the HHS Learning portal must be maintained in the employee’s personal record and must be available for review on request.
The training, if provided by the DBMD program provider, must have addressed the following elements:
The DBMD Program service delivery model, which includes:
- the role of the case manager and DBMD program provider;
- the role of the service planning team;
- person-centered planning; and
- the CDS option.
DBMD Program services, including how these services:
- complement other Medicaid services;
- supplement family supports and non-waiver services available in the person’s community; and
- prevent institutionalization.
DBMD Program Process and Procedures for:
- eligibility and enrollment;
- service planning, service authorization and program plans;
- access to non-waiver resources; and
- complaint procedures and the fair hearing process.
Rules, Policies and Procedures about:
- preventing abuse, neglect and exploitation of a person;
- reporting abuse, neglect and exploitation to local and state authorities; and
- financial improprieties involving a person.
Signature of Service Provider and Date — The service provider signs and dates the form. The service provider’s signature confirms they have received training on the training topics documented on the form.
Signature of Trainer and Date — The trainer signs and dates the form. The trainer’s signature confirms instruction has been provided to the service provider on the training topics documented on the form.
Signature of Person Providing Verification and Date — The person providing verification of the computer-based training requirements signs and dates the form. The person’s signature confirms completion of those requirements was verified.
Contact Program Staff
Email the CLASS/DBMD Provider Monitoring team for questions about the form or instructions.
Email the Long Term Services and Support (LTSS) Policy team for questions about DBMD program policies.