---
type: "example"
title: "Procedure Example: procedure-example-HCBS"
resource: "Procedure"
example: "procedure-example-HCBS"
---
# Procedure Example: procedure-example-HCBS

## Narrative

**Personal care services provided at person's home**

**Based On** : Peter's Long Term Services and Supports (LTSS) care plan

**Status** : completed

**Beneficiary** : Peter James

**Service Name/Code** : Personal care services (Details : {HCPCS code 'T1019' = 'Personal care services, per 15 minutes'})

**Service Date** : Apr 5, 2018

**Service Provider** : Adam Careful

**Service Delivery Address** : Peter's home

**Service Comment** : Assisted with bathing and dressing, doing laundry, and meal preparation

## Example XML



```xml
<?xml version="1.0" encoding="UTF-8"?>
<Procedure xmlns="http://hl7.org/fhir" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="http://hl7.org/fhir ../../schema/procedure.xsd">
	<id value="HCBS"/>
	<text>
		<status value="generated"/>
		<div xmlns="http://www.w3.org/1999/xhtml">
			<p>
				<b> Personal care services provided at person's home</b>
			</p>
			<p>
				<b> Based On</b> : Peter's Long Term Services and Supports (LTSS) care plan</p>
			<p>
				<b> Status</b> : completed</p>
			<p>
				<b> Beneficiary</b> : Peter James</p>
			<p>
				<b> Service Name/Code</b> : Personal care services <span> (Details : {HCPCS code 'T1019' = 'Personal care services, per 15 minutes'})</span>
			</p>
			<p>
				<b> Service Date</b> : Apr 5, 2018</p>
			<p>
				<b> Service Provider</b> : Adam Careful</p>
			<p>
				<b> Service Delivery Address</b> : Peter's home</p>
			<p>
				<b> Service Comment</b> : Assisted with bathing and dressing, doing laundry, and meal preparation</p>
		</div>
	</text>
	<basedOn>
		<!-- <reference value="CarePlan/example-HCBS"/>   -->
		<display value="Peter's Long Term Service and Supports (LTSS) Care Plan"/>
	</basedOn>
	<status value="completed"/>
	<code>
		<coding>
			<system value="https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html"/>
			<code value="T1019"/>
			<display value="Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, icf/mr or imd, part of the individualized plan of treatment."/>
		</coding>
		<text value="Personal care services"/>
	</code>
	<subject>
		<reference value="Patient/example"/>
		<display value="Peter James"/>
	</subject>
	<occurrenceDateTime value="2018-04-05"/>
	<performer>
		<actor>
			<reference value="Practitioner/example"/>
			<display value="Adam Careful"/>
		</actor>
	</performer>
	<location>
		<reference value="Location/ph"/>
		<display value="Peter's Home"/>
	</location>
	<note>
		<text value="Assisted with bathing and dressing, doing laundry, and meal preparation"/>
	</note>
</Procedure>
```