5008

RECORDS

5008.1 Each Provider shall maintain complete and accurate records reflecting past and current findings, the initial and subsequent plans of care, and the ongoing progress of each beneficiary.5008.2 Each Provider shall maintain complete and accurate records reflecting the specific personal care services provided to each beneficiary.5008.3 Each Provider shall maintain beneficiary records that are confidential, complete and contain up-to-date information relevant to each beneficiary's care and treatment. For purposes of record confidentiality, the disclosure of treatment information by the Provider is subject to all the provisions of applicable District and Federal Laws.5008.4 Each beneficiary's record shall include clear written documentation of the beneficiary's treatment needs and services. The documentation shall be written so that it is easily understood by a lay person.5008.5 Each beneficiary's record shall be kept in a locked room or file maintained and safeguarded against loss or unauthorized use.5008.6 Copies of all records for PCA services provided to beneficiaries by the Provider and/or the Provider's contractors shall be maintained at the location of the Provider's place of business that is identified on the Provider's Medicaid Provider application.5008.7 Each Provider shall permit on-site inspections to be conducted by CMS, its agents, DHCF and its agents to determine Provider compliance with all applicable laws.5008.8 Each Provider shall maintain beneficiary records for ten (10) years.5008.9 Each beneficiary's record shall include, but is not limited to, the following information:- (a) Medical information, including the initial and annual assessments, and the initial certification and re-certifications of the plan of care;

- (b) General information including the beneficiary's name, Medicaid identification number, address, telephone number, age, sex, name and telephone of emergency contact person,

primary care physician's or advanced practice registered nurse's name, address and telephone number;

(c) Description and dates of services rendered, including the name and NPI of the personal care aide performing the services;

(d) Documentation of each supervisory visit of the registered nurse including signed and dated clinical progress notes;

(e) Extended authorizations for services;

(f) Discharge summary, if applicable; and

(g) Any other appropriate identifying information that is pertinent to beneficiary care.

SOURCE: Final Rulemaking published at 50 DCR 3957 (May 23, 2003); as amended by Notice of Final Rulemaking published at 59 DCR 1760, 1773 (March 2, 2012).