1. (a) Provider agencies of home and community‑based care for individuals with developmental disabilities or acquired brain disorders shall maintain the documentation described in (b)-(r) below at the sites where services are provided.

2. (b) Service coordination records shall include:

   1. (1) Information about the individual that would be essential in case of an emergency, including:

      1. a. Name, address, and telephone number of legal guardian, representative, or next of kin; and

      2. b. Medical information, including:

         1. 1. Diagnosis(es);
         2. 2. Health history;
         3. 3. Medications, including dose, frequency, and route;
         4. 4. Allergies;
         5. 5. Do not resuscitate (DNR) status;
         6. 6. Advance directives created in accordance with RSA 137-J; and
         7. 7. Any correspondence related to medical information relevant to the individual;
   2. (2) A copy of each individual’s service agreement;
   3. (3) Copies of all service agreement revisions approved by the individual or their guardian;

   4. (4) Documentation of service agreement monitoring pursuant to He-M 503 or He-M 522 including:

      1. a. Progress notes on goals for which the service coordinator has primary responsibility;
      2. b. Monthly documentation by the service coordinator of service coordination activities, including activities promoting community participation and integration; and

      3. c. At least quarterly documentation of face-to-face visits, inclusive of those that occur in the individual’s home, assessing progress on goals and identifying whether the services:

         1. 1. Match the interests and needs of the individual;
         2. 2. Met with the individual’s and guardian’s satisfaction; and
         3. 3. Meet the terms of the service agreement;
   5. (5) Copies of all evaluations and reviews by providers and professionals;
   6. (6) Copies of correspondence within the past year with the individual or guardian, providers, physicians, attorneys, state and federal agencies, family members, and others in the individual’s life with whom the service coordinator has corresponded; and
   7. (7) Other correspondence or memoranda concerning any significant events in the individual’s life.

3. (c) For residential habilitation services provided in a community residence pursuant to He-M 1001, services documentation shall include:

   1. (1) Individual records, which shall include:

      1. a. Information about the individual that would be essential in case of an emergency, including that information specified in (b)(1) above;
      2. b. The portion of the service agreement pertaining to residential services, with any revisions; and
      3. c. Monthly progress notes;

   2. (2) Community residence daily service provision records, which shall:

      1. a. Be completed by the provider agency;
      2. b. Include the date;
      3. c. Indicate each individual’s daily presence or absence;
      4. d. If the individual is not present, indicate the date and time of the individual’s departure and return, and include the reason for the absence;
      5. e. For those community residences where supervision is less than 24 hours a day, indicate the days in which services were provided; and
      6. f. Be on file at both the community residence and the provider agency; and
   3. (3) A daily medication log, which shall be completed at the residence pursuant to He-M 1201.07.

4. (d) For services provided in a family home pursuant to He-M 521, documentation shall include:

   1. (1) Individual records, which shall include:

      1. a. Information about the individual that would be essential in case of an emergency, including that information specified in (b)(1) above;
      2. b. The portion of the service agreement pertaining to residential services with any revisions; and
      3. c. Monthly progress notes; and

   2. (2) Daily service provision records, which shall:

      1. a. Be completed by the provider agency;
      2. b. Include the date; and
      3. c. Indicate days that services were provided.

5. (e) For community participation services pursuant to He-M 507, individual records shall include:

   1. (1) A copy of the current service agreement containing:

      1. a. Goals and desired outcomes specific to the individual’s participation in community participation services; and
      2. b. The methods or strategies for achieving the individual’s community participation services’ goals and desired outcomes;

   2. (2) As a guide for planning activities, an individual, week-long, personal schedule or calendar that is created at the time of the annual service planning meeting and, if applicable, identifies:

      1. a. The days, times, and locations of the individual’s:

         1. 1. Paid employment;
         2. 2. Community activities, volunteerism, or internship; and
         3. 3. Other regularly recurring activities, such as therapeutic activities related to communication, mobility, and personal care; and
      2. b. The days and approximate times of unspecified community activities, which shall not exceed 20% of the total day service hours the individual receives per week;

   3. (3) A record of daily community participation services activities maintained by the provider agency, which shall include the following:

      1. a. The name(s) of individual(s) served and names of staff supporting them;
      2. b. The dates on which services were provided; and
      3. c. Activities that took place and the locations of the activities;

   4. (4) Narrative progress notes, and other service documentation as specified in the service agreement, recorded at least monthly, and addressing:

      1. a. The individual’s community participation services goals and actual outcomes; and
      2. b. Other activities related to the individual’s support services, health, interests, achievements, and relationships;
   5. (5) The individual’s medical status, including current medications, known allergies, and other pertinent health care information;

   6. (6) Results of any screenings or evaluations including, if applicable:

      1. a. The Supports Intensity Scale, SIS-A ® (2023 edition), available as noted in Appendix A;
      2. b. Vocational assessments;
      3. c. Results of any assistive technology assessments;
      4. d. The Health Risk Screening Tool (HRST) (2015 edition), available as noted in Appendix A;
      5. e. Systematic, therapeutic, assessment, respite and treatment (START) in-depth assessments and crisis plans; and
      6. f. Risk management plans for individuals who are deemed to pose a risk to community safety; and
   7. (7) For each individual for whom medications are administered during community participation services, medication log documentation pursuant to He-M 1201.07.

6. (f) Individual records for supported employment services shall include:

   1. (1) Information about the individual that would be essential in case of an emergency, including that information specified in (b)(1) above;
   2. (2) The portion of the service agreement pertaining to employment services, with any revisions;
   3. (3) Quarterly progress notes regarding services provided and progress toward goals identified in the service agreement;
   4. (4) Weekly work schedules; and

   5. (5) If there is a provider agency staff person with the individual or individuals at the job site:

      1. a. Service provision records, including documentation of the individual’s attendance at work; and
      2. b. As needed, notation of any employment-related events apart from each individual’s expected work routine.
7. (g) Respite service records shall include attendance records indicating the dates and duration of the services provided.

8. (h) Environmental and vehicle modification services documentation shall include:

   1. (1) A specific description of the modifications and estimate(s) of cost, in accordance with He-M 517.08;
   2. (2) A rationale as to why the requested modification is specifically related to the individual’s disability;
   3. (3) The section of the individual’s service agreement that outlines the need for the modifications; and
   4. (4) The date of completion.

9. (i) Crisis response services documentation shall include:

   1. (1) A brief description of the crisis in the service agreement written by the service coordinator;
   2. (2) A summary of the crisis response services proposed;
   3. (3) Monthly progress notes, including a description of the services provided and the individual’s response to services; and
   4. (4) Service provision records indicating the units of services provided.

10. (j) Community support services documentation shall include:

    1. (1) Individual records, which shall include:

       1. a. Information about the individual that would be essential in case of an emergency, including that information specified in (b)(1) above;
       2. b. A service agreement with all approved revisions; and
       3. c. Monthly progress notes; and
    2. (2) Service provision records indicating the units of services provided.

11. (k) Assistive technology documentation shall include:

    1. (1) A brief statement in the service agreement describing:

       1. a. The item or service;
       2. b. The name of the healthcare practitioner recommending the item or service;
       3. c. An evaluation or assessment regarding the appropriateness of the item;
       4. d. A goal related to the use of the item;
       5. e. The anticipated environment in which any item will be used; and
       6. f. Current modifications to the item or product and anticipated future modifications and anticipated cost;
    2. (2) Records indicating the dates and services provided; and
    3. (3) For lease of assistive technology equipment, a written proposal for the cost of the lease.

12. (l) Specialty services shall include:

    1. (1) Documentation in the service agreement of:

       1. a. The service;
       2. b. An evaluation or assessment regarding the need for the services; and
       3. c. The nature of the service, date, and number of units; and
    2. (2) Records indicating the dates, units and services provided.

13. (m) Community integration services shall include:

    1. (1) Documentation in the service agreement of:

       1. a. The service;
       2. b. The name of the healthcare practitioner recommending the service when a single service exceeds $2,000 except when such service is a community-based campership;
       3. c. An evaluation or assessment regarding the appropriateness of the services; and
       4. d. The individual’s goal(s) that will be supported through the use of the service; and
    2. (2) Records indicating the dates, costs and services provided.

14. (n) Individual goods and services documentation shall include:

    1. (1) A summary in the service agreement to include:

       1. a. The service;
       2. b. The duration of any service to include a finite end-date;
       3. c. An evaluation or assessment regarding the appropriateness of the services; and
       4. d. A goal related to the use of the service;

    2. (2) Monthly documentation, pursuant to He-M 503.10, related to the use of the item or service to include:

       1. a. The frequency of purchase; and
       2. b. That the item continues to meet the individual’s identified need; and
    3. (3) Records indicating the dates, costs, and services provided.

15. (o) Non-medical transportation shall include:

    1. (1) Documentation in the service agreement of:

       1. a. The service; and
       2. b. How the service will be utilized; and
    2. (2) Records indicating the dates and costs of services provided.

16. (p) Personal emergency response system shall include:

    1. (1) Documentation in the service agreement of:

       1. a. The service; and
       2. b. An evaluation or assessment regarding the need for the services; and
    2. (2) Records indicating the dates, costs, and services provided.

17. (q) Wellness coaching shall include:

    1. (1) Documentation in the service agreement of:

       1. a. The service;
       2. b. An evaluation or assessment regarding the need for the services; and
       3. c. The desired wellness goals and outcomes for the individual over the coming year; and
    2. (2) Records indicating the dates, costs, and services provided.

18. (r) Removable prosthodontic services documentation shall include:

    1. (1) Documentation in the service agreement of the need for the service;
    2. (2) Treatment notes;
    3. (3) Radiographic images;
    4. (4) Laboratory prescriptions; and
    5. (5) Laboratory invoices.
19. (s) Each provider agency shall retain individual records for a period of 6 years following the termination of services to an individual.

Source. #4315, eff 9-25-87; EXPIRED: 9-25-93 New. #6360, eff 10-23-96, EXPIRED: 10-23-04 New. #8195, INTERIM, eff 10-29-04, EXPIRED: 4-27-05 New. #8424, eff 9-1-05 (from He-M 517.09) ; ss by #10454, eff 10-31-13; ss by #13988, eff 5-30-24 (formerly He-M 517.07)