The provider shall maintain the following documentation for all extended services care provided:

1. (a) A plan of care containing:

   1. (1) The initial assessment, which shall contain:

      1. a. The recipient’s name and medicaid identification number;
      2. b. The date of entry into clinic service;
      3. c. The number of weeks of gestation at the date of entry;
      4. d. The recipient’s medical, nutritional, and social needs and risks;
      5. e. A listing of services and types of providers to be used, to address the recipient’s needs and risks, as well as the frequency of services;
      6. f. A dated signature on the plan of care by the physician or advanced practice registered nurse, or a physician assistant if so delegated by a physician in accordance with Med 603.01, along with the signature of the recipient, approving the plan of care;
      7. g. A statement signed by the recipient which gives the agency staff permission to discuss the recipient’s needs with other medical and social service caregivers; and
      8. h. The date of, and reason for, discharge from the program;

   2. (2) Ongoing plan of care notes, relating to the original plan of care, containing:

      1. a. Date(s) of service(s); and
      2. b. Description of service(s); and
   3. (3) Changes to the original plan of care described in (1)d. and (1)e. above, to be attached to the original plan of care;
2. (b) Attendance records for any group education attended by a recipient;
3. (c) An extended services summary sheet listing the recipient’s name and medicaid identification number, and the date(s) and type(s) of extended service(s) rendered;
4. (d) Supporting records in accordance with He-W 520 and this part, and failure to maintain records in accordance with He-W 520 and this part shall entitle the department to recoupment of state and federal medicaid payments made as permitted by 42 CFR 455 and 42 CFR 447; and
5. (e) Documentation required by He-W 520 and this part for a minimum of 6 years or until the resolution of any legal action(s) commenced within the 6 year period, whichever is longer.

Source. (See Revision Note at chapter heading He-W 500); ss by #5578, eff 2-11-93; ss by #6939, Interim, eff. 1-30-99, EXPIRED 5-30-99 New. #7036, eff 6-25-99; ss by #8904, eff 6-25-07; ss by #10914, eff 8-26-15