Each participating provider shall develop and maintain on file the following documentation for each recipient:

1. (a) A plan of care which shall be developed following the initial assessment, in accordance with the following:

   1. (1) The plan of care shall include:

      1. a. The recipient’s name, date of birth and Title XIX identification number;
      2. b. The recipient’s identified needs and/or risk factors;
      3. c. The recommended HVNH or child/family health care support services; and
      4. d. The frequency of the recommended HVNH or child/family health care support services;

   2. (2) The plan of care shall be approved, dated, and signed by:

      1. a. A physician or APRN, when the plan of care contains a nursing or SMS nutrition component; or
      2. b. A physician, APRN, LCSW, psychologist, associate psychologist, licensed clinical mental health counselor, or licensed marriage and family therapist, when the plan of care does not contain a nursing component; and
   3. (3) The plan of care shall be reviewed and updated at least annually and as necessary, including being approved, dated, and signed in accordance with (2) above;

2. (b) A family support plan which shall:

   1. (1) Be required only of participating HVNH providers;
   2. (2) Be developed, in conjunction with the family, based on initial assessment and the plan of care;
   3. (3) Be updated at least quarterly, in conjunction with the family, based on the health care provider’s assessment of progress or lack of progress towards the goals in (4) below; and

   4. (4) Specify family-specific goal information including, but not limited to:

      1. a. Family-specific goals, including the date each goal is identified;
      2. b. Action steps to achieve each family-specific goal;
      3. c. Frequency of services required to achieve each family-specific goal;
      4. d. Sources of support resources for the family to utilize to achieve each family-specific goal;
      5. e. Name and goal-related role of each anticipated and involved health care provider;
      6. f. Dates on which progress toward each goal is to be reviewed, which shall be at least quarterly; and
      7. g. Status of goal at review date;

3. (c) Progress notes, which shall be prepared at the time of each visit, or at the time of a telephone call made or video conference conducted in lieu of a face-to-face visit, by the health care provider, to include, but not be limited to:

   1. (1) The date of each visit, telephone call or video conference;
   2. (2) The location of each visit, if other than the recipient’s home or the participating provider or health care provider agency, and the reason therefor;
   3. (3) The reason for a telephone call or video conference if in lieu of a visit;
   4. (4) The individuals present at the time of the visit;
   5. (5) The start time and end time of each visit, telephone call or video conference;
   6. (6) For HVNH only, documentation of the service(s) provided at each visit, or via telephone call or video conferencing and how the service(s) provided relates to a specific goal contained in the family support plan;
   7. (7) For MCH providers of child/family health care support services, documentation of which service(s) specified in He-W 549.05(b)(5), as related to the plan of care, were provided at each visit, or via telephone call or video conference;
   8. (8) For participating providers under contract obligation with SMS, documentation of the service(s) provided at each visit or via telephone call or via video conference; and
   9. (9) The dated signature and credentials of the health care provider;

4. (d) For HVNH only, documentation in the recipient’s chart as follows:

   1. (1) Family/household information, including, but not limited to:

      1. a. Names of family members;
      2. b. Dates of birth of family members; and
      3. c. Relationship of family members to recipient;
   2. (2) Family support team information, including, but not limited to the name and role of each health care provider providing services; and

   3. (3) The names and types of other sources of support being received by the recipient, such as, but not limited to:

      1. a. Primary care, dental, and mental health providers; and
      2. b. Support from such programs as women, infants and children nutrition services, and the division for children, youth and families; and
5. (e) For child/family health care support services only, documentation verifying that the recipients served met the eligibility criteria in He-W 549.02(b).

Source. #7775, eff 10-8-02; ss by #9768, eff 10-8-10; ss by #10092, eff 3-1-12 (fr5om He-W 549.06); amd by #11124, eff 6-22-16