1. (a) Documentation to provide a record of services delivered to an individual shall be prepared by the provider for the purpose of substantiating a claim.

2. (b) The provider shall document service delivery on the date the service is delivered.

   1. (1) A service note shall be completed for each continuous span of billing units or each day unit.
   2. (2) A new service note shall be completed when there is an interruption of service within a 24-hour period, if service is reinitiated within that 24-hour period, except for a service that is billed as a day unit.
   3. (3) If there is a change in the staff person providing the service or a change in shift involving multiple staff persons during a 24-hour period, a new service note shall be completed, except for a service that is billed as a day unit.

3. (c) Documentation of service delivery must include the following:

   1. (1) The name of the individual.
   2. (2) The name of the provider.
   3. (3) The date of the service delivery.
   4. (4) The date, name and signature of the person completing the documentation.
   5. (5) Identification of the service delivered, the nature or description of the activities involved in the service, who delivered the service and where the service was delivered.
   6. (6) The total number of units of service delivered from the beginning to the end of the service on the specified date.
4. (d) The provider shall maintain a record of the time worked or the time that a service was delivered to support the claim.
5. (e) The amount, frequency and duration of the service delivered shall be consistent with the individual plan.
6. (f) Documentation of claims, including supporting documentation, shall be kept.

Cross References

This section cited in 55 Pa. Code § 6100.227 (relating to progress notes); 55 Pa. Code § 6100.483 (relating to provider billing); 55 Pa. Code § 6100.801 (relating to agency with choice); 55 Pa. Code § 6100.804 (relating to base-funding); and 55 Pa. Code § 6100.805 (relating to vendor goods and services).