Code of Maine Rules
10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES
144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL
Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL)
Chapter II - Specific Policies By Service
Section 144-101-II-21 - Home and Community Benefits for Members with Intellectual Disabilities or Autism Spectrum Disorder
Subsection 144-101-II-21.09 - MEMBER RECORDS
Current through 2024-38, September 18, 2024
Each provider serving the Member must maintain a specific record for each Member it serves in accordance with the requirements of Chapter I of the MaineCare Benefits Manual. The Member's record is subject to DHHS's review.
In addition, the Member's records must contain:
21.09-1 The Member's name, address, birth date, MaineCare identification number, guardian contacts, if applicable, and emergency contacts;
21.09-2 The Member's social and medical history, including any allergies, and diagnoses;
21.09-3 The Member's Person-Centered Service Plan; and
21.09-4 Written progress notes that identify actions related to the progress toward the achievement of the goals, activities and needs established by the Member's Person-Centered Service Plan signed by the staff performing the service.
DHHS will conduct a review of provider records that may include, but is not limited to, staff schedules, payroll records and Member records to substantiate service delivery and units of authorization.
All providers must document each service provided, the date of each service, the type of service, the activity, need or goal to which the service relates, the length of time of the service, and the signature of the individual performing the service.
If services are provided by two (2) or more staff working different shifts, then each shift must be documented separately.
Example: A Member receives twenty-four hour (24) coverage from three (3) staff members working Monday through Friday in eight (8) hour shifts, and one (1) staff member that covers the weekend. The provider must have documentation for each eight (8) hour shift per day.
If Crisis Intervention is required, a separate progress note must be included in the Member's record. The documentation must describe the crisis services provided, the date in which the crisis service was provided, the length of the crisis service, and the signature of the individual performing the crisis service.
