(A) The record maintained by an independent
nurse for each member must conform to 130 CMR 450.000: Administrative
and Billing Regulations. Payment for any service listed in 130 CMR
414.000 requires full and complete documentation in the member's medical
record. The independent nurse must maintain records for each member to whom
nursing services are provided.
(B)
In order for a medical record to completely document a service to a member, the
record must disclose fully the nature, extent, quality, and necessity of the
nursing services furnished to the member. When the information contained in a
member's record does not provide sufficient documentation for the service, the
MassHealth agency may disallow payment (see 130 CMR 450.000:
Administrative and Billing Regulations).
(C) The independent nurse must submit
requested documentation to the MassHealth agency or its designee for purposes
of utilization review and provider review and audit, within the MassHealth
agency's or its designee's time specifications. The MassHealth agency or its
designee may periodically review a member's plan of care and other records to
determine if services are medically necessary in accordance with
130
CMR 414.409(C). The
independent nurse must provide the MassHealth agency or its designee with any
supporting documentation the MassHealth agency or its designee requests, in
accordance with M.G.L. c. 118E, § 38 and 130 CMR 450.000:
Administrative and Billing Regulations.
(D) The independent nurse must maintain an
up-to-date medical record of nursing services provided to each member that must
be reviewed by the independent nurse at least monthly. The medical record must
contain at least the following:
(1) the
member's name, address, phone number, date of birth, and MassHealth ID
number;
(2) the name and phone
number of the member's primary care physician;
(3) the primary natural caregiver's name,
address, phone number, and relationship to member;
(4) the name and phone number of the member's
emergency contact person;
(5) a
copy of the approved prior authorization decision;
(6) a copy of the plan of care signed by the
member's physician and, if appropriate, verbal orders signed by the
physician;
(7) a medical history as
defined in
130
CMR 414.402;
(8) accessible and legible nursing progress
notes for each visit, signed by the independent nurse, that include the
following information:
(a) the full date of
service and time that each visit began and ended;
(b) all treatments and services ordered by
the physician or ordering non-physician practitioner that are included in the
member's plan of care, as well as documentation of the treatments and services
that were provided during the visit and the member's response;
(c) any additional treatment or service that
is not included in the member's plan of care provided, as well as the member's
response, including documentation of medication administration as described in
130
CMR 414.417(D)(9);
(d) any service or treatment the member may
have declined during the visit and an explanation of the denial;
(e) the member's vital signs and any other
required measurements;
(f) progress
toward achievement of long- and short-term goals as specified in the plan of
care, including, when applicable, an explanation of why goals are not achieved
as expected;
(g) a pain assessment,
as appropriate;
(h) the status of
any equipment maintenance and management, as appropriate; and
(i) any contacts with physicians or other
health-care providers about the member's needs or change in plan of care, as
applicable;
(9) a current
medication-administration list or other documentation, such as nursing notes,
that includes the time of administration as ordered, drug identification and
dose, the route of administration, the member's response to the medication
being administered, and the signature of the person administering the
medication;
(10) documentation
about teaching provided to the member, member's family, or primary natural
caregiver by the independent nurse on how to manage the member's treatment
regimen, any ongoing teaching required by a change in the procedure or the
member's condition, and the response to the teaching, if applicable;
(11) any clinical tests and their
results;
(12) the names and
telephone numbers of all the providers involved in co-vending care and the
number of nursing hours approved for each provider by the MassHealth agency or
its designee, to the best of the independent nurse's ability; and
(13) a signed medical records release
form.
(E) The independent
nurse must maintain a copy of the member's medical record in the member's home
as described in
130
CMR 414.417(D). The copy
must be made available to the member and/or their representative on request.
The independent nurse must make every attempt to coordinate care and/or changes
in shifts with other CSN providers.
(F) The independent nurse is responsible for
maintaining the member's medical record. The independent nurse must maintain
the member's original medical record along with current and previous
certification period documentation in accordance with
130
CMR 414.417(A) and
(B).
(G) On the request of the member or their
representative, the independent nurse must provide a copy of the medical record
to a person or entity that the member or their representative designates.
Additionally, on request of the MassHealth agency or its designee, the
independent nurse must provide a copy of the member's complete medical record
to the agency or designee.
(H)
Incident and Accident Records. The independent nurse must maintain an easily
accessible record of the members' incidents and accidents. The record may be
kept in the individual member medical record.
(1) The independent nurse must submit to the
MassHealth agency or its designee an incident or accident report within five
days under the following circumstances:
(a) an
incident or accident that occurred during a CSN service visit that results in
serious injury to the member;
(b)
an incident or accident resulting in the member's unexpected death even if the
independent nurse was not involved in the incident or accident;
(c) an incident of abuse or neglect involving
the independent nurse and the member; or
(d) an incident of abuse or neglect committed
by another provider who was supporting the member (if known).
(2) The incident or accident
report must include at least the following:
(a) general information including but not
limited to the member's name and MassHealth ID number;
(b) the general nature of the incident or
accident; and
(c) any action that
was taken as a result of the incident or accident, including all
outcomes.
