Mississippi Administrative Code
Title 23 - Division of Medicaid
Part 205 - Hospice Services
Chapter 1 - Program Overview
Rule 23-205-1.9 - Documentation Requirements
Universal Citation: MS Code of Rules 23-205-1.9
Current through September 24, 2024
A. The hospice provider must maintain medical records for each beneficiary at the hospice site which corresponds to the address associated with the provider license and Division of Medicaid provider number and must include, but not limited to, the following:
1. The Division of Medicaid's
specific hospice related forms which must be complete and accurate:
a) Terminal illness
certification/recertification form with supporting documentation,
b) Hospice notice of election form,
c) Hospice discharge/Hospice
revocation form, if applicable,
d)
Hospice transfer form, if applicable,
e) Hospice discharge/Hospice revocation form
including the discharge summary for a hospice beneficiary which must include
the following:
1) A summary of the
beneficiary's stay including treatments, symptoms, and pain management,
2) The beneficiary's current plan
of care (POC),
3) The beneficiary's
current physician orders, and
4)
Any other documentation that will assist in post-discharge continuity of care
or that is requested by the attending physician or receiving facility.
(a) The hospice must forward to the receiving
facility for any beneficiary transferred to another hospice provider, the
following:
(1) The hospice discharge summary,
and
(2) The beneficiary's clinical
record, if requested.
(b)
The hospice must forward to the beneficiary's attending physician for any
beneficiary that revokes hospice election or is discharged the following:
(1) The hospice discharge summary,
and
(2) The beneficiary's clinical
record, if requested.
2. An interdisciplinary POC including the
initial plan of care, updated plans of care, initial assessment, comprehensive
assessment, updated comprehensive assessments, and clinical notes that support
each hospice service rendered including needs, care, services and goals.
3. A copy of a waiver
participant's plan of services and supports (PSS) when the hospice beneficiary
is also receiving waiver services.
4. The certifying physician's election period
face-to-face encounter and date of encounter with clinical findings to support
a life expectancy of six months or less. If a non-certifying hospice physician
or nurse practitioner performs the face-to-face encounter, documentation must
show:
a) An attestation in writing of the
face-to-face encounter that the clinical findings of the visit were provided to
the certifying physician for use in determining continued eligibility for
hospice care, and
b) The date of
the face-to-face encounter.
5. Treatment rendered including:
a) Each discipline's visit or contact of the
treatment or intervention rendered at the frequency ordered on the POC.
b) Documentation to show
relationship of the treatment plan and medications to the terminal illness and
related conditions,
c) Responses to
medications, symptom management, treatments, and services, and
d) Appropriate discipline's signature or
initials on all medical records.
6. A current medication list for each month
of certification that clearly indicates the medications the hospice paid
related to the terminal illness and related conditions. The list must contain
the name, strength, dosage, and route of the drugs administered to the hospice
beneficiary and the name and address of the pharmacies that provided the
medications to the hospice beneficiary.
7. A current list of medical appliances and
supplies related to the terminal illness and related conditions paid for by the
hospice and the names and address(s) of the providers paid.
B. Documentation must be maintained in accordance with requirements set forth in Part 200, Chapter 1, Rule 1.3. and all hospice providers must retain medical records for a minimum of six (6) years after death or discharge of a beneficiary, unless State law stipulates a longer period of time.
C. Concurrent providers of hospice services and home and community-based (HCBS) waiver services must maintain medical records in accordance with requirements set forth in Miss. Admin. Code Part 200, Rule 1.3 and must include, but not limited to:
1. Additional documentation requirements
included in Miss. Admin. Code Part 205, Rule
1.8 for hospice providers and in
Miss. Admin. Code Part 207 for HCBS waiver providers.
2. All person centered planning (PCP)
conferences, including but not limited to:
a)
Time and date of conference,
b)
Persons in attendance,
c) Any
applicable notes, and
d) Signatures
of the hospice provider and HCBS case manager/support coordinator.
3. The hospice plan of
care (POC) and the HCBS plan of services and supports (PSS) which must include,
but not limited to:
a) A list of all hospice
and HCBS waiver services the person receives,
b) The provider responsible for providing
each listed service,
c) The
frequency of each service, and
d)
An explanation when a service is provided by a HCBS waiver provider instead of
a hospice provider.
e) Monthly
communication between the hospice provider and the HCBS waiver provider must be
documented in the person's medical record including, but not limited to:
1) Date and time of the communication,
2) Staff included in the
communication,
3) Method of
communication, and
4) Topics
discussed.
42 C.F.R. Part 418; Miss. Code Ann. § 43-13-121.
Disclaimer: These regulations may not be the most recent version. Mississippi may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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