Mississippi Administrative Code
Title 23 - Division of Medicaid
Part 223 - Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)
Chapter 5 - Personal Care Services
Rule 23-223-5.9 - Documentation Requirements
Universal Citation: MS Code of Rules 23-223-5.9
Current through September 24, 2024
A. Certified Nursing Assistants (CNAs) providing personal care services (PCS) must document all care rendered during each shift including, but not limited to:
1. Assistance with activities of daily living
(ADL), and
2. Any significant
changes in the beneficiary's condition.
B. Weekly timesheets must be maintained for each CNA providing PCS that include:
1. The
date the services were provided,
2.
Begin and end times of services and a list of services provided during that
time,
3. The dated signature of the
CNA, and
4. The dated signature of
the beneficiary's guardian or legal representative.
C. The PDN provider must establish and maintain a permanent, legible medical record for each beneficiary at the provider's office which must include, at a minimum, the following:
1. Physician orders updated and signed by the
physician every six (6) months,
2.
Current physician's treatment plan updated every six (6) months,
3. Plan of care (POC) based on the
diagnosis(es), clinical and social status of the beneficiary including
measurable goals updated every six (6) months,
4. Documentation of changes in clinical
status and/or significant occurrences,
5. Weekly progress notes,
6. Monthly summaries must include the
following, at a minimum:
a) CNA services
provided,
b) Progress or lack of
progress toward goals,
c) Clinical
and social status of the beneficiary, and
d) Changes in the POC.
7. Information regarding other home care
services being provided to the beneficiary including:
a) The specific services provided,
b) Date and times of services, and
c) The providers of the services.
8. Copies of all prior
authorizations.
D. All records must be maintained and retained in accordance with HIPPA and Medicaid regulations. [Refer to Part 200, Rule 1.3, Maintenance of Records.]
Miss. Code Ann. §§ 43-13-117, 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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