Current through Register No. 40, October 3, 2024
(a) With the exception of peer recovery
programs, SUD treatment and recovery support services providers shall maintain
supporting records, in accordance with He-W 520 and (b) - (f) below.
(b) Supporting documentation shall include:
(1) A complete record of all physical
examinations, laboratory tests, and treatments including drug and counseling
therapies, whether provided directly or by referral;
(2) A progress note for each treatment
session, including:
a. The treatment modality
and duration;
b. The signature of
the primary therapist for each entry;
c. The primary therapist's professional
discipline; and
d. The date of each
treatment session; and
(3) A copy of the treatment plan that is:
a. Updated at least every 4 sessions or 4
weeks, whichever is less frequent;
b. Signed by the provider and the recipient
prior to treatment being rendered; and
c. Signed by the clinical supervisor, prior
to treatment being rendered, if the service is an outpatient or comprehensive
SUD program.
(c) The recipient's individual record shall
include at a minimum:
(1) The recipient's
name, date of birth, address, and phone number; and
(2) A copy of the evaluation described in
He-W 513.05(u) (2)
.
(d) SUD providers that close their treatment
and recovery support programs shall arrange for continued management of all
medicaid recipient records as follows:
(1)
The provider shall notify the department in writing of the address where
records will be stored;
(2) The
provider shall specify to the department the person who will be managing the
records and the person's contact information; and
(3) The provider shall arrange for storage of
each record through one or more of the following measures:
a. The provider shall continue to manage the
records and give written assurance to the department that it will respond to
authorized requests for copies of client records within 10 working
days;
b. The provider shall
transfer records of clients who have given written consent to another medicaid
enrolled provider; or
c. The
provider shall enter into an agreement with a medicaid enrolled provider to
store and manage records.
(e) All electronic or written documentation
shall be legible and written in English.
(f) The SUD treatment and recovery support
services provider shall provide documentation to the department upon
request.
(g) Peer recovery programs
shall maintain supporting records in accordance with He-W 520 and (d), (e), and
(f) above, and shall include the following supporting documentation:
(1) . Progress on goals for each recovery
contact including:
a. The type of support
received and duration;
b. The
topics addressed with the recipient;
c. The signature of the person delivering
services; and
d. The date of each
recovery contact;
(2)
Where applicable, a copy of the recovery plan that is:
a. Updated a every session; and
b. Signed by the provider and the recipient
prior to services being rendered; and
(3) The recipient's name, date of birth,
address, and phone number.
#10655, INTERIM, eff 8-15-14, EXPIRES: 2-11-15
