Current through Register No. 40, October 3, 2024
(a) Home health care providers and
independent nurses shall maintain complete and timely records for each
recipient receiving services in accordance with He-W 520, and this
part.
(b) Where a home health care
provider or independent nurse has failed to maintain records pursuant to (a)
above, the department shall be entitled to recoupment of state or federal
medicaid payments made, as permitted by
42 CFR
455,
42 CFR 456
and42 CFR
447.
(c) In addition to the requirement set forth
in (a) above, home health care providers and independent nurses shall maintain
the documentation required by this part and He-W 520 to support claims
submitted for reimbursement for a minimum of 6 years or until the resolution of
any legal action(s) commenced within the 6 year period, whichever is
longer.
(d) Recipient records shall
include all of the following:
(1) Written
orders for initial home health services and certification of the need for home
health services signed by the recipient's physician specifying:
a. The frequency of medication and treatment
to be administered; and
b. The
period of time to be covered by the orders;
(2) Documentation of the occurrence of a
face-to-face encounter which is related to the primary reason the recipient
requires home health services indicating the time frame the encounter took
place, the date, the practitioner who conducted the encounter, and the
practitioner's findings in accordance with
He-W
553.06(a) below;
(3) For recipients under the age of 21, a
recipient history and a health assessment with an appropriate pediatric tool
completed upon admission by the RN or appropriate rehabilitation skilled
professional in accordance with
42 CFR
484.55;
(4) For recipients over the age of 21, a
recipient history and a health assessment, completed upon admission by the RN
or appropriate rehabilitation skilled professional in accordance with
42 CFR
484.55, except that the homebound assessment
of 42 CFR
484.55 is not required;
(5) Documentation at least every 60 days to
indicate review of the recipient's health assessment by the RN or appropriate
rehabilitation skilled professional in accordance with
42 CFR
484.55;
(6) A written individualized plan of care
which shall include the following:
a. The
diagnosis related to the recipient's need for home health services;
b. Other diagnoses;
c. An assessment of the recipient's mental
alertness and cognitive level;
d.
Measurable recipient goals;
e.
Types of services and equipment required;
f. Frequency of home health
services;
g. Anticipated length of
treatment;
h. General
prognosis;
i. Rehabilitation
potential;
j. Functional
limitations including activities of daily living;
k. Activities permitted;
l. Nutritional requirements;
m. Medications;
n. Treatments;
o. Safety measures required to protect the
recipient from potential injury;
p.
Services being provided by non-paid caregivers involved in the recipient's
treatment and any related education or training needs of the caregivers;
and
q. Discharge plans;
(7) Documentation at least every
60 days, to indicate review of the written plan of care by the recipient's
physician;
(8) Documentation at
least every 60 days that indicates the locations of service delivery other than
the recipient's home for services already provided;
(9) Auditable, paper, or electronic service
notes for each service provided to the recipient identifying:
a. Name of recipient;
b. Date of service;
c. Location(s) where service was provided, if
other than the recipient's primary residence;
d. Primary purpose of the home health
services;
e. Description of
services provided;
f. Amount of
direct care time spent providing each home health service;
g. Condition of the recipient at the time the
service was provided, and any significant change in recipient's mental or
physical condition;
h. Any progress
the recipient has made towards goals identified on the written plan of
care;
i. An explanation of any
variation from the written plan of care; and
j. Name, title, and written or electronic
signature of the individual providing the home health service; and
(10) Documentation of any consults
or meetings regarding the recipient's care, which also indicates the results of
the consult or meeting.
(e) Home health care providers and
independent nurses shall make the documentation required by this part and He-W
520 available for review to the department upon the request of the
department.
