New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 77A - ADULT MENTAL HEALTH REHABILITATION SERVICES PROVIDED IN/BY COMMUNITY RESIDENCE PROGRAMS
Subchapter 2 - PROGRAM OPERATIONS
Section 10:77A-2.6 - Recordkeeping

Universal Citation: NJ Admin Code 10:77A-2.6

Current through Register Vol. 56, No. 18, September 16, 2024

(a) All community residences for mentally ill adults shall keep such legible records as are necessary to fully disclose the kind and extent of services provided, as well as the medical necessity for such services, and the place, date and the total units of service that were provided.

(b) Recordkeeping for AMHR services shall include clinical records and reports for each individual beneficiary. These reports shall cover the medical, nursing, social and health-related care rendered to the beneficiary, in accordance with accepted professional standards.

(c) The provider shall maintain, at a minimum, the following documentation in support of all claims for payment:

1. The name of the beneficiary;

2. The date(s) of service(s);

3. The type(s) of service(s) provided;

4. The name of the residential program providing the service and the specific location that the service was provided; and

5. Appropriate service documentation:
i. For services reimbursed on a per diem basis, documentation shall include a daily census of the residence and proof of staffing levels consistent with the level of care.

ii. For services reimbursed on a per quarter-hour basis documentation shall include the time of arrival and departure of the staff member, the total amount of time the Medicaid-reimbursable service(s) were provided, the name(s) of the staff rendering the service(s) and the name of the resident(s) receiving the service(s).

(d) All records shall be made available upon request to representatives of the Department of Human Services or its authorized agents.

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