411-048-0200 Additional Documentation Requirements (1) The RN must meet the documentation, record keeping, and communication standards as required by the Department. The RN who meets the Department’s standards remains responsible to also document in accordance with the Nurse Practice Act. This documentation shall include a record of all RN delegation as described in OAR 411-048-0180 and the RN’s initial and assessment of the nursing procedures delegated to the individual’s unregulated assistive person. (2) The documentation standards in this rule and on the Department approved forms provided by the Department do not replace or substitute for the documentation requirements in the: (a) Rules for professional nursing standards as prescribed by the OSBN in OAR chapter 851, divisions 006, 045, and 047; (b) Medicaid provider rules governing provider requirements in OAR chapter 407, division 120; and (c) As applicable, the Medicaid General Rules in OAR chapter 410, division 120. (3) The RN is expected to complete the Department approved forms specified by the Department to support the long term care community nursing services in these rules. The Department may approve the use of alternative but equivalent forms. (4) The RN must send completed forms to the case manager prior to or at the time of invoice submission. Documentation must support the long term care community nursing services billed and adhere to the timeframes noted in these rules. (a) An individual's case manager must receive the required forms and documentation to pay a claim. (b) The provider must submit true, accurate and complete information when billing the Department. Use of a billing provider does not overrule the performing provider’s responsibility for the truth and accuracy of submitted information. (c) Authorization or payment by the department does not restrict or limit the Department, Authority or any state or federal oversight entity’s right to review or audit a claim before or after the payment. (d) Failure to comply with the documentation standards in this rule may result in the determination of overpayment for which recovery may be sought. (5) All electronic documentation must be sent in HIPAA secured format. (6) The self-employed RN that is enrolled as a Medicaid provider or an agency enrolled as a Medicaid provider as described in OAR 411-048-0210 must maintain a record of all long term care community nursing services provided to each assigned individual and the individual's caregiver and as required by OAR 410-120-1280 for individuals served through a Medicaid program. (a) The record must include copies of all documentation provided to the local office as well as any additional documentation the RN or agency maintained to meet OSBN and Medicaid provider rules. (b) The documentation must be retained in an electronic or hard copy format until the RN or agency no longer provides long term care community nursing services to the individual, at which time the RN or agency must provide the individual's case manager a copy of any part of the record not previously provided. (c) The RN or agency must retain original records in hard copy or electronic format for each individual following Department security and HIPAA practices for a period of seven years. Statutory/Other Authority: ORS 410.070 Statutes/Other Implemented: ORS 410.070 History: APD 18-2023, amend filed 10/13/2023, effective 11/01/2023 SPD 8-2013, f. & cert. ef. 4-15-13