Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Mental Health Rehabilitation Services for Adults Provided by Private Non-Medical Institutions › Section 17b-262-766 - Documentation and record retention requirements

Current through July 10, 2024
Providers shall comply with the following documentation and record retention requirements:
(1) An initial residential rehabilitation plan and all updated versions, including the current plan, shall be maintained.
(2) A case record, as required by section 19a-495-551(k) (3) of the Regulations of Connecticut State Agencies, shall be maintained and shall include, at a minimum: identifying information; social and health history; the reason for admission to the PNMI program; copies of the initial and all subsequent orders for PNMI rehabilitative services; the individual residential rehabilitation plan; identification of the care and services provided; a current list of all medications; and the plan for discharge and disposition of the PNMI client.
(3) Encounter notes shall be maintained for each rehabilitative service provided. The notes shall include the service rendered, actual time the service was rendered, location of service, the goal and objective that is the focus of the intervention, a general description of the content of the intervention to provide evidence that it is a rehabilitative service as described in section 17b-262-763 of the Regulations of Connecticut State Agencies and the client's response to the intervention. Encounter notes shall be signed, dated and indicate the credentials of the staff member who provided the service. Shift notes are not a substitute for encounter notes.
(4) At least monthly, a progress note shall be prepared that describes the services the client has received over the past month, the client's overall response, and the client's specific progress toward the goals and objectives listed on the residential rehabilitation plan. The note shall be signed or co-signed by the program director or the licensed clinician. The note shall discuss any variance between the services listed on the residential rehabilitation plan and the services actually delivered. The note shall also discuss suggested changes, if any, to the residential rehabilitation plan.
(5) Other documentation and record retention requirements:
(A) The provider shall maintain a current record of the applicable licenses and certificates of practice of all licensed or certified individuals furnishing PNMI rehabilitative services.
(B) The provider shall be substantially in compliance with all documentation requirements in its most recent licensure review and relevant state agency quality assurance reviews.
(C) The provider shall maintain all required records for at least five years or longer as required by statutes or regulation. All required records shall be subject to review by the department. In the event of a dispute concerning a service provided, documentation shall be maintained until the end of the dispute or five years, whichever is longer.
(D) All documentation shall be physically placed into the eligible PNMI client's case record in a complete, prompt and accurate manner. All documents shall be made available to authorized personnel of the department upon request.