Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 461.000 - Community Support Program Services › Section 461.414 - Recordkeeping Requirements

Current through Register 1525, July 5, 2024
(A)
Release of Information
. Each CSP must obtain written
			 authorization from each member or the member's legal guardian to release
			 information obtained by the provider, to other community-based providers,
			 federal and state regulatory agencies, and, when applicable, referral providers
			 or other relevant parties to the extent necessary to carry out the purposes of
			 the program and to meet regulatory requirements. All such information must be
			 released on a confidential basis and in accordance with all applicable
			 requirements.
(B)
Member Records
.
(1) A
			 CSP must maintain member records in accordance with
			 130 CMR
			 450.000:
Administrative and Billing
			 Regulations
. When a member is referred to any other provider, the
			 program must maintain the original member record and forward a copy to the
			 other provider.
(2) Member records
			 must be complete, accurate, and properly organized.
(3) The member's record must include at least
			 the following information:
(a) the member's
			 name and case number, MassHealth identification number, address, telephone
			 number, gender identity, date of birth, marital status, next of kin, school or
			 employment status (or both), and date of initial contact;
(b) the place of service;
(c) the member's description of the problem,
			 and any additional information from other sources, including the referral
			 source, if any;
(d) the events
			 precipitating the member's contact with the CSP;
(e) Written documentation that the member
			 receiving services meets the clinical standards published by the MassHealth
			 agency, including the following:
1. CSP-HI
			 providers must generate written documentation of homelessness from the local
			 Continuum of Care Homeless Management Information System (HMIS) or comparable
			 system used by providers of services for victims of domestic
			 violence;
2. CSP-TPP providers must
			 maintain a copy of the Notice to Quit, a request for temporary, preliminary, or
			 permanent relief or against whom such relief has been granted, or related
			 Housing Court filings and records; and
3. CSP-JI providers must maintain
			 documentation of justice involvement, including whether referral was received
			 from a correctional institution or BH-JI vendor.
(f) the relevant medical, psychosocial,
			 educational, and vocational history;
(g) a needs assessment of the
			 member;
(h) short- and long-range
			 goals that are realistic and obtainable and a time frame for their
			 achievement;
(i) the member's
			 service plan, updates, and related CSP service planning meetings, including
			 schedule of activities and services necessary to achieve the member's goals,
			 signed by both the CSP staff person and the member;
(j) written record of all services provided,
			 including face-to-face, virtual, and collateral contacts, and including
			 progress notes;
(k) a written
			 record of the reassessments that includes recommendations for revision of the
			 service plan, when indicated, and the names of the reviewers;
(l) the name(s) of the CSP staff person(s)
			 responsible for providing services to the member;
(m) reports on all collateral consults and
			 collaborations with family, friends, and outside professionals, including
			 probation, parole or correctional institution staff, who are involved in the
			 member's treatment;
(n) all
			 information and correspondence to and from other involved agencies, including
			 appropriately signed and dated consent forms;
(o) when discharged, a discharge summary,
			 including a summary of the member's services, a brief summary of the member's
			 condition and response to services on discharge, achievement of goals, and
			 recommendations for appropriate services that should be provided in subsequent
			 programs by the same or other agencies to accomplish the member's long-range
			 goals, and the program's future responsibility for the member's care;
(p) if the member fails to keep appointments
			 or to adequately participate in the service plan, CSP staff must make every
			 effort to encourage the member to do so, and these follow-up efforts must be
			 documented in the member's record; and