Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 448.000 - Community Behavioral Health Center Services › Section 448.419 - Recordkeeping Requirements

Current through Register 1525, July 5, 2024
(A) Each center
			 must obtain written authorization from each member or the member's legal
			 guardian to release information obtained by the center, to center staff,
			 federal and state regulatory agencies, and, when applicable, referral
			 providers, to the extent necessary to carry out the purposes of the center and
			 to meet regulatory requirements. All such information will be released on a
			 confidential basis and in accordance with all applicable
			 requirements.
(B)
Member Records
.
(1)
			 A center must maintain member records in accordance with
			 130 CMR
			 450.000:
Administrative and Billing
			 Regulations
and
			 105 CMR
			 140.000:
Licensure of Clinics
, in
			 addition to applicable recordkeeping requirements for clinics under M.G.L. c.
			 111 § 70. When a member is referred to any other provider, each center
			 will 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 will 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) a report of a physical examination
			 performed within 12 months of the date of intake, including documentation the
			 physical examination informed the treatment plan, or documentation that the
			 member did not want to be examined and any stated reason for that
			 preference;
(d) the name and
			 address of the member's primary care physician or, if not available, another
			 physician who has treated the member;
(e) the member's description of the problem,
			 and any additional information from other sources, including the referral
			 source, if any;
(f) the events
			 precipitating the member's contact with the center;
(g) the relevant medical, psychosocial,
			 educational, and vocational history;
(h) a comprehensive assessment of the member
			 initiated at intake;
(i) the
			 clinical impression of the member and a diagnostic formulation, including a
			 specific diagnosis using standard nomenclature;
(j) short- and long-range goals that are
			 measurable, realistic and obtainable, and a timeframe for their
			 achievement;
(k) the proposed
			 schedule of therapeutic activities, both in and out of the center, necessary to
			 achieve such goals and objectives and the responsibilities of each individual
			 member of the interdisciplinary team;
(l) a schedule of dates for utilization
			 review to determine the member's progress in accomplishing goals and
			 objectives;
(m) the name,
			 qualifications, and discipline of the therapist primarily responsible for the
			 member;
(n) a written record of
			 semi-annual reviews (every six months) by the primary therapist, which relate
			 to the short and long range goals;
(o) progress notes, including those related
			 to the defined treatment plan goals on each visit written and signed by the
			 primary therapist that include the therapist's discipline and degree;
(p) a treatment plan for the member signed by
			 the primary therapist, or the supervisor of an unlicensed primary therapist,
			 pursuant to
			 130
			 CMR 448.412(A)(3);
(q) all information and correspondence
			 regarding the member, including appropriately signed and dated consent
			 forms;
(r) a drug-use profile (both
			 prescribed and other);
(s) when the
			 member is discharged, a discharge summary, including a brief summary of the
			 member's condition and response to treatment, achievement of treatment and
			 recovery goals, and recommendations for any future appropriate services;
			 and
(t) for members younger than 21
			 years old, a CANS completed during the initial behavioral health assessment and
			 updated at least every 90 days thereafter.
(4) A brief history is acceptable for
			 emergency or walk-in visits when the treatment plan does not call for extended
			 care.