Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 414.000 - Independent Nurse › Section 414.417 - Recordkeeping Requirements and Utilization Review

Current through Register 1525, July 5, 2024
(A) The record maintained by an independent
			 nurse for each member must conform to
			 130 CMR 450.000:
Administrative and Billing Regulations.
Payment for any
			 service listed in
			 130
			 CMR 414.000 requires full and complete documentation
			 in the member's medical record. The independent nurse must maintain records for
			 each member to whom nursing services are provided.
(B) In order for a medical record to
			 completely document a service to a member, the record must disclose fully the
			 nature, extent, quality, and necessity of the nursing services furnished to the
			 member. When the information contained in a member's record does not provide
			 sufficient documentation for the service, the MassHealth agency may disallow
			 payment
(see
130 CMR 450.000:
Administrative and Billing Regulations).
(C) The independent nurse must submit
			 requested documentation to the MassHealth agency or its designee for purposes
			 of utilization review and provider review and audit, within the MassHealth
			 agency's or its designee's time specifications. The MassHealth agency or its
			 designee may periodically review a member's plan of care and other records to
			 determine if services are medically necessary in accordance with
			 130 CMR
			 414.409(D). The independent
			 nurse must provide the MassHealth agency or its designee with any supporting
			 documentation the MassHealth agency or its designee requests, in accordance
			 with M.G.L. c. 118E, § 38 and
			 130 CMR 450.000:
Administrative and Billing Regulations.
(D) The independent nurse must maintain an
			 up-to-date medical record of nursing services provided to each member that must
			 be reviewed by the independent nurse at least monthly. The medical record must
			 contain at least the following:
(1) the
			 member's name, address, phone number, date of birth, MassHealth ID
			 number;
(2) the name and phone
			 number of the member's primary care physician;
(3) the primary caregiver's name, address,
			 phone number, and relationship to member;
(4) the name and phone number of the member's
			 emergency contact person;
(5) a
			 copy of the approved prior authorization decision;
(6) a copy of the plan of care signed by the
			 member's physician and, if appropriate, verbal orders signed by the
			 physician;
(7) a medical history as
			 defined in
			 130 CMR
			 414.402;
(8) easily reviewable and legible nursing
			 progress notes for each visit, signed by the independent nurse, that include
			 the following information:
(a) the full date
			 of service;
(b) a notation of the
			 specific time that each shift began and ended;
(c) a description of the assessed signs and
			 symptoms of illness;
(d) any
			 treatments and drugs administered and the member's response;
(e) the member's vital signs and any other
			 required measurements;
(f) progress
			 toward achievement of long- and short-term goals as specified in the plan of
			 care, including, when applicable, an explanation of why goals are not achieved
			 as expected;
(g) a pain
			 assessment;
(h) the status of any
			 equipment maintenance and management; and
(i) any contacts with physicians or other
			 health-care providers about the member's needs or change in plan of
			 care;
(9) a current
			 medication-administration sheet that includes the time of administration, drug
			 identification and strength, route of administration, the member's response to
			 the medication, and the signature of the person administering the
			 medication;
(10) a current
			 treatment list or description of treatments administered, the time of
			 administration, the member's response to the treatment, and the signature of
			 the person administering the treatment;
(11) documentation on the teaching provided
			 to the member, member's family, or caregiver by the independent nurse on how to
			 manage the member's treatment regimen, any ongoing teaching required due to a
			 change in the procedure or the member's condition and the response to the
			 teaching;
(12) any clinical tests
			 and their results; and
(13) a
			 signed medical records release form.