Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part II - Long-Stay Acute Care Hospitals › Section 12VAC30-130-110 - Documentation requirements

Current through Register Vol. 40, No. 24, July 15, 2024
A. Services
				  not specifically documented in the resident's medical record as having been
				  rendered shall be deemed not to have been rendered and no coverage shall be
				  provided.
B. The long-stay acute
				  care hospital shall maintain and retain the business and professional records
				  sufficient to document fully and accurately the nature, scope, and details of
				  the health care provided. Such records shall be retained for a period of not
				  less than five years from the date of service or as provided by applicable
				  state laws, whichever period is longer, except that, if an audit is initiated
				  within the required retention period, the records must be retained until the
				  audit is completed and every exception resolved.
C. The following documentation must be
				  maintained in the resident's medical record:
1. Each record must identify the resident on
				  each page.
2. Entries must be
				  signed and dated (month, day, and year) by the author, followed by professional
				  title. Care rendered by personnel under the supervision of the provider, which
				  is in accordance with Medicaid policy, must be countersigned by the responsible
				  licensed participating provider.
3.
				  The attending physician must certify at the time of admission that the resident
				  requires long-stay acute hospital care and meets the criteria as defined by
				  DMAS.
4. The record must contain a
				  preliminary working diagnosis and the elements of a history and physical
				  examination upon which the diagnosis is based.
5. All services provided, as well as any
				  treatment plan, must be entered in the record. Any drugs prescribed and
				  administered as part of a physician's treatment plan, including the quantities,
				  route of administration, and the dosage must be recorded.
6. The record must indicate the resident's
				  progress, any change in diagnosis or treatment, and the response to the
				  treatment. The documentation must include in detail all treatment rendered to
				  the resident in accordance with the plan with specific attention to frequency,
				  duration, modality, response to treatment, and identify who provided such
				  treatment.
7. Physician progress
				  notes must be written at least weekly and must reflect that the resident has
				  been examined by the physician.
8.
				  A comprehensive nursing assessment must be made by a registered nurse at the
				  time of admission to the facility. Nursing care plans based on an admission
				  assessment must be resident-specific and must indicate realistic nursing needs,
				  measurable goals, and specifically state the method by which the goals are to
				  be accomplished. They must be updated as needed, but at least monthly. Nursing
				  summaries, in addition to the p.r.n. (as needed) notes, are required weekly.
				  Nursing summaries must give a current, written picture of the resident, the
				  resident's nursing needs, the care being provided, and the resident's response
				  to treatment. The nursing summary at a minimum must address the following:
				  medical status; functional status in activities of daily living, elimination,
				  mobility, and emotional/mental status; special nursing procedures; and
				  identification and resolution of acute illnesses or episodes.
9. Social services documentation must include
				  a social evaluation and history and a social services plan of care including a
				  discharge plan. The social work plans of care must be resident-specific and
				  include measurable goals with realistic time frames. Social work plans of care
				  must be updated as needed and at least monthly every 30 days. Social services
				  progress notes must be written at least every 30 days.
10. Activities documentation must be based on
				  a comprehensive assessment completed by the designated activity coordinator. An
				  activity plan of care must be developed for each resident and must include
				  consideration of the individual's interests and skills, the physician's
				  recommendations, social and rehabilitation goals, and personal care
				  requirements. Individual and group activities must be included in the plan. The
				  activity plan of care must be updated as needed but at least every 30 days.
				  Activity progress notes must be written at least every 30 days. Therapeutic
				  leisure activities must be provided daily.
11. Rehabilitative therapy (physical and
				  occupational therapy or speech-language services) or other health care
				  professional (psychologist, respiratory therapist, etc.) documentation must
				  include an assessment completed by the qualified rehabilitation professional. A
				  plan of care developed specific to the resident must be developed and must
				  include measurable goals with realistic time frames. The plan of care must be
				  updated as needed but at least every 30 days. Rehabilitative therapy or other
				  health care professional progress notes must be written at least every 30
				  days.
12. Each resident's record
				  must contain a dietary evaluation and plan of care completed by a registered
				  dietician. The plan of care must be resident-specific and must have measurable
				  goals within realistic time frames. The plan of care must be updated as needed,
				  but at least every 30 days. The dietary assessment and monthly plans of care
				  must be completed by a registered dietician. Dietary progress notes must be
				  written at least every 30 days.
13.
				  A coordinated interdisciplinary plan of care must be developed for each
				  resident. The plan of care must be resident-specific and must contain
				  measurable goals within realistic time frames. Based on the physician's plan of
				  care, the interdisciplinary team should include, but is not necessarily limited
				  to, nurses, social workers, activities coordinators, dieticians, rehabilitative
				  therapists, direct care staff, and the resident or responsible party. At a
				  minimum, the interdisciplinary team must review and update the
				  interdisciplinary plan of care as needed but at least every 30 days. The
				  interdisciplinary plan of care review must identify those attending the
				  meeting, changes in goals and approaches, and progress made toward meeting
				  established goals and discharge.
14. For residents age 21 and younger, the
				  record must contain documentation that educational or habilitative services are
				  provided as required. The documentation shall include an evaluation of the
				  resident's educational or habilitative needs, a description of the educational
				  or habilitative services provided, a schedule of planned programs, and records
				  of resident attendance. Educational or habilitative progress notes shall be
				  written at least every 30 days.