N.H. Code Admin. R. He-M 517.07 - Documentation

(a) Providers of home and community-based care for persons with developmental disabilities or acquired brain disorders shall maintain the documentation described in (b) -(k) below at the sites where services are provided.

(b) Service coordination records shall include:

(1) Information about the individual that would be essential in case of an emergency, including:

a. Name, address, and telephone number of legal guardian or next of kin; and

b. Medical information, including:

1. Diagnosis(es);

2. Health history;

3. Medications, including dose, frequency, and route;

4. Allergies;

5. Do not resuscitate (DNR) status; and

6. Advance directives;

(2) A copy of each individual's service agreement;

(3) Copies of all service agreement revisions approved by the individual or his/her guardian;

(4) Progress notes on goals for which the service coordinator has primary responsibility;

(5) Monthly documentation by the service coordinator of service coordination activities, including activities promoting community participation and integration;

(6) At least quarterly documentation assessing progress on goals and identifying whether the services:

a. Match the interests and needs of the individual;

b. Met with the individual's and guardian's satisfaction; and

c. Meet the terms of the service agreement;

(7) Copies of all evaluations and reviews by providers and professionals;

(8) Copies of correspondence within the past year with the individual or guardian, service providers, physicians, attorneys, state and federal agencies, family members and others in the individual's life with whom the service coordinator has corresponded; and

(9) Other correspondence or memoranda concerning any significant events in the individual's life.

(c) For services provided in a community residence pursuant to He-M 1001, personal care services documentation shall include:

(1) Individual records, which shall include:

a. Information about the individual that would be essential in case of an emergency, including that information specified in (b) (1) above;

b. The portion of the service agreement pertaining to residential services, with any revisions; and

c. Monthly progress notes;

(2) Community residence daily service provision records, which shall:

a. Be completed by the service provider;

b. Include the date;

c. Indicate each individual's daily presence or absence;

d. If the individual is not present, indicate the date and time of the individual's departure and return, and include the reason for the absence;

e. For those community residences where supervision is less than 24 hours a day, indicate the days in which services were provided; and

f. Be on file at both the community residence and the area agency; and

(3) A daily medication log, which shall be completed at the residence pursuant to He-M 1201.07.

(d) For services provided in a family home pursuant to He-M 521, personal care services documentation shall include:

(1) Individual records, which shall include:

a. Information about the individual that would be essential in case of an emergency, including that information specified in (b) (1) above;

b. The portion of the service agreement pertaining to residential services with any revisions; and

c. Monthly progress notes; and

(2) Daily service provision records, which shall:

a. Be completed by the service provider;

b. Include the date; and

c. Indicate days that services were provided.

(e) For community participation services pursuant to He-M 507, individual records shall include:

(1) A copy of the current service agreement containing:

a. Goals and desired outcomes specific to the individual's participation in community participation services; and

b. The methods or strategies for achieving the individual's community participation services' goals and desired outcomes;

(2) As a guide for planning activities, an individual, week-long, personal schedule or calendar that is created at the time of the annual service planning meeting and, if applicable, identifies:

a. The days, times, and locations of the individual's:

1. Paid employment;

2. Community activities, volunteerism, or internship; and

3. Other regularly recurring activities, such as therapeutic activities related to communication, mobility, and personal care; and

b. The days and approximate times of unspecified community activities, which shall not exceed 20% of the total day service hours the individual receives per week;

(3) A record of daily community participation services activities maintained by the provider agency, which shall include the following:

a. The name(s) of individual(s) served and names of staff supporting them;

b. The dates on which services were provided; and

c. Activities that took place and the locations of the activities;

(4) Narrative progress notes, and other service documentation as specified in the service agreement, recorded at least monthly, and addressing:

a. The individual's community participation services goals and actual outcomes; and

b. Other activities related to the individual's support services, health, interests, achievements, and relationships;

(5) The individual's medical status, including current medications, known allergies, and other pertinent health care information;

(6) Results of any screenings or evaluations including, if applicable:

a. The Supports Intensity Scale (2004 edition), available as noted in Appendix A;

b. Vocational assessments;

c. Results of any assistive technology assessments;

d. The Health Risk Screening Tool (HRST) (2009 edition), available as noted in Appendix A;

e. Systematic, therapeutic, assessment, respite and treatment (START) in-depth assessments and crisis plans; and

f. Risk management plans for individuals who are deemed to pose a risk to community safety; and

(7) For each individual for whom medications are administered during community participation services, medication log documentation pursuant to He-M 1201.07.

(f) Individual records for employment services shall include:

(1) Information about the individual that would be essential in case of an emergency, including that information specified in (b) (1) above;

(2) The portion of the service agreement pertaining to employment services, with any revisions;

(3) Quarterly progress notes regarding services provided and progress toward goals identified in the service agreement;

(4) Weekly work schedules; and

(5) If there is a provider agency staff person with the individual or individuals at the job site:

a. Service provision records, including documentation of the individual's attendance at work; and

b. As needed, notation of any employment-related events apart from each individual's expected work routine.

(g) Respite service records shall include attendance records indicating the dates and duration of the services provided.

(h) Environmental accessibility modifications documentation shall include:

(1) A specific description of the modifications and estimate(s) of cost;

(2) A rationale as to why the requested modification is specifically related to the individual's disability;

(3) The section of the individual's service agreement or IFSP that specifies the need for the modifications; and

(4) The date of completion.

(i) Crisis response documentation shall include:

(1) A brief description of the crisis written by the service coordinator;

(2) An initial summary of the crisis response services proposed;

(3) Monthly progress notes, including a description of the services provided and the individual's response to services; and

(4) Service provision records indicating the units of services provided.

(j) Community support services documentation shall include:

(1) Individual records, which shall include:

a. Information about the individual that would be essential in case of an emergency, including that information specified in (b) (1) above;

b. A service agreement with all approved revisions; and

c. Monthly progress notes; and

(2) Service provision records indicating the units of services provided.

(k) Participant directed and managed services documentation shall include:

(1) Individual records, including:

a. Information about the individual that would be essential in case of an emergency, including that information specified in (b) (1) above;

b. The portion of the individual's service agreement pertaining to participant directed and managed services, with any revisions;

c. Monthly progress notes;

d. Monthly notes describing the family's satisfaction with the services; and

e. Monthly financial statements provided to the individual and family by the area agency or representative; and

(2) Detailed description of all services provided, including:

a. The date;

b. The activity or type of service;

c. The location;

d. The duration; and

e. The provider.

(l) Assistive technology support services documentation shall include:

(1) A brief statement in the service agreement or IFSP describing the need for assistive technology support services;

(2) A report of any evaluation or consultation performed, with recommendations;

(3) A report regarding the nature of the services provided;

(4) Records indicating the dates and units of services provided; and

(5) For lease of assistive technology equipment, a written proposal for the cost of the lease.

(m) Each provider agency shall retain individual records for a period of 7 years following the termination of services to an individual.

Notes

N.H. Code Admin. R. He-M 517.07

#4315, eff 9-25-87; EXPIRED: 9-25-93

New. #6360, eff 10-23-96, EXPIRED: 10-23-04

New. #8195, INTERIM, eff 10-29-04, EXPIRED: 4-27-05

New. #8424, eff 9-1-05; amd by #9370, eff 1-24-09; ss by #10454, eff 10-31-13