N.J. Admin. Code § 10:77-5.12 - Recordkeeping; beneficiary information

Current through Register Vol. 54, No. 7, April 4, 2022

(a) Each provider entity shall maintain all beneficiary records in compliance with appropriate State law and rules (see 10:49-9.8 ).
(b) Providers shall keep such individual and legible records as are necessary to fully disclose the nature and extent of the services provided in accordance with all applicable Federal and State requirements.
(c) Providers shall make the records described in (a) and (b) above available to the Department of Human Services, the Division of Medical Assistance and Health Services, the Division of Mental Health and Addiction Services, the Department of Children and Families, the Children's System of Care, the Division of Child Protection and Permanency, the contracted system administrator, or other authorized State agents, as requested.
(d) Providers shall maintain the following data in support of all intensive in-community mental health rehabilitation services claims:
1. The name and address of the beneficiary;
2. The name and credentials of the person(s) providing the service;
3. The exact date(s), location(s) and time(s) of service;
4. The type of the service(s) provided; and
5. The length of face-to-face contact, excluding travel time to or from the location of the beneficiary contact.
(e) The provider shall maintain an individual service record for each child, youth or young adult which shall contain, at a minimum, the following information:
1. The dates of service and number of care hours, per level of service, received;
2. The diagnosis provided with the initial referral;
3. The reason for initial referral and involvement;
4. The individual plan of care, including any amendments;
5. Documentation of any and all crisis or emergency situations that occur during the provision of the services, including a summary of corrective action taken and resolution of the situation; and
6. For each discrete contact with the child/family, progress notes which address the defined goals stipulated in the child/youth or young adult's plan of care must be completed.
(f) All providers shall meet all Management Information Systems specifications as provided by the CSA or other Department of Human Services or Children and Families-designated agent.

Notes

N.J. Admin. Code § 10:77-5.12
Amended by 48 N.J.R. 81(a), effective 1/4/2016

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