Or. Admin. R. 411-415-0110 - Record Requirements
(1) In order
to meet Department and federal record documentation requirements, the CME
through the employees of the CME, must maintain a service record for each
individual who receives services from the CME. The service record must include:
(a) Documentation of the functional needs
assessment defining the support needs for ADL, IADL, and other health-related
tasks. This may be a current ONA available in the Department's electronic
payment and reporting system.
(b)
Documentation of choice advising.
(c) Documentation that the individual is
eligible for any service authorized in an ISP.
(d) Referral information or documentation of
referral materials sent to a provider or another CME.
(e) Progress notes written by a case manager
as described in section (2) of this rule.
(f) The findings from service
monitoring.
(g) Medical
information, as appropriate.
(h)
Entry and exit meeting documentation related to residential programs, including
plans developed as a result of the meeting.
(i) Current and previous ISP or Annual Plan,
including support documents and documentation that the plan is authorized by a
case manager.
(j) A Nursing Service
Plan must be present when Department funds are used to purchase services
requiring the education and training of a licensed professional
nurse.
(k) Copies of any incident
reports initiated by a CME representative for a serious incident.
(l) Documentation of a review of serious
incidents received from providers. Documentation of the review of serious
incidents must be made in CAM, for a CME certified as a CAM user, and progress
notes and a copy of the incident report must be maintained by the
CME.
(m) Documentation of Medicaid
eligibility, if applicable.
(n) For
individuals whose level of care was determined before July 1, 2018, the initial
and, when present, the annual level of care determination on a form prescribed
by the Department.
(o) The CDDP
must maintain a copy of the initial level of care determination form completed
by the CDDP. For an individual whose level of care was determined before July
1, 2018 and is receiving CIIS or services in a 24-hour residential program for
children, the CDDP must maintain a copy of annual level of care determinations
or maintain documentation of attempts to obtain them.
(p) Legal records, such as guardianship
papers, civil commitment records, court orders, and probation and parole
information (as appropriate).
(q) A
case manager must maintain documentation of the referral process of an
individual to a provider and if applicable, include the reason the provider
preferred by the individual declined to deliver services to the
individual.
(r) An information
sheet or reasonable alternative must be kept current and reviewed at least
annually for each individual receiving case management services. Information
must include:
(A) The name of the individual,
current address, date of entry into the CME, date of birth, gender, marital
status (for individuals 18 or older), religious preference, preferred hospital,
medical prime number and private insurance number (where applicable), and
guardianship status; and
(B) The
name, address, and telephone number of:
(i)
For an adult, the legal or designated representative, family, and other
significant person of the individual (as applicable), and for a child, the
parent or guardian and education surrogate (if applicable);
(ii) The primary care provider and clinic
preferred by the individual;
(iii)
The dentist preferred by the individual;
(iv) The school, day program, or employer of
the individual (if applicable);
(v)
Other agency representatives providing services to the individual;
and
(vi) Any court ordered or legal
representative authorized contacts or limitations from contact for individuals
living in a foster home, supported living program, or 24-hour residential
program.
(2) PROGRESS NOTES. Progress notes must
include documentation of the delivery of case management services provided to
an individual by a case manager. Progress notes must be recorded
chronologically in the order they are made and documented consistent with CME
policies and procedures. All late entries must be appropriately noted as such.
At a minimum, progress notes must include:
(a)
The month, day, and year the services were rendered and the month, day, and
year the entry was made if different from the date services were
rendered;
(b) The name of the
individual receiving service;
(c)
The name of the CME, the person providing the services (i.e., the signature and
title of the case manager), and the date the entry was recorded and
signed;
(d) The nature and content
of the case management services delivered and whether goals specified in the
service plan have been achieved;
(e) Place of service. Place of service means
the county where the CME or agency providing case management services is
located, including the main address. The place of service may be a standard
heading on each page of the progress notes; and
(f) For notes pertaining to meetings with or
discussions about the individual, the names of other participants, including
the titles and agency representation of the participants, if any.
(3) For individuals living in
their own or family home, the CME must maintain a minimum acceptable record of
expenditures for at least three years that includes:
(a) Itemized invoices and receipts to record
the purchase of any single item.
(b) A trip log indicating purpose, date, and
total miles to verify vehicle mileage reimbursement.
(c) Pay records to record employee services,
including timesheets signed by both employee and employer.
(d) Itemized invoices for any services
purchased from independent contractors, provider agencies, and professionals.
Itemized invoices must include:
(A) The name
of the individual to whom services were provided;
(B) The date of the services;
(C) The amount of services; and
(D) A description of the services.
(e) Evidence confirming the
receipt, and securing the use of, assistive devices, environmental safety
modifications, and environmental modifications.
(A) When an assistive device is obtained for
the exclusive use of an individual, the CME must record the purpose, final
cost, and date of receipt.
(B) The
CME must secure use of equipment or furnishings costing more than $500 through
a written agreement between the CME and the individual or the legal
representative of the individual that specifies the time period the item is to
be available to the individual and the responsibilities of all parties if the
item is lost, damaged, or sold within that time period.
(4) Verification that providers
meet the requirements to deliver services they are authorized to deliver
including:
(a) Verification of a valid
license to drive for any personal support worker, and proof of current auto
insurance for the vehicle used for transportation, upon authorization of
community transportation services.
(b) Documentation supporting the rate paid to
a provider when it is above the minimum described in rule, policy, Expenditure
Guidelines, or the base rate for a personal support worker identified in the
current Collective Bargaining Agreement, including support for an enhanced and
an exceptional personal support worker rate.
(5) Failure to furnish written documentation
upon the written request from the Department, the Oregon Department of Justice
Medicaid Fraud Unit, Centers for Medicare and Medicaid Services, or their
authorized representatives, immediately or within timeframes specified in the
written request, may be deemed reason to recover payments or deny further
assistance.
Notes
Statutory/Other Authority: ORS 409.050, 427.104, 427.105, 427.115, 427.154, 430.662 & 430.731
Statutes/Other Implemented: ORS 427.007, 427.104, 427.105, 427.115, 427.121, 427.154, 427.160, 430.212, 430.215, 430.610, 430.620, 430.662, 430.664 & 430.731-430.768
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