Or. Admin. Code § 411-048-0200 - Additional Documentation Requirements
(1) The RN must meet the documentation,
record keeping, and communication standards as required by the Department. The
RN who meets the Department's standards remains responsible to also document in
accordance with the Nurse Practice Act. This documentation shall include a
record of all RN delegation as described in OAR
411-048-0180 and the RN's
initial and assessment of the nursing procedures delegated to the individual's
unregulated assistive person.
(2)
The documentation standards in this rule and on the Department approved forms
provided by the Department do not replace or substitute for the documentation
requirements in the:
(a) Rules for
professional nursing standards as prescribed by the OSBN in OAR chapter 851,
divisions 006, 045, and 047;
(b)
Medicaid provider rules governing provider requirements in OAR chapter 407,
division 120; and
(c) As
applicable, the Medicaid General Rules in OAR chapter 410, division
120.
(3) The RN is
expected to complete the Department approved forms specified by the Department
to support the long term care community nursing services in these rules. The
Department may approve the use of alternative but equivalent forms.
(4) The RN must send completed forms to the
case manager prior to or at the time of invoice submission. Documentation must
support the long term care community nursing services billed and adhere to the
timeframes noted in these rules.
(a) An
individual's case manager must receive the required forms and documentation to
pay a claim.
(b) The provider must
submit true, accurate and complete information when billing the Department. Use
of a billing provider does not overrule the performing provider's
responsibility for the truth and accuracy of submitted information.
(c) Authorization or payment by the
department does not restrict or limit the Department, Authority or any state or
federal oversight entity's right to review or audit a claim before or after the
payment.
(d) Failure to comply with
the documentation standards in this rule may result in the determination of
overpayment for which recovery may be sought.
(5) All electronic documentation must be sent
in HIPAA secured format.
(6) The
self-employed RN that is enrolled as a Medicaid provider or an agency enrolled
as a Medicaid provider as described in OAR
411-048-0210 must maintain a
record of all long term care community nursing services provided to each
assigned individual and the individual's caregiver and as required by OAR
410-120-1280 for individuals
served through a Medicaid program.
(a) The
record must include copies of all documentation provided to the local office as
well as any additional documentation the RN or agency maintained to meet OSBN
and Medicaid provider rules.
(b)
The documentation must be retained in an electronic or hard copy format until
the RN or agency no longer provides long term care community nursing services
to the individual, at which time the RN or agency must provide the individual's
case manager a copy of any part of the record not previously
provided.
(c) The RN or agency must
retain original records in hard copy or electronic format for each individual
following Department security and HIPAA practices for a period of seven
years.
Notes
Statutory/Other Authority: ORS 410.070
Statutes/Other Implemented: ORS 410.070
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