048-34 Wyo. Code R. §§ 34-20 - Service Documentation Standards

(a) A provider shall document the following information whenever a service is provided:

(i) The location of services;

(ii) The date of service, including year, month, and day;

(iii) The time services begin and end, using either AM and PM or military time, with documentation for each calendar day, even when services span a period longer than one calendar day;

(iv) An initial or signature of the staff member performing the service; and

(v) A detailed description of services provided in accordance with Department standards and requirements.

(b) A provider shall document services electronically or in writing in accordance with Department standards.

(c) Electronic documentation shall have automated tracking of all attempts to alter or delete information that was previously altered.

(d) Electronic documentation shall include electronic signatures and automatic date stamps.

(e) A provider delivering a waiver service requiring electronic visit verification (EVV) shall utilize the Department's EVV system or another operational EVV system that complies with Department policy and federal requirements, including those for the information gathered and verified. Another EVV system may not be used unless it connects to and interacts with the Department's EVV system for integration and billing of waiver services.

(f) A provider shall separately maintain all written or electronic service documentation to support the provision of service, notwithstanding the maintenance of documentation by others for purposes of claims submission.

(g) The provider shall make service documentation, as described in Section 20(a), available to the case manager each month by the tenth (10^th) business day of the month following the date that the services were provided. If services are not provided during a month, the provider shall report that information to the case manager by the tenth (10^th) business day of the following month.

(h) The case manager shall submit service documentation, in a manner established by the Department, by the tenth (10th) business day of the month following the month that the case management service was provided.

(i) The case manager shall maintain a participant's file and service documentation.

(i) The case manager shall assure that all information, including but not limited to guardianship paperwork and physical and mailing addresses of the participant, legal guardian, and other contacts is updated and accurate at all times. The case manager shall notify the Department and other providers of any changes.

(ii) The case manager shall securely store and retain all confidential documentation received from other providers for a twelve (12) month period from the month services were provided, and shall follow safe destruction policies, even if the participant changes case managers.

(iii) The case manager shall document all monitoring and evaluation activities, and follow-up on concerns and actions completed.

(j) All documentation shall be made available to the Department upon request.

(k) A provider or case manager that fails to make documentation available to the Department as required in this Section may receive a corrective or adverse action.

Notes

048-34 Wyo. Code R. §§ 34-20

Adopted, Eff. 1/3/2024.