Section 458.414 - Recordkeeping Requirements(A)Protection of Personal Health Information. The medical respite provider must abide by all applicable laws relating to privacy and data security, including but not limited to the federal Health Information Portability and Accountability Act, and must obtain a Release of Information document from each member or the member's legal guardian to release information obtained by the provider when necessary, as required by such laws.(B)Member Records. (1) The medical respite provider must maintain member records in accordance with 130 CMR 450.000: Administrative and Billing Regulations, and, where appropriate, share the member records with other health care providers, including other medical respite providers.(2) Member records must be complete, accurate, and properly organized.(3) At a minimum, member records must include: (a) member demographics including the member's name, date of birth, and MassHealth identification number or other insurance identification information. Additional member demographic elements shall be requested and documented, if provided, including member contact information, gender identity, race, ethnicity, disability status, sexual orientation, marital status, language spoken, emergency contact, and the events precipitating the member's referral to the medical respite program;(b) Documentation that the member receiving services meets the member eligibility criteria;(c) Documentation of assessments conducted by staff to determine member needs, including relevant medical, psychosocial, educational, and vocational history;(d) The member's individualized care plan, along with any updates, and documentation of related care planning meetings;(e) Written record of all medical respite services, including clinical, case management and intensive housing navigation services provided to each member, including face-to-face, virtual, and collateral contacts, identification of the staff person(s) responsible for providing these services to the members, applications for programs or services completed, including housing applications and other state agency applications, and progress notes;(f) Reports on all collateral consults and collaborations with family, friends, and outside professionals involved in the member's treatment;(g) All information and correspondence to and from other involved agencies, including appropriately signed and dated Release of Information forms;(h) If discharged, a discharge summary, including a summary of the member's services, a brief summary of the member's condition and response to services on discharge, achievement of goals, and housing plans.(C)Program Records. The medical respite provider must maintain documentation reflecting compliance with the requirements of 130 CMR 458.000, including 130 CMR 458.403.(D)Other Records and Reports as Directed by EOHHS. The program must maintain other records and reports as directed by EOHHS.(E)Availability of Records. Any and all records must be made available to the MassHealth agency upon request.(F) The medical respite provider must ensure that for any services delivered through a subcontractor, the subcontractors meet the recordkeeping requirements in 130 CMR 458.414.(G) The medical respite provider must ensure that they have processes in place to receive information securely and regularly from any entities it may partner with for the purposes of 130 CMR 458.404(B) or (D).Adopted by Mass Register Issue 1538, eff. 1/3/2025.