Section 17b-262-828 - Documentation and audit requirements(a) Providers shall maintain a specific record for all services rendered for each client eligible for Medicaid payment including, but not limited to: (1) Client's name, address, birth date and Medicaid identification number;(2) Results of the initial evaluation and clinical tests, and a summary of current diagnosis, functional status, symptoms, prognosis and progress to date;(3) The initial plan of care, signed by a physician not more than 30 days after the initial evaluation, that includes the types and frequencies of treatment ordered. The physician shall also sign the plan of care at the time of each periodic review and when the plan of care is updated to reflect any change in the types of service. When a physician signs off on the plan of care, the signature indicates that the plan of care is valid, conducted properly and based on the evaluation;(4) Documentation of each service provided by the clinician, including types of service or modalities, date of service, location or site at which the service was rendered and the start and stop time of the service;(5) The name and credentials of the individual performing the services on that date; and(6) Medication prescription and monitoring.(b) For treatment services, the provider shall document the treatment intervention and progress with respect to the client's goals as identified in the plan of care.(c) For providers licensed under section 19a-495-550 of the Regulations of Connecticut State Agencies, the medical record shall conform to the requirements of section 19a-495-550(k)(2) of the Regulations of Connecticut State Agencies.(d) For providers licensed under section 19a-495-570 of the Regulations of Connecticut State Agencies, the medical record shall conform to the requirements of section 19a-495-570(m)(3) of the Regulations of Connecticut State Agencies.(e) For intermediate care programs a note shall document the duration of each distinct therapeutic session or activity and progress toward treatment goals.(f) For psychological testing, documentation shall include the tests performed, the time spent on the interview, the administration of testing and the completion of the clinical notes.(g) For services performed by an unlicensed individual or a non-certified individual or an individual in training, progress notes entered pursuant to subsection (b) of this section shall be co-signed by the supervisor at least weekly for each client in care and shall contain the name, credentials and the date of such signature. For services provided by a certified individual, evidence of clinical supervision for each client in care shall be documented in the client's chart and shall contain the name, credentials and the date of such signature. The supervisor's signature means that the supervisor attests to having reviewed the documentation.(h) The medication plan shall include instructions for administration for each medication prescribed by a clinic practitioner and a list of other medications that the patient is taking that may be prescribed by non-clinic practitioners.(i) All required documentation shall be maintained in its original form for at least five years or longer by the provider in accordance with applicable statutes or regulations and subject to review by authorized department personnel. In the event of a dispute concerning a service provided, documentation shall be maintained until the end of the dispute, five years or the length of time required by statute or regulation, whichever is longest.(j) Failure to maintain all required documentation shall result in the disallowance and recovery by the department of any amounts paid to the provider for which the required documentation is not maintained or not provided to the department upon request.(k) The department retains the right to audit any and all relevant records and documentation and to take any other appropriate quality assurance measures it deems necessary to assure compliance with these and other regulatory and statutory requirements.(l) All documentation shall be entered in ink or electronically and incorporated into the client's permanent medical record in a complete, prompt and accurate manner.(m) All documentation shall be made available to authorized department personnel upon request in accordance with 42 CFR § 431.107.Conn. Agencies Regs. § 17b-262-828
Effective October 9, 2013