Conn. Agencies Regs. § 17b-262-604

Current through December 27, 2024

Section 17b-262-604 - Documentation requirements

Early intervention services shall be paid by the department only when the lead agency ensures compliance of the following documentation requirements on file with the performing provider, as appropriate:

(a)Evaluation

(1) A copy of the evaluation report which shall meet the requirements of Part H of IDEA, Title 20 USC 1471 et seq., Title 20 USC section 1477(a), and at Title 34 CFR, Part 303, subdivision (1) of subsection (b) of section 303.322, shall be on file, recommending the specific medical diagnosis or diagnoses according to the International Classification of Diseases (ICD) in a form and manner specified by the department, and signed by all members of the evaluation team.

(2) The evaluation shall include:

(A) for eligible Birth to Three children, a signature on a form and manner to be specified by the department, by the physician who recommended the evaluation and stated diagnosis or diagnoses; which authorizes the development of the IFSP, and

(B) for ineligible children, a signature by a physician within forty-five days of the date the evaluation was completed and signed.

(b)Assessment

(1) A copy of the assessment which shall meet the requirements of Part H of IDEA, Title 20 USC 1471 et seq., Title 20 USC, section 1477(a), and at Title 34 CFR, Part 303, subdivisions (1) and (2) of subsection (a) of section 303.322 and subdivision (2) of subsection (b) of section 303.322, shall be on file.

(2) The assessment shall be a multidisciplinary team assessment of the child's and child's family's unique needs and the identification of services appropriate to meet such needs.

(3) The written assessment report shall be signed by all members of the multidisciplinary team recommending the type of services appropriate for the child as listed in the IFSP.

(4) If any member of the multidisciplinary team does not attend the IFSP meeting, that member shall provide a written report regarding recommended services appropriate to their scope of practice.

(c)Individualized Family Service Plan (IFSP)

(1) The IFSP shall meet the requirements of Part H of IDEA, Title 20 USC 1471 et seq., Title 20 USC, section 1477(b), (c), and (d), and at Title 34 CFR, Part 303, sections 303.340 through 303.346, and be provided in accordance with the Birth to Three eligible child's service page as delineated in the IFSP. The IFSP shall be evaluated not less than once a year and the family shall be provided a review of the plan at six month intervals, or more often where appropriate, based on infant and toddler and family needs.

(2) At a minimum, the IFSP shall:

(A) be developed by the multidisciplinary team, of which the service coordinator shall be a member, within forty-five days of referral for early intervention services and indicate that the Birth to Three eligible child, his or her family or their representative has participated in, or been given the opportunity to participate in, the development of the child's plan of services service page of the IFSP;

(B) include a signature by a physician functioning within his or her scope of practice as defined in state law recommending the diagnostic and treatment services contained in the IFSP and the ICD diagnosis code. The physician shall sign the document within forty-five days of the date the IFSP was completed and signed by the parent;

(C) be based on an assessment of a Birth to Three eligible child's and child's family's needs which include, but are not limited to, assessments of medical, clinical, social, educational, or other needs;

(D) include a statement of the major outcomes expected to be achieved for the Birth to Three eligible child and the family, and the criteria, procedures, and timelines used to determine the degree to which progress toward achieving the outcomes is being made and whether modifications or revisions of the outcomes or services are necessary;

(E) include a statement of specific early intervention services necessary to meet the unique needs of the Birth to Three eligible child and the family, including the frequency, intensity, and the method of delivering services;

(F) include the name of the service coordinator from the profession most immediately relevant to the Birth to Three eligible child's or family's needs who shall be responsible for the implementation of the plan and coordination with other agencies and persons;

(G) include the steps to be taken supporting the transition of the Birth to Three eligible child to other appropriate services; and

(H) develop and implement an interim IFSP for a Birth to Three eligible child whose developmental status requires early intervention services while the evaluation and assessment are being completed such as a Birth to Three eligible child discharged from a hospital and who needs immediate continuation of care. Interim IFSPs may be developed and implemented if written parental consent is obtained, the name of the service coordinator and the early intervention services that are needed immediately for the child and the child's family are included in the interim IFSP, and the initial evaluation is completed within forty-five days after the performing provider receives the referral.

(d)Progress Notes

(1) Progress notes shall be kept in a form and manner as specified by the department. They shall provide a comprehensive treatment narrative of the contacts with the child and family throughout the month, highlighting activities, nature and extent of the contacts, and relationship of activities to the medical necessity and medical appropriateness of the early intervention services in relation to the outcomes specified in the evaluation, assessment reports, and the service page as delineated in the IFSP.

(2) Any changes or differences in treatment shall be noted and related to the dates of services. Any increases in services shall meet signature requirements contained in these regulations. If a child is seen more than once during the same week, a summary and progress note for the month is acceptable if any changes in progress or treatment are documented each time they occur with the specific date that they occurred. The progress notes at a minimum shall:

(A) include a summary of progress made according to the IFSP;

(B) include a summary statement of service delivered noting any significant changes in the child's condition;

(C) be kept by the performing provider or the state agency in a form and manner to be determined, as specified by the department; and

(D) include the signature of the AHP providing the service.

(e)Medical Expertise

(1) Records of services provided by individuals who are AHPs but do not have a scope of practice defined by state law, such as a special education teacher, shall include written documentation of the involvement of a licensed practitioner of the healing arts in the delivery of service.

(2) Except for service coordination, the documentation required by this subsection shall be updated and signed, and in the child's early intervention record at least quarterly. This documentation shall include:

(A) identifying information about the child;

(B) the name of the AHP; and

(C) a signed statement by a licensed practitioner of the healing arts who shall be a member of the multidisciplinary team.

(f)Early Intervention Record

(1) An early intervention record for a child eligible for the Birth to Three System shall be maintained as provided by these regulations. At a minimum, the record shall contain the following:

(A) the initial written referral, all evaluations, all assessments, and reassessments, as necessary, to determine needed services;

(B) the Birth to Three eligible child's name, date of birth, address, social security or medical assistance number, and other relevant historical and financial information;

(C) all IFSPs;

(D) a statement by a physician recommending diagnostic or treatment services;

(E) all records of actual service delivery indicating the dates of service, type of service, location of service, units of service, and dated signature of the individual AHP providing the service;

(F) all records of service entries of service coordination indicating the date, place of service, the name of the service coordinator, and type of ongoing service coordination provided, and a signature, by an AHP, confirming monthly data; and

(G) a transition plan, as appropriate, and an exit form.

(2) For a child who is determined ineligible for the Birth to Three System, the early intervention record shall include at a minimum:

(A) a written review of the diagnostic services by a physician;

(B) the ineligible child's name, date of birth, address, social security or medical assistance number, and other relevant historical and financial information; and

(C) all evaluations and ICD code.

(g)Other Documentation Requirements

(1) A contract establishing the independent provider as a Birth to Three performing provider for a particular type of service at a particular rate shall be available and include the following:

(A) any relevant terms and conditions associated with being a Birth to Three performing provider including the agreement not to bill the Medical Assistance Program for these services provided to Birth to Three children; and

(B) the performing provider shall be responsible for the development, maintenance, and monitoring of current and updated lists of the names and credentials of all employed and contracted Birth to Three performing providers and their employees, and the effective dates they were eligible to provide Birth to Three services. The list shall:

(i) include the performing provider's certification number, license number, and the Medical Assistance Program number, if applicable; and

(ii) be kept by the performing providers, in a central location, and be available upon request to authorized persons such as the Health Care Financing Administration (HCFA) or the department.

(2) The billing provider may choose to require performing providers which employ more than twenty people qualified to provide services under the contract, when contracted for service provision, to maintain and update the necessary list of persons providing services, their credentials, and their Medical Assistance Program billing number if they are enrolled with the Medical Assistance Program as a billing provider. A statement to this effect shall be part of the contract between the billing provider and the performing provider and shall be signed and dated:

(A) the contract shall also provide for the transfer of employee lists, should the organization subsequently go out of business; and

(B) each state agency shall be responsible for maintaining the licensure and certification document on each state employee providing direct service in the Birth to Three System.

(3) The performing provider shall be responsible for maintaining fiscal and medical records which fully disclose services and goods rendered or delivered to all persons receiving services in the Birth to Three System:

(A) these records and information shall be made available to authorized representatives of the department and billing provider upon request;

(B) all documentation shall be entered in ink and incorporated into the early intervention record in a complete, prompt, and accurate manner; and

(C) all documentation shall be made available to authorized department personnel upon request in accordance with Title 42 CFR, Part 431, section 431.17.

(4) The procedural safeguards required by Part H of IDEA, Title 20, USC 1471 et seq., Title 20. USC, section 1480, and specifically Title 34 CFR, Part 303, section 303.400 et seq., shall be developed and implemented by the lead agency. In addition to these safeguards, any child who is a Birth to Three eligible child and is also a Medical Assistance Program client may avail themselves of the department's fair hearing process pursuant to section 17b-60 of the Connecticut General Statutes.

Conn. Agencies Regs. § 17b-262-604

Effective August 28, 1998