Section 17b-262-858 - Documentation and record retention requirements(a) Providers shall comply with the following documentation and record retention requirements:(1) An initial rehabilitation plan and all updated versions, including the current plan, shall be maintained.(2) All rehabilitation service providers are required to develop a rehabilitation plan that meets the requirements of section 17a-20-42 of the Regulations of Connecticut State Agencies, except as provided for under subsection 17b-262-851(7) of the Regulations of Connecticut State Agencies. The rehabilitation plan shall include a medication plan, if the rehabilitation service includes medication management. The medication plan shall include an order and instructions for administration for each medication prescribed by a provider staff member and a list of other medications that the individual is taking that may be prescribed by non-clinic practitioners.(3) A case record that meets the requirements of section 17a-20-54 of the Regulations of Connecticut State Agencies, shall be maintained and shall include, at a minimum: identifying information; social and health history; the reason for admission to the rehabilitation program; copies of the initial and all subsequent orders for rehabilitation services; the rehabilitation plan; identification of the care and services provided; a current list of all medications; and the plan for discharge and disposition of the individual. This case record requirement applies to all providers of rehabilitation services for individuals, not just to DCF-licensed psychiatric clinics that are subject to section 17b-20-54 of the Regulations of Connecticut State Agencies.(4) Encounter notes shall be maintained for each rehabilitative service provided. The notes shall include the service rendered; actual time the service was rendered; location of service; the goal and objective that is the focus of the intervention; a general description of the content of the intervention to provide evidence that it is a rehabilitative service, as described in section 17b-262-854 of the Regulations of Connecticut State Agencies; and the individual's response to the intervention. Encounter notes shall be signed and dated and shall indicate the credentials of the staff member who provided the service.(5) For EDT programs the encounter notes shall document the duration of each distinct therapeutic session or activity and progress toward treatment goals.(6) For the purpose of documenting the supervision of services provided by unlicensed direct care staff, licensed clinical staff shall document in the case record that they have reviewed the encounter notes corresponding to services provided by such unlicensed direct care staff at least once every 30 days. Documentation shall include the signature and credentials of the licensed clinical staff that reviewed the encounter notes.(b) Other documentation and record retention requirements: (1) The provider shall maintain a current record of the applicable licenses and certificates of practice of all licensed or certified persons furnishing rehabilitation services.(2) The provider shall be substantially in compliance with all documentation requirements in its most recent licensure review and relevant state agency quality assurance reviews.(3) The provider shall maintain all required records for at least five years or longer as required by statutes or regulation. All required records shall be subject to review by the department. In the event of a dispute concerning a service provided, documentation shall be maintained until the end of the dispute or five years, whichever is longer.(4) All documentation shall be recorded in the eligible individual's case record in a complete, prompt and accurate manner. All documents shall be made available to authorized personnel of the department upon request.(5) 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 and not provided to the department upon request.Conn. Agencies Regs. § 17b-262-858
Effective February 2, 2012