Conn. Agencies Regs. § 17b-262-1004

Current through December 27, 2024
Section 17b-262-1004 - Documentation and audit requirements
(a) Each FQHC shall maintain a specific record for all services provided to each client including, but not limited to: name, address, birth date, Medicaid Identification Number, pertinent diagnostic information, treatment notes signed by the provider, documentation of services provided and the dates on which the services were provided.
(b) For services performed by an LMSW, an unlicensed individual, a non-certified individual or an individual in training, progress notes 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.
(c) Each FQHC shall maintain all required documentation in its original form for at least five years or longer in accordance with statute or regulation, subject to review by authorized departmental personnel. In the event of a dispute concerning a service provided, the provider shall maintain the documentation until the dispute is resolved.
(d) The department may disallow and recover any amounts paid to the provider for which the required documentation is not maintained and not provided to the department upon request.
(e) The department may audit all relevant records and documentation and may take any other appropriate quality assurance measures it deems necessary to assure compliance with all regulatory and statutory requirements.
(f) Notwithstanding the provisions of subsections (a) through (d) of this section, FQHCs may maintain an electronic medical record system such that medical records for all patients treated within the FQHC shall be available to, and shared by, all health professionals.

Conn. Agencies Regs. § 17b-262-1004

Effective May 13, 2015