C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-18, subsec. 144-101-II-18.09

Current through 2024-51, December 18, 2024

Subsection 144-101-II-18.09 - RECORDS

Each provider serving the member must maintain records for each member it serves in accordance with the requirements of Chapter I of the MaineCare Benefits Manual. The member's records are subject to DHHS's review.

The member's records must contain:

A. The member's name, address, birth date, and MaineCare identification number;

B. The member's social and medical history, and diagnoses;

C. The member's Care Plan;

D. The member's most recent Mayo Portland Adaptability Index;

E. A summary of authorized services; and

F. Written progress notes that identify any progress toward the achievement of the goals, identify activities and identify needs established by the member's Care Plan. Written progress notes must be signed and dated by the staff performing the service.

The provider must document each service provided including: the date of each service, the type of service, the activity, the need or goal to which the service relates, the length of time of the service, and the signature of the individual performing the service.

DHHS will conduct a review of provider records that may include, but is not limited to, staff schedules, payroll records and member records to substantiate service delivery and units of authorization.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-18, subsec. 144-101-II-18.09