N.H. Admin. Code § He-E 502.15

Current through Register No. 50, December 12, 2024

Section He-E 502.15 - Service Records

(a) Contract agencies shall maintain a service record for all individuals receiving one or more Title III services except as provided in (h) below.

(b) The service record shall contain:

(1) The individual's name, address, and telephone number;

(2) A notation that the individual meets the eligibility requirements for services as described in He-E 502.05;

(3) An annual notation of the decision to recertify or terminate services as described in He-E 502.08;

(4) Notation of the following:

a. The name of the Title III service(s) being provided and the type of service activities, based on the service description contained in this rule;

b. The dates of service provision and the number of service units provided;

c. Identification of the individual's communication access needs, including type and modality, and the name of the communication access provider or type of device utilized, if applicable; and

d. Any other information or correspondence deemed relevant to service provision; and

(5) The service authorization as described in He-E 502.14(a), if applicable.

(c) The following services shall require additional documentation in the service record:

(1) Adult in-home care services;

(2) Home health aide services;

(3) Homemaker services;

(4) Nursing services; and

(5) Nutrition services: home delivered meals.

(d) The additional documentation specified in (c) above shall include:

(1) A copy of the notice of decision for the provision of service(s) as described in He-E 502.07, as applicable;

(2) The name and telephone number of a person who may be contacted in an emergency;

(3) The name, address, and telephone number of the individual's primary caregiver, if applicable;

(4) The name and telephone number of the individual's licensed practitioner, if applicable;

(5) Documentation of changes in the individual's health or other circumstances affecting service provision;

(6) A copy of any termination notification(s) to the individual and BEAS as described in He-E 502.09, if applicable, or a notation that the individual voluntarily terminated services;

(7) The person-centered plan as described in He-E 502.17;

(8) The dates upon which service(s) will begin and end;

(9) The planned frequency of the service(s);

(10) The total number of service units that will be provided on each date of service, if appropriate; and

(11) Copies of all executed legal directives provided to the contract agency, such as guardianship orders for health care under RSA 464-A, a durable power of attorney or a living will, or any advanced directives under RSA 137-J.

(e) Contract agencies providing adult day program services shall be required to comply with all documentation requirements as described in He-P 818, in addition to the requirements outlined in He-E 502.15(b).

(f) Service records shall be kept confidential in accordance with He-E 502.03 and all applicable federal and state laws and regulations.

(g) Service records shall be retained for a period of 4 years after services have ended or have been terminated.

(h) No service record shall be required for individuals receiving only group educational or walk-in services, or telephone services as described in He-E 502.25 Legal Services.

N.H. Admin. Code § He-E 502.15

(See Revision Note at part heading for He-E 502) #10530, eff 2-28-14

Amended by Volume XLII Number 14, Filed April 7, 2022, Proposed by #13354, Effective 3/19/2022, Expires 3/19/2032