N.H. Admin. Code § He-M 522.13

Current through Register No. 50, December 12, 2024

Section He-M 522.13 - Record Requirements for Area Agencies

(a) Service coordinators or their designees shall maintain a separate record for each individual who receives services and ensure the confidentiality of information pertaining to the individual, including:

(1) Maintaining the confidentiality of any personal data in the records;

(2) Storing and disposing of records in a manner that preserves confidentiality; and

(3) Obtaining a release of information pursuant to He-M 522.04(f) prior to release of any part of a record to a third party.

(b) An individual's record shall include:

(1) Personal and identifying information, including the individual's:

a. Name;

b. Address;

c. Date of birth; and

d. Telephone number;

(2) All information used to determine eligibility for services pursuant to He-M 522.05, He-M 522.06 and He-M 522.07;

(3) Information about the individual that would be essential in case of an emergency, including:

a. The name, address, and telephone number of the legal guardian or next of kin or

other person to be notified;

b. The names, addresses, and telephone numbers of current service providers;

c. Medical information, including the individual's:

1. Diagnosis(es);

2. Health history;

3. Allergies;

4. Do not resuscitate (DNR) orders, as appropriate; and

5. Advance directives, as determined by the individual;

(4) Copies of correspondence within the past year with the individual and guardian, service providers, physicians, attorneys, state and federal agencies, family members, and others in the individual's life;

(5) Other correspondence or memoranda concerning any significant events in the individual's life; and

(6) Information about transfer or termination of services, as appropriate.

(c) All entries made into an individual record shall be legible and dated and have the author identified by name and position.

(d) In addition to the documentation requirements identified in He-M 522, each area agency shall comply with all applicable documentation requirements of other bureau rules.

(e) Each area agency shall:

(1) Retain records supporting each Medicaid bill for a period of not less than 6 years; and

(2) Retain an individual's social history, medical history, evaluations, and any court-related documentation for a period of not less than 6 years after termination of services.

(f) For those receiving Medicaid home- and community-based care services, the record shall additionally contain, as applicable, a copy of:

(1) The individual's current service agreement;

(2) All service agreement amendments;

(3) Progress notes on goals and support services provided as identified in the service agreement;

(4) All service coordination contact notes and quarterly assessments pursuant to He-M 522.12(g) (2) -(4) ; and

(5) Evaluations and reviews by providers and professionals.

N.H. Admin. Code § He-M 522.13

#7120, eff 10-20-99; ss by #8974, INTERIM, eff 10-6-07, EXPIRED: 4-3-08

New. #9734, eff 6-25-10

The amended version of this section by New Hampshire Register Volume 38, Number 50, eff. 11/30/2018 is not yet available.