N.H. Admin. Code § He-W 513.10

Current through Register No. 45, November 7, 2024

Section He-W 513.10 - Documentation

(a) With the exception of peer recovery programs, SUD treatment and recovery support services providers shall maintain supporting records, in accordance with He-W 520 and (b) - (f) below.

(b) Supporting documentation shall include:

(1) A complete record of all physical examinations, laboratory tests, and treatments including drug and counseling therapies, whether provided directly or by referral;

(2) A progress note for each treatment session, including:

a. The treatment modality and duration;

b. The signature of the primary therapist for each entry;

c. The primary therapist's professional discipline; and

d. The date of each treatment session; and

(3) A copy of the treatment plan that is:

a. Updated at least every 4 sessions or 4 weeks, whichever is less frequent;

b. Signed by the provider and the recipient prior to treatment being rendered; and

c. Signed by the clinical supervisor, prior to treatment being rendered, if the service is an outpatient or comprehensive SUD program.

(c) The recipient's individual record shall include at a minimum:

(1) The recipient's name, date of birth, address, and phone number; and

(2) A copy of the evaluation described in He-W 513.05(u) (2) .

(d) SUD providers that close their treatment and recovery support programs shall arrange for continued management of all medicaid recipient records as follows:

(1) The provider shall notify the department in writing of the address where records will be stored;

(2) The provider shall specify to the department the person who will be managing the records and the person's contact information; and

(3) The provider shall arrange for storage of each record through one or more of the following measures:

a. The provider shall continue to manage the records and give written assurance to the department that it will respond to authorized requests for copies of client records within 10 working days;

b. The provider shall transfer records of clients who have given written consent to another medicaid enrolled provider; or

c. The provider shall enter into an agreement with a medicaid enrolled provider to store and manage records.

(e) All electronic or written documentation shall be legible and written in English.

(f) The SUD treatment and recovery support services provider shall provide documentation to the department upon request.

(g) Peer recovery programs shall maintain supporting records in accordance with He-W 520 and (d), (e), and (f) above, and shall include the following supporting documentation:

(1) . Progress on goals for each recovery contact including:

a. The type of support received and duration;

b. The topics addressed with the recipient;

c. The signature of the person delivering services; and

d. The date of each recovery contact;

(2) Where applicable, a copy of the recovery plan that is:

a. Updated a every session; and

b. Signed by the provider and the recipient prior to services being rendered; and

(3) The recipient's name, date of birth, address, and phone number.

N.H. Admin. Code § He-W 513.10

#10655, INTERIM, eff 8-15-14, EXPIRES: 2-11-15

Amended byVolume XXXV Number 06, Filed February 12, 2015, Proposed by #10774, Effective 1/27/2015, Expires7/27/2015.

Amended by Volume XXXV Number 36, Filed September 10, 2015, Proposed by #10922, Effective 9/1/2015, Expires9/1/2025.

Amended by Volume XXXVI Number 23, Filed June 9, 2016, Proposed by #11107, Effective 7/1/2016, Expires 7/1/2026.

Amended by Volume XXXVIII Number 50, Filed December 13, 2018, Proposed by #12681, Effective 11/27/2018, Expires 11/27/2028.