Section 414.417 - Recordkeeping Requirement and Utilization Review(A) The record maintained by an independent nurse for each member must conform to 130 CMR 450.000: Administrative and Billing Regulations. Payment for any service listed in 130 CMR 414.000 requires full and complete documentation in the member's medical record. The independent nurse must maintain records for each member to whom nursing services are provided.(B) In order for a medical record to completely document a service to a member, the record must disclose fully the nature, extent, quality, and necessity of the nursing services furnished to the member. When the information contained in a member's record does not provide sufficient documentation for the service, the MassHealth agency may disallow payment (see 130 CMR 450.000: Administrative and Billing Regulations).(C) The independent nurse must submit requested documentation to the MassHealth agency or its designee for purposes of utilization review and provider review and audit, within the MassHealth agency's or its designee's time specifications. The MassHealth agency or its designee may periodically review a member's plan of care and other records to determine if services are medically necessary in accordance with 130 CMR 414.409(C). The independent nurse must provide the MassHealth agency or its designee with any supporting documentation the MassHealth agency or its designee requests, in accordance with M.G.L. c. 118E, § 38 and 130 CMR 450.000: Administrative and Billing Regulations.(D) The independent nurse must maintain an up-to-date medical record of nursing services provided to each member that must be reviewed by the independent nurse at least monthly. The medical record must contain at least the following:(1) the member's name, address, phone number, date of birth, and MassHealth ID number;(2) the name and phone number of the member's primary care physician;(3) the primary natural caregiver's name, address, phone number, and relationship to member;(4) the name and phone number of the member's emergency contact person;(5) a copy of the approved prior authorization decision;(6) a copy of the plan of care signed by the member's physician and, if appropriate, verbal orders signed by the physician;(7) a medical history as defined in 130 CMR 414.402;(8) accessible and legible nursing progress notes for each visit, signed by the independent nurse, that include the following information:(a) the full date of service and time that each visit began and ended;(b) all treatments and services ordered by the physician or ordering non-physician practitioner that are included in the member's plan of care, as well as documentation of the treatments and services that were provided during the visit and the member's response;(c) any additional treatment or service that is not included in the member's plan of care provided, as well as the member's response, including documentation of medication administration as described in 130 CMR 414.417(D)(9);(d) any service or treatment the member may have declined during the visit and an explanation of the denial;(e) the member's vital signs and any other required measurements;(f) progress toward achievement of long- and short-term goals as specified in the plan of care, including, when applicable, an explanation of why goals are not achieved as expected;(g) a pain assessment, as appropriate;(h) the status of any equipment maintenance and management, as appropriate; and(i) any contacts with physicians or other health-care providers about the member's needs or change in plan of care, as applicable;(9) a current medication-administration list or other documentation, such as nursing notes, that includes the time of administration as ordered, drug identification and dose, the route of administration, the member's response to the medication being administered, and the signature of the person administering the medication;(10) documentation about teaching provided to the member, member's family, or primary natural caregiver by the independent nurse on how to manage the member's treatment regimen, any ongoing teaching required by a change in the procedure or the member's condition, and the response to the teaching, if applicable;(11) any clinical tests and their results;(12) the names and telephone numbers of all the providers involved in co-vending care and the number of nursing hours approved for each provider by the MassHealth agency or its designee, to the best of the independent nurse's ability; and(13) a signed medical records release form.(E) The independent nurse must maintain a copy of the member's medical record in the member's home as described in 130 CMR 414.417(D). The copy must be made available to the member and/or their representative on request. The independent nurse must make every attempt to coordinate care and/or changes in shifts with other CSN providers.(F) The independent nurse is responsible for maintaining the member's medical record. The independent nurse must maintain the member's original medical record along with current and previous certification period documentation in accordance with 130 CMR 414.417(A) and (B).(G) On the request of the member or their representative, the independent nurse must provide a copy of the medical record to a person or entity that the member or their representative designates. Additionally, on request of the MassHealth agency or its designee, the independent nurse must provide a copy of the member's complete medical record to the agency or designee.(H) Incident and Accident Records. The independent nurse must maintain an easily accessible record of the members' incidents and accidents. The record may be kept in the individual member medical record. (1) The independent nurse must submit to the MassHealth agency or its designee an incident or accident report within five days under the following circumstances:(a) an incident or accident that occurred during a CSN service visit that results in serious injury to the member;(b) an incident or accident resulting in the member's unexpected death even if the independent nurse was not involved in the incident or accident;(c) an incident of abuse or neglect involving the independent nurse and the member; or(d) an incident of abuse or neglect committed by another provider who was supporting the member (if known).(2) The incident or accident report must include at least the following: (a) general information including but not limited to the member's name and MassHealth ID number;(b) the general nature of the incident or accident; and(c) any action that was taken as a result of the incident or accident, including all outcomes.Amended by Mass Register Issue 1529, eff. 8/30/2024.