Section 414.417 - Recordkeeping Requirements 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(D). 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, MassHealth ID number;(2) the name and phone number of the member's primary care physician;(3) the primary 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) easily reviewable and legible nursing progress notes for each visit, signed by the independent nurse, that include the following information:(a) the full date of service;(b) a notation of the specific time that each shift began and ended;(c) a description of the assessed signs and symptoms of illness;(d) any treatments and drugs administered and the member's response;(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;(h) the status of any equipment maintenance and management; and(i) any contacts with physicians or other health-care providers about the member's needs or change in plan of care;(9) a current medication-administration sheet that includes the time of administration, drug identification and strength, route of administration, the member's response to the medication, and the signature of the person administering the medication;(10) a current treatment list or description of treatments administered, the time of administration, the member's response to the treatment, and the signature of the person administering the treatment;(11) documentation on the teaching provided to the member, member's family, or caregiver by the independent nurse on how to manage the member's treatment regimen, any ongoing teaching required due to a change in the procedure or the member's condition and the response to the teaching;(12) any clinical tests and their results; and(13) a signed medical records release form.(E) When providing CSN services, the independent nurse and, if co-vending, other providers must leave a copy of the member's medical record, including current progress notes, medication administration sheet, prior-authorization form, plan of care, and physician orders in the member's home for the purpose of ensuring continuity of care.(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) Upon the request of the member or the member's legal representative, the independent nurse must make a copy of the medical record available to the person or entity that the member or the member's representative designates.