C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-89, subsec. 144-101-II-89.08

Current through 2024-44, October 30, 2024

Subsection 144-101-II-89.08 - DOCUMENTATION AND CONFIDENTIALITY

In addition to the requirements, above and set forth in Chapter I, Section 1, of the MBM, the MaineMOM provider must maintain a specific record and documentation of services for each member receiving covered services.

A.Records: The member's record must minimally include:

1. Name, address, birthdate, and MaineCare identification number;

2. Diagnoses that support eligibility for services herein, including the most recent documentation of diagnoses that substantiate ongoing eligibility for services;

3. The Screening and Comprehensive Assessment (Section 89.05-1(A)(1)), and any reassessments that occur, to which must include the signature and credentials of the individual performing the service;

4. The Care Plan and any updates to the Care Plan, which must include the signature and credentials of the individual performing the service and the date of any updates;

5. Correspondence to and from other providers;

6. Release of information statements as necessary, signed by the member, including right notification, rules and regulations, confidentiality statement and release of information;

7. Documentation/record entries (i.e., progress notes) that clearly reflect implementation of the Care Plan and the member's response to treatment, as well as subsequent amendments to the plan. Progress notes for each service provided, including the date of service, the type of service, the place of the service or method of delivery (i.e., phone contact), the Care Plan goal to which the service relates to, the duration of the service, the progress the member has made towards goal attainment, the signature and credentials of the individual performing the service, whether the individual has declined services in the Care Plan, and timelines for obtaining needed services; and

8. A record of discharge/transfer planning, beginning at admission and any referrals made.

B.Confidentiality and Disclosure of Confidential Documents/Information: MaineMOM providers shall maintain the confidentiality of information regarding these members in accordance with the MBM, Chapter I, Section 1 of the MBM and with all other applicable sections of state and federal law and regulation.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-89, subsec. 144-101-II-89.08