N.H. Admin. Code § He-W 540.06

Current through Register No. 36, September 5, 2024

Section He-W 540.06 - Required Documentation

For each recipient, PDN service providers shall maintain complete and timely records as follows:

(a) A written, signed, and dated physician's or other licensed practitioner's order for care provided, updated and signed every 60 days, which shall include:

(1) The recipient's diagnosis, with a description of the severity of the illness or condition; and

(2) A detailed explanation of the medical need for PDN, including:

a. The specific nursing services that are required; and

b. A description of the specific medical complications necessitating PDN;

(b) A nursing assessment with information that supports the need for PDN including, but not limited to, the following:

(1) Recipient identification information including:

a. Recipient name;

b. Medicaid identification number (MID); and

c. Date of birth;

(2) Contact information of the recipient's parent, guardian, or primary caregiver including addresses and phone numbers;

(3) Private health insurance information including coverage dates;

(4) Information regarding the recipient's participation in any medicaid program, including medicaid to schools, waiver programs, and licensed nursing assistant (LNA) services, or participation in the special medical services program;

(5) Name and contact information of the recipient's treating physician or other licensed practitioner, including the primary care physician, and any specialists;

(6) A summary of the recipient's physical and behavioral health status including:

a. A list of the recipient's current conditions; and

b. A history of the conditions leading to the need for PDN;

(7) An assessment of the recipient's body systems including a medication profile;

(8) A functional assessment of the recipient's physical and cognitive status including a list of any durable medical equipment being utilized;

(9) A description of the household make-up including the nature of the household member's relationship with the recipient and their ability and availability to provide care and support to the recipient;

(10) Information about the recipient's school participation including the number of hours per week the recipient attends and whether a nurse or aide is available to assist the recipient while at school;

(11) The recipient's emergency plan in the event that the primary caregiver is unable to provide care; and

(12) Any additional medical or social information, such as family stressors and their impact on the mental and emotional health of the recipient that the recipient wants to provide that supports the need for PDN.

(c) A plan of care documenting the extent of the recipient's nursing needs, prepared by the PDN service provider, signed and dated by the recipient's physician or other licensed practitioner, and updated every 60 days in accordance with 42 CFR 484.60(c)(1);

(d) Nurses' notes that fully document, for each date of service, the provision of services and the care and treatment provided to the recipient, including:

(1) The location of where the care was provided, and the time that the nursing shift began and ended;

(2) A description of each nursing service provided, including the type of nursing service, the time of the service delivery, and the recipient's response to the service so that an independent reviewer can replicate what happened during the shift;

(3) Details showing that the nursing services are consistent with the care plan and orders of the recipient's physician or other licensed practitioner;

(4) Any adverse findings and, if so, a plan of action to address those findings; and

(5) The recipient's progress towards established goals; and

(e) Documentation of a face-to-face encounter between the recipient's physician or other licensed practitioner and the recipient within 90 days prior to, or within 30 days following the start of, the PDN service provision, as established in 42 USC 1395n of the SSA and in accordance with 42 CFR 440.

N.H. Admin. Code § He-W 540.06

(See Revision Note at chapter heading He-W 500); ss by #6134, eff 11-30-95, EXPIRED: 11-30-03

New. #8069, eff 4-17-04; ss by #10107, INTERIM, eff 4-17-12, EXPIRES: 10-15-12; amd by #10139, eff 7-1-12; ss by #10186, eff 10-15-12

Amended by Number 6, Filed February 9, 2023, Proposed by #13544, Effective 1/28/2023, Expires 1/28/2033.