N.H. Admin. Code § He-W 553.05

Current through Register No. 36, September 5, 2024

Section He-W 553.05 - Required Documentation

(a) Home health care providers and independent nurses shall maintain complete and timely records for each recipient receiving services in accordance with He-W 520, and this part.

(b) Where a home health care provider or independent nurse has failed to maintain records pursuant to (a) above, the department shall be entitled to recoupment of state or federal medicaid payments made, as permitted by 42 CFR 455, 42 CFR 456 and42 CFR 447.

(c) In addition to the requirement set forth in (a) above, home health care providers and independent nurses shall maintain the documentation required by this part and He-W 520 to support claims submitted for reimbursement for a minimum of 6 years or until the resolution of any legal action(s) commenced within the 6 year period, whichever is longer.

(d) Recipient records shall include all of the following:

(1) Written orders for initial home health services and certification of the need for home health services signed by the recipient's physician specifying:

a. The frequency of medication and treatment to be administered; and

b. The period of time to be covered by the orders;

(2) Documentation of the occurrence of a face-to-face encounter which is related to the primary reason the recipient requires home health services indicating the time frame the encounter took place, the date, the practitioner who conducted the encounter, and the practitioner's findings in accordance with He-W 553.06(a) below;

(3) For recipients under the age of 21, a recipient history and a health assessment with an appropriate pediatric tool completed upon admission by the RN or appropriate rehabilitation skilled professional in accordance with 42 CFR 484.55;

(4) For recipients over the age of 21, a recipient history and a health assessment, completed upon admission by the RN or appropriate rehabilitation skilled professional in accordance with 42 CFR 484.55, except that the homebound assessment of 42 CFR 484.55 is not required;

(5) Documentation at least every 60 days to indicate review of the recipient's health assessment by the RN or appropriate rehabilitation skilled professional in accordance with 42 CFR 484.55;

(6) A written individualized plan of care which shall include the following:

a. The diagnosis related to the recipient's need for home health services;

b. Other diagnoses;

c. An assessment of the recipient's mental alertness and cognitive level;

d. Measurable recipient goals;

e. Types of services and equipment required;

f. Frequency of home health services;

g. Anticipated length of treatment;

h. General prognosis;

i. Rehabilitation potential;

j. Functional limitations including activities of daily living;

k. Activities permitted;

l. Nutritional requirements;

m. Medications;

n. Treatments;

o. Safety measures required to protect the recipient from potential injury;

p. Services being provided by non-paid caregivers involved in the recipient's treatment and any related education or training needs of the caregivers; and

q. Discharge plans;

(7) Documentation at least every 60 days, to indicate review of the written plan of care by the recipient's physician;

(8) Documentation at least every 60 days that indicates the locations of service delivery other than the recipient's home for services already provided;

(9) Auditable, paper, or electronic service notes for each service provided to the recipient identifying:

a. Name of recipient;

b. Date of service;

c. Location(s) where service was provided, if other than the recipient's primary residence;

d. Primary purpose of the home health services;

e. Description of services provided;

f. Amount of direct care time spent providing each home health service;

g. Condition of the recipient at the time the service was provided, and any significant change in recipient's mental or physical condition;

h. Any progress the recipient has made towards goals identified on the written plan of care;

i. An explanation of any variation from the written plan of care; and

j. Name, title, and written or electronic signature of the individual providing the home health service; and

(10) Documentation of any consults or meetings regarding the recipient's care, which also indicates the results of the consult or meeting.

(e) Home health care providers and independent nurses shall make the documentation required by this part and He-W 520 available for review to the department upon the request of the department.

N.H. Admin. Code § He-W 553.05

#8972, eff 9-11-07

Amended by Volume XXXVI Number 28, Filed July 14, 2016, Proposed by #11127, Effective 7/1/2016, Expires 7/1/2026.