Rule 23-223-5.9 - Documentation RequirementsA. Certified Nursing Assistants (CNAs) providing personal care services (PCS) must document all care rendered during each shift including, but not limited to: 1. Assistance with activities of daily living (ADL), and2. Any significant changes in the beneficiary's condition.B. Weekly timesheets must be maintained for each CNA providing PCS that include:1. The date the services were provided,2. Begin and end times of services and a list of services provided during that time,3. The dated signature of the CNA, and4. The dated signature of the beneficiary's guardian or legal representative.C. The PDN provider must establish and maintain a permanent, legible medical record for each beneficiary at the provider's office which must include, at a minimum, the following: 1. Physician orders updated and signed by the physician every six (6) months,2. Current physician's treatment plan updated every six (6) months,3. Plan of care (POC) based on the diagnosis(es), clinical and social status of the beneficiary including measurable goals updated every six (6) months,4. Documentation of changes in clinical status and/or significant occurrences,5. Weekly progress notes,6. Monthly summaries must include the following, at a minimum:a) CNA services provided,b) Progress or lack of progress toward goals,c) Clinical and social status of the beneficiary, and7. Information regarding other home care services being provided to the beneficiary including: a) The specific services provided,b) Date and times of services, andc) The providers of the services.8. Copies of all prior authorizations.D. All records must be maintained and retained in accordance with HIPPA and Medicaid regulations. [Refer to Part 200, Rule 1.3, Maintenance of Records.]23 Miss. Code. R. 223-5.9
Miss. Code Ann. §§ 43-13-117, 43-13-121.