Section 461.414 - Recordkeeping Requirements(A)Release of Information. Each CSP must obtain written authorization from each member or the member's legal guardian to release information obtained by the provider, to other community-based providers, federal and state regulatory agencies, and, when applicable, referral providers or other relevant parties to the extent necessary to carry out the purposes of the program and to meet regulatory requirements. All such information must be released on a confidential basis and in accordance with all applicable requirements.(B)Member Records.(1) A CSP must maintain member records in accordance with 130 CMR 450.000: Administrative and Billing Regulations. When a member is referred to any other provider, the program must maintain the original member record and forward a copy to the other provider.(2) Member records must be complete, accurate, and properly organized.(3) The member's record must include at least the following information:(a) the member's name and case number, MassHealth identification number, address, telephone number, gender identity, date of birth, marital status, next of kin, school or employment status (or both), and date of initial contact;(b) the place of service;(c) the member's description of the problem, and any additional information from other sources, including the referral source, if any;(d) the events precipitating the member's contact with the CSP;(e) Written documentation that the member receiving services meets the clinical standards published by the MassHealth agency, including the following:1. CSP-HI providers must generate written documentation of homelessness from the local Continuum of Care Homeless Management Information System (HMIS) or comparable system used by providers of services for victims of domestic violence;2. CSP-TPP providers must maintain a copy of the Notice to Quit, a request for temporary, preliminary, or permanent relief or against whom such relief has been granted, or related Housing Court filings and records; and3. CSP-JI providers must maintain documentation of justice involvement, including whether referral was received from a correctional institution or BH-JI vendor.(f) the relevant medical, psychosocial, educational, and vocational history;(g) a needs assessment of the member;(h) short- and long-range goals that are realistic and obtainable and a time frame for their achievement;(i) the member's service plan, updates, and related CSP service planning meetings, including schedule of activities and services necessary to achieve the member's goals, signed by both the CSP staff person and the member;(j) written record of all services provided, including face-to-face, virtual, and collateral contacts, and including progress notes;(k) a written record of the reassessments that includes recommendations for revision of the service plan, when indicated, and the names of the reviewers;(l) the name(s) of the CSP staff person(s) responsible for providing services to the member;(m) reports on all collateral consults and collaborations with family, friends, and outside professionals, including probation, parole or correctional institution staff, who are involved in the member's treatment;(n) all information and correspondence to and from other involved agencies, including appropriately signed and dated consent forms;(o) when discharged, a discharge summary, including a summary of the member's services, a brief summary of the member's condition and response to services on discharge, achievement of goals, and recommendations for appropriate services that should be provided in subsequent programs by the same or other agencies to accomplish the member's long-range goals, and the program's future responsibility for the member's care;(p) if the member fails to keep appointments or to adequately participate in the service plan, CSP staff must make every effort to encourage the member to do so, and these follow-up efforts must be documented in the member's record; and(C)Program Records. The program must retain documentation reflecting compliance with the requirements of 130 CMR 461.000, including 130 CMR 461.403.(D)Other Records and Reports as Directed by EOHHS. The program must maintain other records and reports as directed by EOHHS.(E)Availability of Records. Any and all records must be made available to the MassHealth agency upon request.Adopted by Mass Register Issue 1494, eff. 4/28/2023.