N.H. Admin. Code § He-M 522.14

Current through Register No. 45, November 7, 2024

Section He-M 522.14 - Record Requirements for Provider Agencies

(a) Provider agencies shall maintain a separate record for each individual who receives Medicaid home- and community-based care services and ensure the confidentiality of information pertaining to the individual, including:

(1) Maintaining the confidentiality of any personal data in the records;

(2) Storing and disposing of records in a manner that preserves confidentiality; and

(3) Obtaining a release of information pursuant to He-M 522.04(f) prior to release of any part of a record to a third party.

(b) An individual's record shall include:

(1) Personal and identifying information including the individual's:

a. Name;

b. Address;

c. Date of birth; and

d. Telephone number;

(2) Information about the individual that would be essential in case of an emergency, including:

a. The name, address, and telephone number of the legal guardian or next of kin or

other person to be notified;

b. The names, addresses, and telephone numbers of current service providers; and

c. Medical information, including the individual's:

1. Diagnosis(es);

2. Health history;

3. Current medications;

4. Allergies;

5. Do not resuscitate (DNR) orders, as appropriate; and

6. Advance directives, as determined by the individual;

(3) A copy of the individual's current service agreement;

(4) Copies of all service agreement amendments;

(5) Progress notes on goals and support services provided as identified in the service agreement;

(6) Copies of evaluations and reviews by providers and professionals that are relevant to the individual's current needs;

(7) Copies of provider correspondence within the past year with the individual and guardian, service providers, physicians, attorneys, state and federal agencies, family members, and others in the individual's life;

(8) Any other correspondence involving the individual and the provider agency; and

(9) Information about transfer or termination of services, as appropriate.

(c) All entries made into an individual record shall be legible and dated and have the author identified by name and position.

(d) In addition to the documentation requirements identified in He-M 522, each provider agency shall comply with all applicable documentation requirements of other bureau rules.

(e) Each provider agency shall:

(1) Retain records supporting each Medicaid bill for a period of not less than 6 years; and

(2) Retain an individual's social history, medical history, evaluations, and any court-related documentation for a period of not less than 6 years after termination of services.

N.H. Admin. Code § He-M 522.14

#7120, eff 10-20-99; ss by #8974, INTERIM, eff 10-6-07, EXPIRED: 4-3-08

New. #9734, eff 6-25-10

The amended version of this section by New Hampshire Register Volume 38, Number 50, eff. 11/30/2018 is not yet available.