Record Keeping for Specific Waiver Providers

1. Requirements for Service Coordinators

In addition to the three components of the record keeping responsibilities listed above (i.e. Detailed Plans, documentation of encounters/case notes and ISR), the SC shall maintain a file for each participant that includes:

  1. The Application Packet including the ISP;
  2. All completed Insurance, Resources and Funding Information forms;
  3. The original and all subsequent PRI and SCREENS;
  4. All RSP(s), including all required documentation attached and ISR(s) submitted from other waiver service providers;
  5. All Addendums;
  6. All copies of Notices of Decision (NOD) forms and documentation that the participant has been informed about the NOD(s), including the right to an Informal Conference and/or Fair Hearing (as appropriate);
  7. Summaries of all Team Meetings (refer to Appendix C – form C.17);
  8. Initial and annual Waiver Participant's Rights and Responsibilities form (refer to Appendix C – form C.5) with the original signature and date;
  9. Current Waiver Contact List (refer to Appendix C – form C.6);
  10. All Plan for Protective Oversight (PPO) (refer to Appendix C – form C. 4);
  11. Documentation of proof of the participant's current Medicaid eligibility each time the SP is submitted to the RRDS;
  12. Documentation of Release of Information forms;
  13. Documentation of the provision of Service Coordination services; and
  14. Documentation of all other contacts with:
    • The participant;
    • Family and informal supports;
    • Local Departments of Social Services (LDSS);
    • Providers of waiver services;
    • Providers of non-waiver services;
    • Regional Resource Development Specialists (RRDS);
    • Nurse Evaluator (NE);
    • Quality Management Specialist (QMS);
    • DOH Waiver Management Staff (WMS); and
    • Any other significant contacts which affect the SP or reflect a change in the participant's situation.

    In addition, providers of Service Coordination must maintain the following separate from the participant's record:

  1. Provider Satisfaction Surveys regarding the participant's satisfaction with service(s) provided;
  2. Documentation of any complaints or grievances received and the outcome of these situations; and
  3. Documentation reflecting any involvement in the Serious Reportable and Recordable Incident processes.

Note: If the current Service Coordination agency was not the agency involved in the development of the Application Packet, a copy of the Application Packet must be obtained from the previous Service Coordination agency or the RRDS and maintained by the current Service Coordination agency in the participant's record. For all other information, the SC is responsible for maintaining information which was obtained and/or written since involvement as the Service Coordination agency with the participant. The SC is responsible for distributing the approved Service Plans to all waiver providers and ensuring each provider receives information that impacts the delivery of his/her services.

2. Requirements for AT, CTS, Congregate and Home Delivered Meals, E-mods, and Moving Assistance

These waiver service providers are responsible to maintain the following in the participant's record:

  1. Bid(s) submitted to the SC, corresponding documentation regarding acceptance of bid(s), and RRDS final approval;
  2. Services provided to any waiver participant;
  3. Copy of page one of the SP and the pages regarding the need for the waiver service that is sent from the Service Coordinator;
  4. The Notice of Decision (NOD) (refer to Appendix B – NOD.1 to NOD.9) sent from the SC;
  5. Copy of the Initial and annual Participant's Rights and Responsibilities form, as applicable;
  6. Documentation of Release of Information forms; and
  7. Documentation of all contacts (through an encounter, or verbal/written communication) with:
    • The Participant;
    • Family and informal supports;
    • Providers of waiver services;
    • RRDS;
    • NE;
    • QMS;
    • DOH WMS; and
    • Any other significant contacts which affect the SP or reflect a change in the participant's situation involving the waiver service provider.

In addition, these waiver service providers must maintain the following separate from the participant's record:

  1. Provider Satisfaction Surveys regarding the participant's satisfaction with service(s) provided;
  2. Documentation of any complaints or grievances received and the outcome of these situations; and
  3. Documentation reflecting any involvement in the Serious Reportable and Recordable Incident process.

3. Requirements for All Other Waiver Service Providers

As noted earlier in this section, waiver service providers are responsible to maintain the three major components of Record Keeping (i.e. Detailed Plans, documentation of encounters/case notes and ISR). In addition to the documentation required by those components, providers must maintain in participant record:

  1. ISP (refer to Appendix C – form C.1);
  2. All RSP(s);
  3. All Addendum(s) (refer to Appendix C – form C.15), if applicable;
  4. All copies of Notices of Decision (NOD) forms;
  5. Documentation of all Team Meetings attended and a copy of the completed Team Meeting Summary received from the SC;
  6. Initial, as applicable and Annual Participant's Rights and Responsibilities form;
  7. Current Waiver Contact List;
  8. All Plan for Protective Oversight (PPO) forms received during provision of service(s);
  9. Release of Information forms, as appropriate;
  10. Documentation of the provision of services;
  11. Documentation of all other contacts with:
    • The participant;
    • Family and informal supports;
    • Local Departments of Social Services;
    • Providers of waiver services;
    • Providers of non-waiver services;
    • RRDS;
    • NE;
    • QMS;
    • DOH WMS; and
    • Any other significant contacts which affect the SP or reflect a change in the participant's situation.
  12. Service-specific assessments conducted or acquired, if applicable; and
  13. Physician Orders (for providers of HCSS, Respiratory Therapy, Wellness Counseling, and Nutritional Counseling/Educational Services only).

In addition, other waiver service providers must maintain the following separate from the participant's record:

  1. Provider Satisfaction Surveys regarding the participant's satisfaction with service(s) provided;
  2. b. Documentation of any complaints or grievances received and the outcome of these situations; and
  3. c. Documentation reflecting any involvement in the Serious Reportable and Recordable Incident process.

Note: If a current waiver service provider was not the original waiver service provider agency involved at the time the ISP was approved, a copy of the ISP, current PPO, current RSP, any Addendum issued during the current RSP period, and NOD form(s) must be obtained from the Service Coordination agency and maintained in the waiver service provider's record for the waiver participant. For all other information, the waiver service provider is responsible for maintaining information which has been obtained and/or written since becoming involved as a waiver service provider agency for the participant.