Recordkeeping Requirements

(A) Each center must obtain written authorization from each member or the member’s legal guardian to release information obtained by the center, to center staff, federal and state regulatory agencies, and, when applicable, referral providers, to the extent necessary to carry out the purposes of the center and to meet regulatory requirements. All such information will be released on a confidential basis and in accordance with all applicable requirements. (B) Member Records. (1) A center must maintain member records in accordance with 130 CMR 450.000: Administrative and Billing Regulations and 105 CMR 140.000: Licensure of Clinics, in addition to applicable recordkeeping requirements for clinics under M.G.L. c. 111 § 70. When a member is referred to any other provider, each center will 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 will 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) a report of a physical examination performed within twelve months of the date of intake, including documentation the physical examination informed the treatment plan, or documentation that the member did not want to be examined and any stated reason for that preference; (d) the name and address of the member's primary care physician or, if not available, another physician who has treated the member; (e) the member's description of the problem, and any additional information from other sources, including the referral source, if any; (f) the events precipitating the member’s contact with the center; (g) the relevant medical, psychosocial, educational, and vocational history; (h) a comprehensive assessment of the member initiated at intake; (i) the clinical impression of the member and a diagnostic formulation, including a specific diagnosis using standard nomenclature; (j) short- and long-range goals that are measurable, realistic and obtainable, and a timeframe for their achievement; (k) the proposed schedule of therapeutic activities, both in and out of the center, necessary to achieve such goals and objectives and the responsibilities of each individual member of the interdisciplinary team; (l) a schedule of dates for utilization review to determine the member's progress in accomplishing goals and objectives; (m) the name, qualifications, and discipline of the therapist primarily responsible for the member; (n) a written record of semi-annual reviews (every six (6) months) by the primary therapist, which relate to the short- and long-range goals; (o) progress notes, including those related to the defined treatment plan goals on each visit written and signed by the primary therapist that include the therapist's discipline and degree; (p) a treatment plan for the member signed by the primary therapist, or the supervisor of an unlicensed primary therapist, pursuant to 130 CMR 448.412(A)(3); (q) all information and correspondence regarding the member, including appropriately signed and dated consent forms; (r) a drug-use profile (both prescribed and other); (s) when the member is discharged, a discharge summary, including a brief summary of the member’s condition and response to treatment, achievement of treatment and recovery goals, and recommendations for any future appropriate services; and (t) for members younger than 21 years of age, a CANS completed during the initial behavioral health assessment and updated at least every 90 days thereafter. (4) A brief history is acceptable for emergency or walk-in visits when the treatment plan does not call for extended care. (C) Program Records. The community behavioral health center must retain documentation reflecting compliance with the requirements of 130 CMR 448.000. (D) Availability of Records. All records must be made available to the MassHealth agency upon request.