Recordkeeping Requirements

(A) Release of Information. Each facility must obtain written authorization from each member or the member’s legal guardian to release information obtained by the facility, 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) Facilities 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 of the information in 130 CMR 449.415(C) and (D) to the other provider. (2) Member records must be complete, accurate, and properly organized. (C) Facilities must maintain case records that document for all individuals receiving case management services the following: (1) the name of the individual; (2) the dates of the case management services; (3) the name of the provider agency (if relevant) and the person providing the case management service; (4) the nature, content, units of the case management services received and whether goals specified in the care plan have been achieved; (5) whether the individual has declined services in the care plan; (6) the need for, and occurrences of, coordination with other case managers; (7) a timeline for obtaining needed services; and (8) a timeline for reevaluation of the plan. (D) The member’s record must include at least the following information: (1) the member's name and case number, MassHealth identification number, gender identity, date of birth, marital status, next of kin, and date of initial contact; (2) the place of service; (3) the member's description of the problem, and any additional information from other sources, including the referral source, if any; (4) written documentation that the member receiving services meets the clinical standards published by the MassHealth agency; (5) the relevant medical, psychosocial, educational, and vocational history; (6) a needs assessment of the member; (7) short- and long-range goals that are realistic and obtainable and a time frame for their achievement; (8) the member’s service plan, updates, and related facility service planning meetings, including a schedule of activities and services necessary to achieve the member’s goals, signed by both the facility staff person and the member; (9) written record of all services provided, including face-to-face, virtual, and collateral contacts, with progress notes; (10) a written record of the reassessments that includes recommendations for revision of the service plan, when indicated, and the names of the reviewers; (11) the name(s) of the facility staff person(s) responsible for providing services to the member; (12) reports on all collateral consultations and collaborations with family, friends, and outside professionals, including probation, parole or correctional institution staff, who are involved in the member’s treatment; (13) all information and correspondence to and from other involved agencies, including appropriately signed and dated consent forms; (14) 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; and (15) if the member fails to keep appointments or to adequately participate in the service plan, facility 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. (16) if the member is receiving case management services, all of the documentation listed in 130 CMR 449.417(C). (E) Program Records. The facility must retain documentation reflecting compliance with the requirements of 130 CMR 449.000, including 130 CMR 449.403. (F) Other Records and Reports as Directed by EOHHS. The facility must maintain other records and reports as directed by EOHHS. (G) Availability of Records. Any and all health records must be made available to the MassHealth agency upon request.