Documentation Requirements

Documentation Requirements A. The hospice provider must maintain medical records for each beneficiary at the hospice site which corresponds to the address associated with the provider license and Division of Medicaid provider number and must include, but not limited to, the following: 1. The Division of Medicaid’s specific hospice related forms which must be complete and accurate: a) Terminal illness certification/recertification form with supporting documentation, b) Hospice notice of election form, c) Hospice discharge/Hospice revocation form, if applicable, d) Hospice transfer form, if applicable, e) Hospice discharge/Hospice revocation form including the discharge summary for a hospice beneficiary which must include the following: 1) A summary of the beneficiary's stay including treatments, symptoms, and pain management, 2) The beneficiary's current plan of care (POC), 3) The beneficiary's current physician orders, and 4) Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility. The hospice must forward to the receiving facility for any beneficiary transferred to another hospice provider, the following: (1) The hospice discharge summary, and (2) The beneficiary's clinical record, if requested. (b) The hospice must forward to the beneficiary's attending physician for any beneficiary that revokes hospice election or is discharged the following: (1) The hospice discharge summary, and (2) The beneficiary's clinical record, if requested. 2. An interdisciplinary POC including the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes that support each hospice service rendered including needs, care, services and goals. 3. A copy of a waiver participant's plan of services and supports (PSS) when the hospice beneficiary is also receiving waiver services. 4. The certifying physician's election period face-to-face encounter and date of encounter with clinical findings to support a life expectancy of six months or less. If a non- certifying hospice physician or nurse practitioner performs the face-to-face encounter, documentation must show: a) An attestation in writing of the face-to-face encounter that the clinical findings of the visit were provided to the certifying physician for use in determining continued eligibility for hospice care, and b) The date of the face-to-face encounter. 5. Treatment rendered including: a) Each discipline’s visit or contact of the treatment or intervention rendered at the frequency ordered on the POC. b) Documentation to show relationship of the treatment plan and medications to the terminal illness and related conditions, c) Responses to medications, symptom management, treatments, and services, and d) Appropriate discipline’s signature or initials on all medical records. 6. A current medication list for each month of certification that clearly indicates the medications the hospice paid related to the terminal illness and related conditions. The list must contain the name, strength, dosage, and route of the drugs administered to the hospice beneficiary and the name and address of the pharmacies that provided the medications to the hospice beneficiary. 7. A current list of medical appliances and supplies related to the terminal illness and related conditions paid for by the hospice and the names and address(s) of the providers paid. B. Documentation must be maintained in accordance with requirements set forth in Part 200, Chapter 1, Rule 1.3. and all hospice providers must retain medical records for a minimum of six (6) years after death or discharge of a beneficiary, unless State law stipulates a longer period of time. C. Concurrent providers of hospice services and home and community-based (HCBS) waiver services must maintain medical records in accordance with requirements set forth in Miss. Admin. Code Part 200,