Documentation/Record Maintenance

Documentation/Record Maintenance A. Documentation and record maintenance for reimbursement purposes must, at a minimum, meet requirements set forth in the Elderly and Disabled (E&D) Waiver. [Refer to Miss. Admin. Code Part 200, Rule 1.3.] B. All staff records should include, at a minimum, the following required credentialing and qualification documents: 1. Copy of valid, state issued ID, 2. Job description, 3. Application and date of hire, 4. High school diploma, General Educational Development (GED) certificate, other educational degrees, or proof of ability to read and write accurately, 5. Any licensure and/or certifications as required by the Division of Medicaid for job description, 6. Results of fingerprint-based National Criminal Background check(s), 7. Results of monthly Nurse Aide Abuse Registry checks, 8. Results of monthly Office of Inspector General (OIG) checks, 9. Annual attestation of health, 10. Signed confidentiality agreement that includes social media waiver, and 11. Proof of training/evaluations, required professional certifications, and credentials including CPR and First Aid. C. Records for beneficiaries receiving Personal Care Services (PCS) & In-Home Respite (IHR) should include, at minimum: 1. Referral form/authorization, 2. Approve Plan of Services and Supports (PSS) 3. Daily activity or time sheets capturing tasks completed and the beneficiary/representative’s signature verifying the provision of services, if task and global positioning system (GPS) information is not captured electronically in the state approved electronic visit verification system. 4. Service note indicating the causes of any significant variation in the case management recommended/agreed upon schedule of service provision. D. Records for PCS/IHR offices should include at minimum: 1. Written criteria for service provision, including procedures for dealing with emergency service requests, 2. Policy and procedure manuals, 3. Records of quarterly advisory committee meetings, 4. Written personnel policies including the process used in the recruitment, selection, retention, and termination of employees, 5. Organizational chart including the names and job titles of owners, operators, managers, administrators, and other supervisory staff., and 6. Current and historical employee listing that captures names, staff/tax id numbers, and employment hire and termination dates. E. Records for beneficiaries receiving Adult Day Care (ADC) should include, at minimum: 1. Individualized Service Plan (ISP), with documentation of annual review, 2. Approved Plan of Services and Supports (PSS), 3. Daily activity or time sheets capturing service notes and the beneficiary/representative’s signature verifying the provision of services, 4. Current photograph, 5. Medical history or medical exam completed within six (6) months of admission, 6. Annual nutritional assessment, and 7. Daily Progress Notes. F. Activity or time sheets must include: 1. Arrival/service start time and date, 2. Departure/service end time and date, 3. Activities/tasks performed, and 4. The signature of the beneficiary or their legal representative verifying the provision of services. G. ADC facility records should include, at minimum: 1. Documentation of maintenance and janitorial services including repairs, maintenance and pest control, 2. Documentation of quarterly drills for fire and inclement weather, 3. Annual fire safety inspection reports conducted by the fire department, 4. Records of quarterly advisory committee meetings, 5. Written criteria for service provision, including procedures for detailing with emergency service requests, 6. Policy and procedure manuals, 7. Written personnel policies including the process used in the recruitment, selection, training, retention, and termination of employees, 8. Current and historical organizational charts including the names and job titles of owners, operators, managers, administrators, and other supervisory staff, 9. Current and historical employee listing that captures names, staff/tax id numbers, employment hire and termination dates, and 10. Service records of licensed nurses which includes dates in the facility, arrival and departure times, services performed, and signature of administrator or program director.