Documentation/ Record Maintenance

Documentation/ Record Maintenance A. Documentation/record maintenance for reimbursement purposes must, at a minimum, reflect requirements set forth in the Assisted Living (AL) Waiver. [Refer to Miss. Admin. Code Part 200, Rule 1.3] B. All staff records should include, at minimum, the following required credentialling and qualification documents: 1. Copy of valid, state issued ID, 2. Job descriptions, 3. Application and date of hire, 4. High school diploma, General Educational Development (GED) diploma, 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 cardiopulmonary resuscitation (CPR) and First Aid. C. Records for beneficiaries receiving AL Waiver services should include, at minimum: 1. Approved Plan of Services and Supports (PSS), 2. Daily activity logs documenting the services rendered and billed under the program, including when a beneficiary is out of the facility and the reason why, 3. Current photograph, 4. Medical history or medical exam completed within six (6) months of admission, and 5. Annual nutritional assessment and, 6. Daily progress notes. D. Assisted Living facility records should include, at minimum: 1. Documentation of monthly 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 dealing 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. Organizational chart including the names and job titles of owners, operators, managers, administrators, etc., 9. Current and historical employee listing that captures names, staff/tax id numbers, employment hire and termination dates, and 10. Service record of licensed nurse which includes dates in the facility, arrival and departure times, services performed, signature of administrator or program director. 11. Statistical and financial data supporting a cost report for at least five (5) years from the date of the cost report or amended cost report or appeals submitted to the Division of Medicaid. 12. Records of medication administration and medication allergies of waiver beneficiaries. 13. A current, signed, and dated copy of the Division of Medicaid-approved admission agreement for each waiver beneficiary which includes, at a minimum: a) Basic charges agreed upon separating costs for room and board and personal care services, b) Period to be covered, c) List of itemized charges, and d) Agreement regarding refunds for payments. E. AL Waiver providers are required to submit, within three (3) business days of the occurrence, the disposition form to the respective case manager anytime a person leaves the facility for a period of twenty-four (24) hours or longer. The disposition form should be submitted when the beneficiary leaves another one indicating their return if applicable.