Documentation/ Record Maintenance

Documentation/ Record Maintenance A. Documentation/record maintenance for reimbursement purposes must, at a minimum, reflect procedures set forth for applicable waiver quality assurance standards. Refer to Maintenance of Records Part 200, Rule 1.3. B. DCW staff records should include, at a minimum, the following required credentialing and qualification documents: 1. Copy of valid, state issued ID, 2. Job descriptions or DCW Certification, 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 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. Attestation of health at hire, 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) and In-Home Respite (IHR) services should include, at minimum: 1. Referral form/authorization, 2. Approved Plan of Services and Supports (PSS), 3. Service Notes documenting monthly and quarterly case management documenting oversight of the DCW, and 4. Daily activity or service notes 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. D. Activity or service notes, if needed must include: 1. Arrival/service time and date, 2. Departure/service time and date, 3. Activities/tasks performed, and 4. The signature of the beneficiary or their legal representative verifying the provision of services.