OAR 411-415-0110: Case Management Record Requirements

(1) In order to meet Department and federal record documentation requirements, a CME through the employees of the CME, must maintain a service record for each individual who receives services from the CME. An individual's service record must include all of the following: (a) Documentation of the functional needs assessment defining the support needs for ADL, IADL, and other health-related tasks. This may be a current ONA available in the Department's electronic payment and reporting system. (b) Documentation of choice advising. (c) Documentation that the individual is eligible for any service authorized in an ISP. (d) Referral information or documentation of referral materials sent to a provider or another CME. (e) Progress notes written by a case manager as described in section (2) of this rule. (f) The findings from service monitoring. (g) Medical information, as appropriate. (h) Entry and exit meeting documentation related to residential programs, including plans developed as a result of the meeting. (i) Current and previous ISP or Annual Plan, including support documents and documentation that the plan is authorized by a case manager. (j) A Nursing Service Plan must be present when Department funds are used to purchase services requiring the education and training of a licensed professional nurse. (k) Copies of any incident reports initiated by a CME representative for a serious incident or suspicion of abuse. (l) Documentation of a review of a serious incident received from a provider. Documentation of the review of a serious incident and abuse allegation must be made in CAM and a progress note and a copy of the incident report must be maintained by the CME. (m) Documentation of Medicaid eligibility, if applicable. (n) For an individual whose level of care was determined before July 1, 2018, the initial and, when present, the annual level of care determination on a form prescribed by the Department. (o) A CDDP must maintain a copy of an initial level of care determination form completed by the CDDP. For an individual whose level of care was determined before July 1, 2018 and is receiving CIIS or services in a 24-hour residential program for children, the CDDP must maintain a copy of annual level of care determinations or maintain documentation of attempts to obtain the annual level of care determinations. (p) Legal records, such as guardianship, civil commitment, a court order, and probation and parole information (as appropriate). (q) A case manager must maintain documentation of the referral process of an individual to a provider and if applicable, include the reason the provider preferred by the individual declined to deliver services to the individual. (r) An information sheet or reasonable alternative must be kept current and reviewed at least annually for each individual receiving case management services. Information must include: (A) The name of the individual, current address, date of entry into the CME, date of birth, gender, marital status (for individuals 18 or older), religious preference, preferred hospital, medical prime number and private insurance number (where applicable), and guardianship status. (B) The name, address, and telephone number of: (i) For an adult, the legal or designated representative, family, and other significant person of the individual (as applicable), and for a child, the parent or guardian and education surrogate (if applicable). (ii) The primary care provider and clinic preferred by the individual. (iii) The dentist preferred by the individual. (iv) The school, day program, or employer of the individual (if applicable). (v) Other agency representatives providing services to the individual. (vi) Any court ordered or legal representative authorized contacts or limitations from contact for individuals living in a foster home, supported living program, or 24-hour residential program. (2) PROGRESS NOTES. Progress notes must include documentation of the delivery of case management services provided to an individual by a case manager. Progress notes must be recorded chronologically in the order they are made and documented consistent with CME policies and procedures. All late entries must be appropriately noted as such. At a minimum, progress notes must include all of the following: (a) The month, day, and year the services were rendered and the month, day, and year the entry was made if different from the date services were rendered. (b) The name of the individual receiving service. (c) The name of the CME, the person providing the services (i.e., the signature and title of the case manager), and the date the entry was recorded and signed. (d) The nature and content of the case management services delivered and whether goals specified in the service plan have been achieved. (e) Place of service. Place of service means the county where the CME or agency providing case management services is located, including the main address. The place of service may be a standard heading on each page of the progress notes. (f) For notes pertaining to meetings with or discussions about the individual, the names of other participants, including the titles and agency representation of the participants, if any. (3) For an individual living in their own or family home, a CME must maintain a minimum acceptable record of expenditures for at least three years that includes all of the following: (a) Itemized invoices and receipts to record the purchase of any single item. (b) A trip log indicating purpose, date, and total miles to verify vehicle mileage reimbursement. (c) Pay records to record employee services, including timesheets signed by both employee and employer. (d) Itemized invoices for any services purchased from independent contractors, provider agencies, and professionals. Itemized invoices must include: (A) The name of the individual to whom services were provided. (B) The date of the services. (C) The amount of services. (D) A description of the services. (e) Evidence confirming the receipt, and securing the use of, assistive devices, environmental safety modifications, and environmental modifications. When an assistive device is obtained for the exclusive use of an individual, a CME must record the purpose, final cost, and date of receipt. (4) Verification that a provider meets the requirements to deliver services the provider is authorized to deliver including: (a) Verification of a valid license to drive for any personal support worker, and proof of current auto insurance for the vehicle used for transportation, upon authorization of community transportation services. (b) Documentation supporting the rate paid to a provider when it is above the minimum described in rule, policy, Expenditure Guidelines, or the base rate for a personal support worker identified in the current Collective Bargaining Agreement, including support for an enhanced and an exceptional personal support worker rate. (5) Failure to furnish written documentation upon the written request from the Department, the Oregon Department of Justice Medicaid Fraud Unit, Centers for Medicare and Medicaid Services, or their authorized representatives, immediately or within timeframes specified in the written request, may be deemed reason to recover payments or deny further assistance.