La. Medicaid Services Manual ch. 24 (Hospice) § 24.8

The hospice provider must have sufficient space, facilities and supplies to ensure effective record

keeping.

A hospice provider must maintain and retain the business and professional records sufficient to

document fully and accurately the nature, scope and details of the health care provided. The

hospice provider must provide reports and keep records as the Louisiana Department of Health

(LDH) determines necessary to administer the program. Failure to comply may result in one or

more of the following:

1. Recoupment;

2. Sanction;

3. Loss of enrollment; or

4. Referral to Surveillance and Utilization Review Systems (SURS).

Contract Services

If services are provided on a contractual basis, the hospice provider must have a legally binding

written agreement for the provision of arranged services that includes requirements as detailed in

the Louisiana Administrative Code ( LAC) 48:I.Chapter 82 -Licensing Standards for Hospices,

Section 8237.

Review by State and Federal Agencies

When requested, a provider must furnish access to all administrative, personnel and beneficiary

records to authorized state and federal personnel, at all reasonable times. Providers’ records are

subject to audit by LDH, the State Attorney General’s Office, the Office of Inspector General

(OIG), and the Centers for Medicare and Medicaid Services (CMS) or other appropriate state or

federal agencies.

Administrative Files

The hospice provider must disclose all financial, beneficial ownership, equity, surety or other

interests in any and all firms, corporations, partnerships, associations, business enterprises, joint

ventures, agencies, institutions or other legal entities providing any form of health care services to

beneficiaries of medical assistance.

The provider's administrative files must include, at a minimum:

1. Documentation identifying the governing body;

2. A list of members and officers of the governing body, their addresses and terms of

membership;

3. An organizational chart which delineates lines of authority and responsibility for

all hospice personnel;

4. Documentation of the provider's administrative policies and procedures as detailed

in LAC 48:I.Chapter 82-Licensing Standards for Hospices, Section 8235; and

5. Documentation of quality assurance as detailed in LAC 48:I.Chapter 82-Licensing

Standards for Hospices, Section 8239.

Personnel Records

The provider must have written employment and personnel policies that detail the following:

1. Job descriptions for all positions, including volunteers and students, that include

the duties, qualifications and competencies;

2. A description of hiring practices that includes a policy against discrimination based

on race, color, religion, sex, age, national origin, disability, political beliefs,

disabled veteran, veteran status or any other non-merit factor;

3. A description of procedures for employee evaluation, promotion, disciplinary

action, termination and hearing of employee grievances; and

4. A written record on each employee that includes the following:

a. An application for employment and/or resume;

b. References;

c. Verification of professional credentials;

d. Performance evaluations;

e. Employee’s starting and termination date; and

f. Time sheets for all times on duty.

Beneficiary Clinical Records

In accordance with LAC 48:I.Chapter 82- Licensing Standards for Hospices, Section 8233, the

hospice provider must establish and maintain a clinical record for every beneficiary receiving care

and services. The record must be complete, promptly and accurately documented, readily

accessible and systematically organized to facilitate retrieval. The clinical records must

substantiate the services billed to Medicaid by the hospice provider. Services not specifically

documented in the beneficiary’s clinical record as having been rendered will be deemed not to

have been rendered and no reimbursement will be provided. Entries are to be made for all services

provided. Entries are to be signed and dated by the person providing the services. The record

includes all services whether furnished directly or un der arrangements made by the hospice

provider. Each beneficiary’s record must contain the following:

1. The initial and subsequent assessments;

2. The plan of care (POC) (updated and original);

3. Identification data;

4. Authorization forms;

5. Pertinent medical history, beneficiary’s primary hospice diagnosis, other diagnoses

and prognosis;

6. Physician’s orders, including, if respite, continuous care or general inpatient care,

orders for these services, including number of days and justification;

7. Complete documentation of all services and events (including evaluations,

treatments, progress notes for all services rendered, etc.);

8. Certification statements and physician narratives of the terminal illness for each

benefit period;

9. Election statements; and

10. Discharge/revocation/transfer forms and notes, if applicable.

Confidentiality and Protection of Records

The hospice provider must safeguard the clinical record against loss, destruction and unauthorized

use in accordance with Medicaid policies, federal and state laws, including the Health Insurance

Portability and Accountability Act ( HIPAA). All medical assistance information regarding

beneficiaries must be held confidential and used for authorized Medicaid purposes only. A

provider shall disclose information in their possession only when the information is to be used in

conjunction with a claim for health benefits or when the data is necessary for t he functioning of

the Medicaid program.