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130 CMR 403.419 - Provider Responsibilities (Recordkeeping), Home Health Agency

MassachusettsregulationMassachusetts Executive Office of Health and Human Services, Division of Medical Assistance (MassHealth)· effective 2022-07-01

What this rule requires your agency to do

  • 1The agency must maintain an up-to-date medical record of services provided to each member. (130 CMR 403.419(D))(130 CMR 403.419 - Provider Responsibilities (Recordkeeping), Home Health Agency)
  • 2The agency must keep payroll, financial, staffing, complaint, contract, and job-description records accessible and available on-site for inspection by the MassHealth agency. (130 CMR 403.419(D))(130 CMR 403.419 - Provider Responsibilities (Recordkeeping), Home Health Agency)
  • 3The agency must document all verbal orders in the member's record and have them properly authenticated. (130 CMR 403.419(D))(130 CMR 403.419 - Provider Responsibilities (Recordkeeping), Home Health Agency)
  • 4The agency must maintain a current medication-administration list in each member's record showing timing, dosage, route, and the administrator's signature. (130 CMR 403.419(D))(130 CMR 403.419 - Provider Responsibilities (Recordkeeping), Home Health Agency)
  • 5The agency must provide complete documentation in the member's medical record for any service billed, as payment requires such documentation. (130 CMR 403.419)(130 CMR 403.419 - Provider Responsibilities (Recordkeeping), Home Health Agency)
  • 6The agency must record progress notes signed by the service provider that include the date, time, treatments provided, and the member's response. (130 CMR 403.419(D))(130 CMR 403.419 - Provider Responsibilities (Recordkeeping), Home Health Agency)
  • 7The agency must maintain administrative records in compliance with the record-retention requirements set forth in 130 CMR 450.205: Recordkeeping and Disclosure. (130 CMR 403.419(D)(1))(130 CMR 403.419 - Provider Responsibilities (Recordkeeping), Home Health Agency)

Applies to: home health agencies delivering in-home services to MassHealth members

Section 403.419 sets the recordkeeping and documentation obligations MassHealth home health agencies must meet, requiring an up-to-date medical record for each member, complete documentation to support payment, and retention of administrative and clinical records per 130 CMR 450.205.

Regulatory information, not legal advice — always confirm against the cited official source. Verification reduces error; it does not certify compliance.