{"ref":"LA-HC-REC-02","title":"Daily Documentation, Progress Notes, and LT-PCS Service Logs","category":"Records","summary":"Tells direct care workers what to write after every visit and when: the progress note items LAC 48:I.5057.A.10 requires for every client, the OAAS LT-PCS service log rules (completed daily as tasks are done, signed at the end of the week, with start and stop times from EVV), how to record changes, refusals and unused hours, and how supervisors review documentation before billing.","inShort":["Write your note during every visit, as you do each task, and finish it before you leave.","Include the date and times, each service you gave, your name, any change in the client, and any doctor appointment.","For LT-PCS, fill in the OAAS service log each day as tasks are done, never in advance; you and the client sign it at the end of the week.","If you did not do a task, or gave more help than the plan shows, write why.","Report any change in the client to your supervisor immediately; writing it down is not enough."],"primaryCitation":"LAC 48:I.5057.A.10","citations":["LAC 48:I.5057.A.10","LAC 48:I.5057.A","LAC 48:I.5055.G.3","LAC 48:I.5055.G.4","LAC 48:I.5055.G.8","LAC 48:I.5055.G.9","LAC 48:I.5029.B.12","LAC 48:I.5039.B.6","LAC 48:I.5021.D.7","Medicaid Services Manual, Chapter 30, §30.8","LDH EVV Policy and Procedures (OAAS-ADM-23-001 / OCDD-A-23-005)"],"federalCitations":["42 U.S.C. §1396b(l)"],"surveyorAsks":["Show me the progress notes for this client’s visits last week. Do they show the date and time, the services, who delivered them, observed changes and doctor appointments?","For this LT-PCS client, show me the service log for the current week in the home. Is it completed for each day already worked, and only for those days?"],"forms":[{"ref":"LA-HC-REC-02-A","title":"Daily Progress Note"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (LAC 48:I.5057.A.10)","5. Writing the Progress Note at Every Visit","6. LT-PCS Service Logs","7. Waiver Participants and Other Clients","8. Reporting What You Document","9. Corrections and Late Entries","10. Supervisor Review and Matching to EVV","11. Honest Documentation","12. Responsibilities","13. Records and Compliance Monitoring","14. Staff Training","15. References","16. Related Policies and Forms","17. Approval","18. Revision History"],"version":"1.0","sample":false,"pack":"la-hca","state":"Louisiana","service":"Home care","guides":[{"path":"/guides/home-care-agency-policies/","h1":"What policies does a home care agency need?"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}