Learn about documentation, reporting MUIs, record keeping, and compliance reviews by following the appropriate tabs below.
Documentation Requirements
For any service you provide, you must have documentation of that service. Best practice is to keep your documentation up to date and to complete it the same day you are providing services.
Each service has its own documentation requirements, which can be found within the rule for each service. Rules can be found on DODD’s website at www.dodd.ohio.gov. Examples of these requirements can be found below.
Your documentation form can appear any way you want it to, but MUST contain all of the required elements. The Medina County Board of DD has templates available for commonly provided services. These forms can be found at www.mcbdd.org/provider
Things to Remember
- Documentation should be maintained in an accessible location.
- Invoices submitted for payment or billing records are not considered documentation.
- You must maintain your documentation records for 7 years or until an initiated audit is complete, whichever is longer.
Commonly Used Service Documentation Requirements
Homemaker Personal Care (HPC)
Type of service, date of service, place of service, name of individual receiving service, Medicaid number of individual, name of provider, provider identifier/contract number, written or electronic signature of the person delivering the service, initials if the provider has corresponding signature and initials on file, group size in which the service was provided, description and details of the service delivered that directly relate to the services specified in the approved service plan, number of units of the delivered service or continuous amount of uninterrupted time the service was provided, times the delivered service started and stopped.
HPC Transportation
Type of service, date of service, license plate number of vehicle, name of individual receiving service, Medicaid number of individual receiving service, name of provider, provider identifier/contract number, origination and destination points of transportation provided, total number of miles of transportation provided, number of individuals being transported, written or electronic signature of the person delivering service, or initials if provider has corresponding signature and initials on file, description and details of the services delivered that directly relate to services specified in the approved service plan.
Shared Living
Type of service, date of service, place of service, name of individual receiving service, Medicaid number of individual, name of provider, provider identifier/contract number, written or electronic signature of the person delivering the service; initials if the provider has corresponding signature and initials on file, group size in which the service was provided, description and details of the service delivered that directly relate to the services specified in the approved service plan.
What is an MUI?
An MUI (major unusual incident) is an alleged, suspected, or actual incident where there is reason to believe the health and safety of an individual has been/will be adversely affected. The incident may place a person at reasonable risk of harm. Examples may include, but are not limited to, physical abuse, sexual abuse, verbal abuse, attempted suicide, death, exploitation, misappropriation, medical emergency, missing individual, neglect, unapproved behavior support, unscheduled hospital admission, and/or significant injury.
Why Are MUIs Reported?
The MUI reporting system is set up to collect information and causes of incidents. MUI reports show the trends and issues around an incident and provide information to help address those issues and reduce the likelihood of them happening again.
Who Must Report An MUI?
In Medina County, MUIs are reported to the MUI Office at the Medina County Board of Developmental Disabilities. The MUI Office reviews all reports and sends them to the State of Ohio’s tracking system.
When Should MUIs Be Reported?
Incidents involving abuse, neglect, death, exploitation, misappropriation, failure to report, and peer-to-peer acts must always be reported within four hours of occurring by calling the MUI Hotline at 330-725-7751 option 4. All other incidents must be reported to muireport@mcbdd.org by 2:00 pm the next working day.
A Provider Must:
- Take immediate action to protect the individuals from further harm.
- Notify the police immediately when there is an alleged crime. Notify the Children’s Services Board if the victim is under 21.
- Report incidents to the Medina County Board of DD.
- Notify legal guardians the same day the incident occurs. Parents who are not legal guardians may only be notified with approval of their son, daughter, or legal guardian.
- Notify the licensed or certified residential provider the same day an incident happens.
- Put preventative measures in place to reduce the likelihood of similar incidents happening again.
MUI/UI Report Requirements
- Anytime a Major Unusual Incident (MUI) or Unusual Incident (UI) occurs, it must be documented on an Unusual Incident Report form.
- Ensure you notify the appropriate parties if a MUI or UI occurs.
- You are required to maintain a monthly UI Log, even if you have 0 incidents. Keep a separate log for each county you serve.
- The Medina County Board of DD requests a sample (two months) of logs from each provider each year.
The MUI Rule can be found at www.dodd.ohio.gov/forms-and-rules.
Annual MUI Analysis
An Annual MUI Analysis must be completed once per year (January – December) by January 31, and submitted to the County Board by February 28 even if there are no MUIs reported.
In Medina County, we send out a courtesy reminder to providers through our provider newsletter distribution list about the analysis and its due date, as well as a form that you can use to fill out. However, it remains the provider’s responsibility to complete and submit this form, regardless of receiving any reminders.
Ensure that you submit the form by the time it is due and retain a copy for your records.
Yearly Timeline for Documentation and Records
Complete Daily:
– Service documentation
– Incident reports (if they occur)
Complete Monthly:
– Completed and signed service documentation
– UI Log (even if there are 0 incidents)
Complete Annually:
– MUI Analysis
– Trainings
– First Aid & CPR Training may be completed every other year
Note: It is your responsibility to ensure you are in compliance with all training requirements and have the documentation/certificates to prove you have completed all requirements. Maintain records of all trainings you complete and all certificates you receive.
At least once in your certification span, you will undergo a compliance review.
A reviewer will contact you in advance to schedule the review. It is important that you are responsive to the reviewer and comply with their requests for scheduling the review and providing them with any/all information that they request.
Review Requirements
You can find all of the information about compliance reviews by clicking here.
General Timeline for a Review
90 days prior to the review: You will receive notification that a review will occur
45- 60 days prior: Reviewer will contact you to set the review date
Onsite Review: Review occurs
The MCBDD can schedule a pre-review if a provider wishes to have one.
After the Review
Once the review is complete:
- If you have received no citations: You will receive a letter signifying that you have completed your review with no citations
- If you have received citations: You will receive a compliance summary and a request for a Plan of Correction (POC)
- Within 14 days of receiving the request, you must submit your POC or you can appeal the citation(s)
- If the POC is approved: You will receive a POC approval letter and a completed compliance survey
- If the POC is disapproved: You will receive correspondence from the reviewer asking for additional information and you will have to resubmit a POC
- Within 90 days of POC approval: The reviewer will verify that the POC has been implemented
Incident Reporting, UIs/MUIs
I think something happened to an individual I serve. What do I do?
In order to report anything that has happened to an individual, you must complete an Unusual Incident Report form and make the applicable notifications.
What is the MUI Annual Analysis?
This required annual report looks at the MUIs you had reported the previous year. You must complete and submit the report to the County Board even if you had no MUIs. Be sure to retain a copy for your own records.
What kind of records do I have to keep for incident reports?
You must keep copies of any incident reports you fill out for any individual you serve. Additionally, each month, you are required to complete a monthly UI log of all of the incidents that occurred each month. The log is required even if you have 0 incidents. Finally, you must complete and submit the Annual MUI Analysis.
Compliance Reviews
I received notification that I am having a compliance review. What does that mean?
All providers have at least 1 compliance review during their certification span. These reviews are designed to ensure you are meeting the standards you agreed to when becoming a provider. You will be required to show your records in all aspects of your service provision (training, documentation, incident reporting, etc.). If you are non-compliant or something needs improvement, that will be noted during the review and you will have the opportunity to fix any areas of concern.