<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".13" citation="COMAR 10.22.02.13" title_num="10" subtitle_num="22" chapter_num="02" heading="Records.">
  <paragraph num="A.">
    <text>A licensee shall maintain records for each individual at the site where the individual is being served.</text>
  </paragraph>
  <paragraph num="B.">
    <text>The records shall include at a minimum:</text>
    <paragraph num="(1)">
      <text>The identifying information which appears on the individual's application for services from the Administration;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Sufficient information that enables the licensee to provide services in a manner which ensures the individual's health and safety, including:</text>
      <paragraph num="(a)">
        <text>An emergency contact person for the individual,</text>
      </paragraph>
      <paragraph num="(b)">
        <text>The names of the individual's next of kin,</text>
      </paragraph>
      <paragraph num="(c)">
        <text>The individual's physician,</text>
      </paragraph>
      <paragraph num="(d)">
        <text>The individual's current diagnosis,</text>
      </paragraph>
      <paragraph num="(e)">
        <text>Documented allergies of the individual, and</text>
      </paragraph>
      <paragraph num="(f)">
        <text>A listing of the medications the individual receives;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(3)">
      <text>The IP as defined in COMAR 10.22.05;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Documentation demonstrating implementation of the IP; and</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Any other information the Administration may require.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>On notification of a medical emergency, the licensee shall ensure that the individual's medical information is available and readily accessible to emergency personnel.</text>
  </paragraph>
  <paragraph num="D.">
    <text>The licensee shall:</text>
    <paragraph num="(1)">
      <text>Maintain an individual's records for a minimum of 6 years, regardless of whether the individual is no longer being served or dies;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Maintain documents relevant to the services the individual is currently receiving, as long as the individual is being served; and</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Organize an individual's record in a manner that facilitates easy access to needed information.</text>
    </paragraph>
  </paragraph>
  <paragraph num="E.">
    <text>Electronic Records.</text>
    <paragraph num="(1)">
      <text>The licensee is encouraged to use electronic records whenever possible.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Electronic records shall:</text>
      <paragraph num="(a)">
        <text>Meet requirements in this chapter;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Comply with the HIPAA privacy and security rules pertaining to personal health information (PHI); and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Be properly backed up and stored at an off-site location.</text>
      </paragraph>
    </paragraph>
  </paragraph>
</regulation>