Regulation .13 Record Keeping.
Regulation .13 Record Keeping.LinkCopy Citation
A.
A provider shall maintain on-site an accurate and current file for each participant.
B.
A participant's file shall contain the following:
(1)
A completed copy of the following forms prescribed by the Department:
(a)
Participant assessment form;
(b)
Application form;
(c)
Provider-participant service agreement and any addenda; and
(d)
Subsidy application, if any;
(2)
Personal data of participant including:
(a)
Name;
(b)
Date of birth;
(c)
Admission date and, if applicable, termination date;
(d)
The type of housing the participant lived in before admission into the Program;
(e)
Name, address, and telephone number of the participant's physician;
(f)
Name, address, and telephone number of the participant's contact person;
(g)
If obtained by the provider, relevant medical history of the participant, including physicians' health reports and information on recent hospitalizations; and
(h)
A copy of any advance health care directive the participant voluntarily provides in response to the provider's inquiring whether it may have a copy of any advance health care directive of participant;
(3)
For participants in an Individualized Congregate Housing Services Plan, a service plan;
(4)
Incident reports related to the participant;
(5)
Documentation verifying on a weekly basis the housekeeping, laundry, and personal assistance services received by the participant during the prior month;
(6)
Reasons for any termination or transfer and, if applicable, the location to which the participant was transferred;
(7)
Any assessments or recommendations concerning the participant which were made by the local health department and received by the provider; and
(8)
If the participant receives a subsidy, a completed copy of the subsidy calculation form and written documentation of the participant's:
(a)
Net annual income;
(b)
Assets; and
(c)
Allowable medical expenses.
C.
Incident Reports.
(1)
A provider shall record on an incident report a description of each accident, injury, or other incident that occurs at the facility and impacts the amount of congregate housing services needed by a participant.
(2)
All incident reports shall include the following information:
(a)
The time, date, and place of the incident;
(b)
The identity of individuals present at the incident;
(c)
A complete description of the incident;
(d)
The response of the staff; and
(e)
Any appropriate follow-up action taken, including notifying the participant's contact person and licensing or law enforcement authorities.
D.
Confidentiality. A provider shall protect the confidentiality of a participant's file. A provider may not disclose information contained in a participant's file to any person or agency other than the participant, the participant's contact person or legal representative, or the Department's authorized employees unless:
(1)
The participant consents in writing to the disclosure; or
(2)
State or federal law or a court order otherwise requires or permits the disclosure.
E.
During ordinary business hours and at other reasonable times, a participant shall have the right to inspect and obtain a copy of the file referred to in §B of this regulation. Upon request by a participant, a provider shall make a copy for the participant of any portion of the file and may charge the participant a reasonable cost for making a copy, not to exceed 30 cents per page.
F.
A provider shall keep a participant's file for at least 3 years after the participant stops participating in the Program at the provider's facility.