<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".13" citation="COMAR 32.03.04.13" title_num="32" subtitle_num="03" chapter_num="04" heading="Record Keeping.">
  <paragraph num="A.">
    <text>A provider shall maintain on-site an accurate and current file for each participant.</text>
  </paragraph>
  <paragraph num="B.">
    <text>A participant's file shall contain the following:</text>
    <paragraph num="(1)">
      <text>A completed copy of the following forms prescribed by the Department:</text>
      <paragraph num="(a)">
        <text>Participant assessment form;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Application form;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Provider-participant service agreement and any addenda; and</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Subsidy application, if any;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>Personal data of participant including:</text>
      <paragraph num="(a)">
        <text>Name;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Date of birth;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Admission date and, if applicable, termination date;</text>
      </paragraph>
      <paragraph num="(d)">
        <text>The type of housing the participant lived in before admission into the Program;</text>
      </paragraph>
      <paragraph num="(e)">
        <text>Name, address, and telephone number of the participant's physician;</text>
      </paragraph>
      <paragraph num="(f)">
        <text>Name, address, and telephone number of the participant's contact person;</text>
      </paragraph>
      <paragraph num="(g)">
        <text>If obtained by the provider, relevant medical history of the participant, including physicians' health reports and information on recent hospitalizations; and</text>
      </paragraph>
      <paragraph num="(h)">
        <text>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;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(3)">
      <text>For participants in an Individualized Congregate Housing Services Plan, a service plan;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Incident reports related to the participant;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Documentation verifying on a weekly basis the housekeeping, laundry, and personal assistance services received by the participant during the prior month;</text>
    </paragraph>
    <paragraph num="(6)">
      <text>Reasons for any termination or transfer and, if applicable, the location to which the participant was transferred;</text>
    </paragraph>
    <paragraph num="(7)">
      <text>Any assessments or recommendations concerning the participant which were made by the local health department and received by the provider; and</text>
    </paragraph>
    <paragraph num="(8)">
      <text>If the participant receives a subsidy, a completed copy of the subsidy calculation form and written documentation of the participant's:</text>
      <paragraph num="(a)">
        <text>Net annual income;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Assets; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Allowable medical expenses.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>Incident Reports.</text>
    <paragraph num="(1)">
      <text>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.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>All incident reports shall include the following information:</text>
      <paragraph num="(a)">
        <text>The time, date, and place of the incident;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>The identity of individuals present at the incident;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>A complete description of the incident;</text>
      </paragraph>
      <paragraph num="(d)">
        <text>The response of the staff; and</text>
      </paragraph>
      <paragraph num="(e)">
        <text>Any appropriate follow-up action taken, including notifying the participant's contact person and licensing or law enforcement authorities.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="D.">
    <text>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:</text>
    <paragraph num="(1)">
      <text>The participant consents in writing to the disclosure; or</text>
    </paragraph>
    <paragraph num="(2)">
      <text>State or federal law or a court order otherwise requires or permits the disclosure.</text>
    </paragraph>
  </paragraph>
  <paragraph num="E.">
    <text>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.</text>
  </paragraph>
  <paragraph num="F.">
    <text>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.</text>
  </paragraph>
</regulation>