Section 29-6224. RECORDKEEPING

 

6224.1Each facility shall maintain a separate written case record for each resident. Each facility shall make timely entries in a resident's case record that are legible, dated and signed by the staff member or other person making the entry.

 

6224.2Each resident's case record shall include:

 

(a)The resident's name, date and place of birth, social security number, date of admission, and citizenship;

 

(b)A description of the resident's identifying features, including but not limited to sex, race, height, weight, color of hair, color of eyes, and identifying marks;

 

(c)A current photograph of the resident;

 

(d)The primary language or means of communication spoken and understood by the resident and the primary language used by the resident's family, if other than English;

 

(e)Religious affiliation;

 

(f)The name, address, and telephone number of the resident's parent(s) or other responsible family members, guardian, attorney, guardian ad litem, and referring agency or case worker, as applicable;

 

(g)Medical, mental health and immunization records, including but not limited to identified emergency medical needs, allergies, basic needs, and non-emergency medical conditions and physical infirmities, including all visible signs of illness or injury;

 

(h)Dental, vision and hearing records;

 

(i)Risk and safety assessments;

 

(j)Social history;

 

(k)Individual service plans and any changes or updates thereto;

 

(l)Discharge plan(s);

 

(m)Discipline and restraint records relating to the resident, where applicable;

 

(n)All correspondence relevant to the resident;

 

(o)Reports of unusual incidents, where applicable;

 

(p)Reports related to abuse, neglect, or other risks to the resident's health and safety produced pursuant to § 6204;

 

(q)Any required consents to treatment;

 

(r)Any restrictions on visitation, mail, or telephone contacts;

 

(s)Court orders, if applicable;

 

(t)Admission and placement information;

 

(u)Signed notification of rights, grievance procedures and applicable consent to treatment protections;

 

(v)Records of the contracting entity pertaining to the resident;

 

(w)Records of CSSD pertaining to the resident, where applicable;

 

(x)Education records;

 

(y)Any evaluation or progress reports prepared for the resident;

 

(z)The resident's grievance and disciplinary record;

 

(aa)Documentation of counseling and treatment sessions; and

 

(bb)Weekly documentation of the resident's status and progress.

 

6224.3The facility shall maintain all information in the resident's case record for so long as the resident is admitted in the facility. Upon the resident's discharge from the facility, the facility shall turn over the original or a copy of the resident's case record to the contracting entity.

 

6224.4The facility shall maintain each resident's case record in a locked and secure location when unattended.

 

6224.5The facility, licensing agency, contracting entity, guardian ad litem and, where applicable, CSSD shall have access to the resident's case record. No other person shall have access to the resident's case record unless authorized in writing by the licensing agency.

 

6224.6Each facility shall maintain a record of each use of discipline and restraint and shall include in such record the information required under §§ 6273-74.

 

6224.7Each facility shall maintain at the facility easily accessible emergency information for each resident, which shall include the name, address, telephone number and relationship of a designated person to be contacted in case of an emergency, a person able to give consent for emergency medical treatment, if applicable and the resident's physician or source of health care and health insurance information.

 

source

Final Rulemaking published at 48 DCR 8675, 8701 (September 21, 2001).