Section 29-717. RECORD KEEPING AND REPORTING

 

717.1Patient/client records shall contain the following identifying information:

 

(a)Name, address, telephone number, sex, age, and ethnic background;

 

(b)The name and telephone number of the person to be notified in case of emergency;

 

(c)Next of kin;

 

(d)Travel directions between home and facility, when indicated; and

 

(e)Identifying numbers related to health care benefits;

 

717.2Patient/client records shall contain functional assessments, including an original and revised version indicating the participant's progress.

 

717.3Patient/client records shall contain an assessment of the participant's home environment.

 

717.4Patient/client records shall include the individual plan of care for each participant, which shall include the following:

 

(a)The physician's report, including medical (or psychiatric, when indicated) status evaluation and subsequent pertinent additional information;

 

(b)Medications prescribed and any drug reactions; and

 

(c)Types of services participant is receiving, how often, who is providing them, and physician's approval, signature, and date.

 

717.5All records shall be maintained so that they are accessible only to the Director, staff, and to the funding and monitoring agencies.

 

717.6The program staff shall not discuss or reveal the contents of any client's record without the client's written permission.

 

717.7Individual personnel records shall be maintained on all program staff and consultants.

 

717.8Individual personnel records shall include the following:

 

(a)Name, address, telephone number, age, and sex;

 

(b)Educational background;

 

(c)Employment history and notes on references;

 

(d)Evaluation of performance and attendance;

 

(e)Certification that the staff member is free of tuberculosis in a communicable stage;

 

(f)The names and means of contacting persons to be notified in case of emergency; and

 

(g)Copies of formalized agreements with consultants identifying services to be provided.

 

717.9Program administrative and fiscal records shall include at least the following:

 

(a)Expenditures with supporting documentation;

 

(b)The fee schedule and fee charges;

 

(c)Current and projected budgets, including specific cost allocations;

 

(d)The annual program evaluation report with supporting statistics;

 

(e)In-service programs offered;

 

(f)Current health and fire safety inspection reports;

 

(g)The daily menus of meals for a thirty (30) day period;

 

(h)The daily schedule of activities;

 

(i)Attendance reports;

 

(j)Audit reports;

 

(k)The number of individuals waiting for admission to the program; and

 

(l) The source of gross monthly program income.

 

717.10The Program Director shall notify the Office of Health Care Financing immediately, in writing, in the following situations:

 

(a)Fire, accident, injury, or evidence of serious communicable disease contracted by staff or participants;

 

(b)Changes in professional staff;

 

(c)The intention to relocate the program site before relocation takes place;

 

(d)The death of a participant at, en route to, or en route from the program site; or

 

(e)At least sixty (60) days in advance of planned action, notice of the provider's intention to withdraw from the Medicaid Program.

 

source

Final Rulemaking published at 31 DCR 326 (January 27, 1984).