Section 29-9713. RECORDKEEPING

 

9713.1Each ADHP provider shall maintain complete and accurate participant records (paper or electronic) for each participant that documents the specific ADHP services provided to each participant for a period of ten (10) years or until all audits are completed, whichever is longer.

 

9713.2Each participant’s record shall include, but not be limited to, the following information:

 

(a) General information including the participant's name, Medicaid identification number, address, telephone number, age, sex, name and telephone of emergency contact person, authorized representative (if applicable), and primary care physician's or advanced practice registered nurse’s name, address, and telephone number;

 

(b) The approved ADHP  assessment determination, certification of chronic medical condition,  and the Medical Release Form;

 

(c) Notes from the participant’s pre-admission interview;

 

(d) An emergency care form to include the name and contact information for at least three people to be notified in case of emergency;

 

(e) ADHP HIPAA Privacy Act Statement and signed acknowledgement in accordance with the HIPAA Privacy Act of 1996, approved August 21, 1996 (Pub. L. 104-191, 110 Stat. 1936);

 

(f) The participant’s person-centered service plan, the ADHP  plan of care, and all monthly updates;

 

(g) The results of the participant’s initial and any revised needs-based assessment;

 

(h) A copy of the written agreement between the ADHP provider and the participant;

 

(i) All physician orders including all orders for medications;

 

(j) Other assessments and consultations;

 

(k) Documentation of services received, how often and by whom;

 

(l) Progress notes and quarterly updates;

 

(m) Incident and accident reports;

 

(n) Copies of any written notices given to the participant; and

 

(o) Discharge summary, if applicable.

 

9713.3Each provider shall maintain the following fiscal records:

 

(a)  Daily attendance roster;

 

(b)The program inspection reports (health, fire, safety, food), if applicable;

 

(c) An annual ADHP program evaluation report including program  enrollment and discharge data;

 

(d)  Current copies of all fully executed contracts pertaining to the  delivery of ADHP services;

 

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

 

(f) General ledger and books of original entry showing receipts and  expenditures with supporting documentation;

 

(g)  The fee schedule and fee charges;

 

(h) The daily schedule of activities;

 

(i)The daily menus for meals and snacks for each thirty (30) day period;

 

(j) Any audits by Centers for Medicare and Medicaid Services (CMS) and/or DHCF;

 

(f)  The discharge planning form/report;

 

(k)  The number of individuals waiting for admission to the program, if  any;

 

(l) The community outreach materials that shall include:

 

(1) A program brochure;

 

(2)Letters to physicians, health facilities, senior centers, and social service agencies informing them of the services provided by the program;

 

(3)Strategies for participation and involvement with community service agencies and community leaders to develop referral mechanisms;

 

(4)Notices posted in community facilities; and

 

(5)Schedule of events held for the general public and various community groups.

 

9713.4Individual personnel records shall be maintained on all program staff and consultants.

 

9713.5Individual 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 and other communicable diseases;

(f)CPR certification(s);

 

(g) Results of reference and criminal background checks including proof of compliance with the Health-Care Facility Unlicensed Personnel Criminal Background Check Act of 1998, effective April 20, 1999 (D.C. Law 12-238; D.C. Official Code §§ 44-551 et seq.); as amended by the Health-Care Facility Unlicensed Personnel Criminal Background Check Amendment Act of 2002, effective April 13, 2002 (D.C. Law 14-98; D.C. Official Code §§ 44-551 et seq.) for the following employees or contract workers:

 

(1) Individuals who assist licensed health professionals in providing direct patient care or common nursing tasks, but are not licensed under Chapter 12, Health Occupations Board, of Title 3 of the D.C. Official Code;

 

(2) Nurse aides, orderlies, assistant technicians, attendants, home health aides, personal care aides, medication aides, geriatric aides, or other health aides; and

 

(3) Housekeeping, maintenance, and administrative staff who may have direct contact with participants. 

 

(h)  Evidence of participation in continuing education; and

 

(i)  Copies of all professional licenses held by employees or any contractor utilized by the Provider for the delivery of ADHP services.

 

9713.6All ADHP participant, personnel and program administrative and fiscal records shall be maintained so that they are accessible and readily retrievable for inspection and review by DHCF, CMS, and other authorized government officials or their agents, as requested.

 

authority

An Act to enable the District of Columbia to receive federal financial assistance under Title XIX of the Social Security Act for a medical assistance program, and for other purposes, approved December 27, 1967 (81 Stat. 744; D.C. Official Code § 1-307.02 (2014 Repl.)), and Section 6(6) of the Department of Health Care Finance Establishment Act of 2007, effective February 27, 2008 (D.C. Law 17-109; D.C. Official Code § 7-771.05(6) (2012 Repl.)).

source

Final Rulemaking published at 63 DCR 1031 (January 29, 2016).