Current through Register Vol. 50, No. 9, September 20, 2024
A. All
provider records must be maintained in an accessible, standardized order and
format and must be retained and disposed of in accordance with state
laws.
B. A provider must have
sufficient space, facilities and supplies for providing effective record
keeping services.
C. Upon agency
closure, all provider records must be maintained according to applicable laws,
rules and regulations.
D. A
provider must have a written record for each consumer which must minimally
include:
1. identifying data recorded on a
standardized form including the following:
a.
name;
b. home address;
c. home telephone number;
d. date of birth;
e. sex;
f. race or ethnic origin;
g. closest living relative;
h. education;
i. marital status;
j. name and address of current employment,
school, or day program, as appropriate;
k. date of initial contact;
l. court and/or legal status, including
relevant legal documents;
m. names,
addresses, and phone numbers of other persons or providers involved with the
consumer's service plan. This shall include the consumer's qualified, licensed
physician or other licensed health care practitioner who is acting within the
scope of practice of his/her respective licensing board(s) and/or
certification(s);
n. other
identifying data as indicated;
o.
date the information was gathered;
p. signature of the staff member gathering
the information.
2.
Interdiction Status. A notation on the inside of the front cover that the
consumer has been interdicted if this information is known.
3. Limited health records including a
description of any serious or life threatening medical condition of the
consumer. This must include a description of any current treatment or
medication necessary for the treatment of any serious or life threatening
medical condition or known allergies.
E. A provider must ensure that all entries in
records are legible, signed by the person making the entry and accompanied by
the date on which the entry was made.
F. Entries must be made in consumer records
when services are provided to and/or on behalf of consumer in accordance with
the following:
1. All entries and forms in
the consumer's record that are completed by the provider must be in ink, are
legible, be dated, be signed and shall include the functional title of the
person making the entry.
2. An
error in the consumer's record made by staff must be corrected by drawing a
line through the erroneous information. The word "error" must be written beside
the correction, and the correction must be initialed.
3. Correction fluid must never be used in a
consumer's record.
G.
Consumer record material must be organized in a manner which encourages staff
to use it as a communication tool.
1. The
location of documents within the record must be consistent among all the
provider's records.
2. The record
must be appropriately thinned so that current material shall be easily located
in the record.
H. Each
record must document the need for case management services and the following,
at a minimum:
1. medical, social,
psychiatric, psychological and other pertinent information regarding the
consumer's disability, illness, or condition which will document eligibility
for case management services for the targeted population;
2. necessary assessments and other
information concerning the consumer's medical, social, familial, cultural,
developmental, legal, educational, vocational, psychiatric and economic status,
as appropriate, to support the initial service plan, and modifications in the
service plan;
3. documentation of
the need for ongoing case management and other identified services;
4. written service plan signed and dated by
the case manager and the consumer and/or guardian shall be placed in the
consumer's record;
5. description
of all contacts, services delivered and/or action taken identifying the persons
involved in service delivery, the date and place of service, the content of
service delivery and the duration of the contact;
6. progress notes written at least monthly to
document progress towards specified goals;
7. summary of services provided and progress
towards goals, as well as the reason for the closure of the case at the time of
termination; and,
8. any joint
agreement with the consumer for closure.
I. The provider must utilize the tracking
and/or data system for the Program Office of the targeted population being
served or a comparable system which tracks the same data elements and allows
reporting of data to the program office.
J. The provider must sign an agreement with
the appropriate Program Office regarding the exchange of consumer-related
data.
K. The record must contain at
least six months of current information.
L. Information older than six months may be
kept in storage but shall be available for review.
M. The records are maintained until audited
and all audit questions answered or for six years from the time of payment,
whichever is longer.
N. When a
consumer transfers to another provider, at a minimum, copies of the following
information must be sent to the requesting provider upon receipt of a release
of information signed by the consumer:
1.
most current service plan;
2.
current assessments upon which service plan is based;
3. number of services used in the calendar
year; and
4. last quarter's
progress notes;
O. A
nonredisclosure clause must accompany all information released to the
requesting provider on all Office of Alcohol and Drug Abuse
consumers;
P. The receiving
provider must bear the cost of copying which shall not to exceed the
community's competitive copying rate.
Q. A written policy must govern the disposal
of consumer records and confidentiality of consumer information must be
protected at the time of disposal.
R. A provider must have a written record for
each employee which includes:
1. the
application for employment and/or resume'
2. references
3. any required medical
examinations
4. all required
documentation of appropriate status which includes:
a. valid driver's license for operating
provider vehicles or transporting consumers.
b. verification of professional
credentials/certification required to hold the position including the
following:
i. current licensure
ii. relevant licensure
iii. relevant education
iv. relevant training
v. relevant experience
5. periodic, at least annual,
performance evaluations.
6.
employee's starting and terminations dates along with salary paid.
S. An employee must have
reasonable access to his/her personnel file and must be allowed to add any
written statement he/she wishes to make to the file at any time.
T. A provider must not release a personnel
file without the employee's written permission except in accordance with state
law.
AUTHORITY
NOTE: Promulgated in accordance with
R.S.
36:254.
