Current through Register Vol. 50, No. 9, September 20, 2024
A. Written
Policies and Procedures. An ICF/MR facility shall have written policies and
procedures governing access to, publication of, and dissemination of
information from client records.
B.
Protection of Records. Client records are the property of the ICF/MR residents
and as such shall be protected from loss, damage, tampering, or use by
unauthorized individuals. Records may be removed from the ICF/MR's jurisdiction
and safekeeping only in accordance with a court order, subpoena or
statute.
C. Confidentiality. An
ICF/MR facility shall ensure confidential treatment of client records,
including information contained in automatic data banks.
1. The client's written consent, if the
client is determined competent, shall be required for the release of
information to any persons not otherwise authorized under law to receive it. If
the client is not documented as competent, a member of the family, responsible
party or advocate shall be required to sign.
NOTE: "Blanket" signed authorizations for release of
information from client records are time limited.
2. A record of all disclosures from client's
records shall be kept.
3. All staff
shall be trained in the policies regarding confidentiality during orientation
to the ICF/MR and in subsequent on-the-job and in-service training.
4. Any information concerning a client or
family considered too confidential for general knowledge by the ICF/MR staff
shall be kept in a separate file by the chief executive officer, his designee,
or social worker. A notation regarding the whereabouts of this information
shall be made in the client's record.
D. Availability of Records. The ICF/MR shall
make necessary records available to appropriate state and federal personnel
upon request.
E. Records Service
System
1. The ICF/MR shall maintain an
organized central record service for collecting and releasing client
information. Copies of appropriate information shall be available in the client
living units.
2. A written policy
shall be maintained regarding a "charge out system" by which a client's record
may be located when it is out of file.
3. The ICF/MR shall maintain a master
alphabetical index of all clients.
4. All records shall be maintained in such a
fashion as to protect the legal rights of clients, the ICF/MR, and ICF/MR
staff.
F. General
Contents of Records. A written record shall be maintained for each client.
1. Records shall be adequate for planning and
for continuously evaluating each client's habilitation plan and documenting
each client's response to and progress in the habilitation plan.
2. Records shall contain sufficient
information to allow staff members to execute, monitor and evaluate each
client's habilitation program.
G. Specifics Regarding Entries into Client
Records. The following procedures shall be adhered to when making entries into
a client's record.
1. All entries shall be
legible, signed, and dated by the person making the entry.
2. All corrections shall be initialed and
completed in such a manner that the original entry remains legible.
3. Entries shall be dated only on the date
when they are made.
4. The ICF/MR
shall maintain a roster of signatures, initials and identification of
individuals making entries in each record.
H. Components of Client Records. Components
of client records shall include, but shall not be limited to, the following:
1. admission records;
2. personal property records;
3. financial records;
4. medical records.
a. This includes records of all treatments,
drugs, and services for which vendor payments have been made, or which are to
be made, under the Medical Assistance Program.
b. This includes the authority for and the
date of administration of such treatment, drugs, or services.
c. The ICF/MR shall provide sufficient
documentation to enable DHH to verify that each charge is due and proper prior
to payment.
5. All other
records which DHH finds necessary to determine a ICF/MR's compliance with any
federal or state law, rule or regulation promulgated by the DHH.
I. Retention of Records. The
ICF/MR shall retain records for whichever of the following time frames is
longer:
1. until records are audited and all
audit questions are answered;
2. in
the case of minors, three years after they become 18 years of age; or
3. three years after the date of discharge,
transfer, or death of the client.
J. Interdicted Client. If the ICF/MR client
has been interdicted, a copy of the legal documents shall be contained in the
client's records.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
36:254 and 42 CFR 433 and
42 CFR
483.400.
