Current through Register Vol. 50, No. 9, September 20, 2024
A. At the time
of admission to the ICF/MR, information shall be entered into the client's
record which shall identify and give a history of the client. This identifying
information shall at least include the following:
1. a recent photograph;
2. full name;
3. sex;
4. date of birth;
5. ethnic group;
6. birthplace;
7. height;
8. weight;
9. color of hair and eyes;
10. identifying marks;
11. home address, including street address,
city, parish and state;
12. Social
Security Number;
13. medical
assistance identification number;
14. Medicare claim number, if
applicable;
15.
citizenship;
16. marital
status;
17. religious
preference;
18. language spoken or
understood;
19. dates of service in
the United States Armed Forces, if applicable;
20. legal competency status if other than
competent;
21. sources of support:
social security, veterans' benefits, etc.;
22. father's name, birthplace, Social
Security Number, current address, and current phone number;
23. mother's maiden name, birthplace, Social
Security Number, current address, and current phone number;
24. name, address, and phone number of next
of kin, legal guardian, or other responsible party;
25. date of admission;
26. name, address and telephone number of
referral agency or hospital;
27.
reason for admission;
28. admitting
diagnosis;
29. current diagnosis,
including primary and secondary DSM III diagnosis, if applicable;
30. medical information, such as allergies
and general health conditions;
31.
current legal status;
32. personal
attending physician and alternate, if applicable;
33. choice of other service
providers;
34. name of funeral
home, if appropriate; and
35. any
other useful identifying information. Refer to Admission
Review for procedures.
B. First Month After Admission. Within 30
calendar days after a client's admission, the ICF/MR shall complete and update
the following:
1. review and update the
pre-admission evaluation;
2.
develop a prognosis for programming and placement;
3. ensure that an interdisciplinary team
completes a comprehensive evaluation and designs an individual habilitation
plan (IHP) for the client which includes a 24-hour schedule.
C. Entries into Client Records
During Stay at the ICF/MR. The following information shall be added to each
client's record during his/her stay at the ICF/MR:
1. reports of accidents; seizures, illnesses,
and treatments for these conditions;
2. records of immunizations;
3. records of all periods where restraints
were used, with authorization and justification for each, and records of
monitoring in accordance with these standards;
4. reports of at least an annual review and
evaluation of the program, developmental progress, and status of each client,
as required in these standards;
5.
behavior incidents and plans to manage inappropriate behavior;
6. records of visits and contacts with family
and other persons;
7. records of
attendance, absences, and visits away from the ICF/MR;
8. correspondence pertaining to the
client;
9. periodic updates of the
admission information (such updating shall be performed in accordance with the
written policy of the ICF/MR but at least annually); and
10. appropriate authorizations and
consents.
D. Entries at
Discharge. At the time of a client's discharge, the QMRP or other professional
staff, as appropriate, shall enter a discharge summary into the client's
record. This summary shall address the findings, events, and progress of the
client while at the ICF/MR and a diagnosis, prognosis, and recommendations for
future programming.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
36:254.
