09/01/07 4.E.1. The facility must develop and maintain a
record-keeping system that includes a separate record for each client. All
reports and records must be available for inspection by the Department upon
request.
09/01/07 4.E.2. Documentation in the record must
include:
a. Health Care Services (if
appropriate):
1. Medical care plan and
progress notes; or nursing/health care plan and progress notes; and
2. Medication administration and response to
drugs
b. Active
Treatment:
09/01/07
1.Annual
Plan
2. Written training
plans;
3. Reviews, as appropriate,
by a member of the IDT;
4.
Professional evaluations and recommendations for treatment; and
5. Reports from external and day
programs;
6. Ensure that the
updated comprehensive functional assessment and the reviewed and revised IPP is
placed in the client's record, together with:
(a) New and revised habilitation plans and
programs; and
(b) All reports and
evaluations which contributed to the development of the new plan including, but
not limited to:
(1) Social Services progress
notes;
(2) Activities assessments
and summaries;
(3) Annual
evaluations with progress notes and recommendations by all professions whose
expertise encompasses areas in which the client does not function
appropriately;
(4) Physician's
statement of current status and evaluation of progress;
(5) Psychological evaluation with summary of
developmental and behavioral progress/problems and recommendations;
(6) Pharmacist's drug regimen
reports;
(7) Nursing summary of
progress/problems and recommendations; and
c. Social Information:
1. Plan of care and progress notes;
2. Discharge plan;
3. Record of family involvement;
and
4. Activities
assessment.
d.
Protection of Clients Rights:
1.
Acknowledgment of client or his/her legal representative having read or heard
the statement of rights;
2. If
anyone other than the facility or appropriate governmental agency staff is to
have access, written permission from the client or his/her legal representative
for that person;
3. Personal
property inventory; and
4.
Appropriate authorizations and consents by clients, parents, or legal
guardians.
e. In
addition to the above, the record for each client admitted will contain:
1. Initial assessments, progress reports, the
most recent individual program plan and current information for the past twelve
(12) months;
2. Name, date of
admission, birth date and place of birth, citizenship status and social
security number;
3. Parent(s)
names, birthplaces and marital status, if known;
4. Name, address and telephone number of
parent(s), legal guardian, correspondent and, if needed, next of kin;
5. Sex, race, height, weight, color of hair,
color of eyes, identifying marks and recent photograph;
6. Language spoken and understood, and
religious affiliation;
7.
Preadmission evaluation and medical history;
8. Physician(s) orders for medication and
other prescribed treatment;
9.
Physician certification for appropriate level of care;
10. Reason for referral for admission as
documented by the Preplacement Interdisciplinary Team;
11. Type and legal status of
admission;
12. Legal competency
status;
13. All sources of
financial support;
14. Records of
significant behavior incidents;
15.
Records of any allegation or instance of abuse, neglect or exploitation of the
client if appropriate, with documentation of resolution;
16. Reports of accidents, seizures, illness
and treatments for these conditions;
17. Records of all periods that restraints
were used, with justification and authorization for each;
18. Correspondence pertaining to the
client;
19. Records of
immunizations; and
20. Contracts
between the client and the facility.
4. E. 3. The facility shall keep confidential all
information in client records regardless of form or method of storage,
including information contained in an automated data bank. The client or
his/her legally designated guardian shall have access to the records (unless
medically contraindicated as documented by the physician in the medical record)
in the presence of a member of the facility staff.
