Current through Register Vol. 51, No. 19, September 20, 2024
A. Records. The
center shall maintain records that are needed to operate the center, as
required by the Department, and to document the progress of the
participants.
B. Retention. The
center shall maintain participants' records for at least 5 years from the date
of discharge, except as provided in Health-General Article, §4-403,
Annotated Code of Maryland.
C.
Confidentiality. The center shall maintain records so that they are accessible
only to the director, the staff, emergency personnel, and to funding and
monitoring agencies. The center may not discuss or reveal the contents of the
records with any persons other than those listed above without the
participant's written permission.
D. Required Records.
(1) Participant Records. The center shall
maintain at least the following information for each participant:
(a) Name, age, sex, address, and telephone
number;
(b) Name and telephone
number of the individual to be notified in case of emergency;
(c) Next of kin;
(d) Medicare, Medicaid, or private insurance
member enrollment numbers related to health care benefits;
(e) Name and address of primary care
provider, with changes noted and dated when change occurs;
(f) Functional assessment with original and
revised versions noting participant progress;
(g) Assessment of the home environment at the
time of intake and as needed, or at change of home address;
(h) Individual plan of care;
(i) Admission physical and subsequent
additional information;
(j)
Medications and adverse drug reactions; and
(k) Accidents.
(2) Personnel Records. The center shall
maintain the following information for each staff member:
(a) Name, age, sex, address, and telephone
number;
(b) Educational
background;
(c) Employment history
and notes on references;
(d)
Performance evaluations and attendance;
(e) Individual to be notified in case of
emergency;
(f) Documentation that
the individual is free from tuberculosis, measles, mumps, rubella, and
varicella as evidenced by:
(i) Physician's
statement;
(ii) Positive disease
histories affirmed by employee's signature;
(iii) Antibody serology's of titer;
(iv) Skin tests; or
(v) Statement of vaccinations, affirmed by
the employee signature;
(g) Evidence that the annual influenza
vaccine has been advised;
(h) Any
impairment which would hinder the performance of assigned responsibilities;
and
(i) Documentation of a criminal
history records check in accordance with Health-General Article, §19-1901,
Annotated Code of Maryland;
(j) The
official driving record and a copy of a valid driver's license if driving is a
condition of employment; and
(k)
Copies of written agreements with consultants, including services to be
provided
(3) Volunteer
Records.
(a) The center shall urge that
volunteers accept annual influenza vaccination and tuberculin testing as
considered necessary by the center
(b) The center shall give appropriate health
care information to such volunteers to provide maximum protection to
residents.
(c) The
center shall maintain documentation of the discussion between the center and
the volunteer concerning influenza vaccine and tuberculin testing.
(4) Administrative and Fiscal
Records. The center shall maintain the following administrative and fiscal
records:
(a) Expenditures with substantiating
documentation;
(b) Current and
projected annual operating budgets, including specific cost allocations and
formula for determining projected expenditures, and including accurate per diem
costs;
(c) Fee charged, and fee
schedule, if appropriate;
(d)
Records of in-service training offered by the center;
(e) Current inspection reports from the
health and fire departments;
(f)
The daily schedule of activities;
(g) Daily menu of meals and snacks served for
a 30-day period;
(h) Attendance
records; and
(i) Audit
reports.