(A) All Programs
shall provide conveniently located and suitably equipped areas for the
recording and storage of health records.
(B) All Programs shall maintain on the
premises, in accordance with acceptable professional standards of practice, a
separate, complete, accurate, systematically organized, and current health
record for each participant from the time of admission to the time of
discharge. All entries shall be dated and signed. The participant health record
shall be kept at the nursing station.
(C) The participant health record shall, at
minimum, include:
(1) Participant information
including the participant's name, social security number, date of birth,
gender, marital status, religion, home address, any public and private
insurance information, and date and time of enrollment.
(2) The name, address, and phone number of
the participant's identified contact person and legally authorized
representative.
(3) Documentation
from primary care providers including orders or prescriptions for Services,
physical examinations, and initial treatment orders, as described at
105 CMR
158.035.
(4) The participant enrollment
agreement.
(5) Participant clinical
information, including:
(a) A copy of the
most recent physical examination;
(b) The primary care provider
orders;
(c) Medical
history;
(d) TB
screening;
(e) A list of known
allergies;
(f) Information
concerning participant's dietary requirements;
(g) The medication administration
record;
(h) The results of all
assessments;
(i) Correspondence
with family, therapists, primary care providers, physicians, health care
consultants, or others pertaining to the health care of the
participant;
(j) Consultation notes
from any health care provider who visits or examines the participant at the
Program.
(k) The participant's
attendance record;
(l) Relevant
legal documentation that may include signed authorizations for release of
information, advanced directives, or health care proxy;
(m) Plans of care;
(n) An inventory of participant's personal
belongings maintained at the program; and
(o) Documentation regarding transfers and
discharges, as required in
105 CMR
158.034.
(6) Any notification provided by Program
Director pursuant to
105 CMR 158.030(K)
shall be recorded in writing in the
participant's health record.
(7)
Professional documentation as applicable, including but not limited to the
following:
(a) Nursing notes and
assessments;
(b) Rehabilitation
services notes and assessments;
(c)
Therapeutic activity notes and assessments;
(d) Service coordination notes and
assessments;
(e) Dietary notes and
assessments; and
(f) Assistance
provided with ADL or a staff log of care provided to participant.
(D) Participant health
records shall be:
(1) Readily accessible to
clinical personnel;
(2) Readily
accessible to the Department upon request and in the manner in which it is
requested;
(3) Safeguarded against
loss, destruction, or unauthorized use;
(4) Maintained in compliance with state and
federal privacy and security laws and regulations, including HIPAA;
and
(5) Maintained on-site for at
least the most recent 24 months.
(E) A Program shall maintain participant
health records for at least seven years. In the event a Program discontinues
operations, the Program shall make arrangements for storage of all health
records for at least seven years, and shall notify the Department as to the
location of the records and the person responsible for their
maintenance.
(F) A Program may
implement and use electronic health records. A Program that implements and uses
electronic health records shall:
(1) Comply
with all requirements of
105 CMR 158.000;
(2) Establish, follow, and make accessible to
all users written policies and procedures for the use of electronic health
records;
(3) Adequately train all
personnel in the use of the electronic health records in order to ensure safe
and quality participant care and to ensure the privacy and security of
participants' health information;
(4) Ensure security of records by
implementing password protections and audit trails to verify entries and access
and by maintaining up-to-date antivirus software and appropriate network
security. Any data on a portable storage device, mobile computing device, or
wireless transmission shall be adequately encrypted;
(5) Establish and follow written policies and
procedures regarding electronic signatures. Electronic health records must be
designed to ensure integrity, authenticity, and non- repudiation of data
entered;
(6) Ensure a minimum of
two participant identity checks prior to data entry;
(7) Ensure the system includes redundancy and
other protections against possible loss, deletion, or destruction of
information;
(8) Ensure the
required health record and pharmaceutical information is and will be available
at all times including during emergencies such as flooding or loss of
electrical power; and
(9) Report
any breach of confidential information to the Department, state, and federal
authorities as required.
