Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 404 - DEVELOPMENTAL DISABILITIES SERVICES
Chapter 5 - CORE REQUIREMENTS FOR ALL CERTIFIED AND INDEPENDENT PROVIDERS OF SERVICES
Section 404-5-006 - RECORD KEEPING
Universal Citation: 404 NE Admin Rules and Regs ch 5 ยง 006
Current through March 20, 2024
The provider must maintain accurate, current, and complete administrative records and records specific to participants in services.
006.01 PARTICIPANT RECORDS. The participant's records must contain information that includes, but is not limited to:
(A) Date of
entry into services with the provider;
(B) Name, gender, and birth date of the
participant;
(C) Current physical
description or current photo of the participant;
(D) The language or means of communication
utilized by the participant;
(E)
Legal status of participant, and name, telephone number, and address of
guardian, if applicable;
(F) Name,
phone number, and address of persons to contact in an emergency;
(G) Name, phone number, and address of the
participant's current personal physician and other health care professionals,
if applicable;
(H) Relevant medical
information including but not limited to: history of seizures, illness,
physician orders, treatments, medications, medication history, known allergies,
immunizations, physician contacts, emergency room visits, dental visits,
counseling visits, and hospitalizations;
(I) Records of incidents and
accidents;
(J) Consents as
appropriate;
(K) Records of
emergency safety intervention usage and the rationale for use;
(L) Individual support plan (ISP);
(M) Documentation of delivery of services and
supports;
(N) The participant's
rights notification;
(O) Notice of
charges;
(P) Name of service
coordinator and phone number;
(Q)
Accounting of the participant's funds, if managed by provider;
(R) Notification of termination of services
with the provider, if applicable; and
(S) Social history information.
006.02 ADMINISTRATIVE AND PARTICIPANT RECORD KEEPING REQUIREMENTS. The provider must keep administrative and participant records that:
(A) Have time frames for the completion,
routing, and filing of all records or documents as required and as appropriate
to the participant;
(B) Are
sufficient, current, and accurate to verify the delivery of services and comply
with state and federal laws and regulations; and
(C) Are dated, legible, and clearly identify
the person making the entry. In the case of electronic records, signatures may
be replaced by an approved, uniquely identifiable electronic
equivalent.
006.03 RECORD MAINTENANCE REQUIREMENTS. Providers must maintain, for six years, records relating to the participant and the provision of services.
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