New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XIV - Office for People With Developmental Disabilities
Part 676 - Diagnostic and Research Clinics
Section 676.10 - Recordkeeping

Universal Citation: 14 NY Comp Codes Rules and Regs ยง 676.10

Current through Register Vol. 46, No. 39, September 25, 2024

(a) OPWDD.

The diagnostic and research clinic shall maintain a comprehensive record of each person referred and admitted to the clinic. Each record shall be organized in the manner and contain the information specified by OPWDD for inclusion. Each individual's record shall contain the following types of information:

(1) person identification information, including, if applicable, a Medicaid or Medicare number, a developmental disabilities information survey profile, etc.;

(2) information regarding the person's medical and developmental history;

(3) copies of previous diagnoses or tentative diagnoses, assessments, progress notes, and, if possible, copies of individual program plans or service plans previously developed for the person at other programs or agencies;

(4) descriptions of treatment and medications previously administered;

(5) name and address of person or organization referring the individual to the diagnostic and research clinic and reason for such referral;

(6) criteria for admission eligibility and itemized lists of diagnostic and evaluation services, specialized clinical laboratory services, need for residential services and any other optional services required by the person. This section of the record shall include written authorizations by clinicians for diagnosis, evaluation or clinical laboratory services;

(7) authorizations signed by the clinic's attending physicians and/or clinicians who have designated that the person receive other optional services in addition to the core or optional services initially authorized by the admission committee;

(8) written authorizations by a physician or other clinician to admit a person for short-term residential care; such record should include date of admission, projected date of discharge, actual date of discharge, services received while in the residential unit, and a report of any significant occurrence in the life and experience of the person while staying at the clinic;

(9) discipline specific diagnostic summaries, evaluations and findings and recommendations for services; and

(10) minutes and decisions made by the interdisciplinary team including copies of the individual's recommended treatment plan in which at least the following shall be stated:
(i) primary and secondary diagnoses;

(ii) integrated evaluations, and statements concerning the severity of the disability;

(iii) prioritized long-range goals and short-range objectives that are matched to prioritized needs and areas of behavioral and medical deficits;

(iv) services and methods of interventions recommended to address the person's deficits; and

(v) recommendations for follow-up visits and/or recommendations to have the person receive services at other specialized diagnostic and evaluation programs;

(11) minutes of conferences conducted between clinical staff and the person and/or his or her correspondent in which the clinician's findings and recommendations are explained and discussed;

(12) minutes of conferences, meetings, discussions, etc., between clinical staff at the diagnostic and research clinic and the referring agency and/or the agency who has been or will be delivering the recommended services to the person; and

(13) notes and correspondence between clinic staff and referring agents, family, family physicians, advocacy organization, and programs providing services to the person or programs considering the person for admission.

(b) Administrative records.

The clinical director shall maintain or cause to be maintained the following administrative records:

(1) a chronological admission and discharge register which is a daily listing of individuals admitted to and discharged from the diagnostic and research clinic and the residential unit;

(2) notation of all accident and incident reports;

(3) a daily census record of the names of persons utilizing specialized clinical laboratory and/or medical services (for example, the clinic should maintain a record of each time the CTT scan is utilized, including the name of the person for whom it was used);

(4) fire drill records;

(5) dietary service records;

(6) records that document compliance with sanitation, health and environmental safety codes including written reports of inspections by State and local authorities having primary jurisdiction and records of action taken on their recommendations;

(7) copies of all transfer and affiliation agreements;

(8) a copy of the emergency disaster plan;

(9) a master plan for staffing;

(10) a personnel record for each staff member including all available preemployment information documentation of any inservice or specialized training received, and, for professional staff, a copy of their current registration and license or certificate.

(c) Confidentiality.

(1) The staff of the diagnostic and research clinic shall maintain the confidentiality of all medical, social, personal and financial information about any person admitted or who is being considered or who has been considered for admission to the clinic; and the clinic shall make such information available only to authorized persons.

(2) The record is the property of the diagnostic and research clinic, which shall protect it from loss, damage, tampering or use by unauthorized individuals.

(3) Before releasing information to parties who are otherwise not authorized to receive it, the diagnostic and research clinic shall obtain written consent from the person, except that the written consent shall be obtained from the person's correspondent when either of the following applies:
(i) the person has been adjudicated incompetent under State law; or

(ii) the person is under the age of eighteen.

(4) The diagnostic and research clinic shall have appropriate records available for persons admitted to the clinic's residential unit.

(d) The diagnostic and research clinic shall submit information and reports to OPWDD in the format and manner prescribed by OPWDD.

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