North Carolina Administrative Code
Title 10A - HEALTH AND HUMAN SERVICES
Chapter 06 - AGING - PROGRAMS OPERATIONS
Subchapter R - ADULT DAY CARE STANDARDS FOR CERTIFICATION
Section .0500 - PROGRAM OPERATION
Section 06R .0508 - RECORDS
Universal Citation: 10A NC Admin Code 06R .0508
Current through Register Vol. 39, No. 6, September 16, 2024
(a) Individual Participant Records. Each adult day care program shall maintain records to document the progress of each participant and to document program operation. These records shall be kept in a locked file. An individual folder for each participant shall be established and maintained and include the following:
(1) a signed application recording:
(A) the participant's full name;
(B) the participant's address and telephone
number;
(C) the date of birth,
marital status and living arrangement of participant;
(D) the time of day participant will arrive
and time of day participant will leave the program;
(E) the travel arrangements to and from the
program for the participant;
(F)
the name, address and telephone number of at least two family members, friends
or caregivers of the participant who can be contacted in emergencies;
(G) the name, address and telephone number of
a licensed medical service provider who will see the participant upon request
of the participant; and
(H) the
personal concerns and knowledge of the caregiver that may have an impact on the
participant's health, safety, and welfare.
(2) copies of all current and former signed
authorizations for the adult day care program to receive and give out
confidential personal identifiable information and health information on the
participant. The current authorization shall include the name of the party from
whom information is requested and to whom information is given. The current
authorization shall be dated within the prior 12 months and obtained each time
a request for participant information is made.
(3) a signed authorization for the
participant to receive emergency medical care from any licensed medical
practitioner, if emergency care is requested by the participant or deemed
necessary by program staff.
(4) a
medical examination report conducted within three months before enrollment and
updated annually, signed by a licensed physician, physician's assistant or
nurse practitioner. The report shall include information on:
(A) any current diseases and chronic
conditions and the degree to which these diseases and conditions require
observation by day care staff, and restriction of normal activities by the
participant;
(B) any presence and
degree of psychiatric problems;
(C)
the amount of supervision the participant requires;
(D) any limitations on physical
activities;
(E) the listing of all
medications with dosages and times medications are to be administered;
and
(F) the most recent date
participant was seen by doctor.
(5) documentation identified in Rule
.0501(a)(2) and (b)(1) and (b)(2) of this Section.
(6) progress notes that are the written
report of staff discussions, conferences, consultation with family, friends or
caregivers, evaluation of a participant's progress and any information
regarding a participant's changed health, social or financial
situation.
(7) service plans for
the participant, including scheduled days of attendance, for the preceding 12
months.
(8) a signed authorization
if the participant or his or her responsible party will permit photographs,
video, audio recordings or slides of the participant to be made by the day care
program, whether for medical documentation, publicity, or any other purpose.
The authorization shall specify how and where such photographs, videos, audio
recordings or slides will be used, and shall be obtained prior to taking any
photographs, videos, audio recordings or slides of the participant.
(9) a statement signed by the participant, a
family member or caregiver acknowledging receipt of the program policies and
agreeing to uphold program policies pertaining to the participant.
(b) The adult day care program shall keep the following program records a minimum of six years:
(1) copies of activity schedules;
(2) monthly records of expenses and income,
including fees collected, and fees to be collected;
(3) all bills, receipts and other information
that document expenses and income;
(4) a daily record of attendance of
participants by name;
(5) accident
reports;
(6) a record of staff
absences, annual leave and sick leave, including dates and names of
substitutes;
(7) reports on
emergency and fire drills;
(8)
individual personnel records on all staff members including:
(A) application for employment;
(B) evidence of a State criminal history
check on each employee providing direct participant care;
(C) job description;
(D) medical certification of absence of a
health condition that would pose a risk to others;
(E) written note or report on any personnel
action taken with the employee;
(F)
written report of annual employee review;
(G) CPR and first aid training documentation;
and
(H) signed statement to keep
all participant information confidential.
(9) a copy of all written policies,
including:
(A) program policies;
(B) personnel policies;
(C) agreements or contracts with other
agencies or individuals;
(D) plan
for emergencies; and
(E) evacuation
plan;
(10) program
evaluation reports; and
(11)
control file of DSS-5027 (SIS Client Entry Form) for all participants for whom
Social Services Block Grant (Title XX) reimbursement is claimed. The SIS Client
Entry form (DSS-5027) shall include the participant's personal information such
as name, social security number, date of birth, address and the case manager's
name in addition to the types of services requested, the action or actions
taken, and if the provider is authorized to claim reimbursement for the
services rendered. A copy of this form is accessible at the North Carolina
Department of Health & Human Services' website.
Authority
G.S.
131D-6;
143B-153(2a);
143B-153(6);
Eff. July 1, 1978;
Amended Eff. February 1, 2008; July 1, 2007;
March 1, 1992; July 1, 1990; January 1, 1981;
Readopted Eff.
September 1, 2019.
Disclaimer: These regulations may not be the most recent version. North Carolina may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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