Current through Register Vol. 48, No. 3, March 22, 2024
A.
Administrative-The following records will be maintained at least 5 years in the
administrative office for the program and shall be readily available for review
by the Department:
(1) Client register for
enrollment;
(2) Daily
attendance;
(3) Current (annual)
certificate of sanitation inspection from DHEC;
(4) Current (annual) certificate of fire
inspection from a fire marshal;
(5)
Current (annual) heating, ventilation and air conditioning inspection report,
dated and signed by a qualified technician;
(6) Electrical system report, signed and
dated by a licensed/certified electrical/contractor with the certification
number listed.
(7) Disaster plan
and a record of fire drills;
(8)
Individual personnel records on each staff member which contain:
(a) TB report at time of employment and
annually if skin test indicates a reactor;
(b) Signed application form or other
statement of staff member's age, educational history and employment
history;
(c) Job
description;
(d) Signed statement
that indicates the employee has never been charged or convicted of a crime
involving abuse or neglect.
(e)
from past employment when applicable
(9) Written policies on:
(a) Access to, duplication of, and
dissemination of information from client records;
(b) Prohibition of the use of physical,
mechanical or chemical restraint unless used for safety or therapeutic purposes
as prescribed by a written plan and as approved by DMR;
(c) The prohibition of corporal
punishment;
(d) Conditions for use
of isolation rooms;
(e) Retention
of records;
(f) Use of volunteers
and substitutes;
(g) Program
evaluation;
(h) Administration of
medication;
(i) Admission and
discharge of participants;
(j)
Personnel practices
(k) Procedures
to be followed when a participant is discovered to be missing.
(l) Prohibition of abuse and neglect which
also includes staff report of any/all abuse to appropriate state agencies and
to the Department of Mental Retardation.
(m) Conditions and policies on the
termination of clients which include:
1. A
list of reasons for dismissal;
2.
Methods of averting the termination;
3. Consultation and concurrence with the
Department prior to termination.
B. Participant-A record shall be maintained
for each participant which contains, as a minimum, the items listed below. All
documents and entries shall be legible, dated, and signed by the person making
the entry. If symbols are used, explanatory legends must be provided.
(1) Report of a medical examination which was
performed not more than twelve (12) months prior to admission;
(2) Report of psychological evaluation(s) as
required by R.
88-430A;
(3) Report of Social History which is updated
annually;
(4) Current Individual
Program Plan as required by R88-435 A;
(5) Monthly summary notations of
progress;
(6) Record of unusual
behavior incidents which are recorded at the time of occurrence;
(7) Record of illness and
accidents;
(8) Authorization for
emergency medical service;
(9)
Record of critical incidents.
C. Confidentiality-All information in a
participant's record shall be considered privileged and confidential. Staff
shall not disclose or knowingly permit the disclosure of any information
concerning the client or his family directly to any unauthorized
person.
D. Maintenance of
Records-After a participant's discharge or dismissal from a program, or his
death, his records shall be retained for five years. Disposal of records must
be performed in a confidential manner.
CODE COMMISSIONER'S NOTE
Pursuant to 2011 Act No. 47, Section 14(B), the Code
Commissioner substituted "intellectual disability" for "mental retardation" and
"person with intellectual disability" or "persons with intellectual disability"
for "mentally retarded." At the Code Commissioner's discretion, the
substitution was not made for the formal reference to the South Carolina
Department of Mental Retardation in this
regulation.
