Texas Administrative Code
Title 26 - HEALTH AND HUMAN SERVICES
Part 1 - HEALTH AND HUMAN SERVICES COMMISSION
Chapter 558 - LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES
Subchapter C - MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES
Division 4 - PROVISION AND COORDINATION OF TREATMENT SERVICES
Section 558.301 - Client Records
Universal Citation: 26 TX Admin Code ยง 558.301
Current through Reg. 49, No. 38; September 20, 2024
(a) In accordance with accepted principles of practice, an agency must establish and maintain a client record system to ensure that the care and services provided to each client are completely and accurately documented, readily accessible, and systematically organized to facilitate the compilation and retrieval of information.
(1) An agency must establish a
record for each client and must maintain the record in accordance with and
contain the information described in paragraph (9) of this subsection. An
agency must keep a single file or separate files for each category of service
provided to the client and the client's family. Hospice services provided to a
client's family must be documented in the clinical record.
(2) The agency must adopt and enforce written
procedures regarding the use and removal of records, the release of
information, and when applicable, the incorporation of clinical, progress, or
other notes into the client record. An agency may not release any portion of a
client record to anyone other than the client except as allowed by
law.
(3) All information regarding
the client's care and services must be centralized in the client's record and
be protected against loss or damage.
(4) The agency must establish an area for
original active client record storage at the agency's place of business. The
original active client record must be stored at the place of business (parent
agency, branch office, or ADS) from which services are provided. Original
active client records must not be stored at an administrative support site or
records storage facility.
(5) The
agency must ensure that each client's record is treated with confidentiality,
safeguarded against loss and unofficial use, and is maintained according to
professional standards of practice.
(6) A clinical record must be an original, a
microfilmed copy, an optical disc imaging system, or a certified copy.
(A) An original record is a signed paper
record or an electronically signed computer record. A signed paper record may
include a physician's stamped signature if the agency meets the following
requirements:
(i) An agency must have on file
at the agency a current written authorization letter from the physician whose
signature the stamp represents, stating that he is the only person authorized
to have the stamp and use it.
(ii)
The authorization letter must be dated before a stamped record from the
physician was accepted by the agency.
(iii) An agency must obtain a new
authorization letter from the physician annually. A physician authorization
letter is void one year from the date of the letter.
(iv) The authorization letter must be
manually signed by the physician and include a copy of the stamped signature
that the physician will use.
(B) Computerized records must meet all
requirements of paper records, including protection from unofficial use and
retention for the period specified in subsection (b) of this section.
(C) An agency must ensure that entries
regarding the delivery of care or services are not altered without evidence and
explanation of such alteration.
(7) Each entry to the client record must be
current, accurate, signed, and dated with the date of entry by the individual
making the entry. The record must include all services whether furnished
directly or under arrangement. Correction fluid or tape must not be used in the
record. Corrections must be made by striking through the error with a single
line and must include the date the correction was made and the initials of the
person making the correction.
(8)
Inactive client records may be preserved on microfilm, optical disc or other
electronic means and may be stored at the parent agency location, branch
office, ADS, administrative support site, or records storage facility. Security
must be maintained, and the record must be readily retrievable by the
agency.
(9) Each client record must
include the following elements as applicable to the scope of services provided
by the agency:
(A) client application for
services including, but not limited to, the following information:
(i) the client's full name;
(ii) sex;
(iii) date of birth;
(iv) the name, address, and telephone number
of each parent or legal guardian of a minor child;
(v) the name, address, and telephone number
of any other person, as identified by the individual;
(vi) the physician's name and telephone
numbers, including emergency numbers; and
(vii) services requested;
(B) initial health assessment,
pertinent medical history, and subsequent health assessments;
(C) care plan, plan of care, or
individualized service plan, as applicable. The care plan or the plan of care
must include, as applicable, medication, dietary, treatment, and activities
orders. An individualized service plan for a personal assistance service client
must comply with § 558.404 of this chapter (relating to Standards Specific
to Agencies Licensed to Provide Personal Assistance Services). A plan of care
for a hospice client must comply with § 558.821 of this chapter (relating
to Hospice Plan of Care;
(D)
clinical and progress notes. Such notes must be written the day service is
rendered and incorporated into the client record within 14 working
days;
(E) current medication
list;
(F) medication administration
record (if medication is administered by agency staff). Notation must also be
made in the medication administration record or in the clinical notes of
medications not given and the reason. Any adverse reaction must be reported to
a supervisor and documented in the client record;
(G) acknowledgement of hospice agency's
policy regarding disposal of controlled substance prescription drugs;
(H) records of supervisory
visits;
(I) complete documentation
of all known services and significant events. Documentation must show that
effective interchange, reporting, and coordination of care occurs as required
in §558.288 of this division (relating to Coordination of
Services);
(J) for clients 60 years
and older, acknowledgment of the client's receipt of a copy of the right and
responsibilities listed in Texas Human Resources Code Chapter 102;
(K) acknowledgment of the client's receipt of
the agency's policy relating to the reporting of abuse, neglect, or
exploitation of a client;
(L)
documentation that the client has been informed of how to register a complaint
in accordance with §558.282(d) of this division (relating to Client
Conduct and Responsibility and client Rights);
(M) client agreement to and acknowledgment of
services by home health medication aides, if home health medication aides are
used;
(N) discharge summary,
including the reason for discharge or transfer and the agency's documented
notice to the client, the client's physician (if applicable), and other
individuals as required in §558.295 of this division (relating to Client
Transfer or Discharge Notification Requirements);
(O) acknowledgement of receipt of the notice
of advance directives;
(P) services
provided to the client's family (as applicable); and
(Q) consent and authorization and election
forms, as applicable.
(b) An agency must adopt and enforce a written policy relating to the retention of records in accordance with this subsection.
(1) An agency must retain
original client records for a minimum of five years after the discharge of the
client.
(2) The agency may not
destroy client records that relate to any matter that is involved in litigation
if the agency knows the litigation has not been finally resolved.
(3) There must be an arrangement for the
preservation of inactive records to insure compliance with this
subsection.
Disclaimer: These regulations may not be the most recent version. Texas 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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