Current through Register Vol. 24-18, September 15, 2024
The licensee must:
(1) Maintain a current record for each client
consistent with chapter 70.02 RCW;
(2) Ensure that client records are:
(a) Accessible in the licensee's office
location for review by appropriate direct care personnel, volunteers,
contractors, and the department;
(b) Written legibly in permanent ink or
retrievable by electronic means;
(c) On the licensee's standardized forms or
electronic templates;
(d) In a
legally acceptable manner;
(e) Kept
confidential;
(f) Chronological in
its entirety or by the service provided;
(g) Fastened together to avoid loss of record
contents (paper documents); and
(h)
Kept current with all documents filed according to agency time frames per
agency policies and procedures.
(3) Except as provided in subsection (4) of
this section, include documentation of the following in each record:
(a) Client's name, age, current address, and
phone number;
(b) Client's consent
for services and care;
(c) Payment
source and client responsibility for payment;
(d) Plan of care according to WAC
246-335-440, depending upon the
services provided;
(e) Signed or
electronically authenticated and dated notes documenting and describing
services provided during each client contact;
(f) Supervision of home care services
according to WAC
246-335-445; and
(g) Other documentation as required by this
chapter.
(4) For clients
receiving a one-time visit, provide the documentation required in WAC
246-335-440(5)
in lieu of the requirements in subsection (3) of this section;
(5) Consider the records as property of the
licensee and allow the client access to his or her own record; and
(6) Upon request and according to agency
policy and procedure, provide client information or a summary of care when the
client is transferred or discharged to another agency or facility.
(7) The licensee must keep client records
for:
(a) Adults - Three years following the
date of termination of services;
(b) Minors - Three years after attaining age
eighteen, or five years following discharge, whichever is longer; and
(c) Client death - Three years following the
last date or termination of services if client was on services when death
occurred.
(d) Home care agencies
under contract with DSHS or the AAA may keep client records for a longer period
of time as established in the terms of the contract.
(8) The licensee must:
(a) Store client records in a safe and secure
manner to prevent loss of information, to maintain the integrity of the record,
and to protect against unauthorized use;
(b) Maintain or release records in accordance
with chapter 70.02 RCW; and
(c)
After ceasing operation, retain or dispose of client records in a confidential
manner according to the time frames in subsection (7) of this
section.
