D.C. Mun. Regs. tit. 22, r. 22-A6509

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 22-A6509 - CONFIDENTIALITY, CONTENTS, AND MANAGEMENT OF CLIENT/CONSUMER RECORDS

6509.1

A transition planning provider shall create and maintain a record that meets the standards described in §§ 6509.3 and 6509.4 for each client/consumer who was referred to them, regardless of whether the provider ultimately delivered a reimbursable service.

6509.2

In the event that the provider does not initiate provision of the transition planning service, for reasons described in §§ 6507.3, the provider shall document the specific reason in the client/consumer record.

6509.3

All information related to provision of the transition planning service shall be entered into the client's/consumer's record. This shall at a minimum include the following elements, unless not applicable per §§ 6509.2:

(a) Complete identification data, including Medicaid number;

(b) Emergency contact information;

(c) The client's/consumer's behavioral health diagnoses and any known physical health diagnoses;

(d) The results of any assessments that were completed by the discharging institution or the transition planning provider;

(e) The discharge plan, which includes documentation of the needed services and supports identified during the discharge planning process. The discharging institution's discharge plan, summary, instruction, or other documentation may serve as the discharge plan for purposes of this chapter. If the discharging institution does not create such document for inclusion in the client/consumer record, the transition planning provider shall develop a discharge plan with the necessary information and detail;

(f) Documentation of all rendered transition planning service components and related encounter notes meeting the standards set forth in §§ 6501.4;

(g) Documentation of any treatment or support services provider(s) with a current relationship with the client/consumer;

(h) Documentation of all referrals to treatment and support services providers;

(i) Documentation of correspondence with other medical, human service, social service, educational, and criminal justice entities as it pertains to a consumer's/client's treatment and recovery;

(j) For children and youth, documentation of family member or guardian involvement in the transition planning service or a statement of reasons why it was not indicated or if the provider was unable to secure participation;

(k) The client's/consumer's consent to the transition planning service;

(l) The signed Consumer Rights or Client's Rights Statement, whichever is applicable;

(m) Documentation that the client/consumer received the transition planning provider's notice of privacy practices; and

(n) Signed confidentiality forms and releases to permit the transition planning provider to obtain and/or release information.

6509.4

Encounter notes shall sufficiently document in writing each activity conducted involving a transition planning service component. At a minimum each note shall consist of:

(a) A dated, timed, and authenticated entry with the author identified, that includes the date, duration, and actual beginning and ending time (denoting a.m. or p.m.) during which the service component was rendered; entered by the person providing the service. The provider shall ensure all entries are authenticated by a process that verifies the author's identity (e.g., a unique log- in used only by the author);

(b) Name, title, credentials, and signature of the person providing the service component;

(c) The specific service component rendered;

(d) A description of each encounter or activity sufficient to document that the service component was provided, and is in support of the needs identified in the discharge plan;

(e) A description of the client/consumer response to the encounter when the service component involves direct client/consumer contact; and

(f) The setting or means by which the service component was rendered (e.g., in person, telephonically, via email).

6509.5

Providers shall utilize an EHR system certified by the Department of Health and Human Services Office of the National Coordinator for Health Information Technology to document all phases of the consumer/client's treatment and care.

6509.6

Each provider shall develop and implement a "Confidentiality and Release of Information Policy" that describes the policies and procedures for storing and managing client/consumer information in compliance with the confidentiality requirements contained in all applicable Federal and District laws and regulations, including the Health Insurance Portability and Accountability Act (HIPAA), the D.C. Mental Health Information Act, and 42 CFR. Part 2. This shall include policies and procedures for requiring the provider to:

(a) Encourage consumers/clients to authorize the disclosure of protected behavioral health information to other health care and human services providers to facilitate access to and coordinate treatment and support services;

(b) Advise each client/consumer of the provider's notice of privacy practices;

(c) Give mental health consumers the opportunity to opt-out of disclosures in accordance to the District of Columbia Mental Health Information Act, D.C. Code §§ 7-1203.01 and document the consumers' decisions; and

(d) Secur e all records in a manner that provides protection from unauthorized disclosure, access, use, or damage.

6509.7

The Confidentiality and Release of Information Policy shall be submitted to the Department for review and approval during the certification and recertification process.

6509.8

A transition planning provider shall have in place back-up and redundant systems and measures to prevent the loss of data, enable data recovery, and safeguard client/consumer records in the event of operator or equipment failure, natural disasters, power outages, and other emergency situations.

6509.9

A transition planning provider shall retain each client/consumer record in accordance with the following requirements:

(a) When the client/consumer is an adult, for at least ten (10) years after the date of the last encounter;

(b) When the client/consumer is a minor, for at least ten (10) years after the minor has reached the age of eighteen (18) years; and

(c) In case of litigation or adverse audit findings, until all such litigation or adverse audit findings have been resolved, or in accordance with the timeframes described in (a) and (b), whichever is later.

D.C. Mun. Regs. tit. 22, r. 22-A6509

Final Rulemaking published at 68 DCR 876 (1/15/2021); amended by Final Rulemaking published at 71 DCR 14542 (11/29/2024)