D.C. Mun. Regs. tit. 22, r. 22-B3517

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

Rule 22-B3517 - RECORDKEEPING

3517.1

The CRFPID shall maintain current and accurate records and reports as required by this section.

3517.2

Each record shall be kept in a centralized file or stored electronically and made available at any time requested for inspection and review by Department personnel. Any records that are stored off-site must be made available for review in the CRFPID within three (3) hours of request.

3517.3

Active and closed records containing any information about persons shall be stored in a locked cabinet or room. A back-up plan, and physical and data security controls shall be implemented for electronic records.

3517.4

Each record and report that is required to be kept in accordance with this chapter shall be filed and retained for six (6) years by the CRFPID, unless otherwise specified. Records required to be kept for person's residing in CRFPIDs shall be maintained for at least six (6) years after the person's discharge or death.

3517.5

The CRFPID shall implement a review process to evaluate both current and closed records for completeness, accuracy and timeliness of entries. The process shall be in writing and shall be available for review by the Department.

3517.6

The CRFPID shall maintain the following records:

(a) Administrative Records, which shall include:

(i) List of current charges and fees for services;

(ii) Personnel records for all staff, which includes the following:

(A) Identifying information, including name, social security number and if applicable driver's license number;

(B) Education and training history;

(C) Employment history;

(D) Results of the provider credentialing process, including methods of verification of applicable professional licenses or certificates;

(E) Results of reference checks and verification of prior employment;

(F) Results of criminal background checks;

(G) Results of performance evaluations; and

(H) Records of any disciplinary actions taken by the CRFPID or any other entity.

(iii) Weekly staff schedules, including substitutions;

(iv) Disaster plans and procedures and documentation of evacuation drills;

(v) Signed agreements or contracts for professional services, if applicable;

(vi) A current master alphabetical index of all persons serviced by the CRFPID that contains the following information:

(A) The person's name;

(B) The name, address and phone number of the parent(s), guardian or authorized representative;

(C) The referring agency, if applicable, and a contact person at the referring agency;

(D) The funding source, if applicable, and a contact person or position at the source;

(vii) A log in which emergencies and other unusual occurrences involving persons is recorded;

(viii) A complaint log, including the results of any investigation initiated pursuant to a complaint; and

(ix) A record of discharges and transfers, including transfer and discharge summaries.

(b) Persons Clinical and Habilitation Record shall include:

(i) Identifying information, including name of the person; current residence; social security number; gender; marital status; date of birth; name of parent, guardian or authorized representative; name, address and phone number of emergency contacts; and date of admission to the CRFPID;

(ii) All current and former ISPs and Individual Program Plans (IPPs) for the last six (6) years;

(iii) A listing of the person's physician and other licensed health care professionals and contact information;

(iv) Clinical and habilitation progress notes;

(v) Medical records, including physician orders, diagnosis, immunizations, health consultation recommendations, nursing care plans, nursing notes, and nursing services; and

(vi) Medication administration record.

3517.7

The CRFPID shall ensure that all medical records accurately reflect the person's current condition and are updated as necessary. Any changes made to a person's records shall be signed with the date, by each employee or contractor who makes the entry.

3517.8

If a person's records, or components of records, are provided to another CRFPID, agency or hospital during any short-term transfer (such as hospitalization or other emergency placement), the CRFPID shall ensure that the receiving agency manages such records subject to the access, use, and disclosure requirements set forth in The Health Insurance Portability and Accountability Act of 1996 (HIPAA).

3517.9

If there is a medical emergency involving a person, the CRFPID shall censure that any medical information necessary for the appropriate treatment of the person is available to the treating medical personnel.

D.C. Mun. Regs. tit. 22, r. 22-B3517

Final Rulemaking published at 39 DCR 3280, 3296 (May 8, 1992); amended by Final Rulemaking published at 68 DCR 4282 (4/23/2021)