La. Admin. Code tit. 48 § I-8581

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-8581 - Record Keeping

A. Accounting and Record Keeping

1. An ICF/DD shall establish a system of business management and staffing to assure maintenance of complete and accurate accounts, books and records.

2. An ICF/DD shall demonstrate fiscal accountability through regular recording of its finances and an annual external audit.

3. An ICF/DD shall not permit funds to be paid, or committed to be paid, to any person to which any of the members of the governing body, administrative personnel, or members of the immediate families have any direct or indirect financial interest, or in which any of these persons serve as an officer or employee, unless the services or goods involved are provided at a competitive cost or under terms favorable to the ICF/DD. The ICF/DD shall have a written disclosure of any financial transaction with the facility in which a member of the governing body, administrative personnel, or his/her immediate family is involved.

4. An ICF/DD shall ensure that all entries in records are legible, signed by the person making the entry and accompanied by the date on which the entry was made.

5. All records shall be maintained in an accessible, standardized order and format and shall be retained and disposed of according to state laws.

6. An ICF/DD shall have sufficient space, facilities and supplies for providing effective record keeping services.

B. Confidentiality and Security of Files

1. An ICF/DD shall have written procedures for the maintenance and security of records specifying who shall supervise the maintenance of records, who shall have custody of the records and to whom records may be released. Records shall be the property of the ICF/DD and the ICF/DD, as custodian, shall secure records against loss, tampering or unauthorized use.

2. An ICF/DD shall maintain all individuals' case records in accordance with federal and state law, rule, and regulation regarding confidentiality, privacy and retention. Employees of the ICF/DD shall not disclose or knowingly permit the disclosure of any information concerning the individual receiving services or his/her family, directly or indirectly, to any unauthorized person.

3. When the individual receiving services is of majority age and non-interdicted, an ICF/DD shall obtain the individual's written, informed permission prior to releasing any information from which the individual receiving services or his/her family might be identified except for authorized State and Federal agencies and another ICF/DD with professional interest in the individual.

4. When the individual is a minor or is interdicted, the ICF/DD shall obtain written, informed consent from the parent(s), tutor or curator prior to releasing any information from which the individual receiving services might be identified except for authorized state and Federal agencies and another ICF/DD with professional interest in the individual.

5. An ICF/DD shall, upon request, make available information in the case record to the individual receiving services, the legally responsible person or legal counsel of the individual. If, in the professional judgment of the administration of the ICF/DD, it is felt that information contained in the record would be damaging to an individual receiving services, that information may be withheld from the individual requesting the information except under court order.

6. An ICF/DD may use material from case records for teaching or research purposes, development of the governing body's understanding and knowledge of the ICF/DD's services, or similar educational purposes, provided that names are deleted and other identifying information is disguised or deleted.

7. Individual records shall be retained in accordance with state and/or federal regulations.

C. Individual's Case Record. An ICF/DD shall have a written record for each individual receiving services, which shall include administrative, treatment, and educational data from the time of admission until the time the individual leaves the ICF/DD. An individual's case record shall include:

1. the name, sex, race, religion, birth date and birthplace of the individual;

2. the individual's history including, where applicable, family data, educational background, employment record, prior medical history and prior placement history;

3. a copy of the individual's service plan and any modifications thereto and an appropriate summary to guide and assist direct service workers in implementing the individual receiving services program;

4. the findings made in periodic reviews of the plan, including a summary of the successes and failures of the individual receiving services program and recommendations for any modifications deemed necessary;

5. monthly status reports;

6. a copy of the aftercare plan and any modifications thereto, and a summary of the steps that have been taken to implement that plan;

7. when restraint in any form other than passive physical restraint has been used, a signed order for each use of restraint issued by a qualified professional prior to such use;

8. critical incident reports;

9. reports of any individual's grievances and the conclusions or dispositions of these reports;

10. a summary of family visits and contacts; and

11. a summary of attendance and leaves of absence from the ICF/DD.

D. Medical and Dental Records

1. An ICF/DD shall maintain complete health records of an individual receiving services, which shall include:

a. a complete record of all immunizations provided; a record of any medication;

b. records of vision, physical or dental examinations; and

c. a complete record of any treatment provided for specific illness or medical emergencies.

2. Upon discharge, the ICF/DD shall provide a summary of the individual's health record to the person or agency responsible for the future planning and care of the individual receiving services.

3. An ICF/DD shall make every effort to compile a complete past medical history on every individual receiving services. This history shall, whenever possible, include:

a. allergies to medication;

b. immunization history;

c. history of serious illness, serious injury or major surgery;

d. developmental history;

e. current use of prescribed medication;

f. current use of alcohol or non-prescribed drugs; and

g. medical history.

E. Retention of Records. The ICF/DD provider shall retain all client records for a period of six years after the date of the client's discharge, transfer or death.

F. Staff Personnel File

1. An ICF/DD shall maintain a personnel file for each employee. At a minimum, this file shall contain the following:

a. the application for employment and/or resume;

b. a criminal history check, prior to an offer of employment, in accordance with state law;

c. reference letters from former employer(s) and personal references or phone notes on such references;

d. documentation of any state or federally required medical examinations or medical testing;

e. evidence of applicable professional credentials/certifications according to state law;

f. annual performance evaluations;

g. personnel actions, other appropriate materials, reports and notes relating to the individual's employment with the facility;

h. employee's hire and termination dates; and

i. documentation of orientation and annual training of staff.

2. The staff member shall have reasonable access to his/her file and shall be allowed to add any written statement he/she wishes to make to the file at any time.

3. An ICF/DD shall retain the personnel file of an employee for at least three years after the employee's termination of employment.

La. Admin. Code tit. 48, § I-8581

Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 38:3203 (December 2012).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and R.S. 40:2180-2180.5.