La. Admin. Code tit. 50 § VII-30703

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

Section VII-30703 - Admission Records

A. At the time of admission to the ICF/MR, information shall be entered into the client's record which shall identify and give a history of the client. This identifying information shall at least include the following:

1. a recent photograph;

2. full name;

3. sex;

4. date of birth;

5. ethnic group;

6. birthplace;

7. height;

8. weight;

9. color of hair and eyes;

10. identifying marks;

11. home address, including street address, city, parish and state;

12. Social Security Number;

13. medical assistance identification number;

14. Medicare claim number, if applicable;

15. citizenship;

16. marital status;

17. religious preference;

18. language spoken or understood;

19. dates of service in the United States Armed Forces, if applicable;

20. legal competency status if other than competent;

21. sources of support: social security, veterans' benefits, etc.;

22. father's name, birthplace, Social Security Number, current address, and current phone number;

23. mother's maiden name, birthplace, Social Security Number, current address, and current phone number;

24. name, address, and phone number of next of kin, legal guardian, or other responsible party;

25. date of admission;

26. name, address and telephone number of referral agency or hospital;

27. reason for admission;

28. admitting diagnosis;

29. current diagnosis, including primary and secondary DSM III diagnosis, if applicable;

30. medical information, such as allergies and general health conditions;

31. current legal status;

32. personal attending physician and alternate, if applicable;

33. choice of other service providers;

34. name of funeral home, if appropriate; and

35. any other useful identifying information. Refer to Admission Review for procedures.

B. First Month After Admission. Within 30 calendar days after a client's admission, the ICF/MR shall complete and update the following:

1. review and update the pre-admission evaluation;

2. develop a prognosis for programming and placement;

3. ensure that an interdisciplinary team completes a comprehensive evaluation and designs an individual habilitation plan (IHP) for the client which includes a 24-hour schedule.

C. Entries into Client Records During Stay at the ICF/MR. The following information shall be added to each client's record during his/her stay at the ICF/MR:

1. reports of accidents; seizures, illnesses, and treatments for these conditions;

2. records of immunizations;

3. records of all periods where restraints were used, with authorization and justification for each, and records of monitoring in accordance with these standards;

4. reports of at least an annual review and evaluation of the program, developmental progress, and status of each client, as required in these standards;

5. behavior incidents and plans to manage inappropriate behavior;

6. records of visits and contacts with family and other persons;

7. records of attendance, absences, and visits away from the ICF/MR;

8. correspondence pertaining to the client;

9. periodic updates of the admission information (such updating shall be performed in accordance with the written policy of the ICF/MR but at least annually); and

10. appropriate authorizations and consents.

D. Entries at Discharge. At the time of a client's discharge, the QMRP or other professional staff, as appropriate, shall enter a discharge summary into the client's record. This summary shall address the findings, events, and progress of the client while at the ICF/MR and a diagnosis, prognosis, and recommendations for future programming.

La. Admin. Code tit. 50, § VII-30703

Promulgated by the Department of Health and Human Resources, Office of Family Security, LR 13:578 (October 1987), amended by the Department of Health and Hospitals, Office of the Undersecretary, Bureau of Health Services Financing, LR 25:685 (April 1999), repromulgated LR 31:2231 (September 2005).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254.