10-144-129 Me. Code R. § 9

Current through 2024-51, December 18, 2024

Section 144-129-9 - RECORDS

A.CONFIDENTIALITY.

1. All administrative and client records must be stored in a secure manner such that unauthorized persons cannot gain access to them. Personal electronic devices used to store or transmit client information must be equipped with software and/or applications to ensure that the information cannot be accessed by unauthorized individuals.

2. Records or information that is confidential pursuant to state or federal law must meet the confidentiality requirements of those applicable statutes.

B.CLIENT RECORDS.

1. An individualized record must be maintained for each client. These records may be paper records or electronic records. The record must contain, at a minimum, the following:

a. Name;

b. Address;

c. Phone number;

d. Emergency contact person;

e. Date of admission;

f. Date services began;

g. Service plans;

h. Documentation of service delivery;

i. Signed service contract;

j. Any concern or complaints the client expressed about his/her care;

k. Discharge summary, including date services ended, reason services ended, and client status at discharge; and

l. Any signed releases of information, updated annually.

m. If services were discontinued because of non-payment or the safety of staff, a copy of the letter sent to the client, family, and/or legal representative.

2. All client records must be accessible to Department representatives upon request.

C.OWNER AND EMPLOYEE RECORDS.

1. An individualized record must be kept at the agency for owners and all employees.

2. Owner records must contain the following:

a. Name;

b. Current address and phone number;

c. Social security number and/or date of birth; and

d. Results of MBCC, APS, and CPS checks.

3. Employee records must contain the following:

a. Name;

b. Current address and phone number;

c. Social security number and/or date of birth;

d. Date of hire;

e. Signed job description;

f. First date employee provided direct care to a client;

g. Evidence of the completion of a Certified Nursing Assistant program or a Department- approved training program related to provision of direct care;

h. If the employee had not completed a required program at the time of hire, the date on which the employee was enrolled in a program;

i. Results of MBCC, APS, and CPS checks;

j. Documentation of completion of the required orientation program and all required trainings;

k. Each annual performance review; and

l. Documentation of all required supervisory visits.

D.BUSINESS RECORDS. The organization must have the following current business records on site for review:

1. The agency's articles of incorporation, if so organized,

2. The agency's insurance policy(ies); and

3. The agency must create a chart showing the organizational structure, including lines of authority.

10-144 C.M.R. ch. 129, § 9