1. (a) The facility must maintain a separate and distinct record for each client.

2. (b) The record must contain:

   1. (1) The client’s name;
   2. (2) The client’s address;
   3. (3) The admission date;
   4. (4) The name, office telephone number, and emergency telephone number of each primary care physician or advanced practice nurse who treats the client;
   5. (5) The name, address, and telephone number of family members and the person identified by the client who should be contacted in the event of an emergency;
   6. (6) The date of birth;
   7. (7) All identification numbers, such as Medicaid, Medicare/Medipak, and Department of Veterans Affairs;
   8. (8) Transportation arrangements, if applicable;
   9. (9) A copy of the client’s signed rights statement;
   10. (10) A copy of the client’s signed admission, discharge agreements;
   11. (11) A written acknowledgement that the client or responsible party has been notified of the charges for the services provided;
   12. (12) Medical and social history;

   13. (13)

       1. (A) Progress notes, including any significant change in the client’s health status, either positive or negative.
       2. (B) Significant changes must be reported to the appropriate person (physician, advance practice nurse, or caregiver, etc.) as soon as possible;
   14. (14) Documentation of who was notified and when they were notified shall be placed in the client’s file;
   15. (15) A list of all current medications kept by the facility for the client;
   16. (16) Documentation of any treatment or therapies;
   17. (17) Documentation of any special diets, if applicable;
   18. (18) Documentation regarding any accident or incident;
   19. (19) A copy of court orders, letters of guardianship, or power of attorney, if applicable;
   20. (20) A copy of any advance directive;
   21. (21) A copy of the client’s care plan;
   22. (22) The discharge date; and
   23. (23) A signed copy of the HIPAA release form.

3. (c) Confidentiality of records.

   1. (1) A client’s records are confidential and shall not be released without legal authorization or subpoena.
   2. (2) Active records shall be available to authorized agents of the Department of Human Services or their designee during normal business hours.
   3. (3) The record shall contain a copy of a signed copy of the HIPAA release form indicating that the facility is in compliance with HIPAA regulations.

4. (d) Record retention.

   1. (1)

      1. (A) All client records will be retained for a period of five (5) years.
      2. (B) In the event that an audit, litigation, or other action involving these pertinent records is started before the end of the five-year period, those records shall be retained until all issues arising out of the actions are resolved or until the end of the five-year period, whichever is later.
   2. (2) Documentation concerning persons whose requests for services were denied as a result of the assessment process will also be retained for five (5) years.

   3. (3)

      1. (A) All records shall be maintained on site.
      2. (B) They shall be made available within twenty-four (24) hours of an official request.
      3. (C) When a facility changes ownership, the original records shall remain at the facility.
   4. (4) Documentation shall be on file that the client or responsible party has been informed of their right to privacy under HIPAA.

5. (e) Care plan.

   1. (1) There shall be a written care plan for each client.

   2. (2) Care plans shall:

      1. (A) Be developed within five (5) contact days following the client’s entry into the program;
      2. (B) Be designed to maintain the client at the optimal level of functioning;
      3. (C) Cover all:

6. (i) Medications;

   1. (ii) Treatments;

      1. (iii) Rehabilitative services, where appropriate;

         1. (iv) Diets;
         2. (v) Precautions related to activities;
         3. (vi) Plans for continuing care; and
         4. (vii) Discharge;

      2. (D) Be individualized for each client to address:

         1. (i) Functional activities, interests, and specific goals; and
         2. (ii) Means of accomplishing these goals;
      3. (E) Identify the client’s regularly scheduled days for attendance, including arrival and departure times;
      4. (F) Be revised as frequently as warranted by the client’s condition; and
      5. (G) Be reviewed and documented at least every six (6) months and updated as necessary.

Codification Notes: Health Insurance Portability Accountability Act of 1996 was enacted as Pub. L. No. 104-191.