(a)

1. (1) A provider must maintain a separate, updated, and complete service record for each beneficiary documenting the services provided to the beneficiary and any other documentation required under this part.
2. (2) A provider must maintain each beneficiary service record in a uniformly organized manner.
3. (3) A beneficiary service record must be made immediately available to a beneficiary and their legal guardian upon request.

(b) A beneficiary’s service record must include a summary document at the front that includes:

1. (1) The beneficiary’s:

   1. (A) Full name;
   2. (B) Address and county of residence;
   3. (C) Telephone number and email address, if available;
   4. (D) Date of birth;
   5. (E) Primary language;
   6. (F) Diagnoses;
   7. (G) Medications, dosage, and frequency, if applicable;
   8. (H) Known allergies;
   9. (I) Social Security number;
   10. (J) Medicaid number;
   11. (K) Commercial or private health insurance information, if applicable; and
   12. (L) Assigned PASSE;
2. (2) The date the beneficiary began receiving each CES Waiver service from the provider;
3. (3) The date the beneficiary ceased receiving each CES Waiver service from the provider, if applicable;
4. (4) The name, address, phone number, and email address, if available, of the beneficiary’s legal guardian, if applicable; and
5. (5) The name, address, and phone number of the beneficiary’s primary care provider (PCP).

(c) A beneficiary’s service record must include at least the following information and documentation:

1. (1) PCSP, or documentation demonstrating a copy of PCSP, has been requested from PASSE;
2. (2) Nonclinical treatment plan;
3. (3) PASSE prior authorizations for all CES Waiver Services performed by a provider;
4. (4) Positive behavior support plan, as applicable;
5. (5) Behavioral prevention and intervention plan, as applicable;
6. (6) Daily activity logs or other documentation for each CES Waiver service;
7. (7) Medication management plan, if applicable;
8. (8) Medication logs, if applicable;
9. (9) Copies of any court orders that place the beneficiary in the custody of another person or entity; and
10. (10) Copies of any leases or residential agreements related to provider-owned, leased, or controlled CES Waiver service residential settings.

(d)

1. (1) A provider must ensure that each beneficiary service record is kept confidential and available only to:

   1. (A) Employees who need to know the information contained in the beneficiary’s service record;
   2. (B) The Division of Developmental Disabilities Services and any governmental entity with jurisdiction or other authority to access the beneficiary’s service record;
   3. (C) The beneficiary’s assigned PASSE;
   4. (D) The beneficiary’s legal guardian, if applicable; and
   5. (E) Any other individual authorized in writing by the beneficiary or, if applicable, the beneficiary’s legal guardian.

2. (2)

   1. (A) A provider must keep beneficiary service records in a file cabinet or room that is always locked.
   2. (B)

(i) A provider may use electronic records in addition to or in place of physical records to comply with this part.

1. (ii) A provider that uses electronic records must take reasonable steps to backup all electronic records and reconstruct a beneficiary’s service record in the event of a breakdown in the provider’s electronic records system.