3907 DOCUMENTATION REQUIREMENTS

3907.1 Each Clubhouse shall establish and adhere to policies and procedures concerning documentation, retention, maintenance, purging and destruction of clinical and rehabilitative records; security, confidentiality, and disclosure of consumer and family information that comply with applicable federal and District laws and regulations (Rehabilitation Records Policy). The Rehabilitation Records Policy shall:

1. (a) Require the Clubhouse to maintain all clinical and rehabilitative records in a secured and locked storage area;
2. (b) Require the Clubhouse to maintain and secure a current, clear, organized, and comprehensive clinical and rehabilitative record for every individual assessed, treated, or served by the Clubhouse, including information deemed necessary to provide treatment or protect the Clubhouse, in a manner that complies with applicable federal and District laws and regulations; and
3. (c) Set forth requirements for documentation maintained in the clinical and rehabilitative record.

3907.2 The following documents shall be included in each member's clinical record:

1. (a) Current behavioral health assessment;
2. (b) Referral source and reason for referral;
3. (c) Current Plan of Care prepared by the Clubhouse and if applicable, the Plan of Care prepared by the CSA in accordance with §§ 3411-3412 of this subtitle that includes a recommendation for Clubhouse services;
4. (d) Identifying information about the member, including enrollment information;
5. (e) Identification of individuals to be contacted in the event of emergency;
6. (f) Basic screening and intake information;
7. (g) Advance instructions and advance directives;
8. (h) Methods for addressing the member's and his or her family's special needs, especially those which relate to communication, cultural, and social factors;

(i) Detailed description of services provided;

(j) Encounter notes as required by § 3907.3 of this chapter;

(k) Discharge planning information;

(l) Appropriate consents for service;

(m) Appropriate release of information forms; and

(n) A Consumer Rights Statement signed by the member, or if applicable, the member's guardian.

3907.3 The Clubhouse staff shall write a daily encounter note at the end of each member's session with the member encouraged but not required to participate in its drafting. The daily encounter note shall:

(a) Identify the activities performed to enhance or support the member's rehabilitation in social, educational, and pre-vocational domains;

(b) Identify what supportive interventions or activities were used to improve a member's potential for establishing and maintaining social relationships or obtaining occupational or educational achievements;

(a) Document the member's response to that day's experience, including the choices of and perceptions by the member regarding the service(s) provided;

(b) Demonstrate a relationship between the activities and interventions identified in the encounter note to at least one rehabilitation goal listed in the Plan of Care;

(c) Include the arrival and departure time of the member; and

(d) Be signed and dated by the staff member making the entry, and at the member's discretion, the member participating in the service.

3907.4 The Clubhouse shall provide the member's referring agency, if applicable, with a copy of the member's Plan of Care and any updates to the Plan of Care.

3907.5 The Clubhouse shall ensure that that all clinical and rehabilitative records of members are completed promptly, filed, and retained in accordance with the Clubhouse's Rehabilitation Records Policy.

3907.6 The member’s referring agency shall provide the Clubhouse the member’s current Plan of Care and any updates to the Plan of Care.

SOURCE: Emergency and Proposed Rulemaking published at 57 DCR 4010 (May 7, 2010)[EXPIRED]; as amended by Emergency and Proposed Rulemaking published at 57 DCR 7734 (August 20, 2010)[EXPIRED]; as amended by Final Rulemaking published at 57 DCR 8698, 8704 (September 24, 2010); as amended by Final Rulemaking published at 66 DCR 5638 (May 3, 2019); as amended by Final Rulemaking published at 67 DCR 10674 (September 4, 2020).