9914.1 Each home support agency shall establish and maintain a complete and accurate client record of the services provided to each client in accordance with this chapter and accepted professional standards and practices.

9914.2 Each client record shall include the following information related to the client:

1. (a) Admission data, including name, address, date of service inquiry, date of birth, sex, next of kin, name and contact information of the client representative (if applicable), date accepted by the home support agency to receive services, and source of payment;
2. (b) Source of referral;
3. (c) Initial assessment and on-going evaluation;
4. (d) Signed client services agreement;
5. (e) Advance directives (living will and durable power of attorney for health care), if applicable;
6. (e) General Power of Attorney or Guardianship, if applicable;
7. (f) MOST, if applicable;
8. (g) Service plan;
9. (h) History of sensitivities and allergies;
10. (j) Medication list;
11. (k) Service delivery notes signed and dated as appropriate by staff;
12. (l) Documentation of supervision of personal care services;
13. (m) Documentation of discharge planning, if appropriate;
14. (n) Discharge summary, including the reason for termination of services and the effective date of discharge;
15. (o) Documentation of coordination of services, if applicable;
16. (p) Communications between the home support agency and all health care

professionals involved in the client's care; and

(q) Documentation of training and education given to the client and the client's caregivers.

SOURCE: Final Rulemaking published at 67 DCR 9476 (August 7, 2020).