1909

RECORDS AND CONFIDENTIALITY OF INFORMATION

1909.1

Each Waiver provider shall allow appropriate personnel of DHCF, DDS and other authorized agents of the District of Columbia government or of other jurisdictions where services are provided, and the federal government full access, whether the visit is announced or unannounced, to all waiver provider locations, including access to the people receiving supports and all records, in any form. For purposes of this section, the term “records” includes, but is not limited to, all information relating to the provider, the services and supports being provided, and the people for whom services are provided; any information which is generated by or in the possession of the provider; the information required by the Citizens with Intellectual Disabilities Constitutional Rights and Dignity Act of 1978, effective March 3, 1979 (D.C. Law 2-137; D.C. Official Code §§ 7-1301.02 et seq.) or its successor; and any information required by the regulations implementing the HCBS Waiver program.

1909.2

Each Waiver provider entity shall maintain the following records at the site of service delivery, where applicable, for each person receiving services for monitoring and audit reviews. For people receiving In-Home Supports, the person and his or her support team make the determination of which records to store in the person’s home and which are kept off-site.

(a) General information including each person’s name, Medicaid identification number, address, telephone number, date of birth, sex, name and telephone number of emergency contact person, physician’s name, address and telephone number, and the DDS Service Coordinator’s name and telephone number;

(b) A copy of the most recent DDS approved ISP and Plan of Care indicating the requirement for and identification of a provider who shall provide the services in accordance with the person’s needs;

(c) A record of all service authorization and prior authorizations for services;

(d) A record of all requests for change in services;

(e) The person’s medical records;

(f) The person’s financial records;

(g) A discharge summary;

(h) A written staffing plan, if applicable;

1. (i) A back-up plan detailing who shall provide services in the absence of staff when the lack of immediate care poses a serious threat to the person's health and welfare;
2. (j) Documents which contain the following information:
3. (1) The results of the provider's functional analysis for service delivery;
4. (2) A schedule of the person's activities in the community, if applicable, including strategies to execute goals identified in the ISP and the date and time of the activity, the staff as identified in the staffing plan;
5. (3) Teaching strategies utilized to execute goals in the ISP and the person's response to the teaching strategy as further described in Subsection 1909.11; and
6. (4) A support plan with SMARTER goals and outcomes using the information from the DDS approved person-centered thinking and discovery tools, the functional analysis, the ISP, Plan of Care, and other information as appropriate to assist the person in achieving his or her goals;
7. (k) Any records relating to adjudication of claims;
8. (l) Any records necessary to demonstrate compliance with all rules and requirements, guidelines, and standards for the implementation and administration of the Waiver;
9. (m) Progress notes, as set forth in each service rule, containing the following information:
10. (1) The progress in meeting the specific goals in the ISP and Plan of Care that are addressed on the day of service and relate to the provider's scope of service;
11. (2) The health or behavioral events or change in status that is not typical to the person;
12. (3) Evidence of all community integration and inclusion activities attended by the person and related to the person's ISP goals and for each, a response to the following questions: 'What did the person like about the activity?' and 'What did the person not like about the

activity?” DDS recommends the use of the Person-Centered Thinking Learning Log for recording this information;

(4) The start time and end time of each shift for any services received including the signature of the Direct Support Professional (DSP) (Note that, where progress notes are written using an electronic record system, an electronic signature meets the requirement for signature.);(5) For services that require awake overnight shifts, the progress notes shall include the support provided as indicated in the specific residential schedule; and(6) The matters requiring follow-up on the part of the Waiver service provider or DDS.(n) Reports on a quarterly basis, containing the following information (DDS recommends use of the Person-Centered Thinking 4+1 Tool for recording this information.):1. (1) An analysis of the goals identified in the ISP and Plan of Care and monthly progress towards reaching the goals;

2. (2) The service interventions provided and the effectiveness of those interventions;

3. (3) A summary analysis of all habilitative support activities that occurred during the quarter;

4. (4) For providers of Supported Living, Supported Living with Transportation, Host Home Without Transportation, Residential Habilitation, In-Home Supports, Day Habilitation, Individualized Day Supports, and Employment Readiness, the quarterly report shall include information on the person's employment, including place of employment, job title, hours of employment, salary/hourly wage, information on fringe benefits, and current checking, savings and burial fund balances, as applicable;

5. (5) Any modifications or recommendations that may be required to be made to the documents described under Subsection 1909.2(j), ISP, and Plan of Care from the summary analysis; and

(6) For providers of Supported Living, Supported Living with Transportation, Host Home Without Transportation, Residential Habilitation, and High Intensity In-Home Supports, documentation of the review, implementation, and update, if applicable, of the person's Health Care Management Plan, in accordance with the DDS Health and Wellness Standards.1909.3 Each Waiver provider shall maintain all records, including but not limited to, progress reports, financial records, medical records, treatment records, and any other documentation relating to costs, payments received and made, and services provided, for six (6) years from service initiation or until all audits, investigations, or reviews are completed, whichever is longer.1909.4 Each Waiver provider agency and independent practitioner shall maintain records to document staff training and licensure requirements, for a period of no less than six (6) years.1909.5 Each Waiver provider shall ensure the person's privacy and limit access to the person's records to only authorized individuals, including the person. Waiver providers shall not publicly post mealtime protocols, clinical therapy schedules, or any other health information.1909.6 The disclosure of treatment information by a Waiver provider shall be subject to all provisions of applicable federal and District laws and rules, for the purpose of confidentiality of information.1909.7 For residential providers, the records, including program, medical, and financial records for the current ISP, shall be located at the person's residence. Providers shall archive their records annually and ensure that they are available upon request.1909.8 Each Waiver provider shall implement a written strategy that outlines where and how records are stored. For residential programs, the written strategy will be unique to each home and developed in coordination with the people who live there. For non-facility based programs, the written strategy shall identify the location for the records and shall include the process for making them available when audits and other reviews are conducted.1909.8 If the provider maintains electronic records, the electronic records shall be immediately available in an established electronic record keeping system. The electronic record keeping system shall meet the following requirements:- (a) Have reasonable controls to ensure the integrity, accuracy, authenticity, and reliability of the records kept in electronic format;

(b) Be capable of retaining, preserving, retrieving, and reproducing the electronic records;

(c) Be able to readily convert paper originals stored in electronic format back into legible and readable paper copies;

(d) Be able to create back-up electronic file copies; and

(e) Provide the appropriate level of security for records to comply with federal requirements for safeguarding information.

1909.10 DHCF shall retain the right to conduct audits at any time. Each Waiver provider shall allow access, during on site audits or review by DHCF or U.S. Department of Health and Human Services auditors, to relevant financial records.

1909.11 For purposes of Subsection 1909.2(j)(3), the teaching strategy used to execute goals in the ISP shall include enough information so that any provider staff member or DSP could step in to assist the person in completing the goal. At minimum, the teaching strategy shall contain:

(a) The goal statement;

(b) The purpose of the goal/measureable outcome;

(c) The materials needed to implement the goal;

(d) The preferred learning/teaching style for the person;

(e) The learning steps (i.e. individual actions that need to be completed for success); and

(f) The method for measuring success.

1909.12 A staff member, designated by the provider, develops and implements an annual supervision plan for each staff member who is classified as a DSP. The annual supervision plan contains the following information:

(a) The name of the DSP and date of hire;

(b) The DSP's place of employment, including the name of the provider entity or day services provider;

(c) The name of the DSP's supervisor who shall have at least two (2) years' experience working with persons with intellectual and developmental disabilities;

(d) A documentation of performance goals for the DSP;

(e) A description of the DSP's duties and responsibilities;

(f) A comment section for the DSP's feedback;

(g) A statement of affirmation by the DSP's supervisor confirming statements are true and accurate;

(h) The signature, date, and title of the DSP; and

(i) The signature, date, and title of the DSP's supervisor.

SOURCE: Final Rulemaking published at 51 DCR 10207 (November 5, 2004); as amended by Final Rulemaking published at 61 DCR 4406 (May 2, 2014); as amended by Final Rulemaking published at 63 DR 10445 (August 12, 2016); as amended by Final Rulemaking published at 65 DCR 2190 (March 2, 2018).