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 to all records during announced and unannounced audits and reviews.

1909.2 Each Waiver provider entity shall maintain the following records, if applicable, for each person receiving services for monitoring and audit reviews:

1. (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;
2. (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;
3. (c) A record of all service authorization and prior authorizations for services;
4. (d) A record of all requests for change in services;
5. (e) The person's medical records;
6. (f) A discharge summary;
7. (g) A written staffing plan;
8. (h) 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;
9. (i) Documents which contain the following information:
10. (1) The results of the provider's functional assessment for service delivery;
11. (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;
12. (3) Age-appropriate and measurable goals based on the assessment tool consistent with the duration of time spent at the person's home, provider's facility or the community venue; and

(j) Teaching strategies utilized to execute goals in the ISP and the person's response to the teaching strategy, Any records relating to adjudication of claims;

(k) Any records necessary to demonstrate compliance with all rules and requirements, guidelines, and standards for the implementation and administration of the Waiver;

(l) A supervision plan for each staff member who is classified as a Direct Support Professional (DSP), developed and implemented by a provider designated staff member, containing the following information:

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

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

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

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

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

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

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

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

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

(m) Daily progress notes, as set forth in each service rule, containing the following information:

(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;

(2) The health or behavioral events or change in status that is not typical to the person;

(3) A listing of all community activities attended by the person;

(4) The start time and end time of any services received including the DSP's signature; and

(5) 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:

(1) An analysis of the goals identified in the ISP and Plan of Care and monthly progress towards reaching the goals;

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

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

(4) Any modifications or recommendations that may be required to be made to the documents described under § 1909.2 (i), ISP, and Plan of Care from the summary analysis.

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 secure service records for each person in a locked room or file cabinet and limit access only to authorized individuals.

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 For non-facility based providers, including Supported Employment and Individualized Day, a policy shall be developed that identifies where records are located and archived, and that ensures that the records are available upon request.

1909.9 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.

SOURCE: Final Rulemaking published at 51 DCR 10207 (November 5, 2004); as amended by Final Rulemaking published at 61 DCR 4406 (May 2, 2014).