6318 CASE RECORD

6318.1 An independent living program shall maintain a separate written case record for each resident.6318.2 The independent living program shall make timely entries in the case record that are legible, dated, and signed by the staff member or other person making the entry.6318.3 A resident's case record shall include:- (a) Name, date and place of birth, date of admission, and citizenship;

- (b) A physical description, including but not limited to sex, race, height, weight, hair color, eye color, and identifying marks;

- (c) A current photograph;

- (d) The primary language or means of communication spoken and understood by the resident and the primary language used by the resident's family, if other than English;

- (e) Religious affiliation, if any;

- (f) The name, address, and telephone number of the resident's parent(s) or other responsible family member(s), guardian, attorney, and referring agency or case worker, as applicable;

- (g) Medical, mental health, and immunization records, including but not limited to identified emergency medical needs, allergies, basic needs, and non-emergency medical conditions and physical infirmities, including all visible signs of illness or injury;

- (h) Dental, vision, and hearing records;

- (i) The social history;

- (j) The contracting entity's case plan, if any;

- (k) The service plan as required by § 6341 and any changes or updates thereto;

- (l) The discharge plan, as required by § 6348;

1. (m) Behavior management and discipline records relating to the resident, where applicable, as required by § 6347;
2. (n) All correspondence relevant to the resident;
3. (o) Reports of unusual incidents as required by § 6319;
4. (p) Reports related to abuse, neglect, or other risks to the resident's health and safety made pursuant to § 6304;
5. (q) Any consents to treatment as required by § 6342.7;
6. (r) Any restrictions on visitation, mail, or telephone contacts;
7. (s) Court orders, if applicable;
8. (t) Admission and placement information as required by § 6339;
9. (u) Signed notification of rights as required by § 6340.3(f);
10. (v) Signed notification of grievance procedures, as required by § 6340.3(g);
11. (w) Education records;
12. (x) Any evaluation or progress reports prepared for the resident;
13. (y) The resident's grievance record; and
14. (z) Documentation of counseling and treatment sessions.

6318.4 An independent living program shall maintain all information in a resident's case record for so long as the resident is admitted to the independent living program. Upon the resident's discharge from the independent living program, the independent living program shall turn over the original case record to the contracting entity.

6318.5 An independent living program shall maintain a resident's case record in a locked and secure location when unattended.

6318.6 An independent living program, CFSA, the contracting entity, and the guardian ad litem shall have access to a resident's case record. No other person may have access to the resident's case record unless authorized in writing by the CFSA.

6318.7 An independent living program shall maintain in the case record easily accessible

emergency information for each resident, including:

(a) The name, address, telephone number, and relationship of a designated person to be contacted in case of an emergency;

(b) If the resident is less than eighteen (18) years of age, a person able to give consent for emergency medical treatment, if applicable;

(c) The resident's physician or source of health care; and

(d) Health insurance information.

SOURCE: Final Rulemaking published at 49 DCR 1591 (February 22, 2002); as amended by Final Rulemaking published at 66 DCR 1058 (January 25, 2019).