Rule 111-8-1-.16. Records

1. (1) Participant Records. An individual file for each participant shall be established and maintained at the adult day center and shall include the following:

   1. (a) The participant's full name, address, telephone number, date of birth, marital status, and living arrangement;
   2. (b) At least two emergency contacts to include name, address, telephone number, and relationship to participant;
   3. (c) Name, address and telephone number of the participant's primary health care provider;
   4. (d) A signed participant agreement;
   5. (e) Any powers of attorney, guardianship orders, or any other documents which identify authorized representatives of the participant, if applicable;
   6. (f) All individual plans of care including updates;
   7. (g) Copies of all signed authorizations for the center to receive and provide confidential information on the participant, if applicable;
   8. (h) Signed authorization for the participant to receive emergency medical care from any licensed medical practitioner, if such emergency care is needed by the participant;
   9. (i) A medical examination report conducted within six months prior to admission or within thirty (30) days after admission, and updated annually, signed by a licensed physician, physician's assistant or nurse practitioner;
   10. (j) A statement signed by the participant or representative acknowledging receipt of center policies;
   11. (k) An activity participation record for each participant;
   12. (l) Medication Assistance Records; and
   13. (m) A record of incidents, accidents, injuries, illnesses and emergencies involving the participant.

2. (2) Adult Day Health Centers. In addition to the above, adult day health centers shall maintain the following records:

   1. (a) Progress notes including the written report of staff discussions, conferences, consultation with family or other interested parties; and
   2. (b) Evaluation of a participant's progress, and any other information regarding a participant's situation.

3. (3) Center Records. The center shall maintain the following center records:

   1. (a) Copies of activities schedules;
   2. (b) Copies of menus served to participants, if applicable;
   3. (c) Monthly fees collected and fees to be collected;
   4. (d) A daily record of attendance of participants by name; and
   5. (e) A written record of all serious or unusual incidents affecting participants, employees or volunteers of the center.
4. (4) All records shall be retained for a minimum of three years.

Authority: O.C.G.A. § 49-6-81.

History. Original Rule entitled "Records" adopted. F. Dec. 18, 2014; eff. Jan. 7, 2015.