1. A. At the time of admission to the ICF/MR, information shall be entered into the client's record which shall identify and give a history of the client. This identifying information shall at least include the following:

   1. 1. a recent photograph;
   2. 2. full name;
   3. 3. sex;
   4. 4. date of birth;
   5. 5. ethnic group;
   6. 6. birthplace;
   7. 7. height;
   8. 8. weight;
   9. 9. color of hair and eyes;
   10. 10. identifying marks;
   11. 11. home address, including street address, city, parish and state;
   12. 12. Social Security Number;
   13. 13. medical assistance identification number;
   14. 14. Medicare claim number, if applicable;
   15. 15. citizenship;
   16. 16. marital status;
   17. 17. religious preference;
   18. 18. language spoken or understood;
   19. 19. dates of service in the United States Armed Forces, if applicable;
   20. 20. legal competency status if other than competent;
   21. 21. sources of support: social security, veterans’ benefits, etc.;
   22. 22. father's name, birthplace, Social Security Number, current address, and current phone number;
   23. 23. mother's maiden name, birthplace, Social Security Number, current address, and current phone number;
   24. 24. name, address, and phone number of next of kin, legal guardian, or other responsible party;
   25. 25. date of admission;
   26. 26. name, address and telephone number of referral agency or hospital;
   27. 27. reason for admission;
   28. 28. admitting diagnosis;
   29. 29. current diagnosis, including primary and secondary DSM III diagnosis, if applicable;
   30. 30. medical information, such as allergies and general health conditions;
   31. 31. current legal status;
   32. 32. personal attending physician and alternate, if applicable;
   33. 33. choice of other service providers;
   34. 34. name of funeral home, if appropriate; and
   35. 35. any other useful identifying information. Refer to Admission Review for procedures.

2. B. First Month After Admission. Within 30 calendar days after a client's admission, the ICF/MR shall complete and update the following:

   1. 1. review and update the pre-admission evaluation;
   2. 2. develop a prognosis for programming and placement;
   3. 3. ensure that an interdisciplinary team completes a comprehensive evaluation and designs an individual habilitation plan (IHP) for the client which includes a 24-hour schedule.

3. C. Entries into Client Records During Stay at the ICF/MR. The following information shall be added to each client's record during his/her stay at the ICF/MR:

   1. 1. reports of accidents; seizures, illnesses, and treatments for these conditions;
   2. 2. records of immunizations;
   3. 3. records of all periods where restraints were used, with authorization and justification for each, and records of monitoring in accordance with these standards;
   4. 4. reports of at least an annual review and evaluation of the program, developmental progress, and status of each client, as required in these standards;
   5. 5. behavior incidents and plans to manage inappropriate behavior;
   6. 6. records of visits and contacts with family and other persons;
   7. 7. records of attendance, absences, and visits away from the ICF/MR;
   8. 8. correspondence pertaining to the client;
   9. 9. periodic updates of the admission information (such updating shall be performed in accordance with the written policy of the ICF/MR but at least annually); and
   10. 10. appropriate authorizations and consents.
4. D. Entries at Discharge. At the time of a client's discharge, the QMRP or other professional staff, as appropriate, shall enter a discharge summary into the client's record. This summary shall address the findings, events, and progress of the client while at the ICF/MR and a diagnosis, prognosis, and recommendations for future programming.

Authority Note

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254.

Historical Note

HISTORICAL NOTE: Promulgated by the Department of Health and Human Resources, Office of Family Security, LR 13:578 (October 1987), amended by the Department of Health and Hospitals, Office of the Undersecretary, Bureau of Health Services Financing, LR 25:685 (April 1999), repromulgated LR 31:2231 (September 2005).