1. A. A provider shall maintain on-site an accurate and current file for each participant.

2. B. A participant's file shall contain the following:

   1. (1) A completed copy of the following forms prescribed by the Department:

      1. (a) Participant assessment form;
      2. (b) Application form;
      3. (c) Provider-participant service agreement and any addenda; and
      4. (d) Subsidy application, if any;

   2. (2) Personal data of participant including:

      1. (a) Name;
      2. (b) Date of birth;
      3. (c) Admission date and, if applicable, termination date;
      4. (d) The type of housing the participant lived in before admission into the Program;
      5. (e) Name, address, and telephone number of the participant's physician;
      6. (f) Name, address, and telephone number of the participant's contact person;
      7. (g) If obtained by the provider, relevant medical history of the participant, including physicians' health reports and information on recent hospitalizations; and
      8. (h) A copy of any advance health care directive the participant voluntarily provides in response to the provider's inquiring whether it may have a copy of any advance health care directive of participant;
   3. (3) For participants in an Individualized Congregate Housing Services Plan, a service plan;
   4. (4) Incident reports related to the participant;
   5. (5) Documentation verifying on a weekly basis the housekeeping, laundry, and personal assistance services received by the participant during the prior month;
   6. (6) Reasons for any termination or transfer and, if applicable, the location to which the participant was transferred;
   7. (7) Any assessments or recommendations concerning the participant which were made by the local health department and received by the provider; and

   8. (8) If the participant receives a subsidy, a completed copy of the subsidy calculation form and written documentation of the participant's:

      1. (a) Net annual income;
      2. (b) Assets; and
      3. (c) Allowable medical expenses.

3. C. Incident Reports.

   1. (1) A provider shall record on an incident report a description of each accident, injury, or other incident that occurs at the facility and impacts the amount of congregate housing services needed by a participant.

   2. (2) All incident reports shall include the following information:

      1. (a) The time, date, and place of the incident;
      2. (b) The identity of individuals present at the incident;
      3. (c) A complete description of the incident;
      4. (d) The response of the staff; and
      5. (e) Any appropriate follow-up action taken, including notifying the participant's contact person and licensing or law enforcement authorities.

4. D. Confidentiality. A provider shall protect the confidentiality of a participant's file. A provider may not disclose information contained in a participant's file to any person or agency other than the participant, the participant's contact person or legal representative, or the Department's authorized employees unless:

   1. (1) The participant consents in writing to the disclosure; or
   2. (2) State or federal law or a court order otherwise requires or permits the disclosure.
5. E. During ordinary business hours and at other reasonable times, a participant shall have the right to inspect and obtain a copy of the file referred to in §B of this regulation. Upon request by a participant, a provider shall make a copy for the participant of any portion of the file and may charge the participant a reasonable cost for making a copy, not to exceed 30 cents per page.
6. F. A provider shall keep a participant's file for at least 3 years after the participant stops participating in the Program at the provider's facility.

Authority: Human Services Article, §§10-209 and 10-210, Annotated Code of Maryland

Effective date: July 1, 2005 (32:10 Md. R. 926)

Regulation .01B amended effective June 4, 2018 (45:11 Md. R. 580)

Regulation .07 amended effective June 4, 2018 (45:11 Md. R. 580)

Regulation .14B amended effective June 4, 2018 (45:11 Md. R. 580)

Regulation .16C amended effective June 4, 2018 (45:11 Md. R. 580)

Regulation .17 amended effective June 4, 2018 (45:11 Md. R. 580)

Regulation .18 amended effective June 4, 2018 (45:11 Md. R. 580)

Regulation .19 amended effective June 4, 2018 (45:11 Md. R. 580)

Regulation .22 amended effective June 4, 2018 (45:11 Md. R. 580)

Regulation .23A—C amended effective June 4, 2018 (45:11 Md. R. 580)

Regulation .26A amended effective June 4, 2018 (45:11 Md. R. 580)

Regulation .28 amended effective June 4, 2018 (45:11 Md. R. 580)

Regulation .32A amended effective June 4, 2018 (45:11 Md. R. 580)