10.22.02.13

.13 Records.

A. A licensee shall maintain records for each individual at the site where the individual is being served.

B. The records shall include at a minimum:

(1) The identifying information which appears on the individual's application for services from the Administration;

(2) Sufficient information that enables the licensee to provide services in a manner which ensures the individual's health and safety, including:

(a) An emergency contact person for the individual,

(b) The names of the individual's next of kin,

(c) The individual's physician,

(d) The individual's current diagnosis,

(e) Documented allergies of the individual, and

(f) A listing of the medications the individual receives;

(3) The IP as defined in COMAR 10.22.05;

(4) Documentation demonstrating implementation of the IP; and

(5) Any other information the Administration may require.

C. On notification of a medical emergency, the licensee shall ensure that the individual's medical information is available and readily accessible to emergency personnel.

D. The licensee shall:

(1) Maintain an individual's records for a minimum of 6 years, regardless of whether the individual is no longer being served or dies;

(2) Maintain documents relevant to the services the individual is currently receiving, as long as the individual is being served; and

(3) Organize an individual's record in a manner that facilitates easy access to needed information.

E. Electronic Records.

(1) The licensee is encouraged to use electronic records whenever possible.

(2) Electronic records shall:

(a) Meet requirements in this chapter;

(b) Comply with the HIPAA privacy and security rules pertaining to personal health information (PHI); and

(c) Be properly backed up and stored at an off-site location.