A. A provider shall maintain on-site an accurate and current file for each participant.
B. A participant's file shall contain the following:
(1) A completed copy of the following forms prescribed by the Department:
(a) Participant assessment form;
(b) Application form;
(c) Provider-participant service agreement and any addenda; and
(d) Subsidy application, if any;
(2) Personal data of participant including:
(b) Date of birth;
(c) Admission date and, if applicable, termination date;
(d) The type of housing the participant lived in before admission into the Program;
(e) Name, address, and telephone number of the participant's physician;
(f) Name, address, and telephone number of the participant's contact person;
(g) If obtained by the provider, relevant medical history of the participant, including physicians' health reports and information on recent hospitalizations; and
(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) For participants in an Individualized Congregate Housing Services Plan, a service plan;
(4) Incident reports related to the participant;
(5) Documentation verifying on a weekly basis the housekeeping, laundry, and personal assistance services received by the participant during the prior month;
(6) Reasons for any termination or transfer and, if applicable, the location to which the participant was transferred;
(7) Any assessments or recommendations concerning the participant which were made by the local health department and received by the provider; and
(8) If the participant receives a subsidy, a completed copy of the subsidy calculation form and written documentation of the participant's:
(a) Net annual income;
(b) Assets; and
(c) Allowable medical expenses.
C. Incident Reports.
(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) All incident reports shall include the following information:
(a) The time, date, and place of the incident;
(b) The identity of individuals present at the incident;
(c) A complete description of the incident;
(d) The response of the staff; and
(e) Any appropriate follow-up action taken, including notifying the participant's contact person and licensing or law enforcement authorities.
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) The participant consents in writing to the disclosure; or
(2) State or federal law or a court order otherwise requires or permits the disclosure.
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.
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.