32.03.04.13

.13 Record Keeping.

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:

(a) Name;

(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.