16 Del. Admin. Code § 3305-III-8.0

Current through Register Vol. 28, No. 5, November 1, 2024

Section 3305-III-8.0 - Records

8.1 The service provider shall maintain an on-site treatment record for each resident that includes sufficient documentation of assessments, treatment plans and treatment to permit a clinician not familiar with the resident to evaluate the course of treatment. Resident treatment records shall be kept confidential and safeguarded in a manner consistent with the requirements of 16 Del.C., § 1121, applicable federal law and Departmental guidelines adopted in conformity with 16 Del.C., § 1119 A.

The resident's records shall be maintained by the service provider in their entirety for at least seven (7) years after the date of discharge or as otherwise directed by the Department.

The resident's record shall contain the following:

8.1.1 An up-to-date face sheet and resident consent to treatment and consent to any occasion of release of treatment information;

8.1.2 Results of all pertinent examinations, tests and other assessment information, reports from referral sources and clinical consults, and hospital discharge summaries;

8.1.3 Assessments and summary of assessments;

8.1.4 A treatment plan;

8.1.5 Weekly and monthly progress notes;

8.1.6 Documentation of at least semiannual reviews of treatment, including reassessment of current functioning, summary of progress and treatment plan revisions;

8.1.7 Medication history and orders including the following:

8.1.7.1 The brand or established name and strength of medication to extent measurable;

8.1.7.2 Identity of dispensing pharmacy;

8.1.7.3 Identity of prescribing physician;

8.1.7.4 Date of order;

8.1.7.5 Dose;

8.1.7.6 Special instructions included on the prescription;

8.1.7.7 Frequency and, if specified, time period of intended administration; and

8.1.7.8 For each discrete self-administration/administration of medication, the following:

8.1.7.8.1 Time and date;

8.1.7.8.2 Amount or dose;

8.1.7.8.3 Route of administration;

8.1.7.8.4 Identity of person administering, assisting with administration, or, if applicable, monitoring self-administration of medication; and

8.1.7.8.5 Any adverse reactions.

8.1.8 Discharge plan developed in conformity with Sections 6.8, 6.9 and 6.10.

8.2 Incident reports, with adequate documentation, shall be completed for each incident. Adequate documentation shall consist of the name of the resident(s) involved; the date, time and place of the incident; a description of the incident; a list of other parties involved, including witnesses; the nature of any injuries; resident outcome; and follow-up action, including notification of the resident's representative or family, attending physician and licensing or law enforcement authorities when appropriate. Incident reports shall be kept on file in the facility. Reportable incidents shall be communicated immediately to the Division of Health Care Quality, 3 Mill Road, Suite 308, Wilmington, DE 19806; telephone number: 1-877-453-0012; fax number: 1-877-264-8516.

16 Del. Admin. Code § 3305-III-8.0

25 DE Reg. 764( 2/1/2022) (final)