16 Del. Admin. Code § 3320-5.0

Current through Register Vol. 28, No. 3, September 1, 2024

Section 3320-5.0 - Records and Reports

5.1 There shall be a separate record maintained on each resident as per acceptable standards of practice.

5.2 There shall be a medication administration record (MAR) including medications, dosages, frequency, route of administration, and initials of the person administering each dose. The record shall include the identity of each person administering medication.

5.3 Confidentiality of residents' records shall be maintained in accordance with the federal Health Insurance Portability and Accountability Act (HIPAA) and 16 Del.C. § 1121(6).

5.4 Records shall be retained for 6 years after discharge.

5.5 Incident reporting

5.5.1 All incidents shall be adequately documented. Adequate documentation shall include:

5.5.1.1 The name of the resident(s) involved and whether they are able to provide information regarding the incident;

5.5.1.2 The date, time and place of the incident;

5.5.1.3 A detailed description of the incident;

5.5.1.4 A list of other parties involved, including witnesses;

5.5.1.5 Witness statements;

5.5.1.6 The nature of any injuries sustained;

5.5.1.7 Resident(s) outcome(s); and

5.5.1.8 Follow-up action:

5.5.1.8.1 Notification of the resident(s) authorized representative(s), attending physician and licensing or law enforcement authorities, when appropriate;

5.5.1.8.2 The corrective action taken immediately for each resident or area impacted;

5.5.1.8.3 How the staff will act to protect residents in a similar situation;

5.5.1.8.4 What measures will be taken or what systems will be changed to ensure that the incident does not recur;

5.5.1.8.5 How the staff will measure the success of the interventions put in place.

5.6 All reports of incidents, whether or not required to be reported, shall be retained for three years.

5.7 Reportable incidents are as follows:

5.7.1 Abuse, neglect, mistreatment or exploitation as defined in 16 Del.C. Ch. 11, Subch. III, or reasonable suspicion of same.

5.7.2 Individual elopement under the following circumstances:

5.7.2.1 An individual's whereabouts on or off the premises is unknown to staff and the individual suffers harm.

5.7.2.2 A cognitively impaired individual's whereabouts are unknown to staff and the individual leaves the neighborhood home premises.

5.7.2.3 An individual cannot be found inside or outside the neighborhood home and the police are summoned.

5.7.3 Significant injuries:

5.7.3.1 Injury from an incident of unknown source in which the initial evaluation supports the conclusion that the injury is suspicious.

5.7.3.1.1 Circumstances which may cause an injury to be suspicious are:

5.7.3.1.1.1 The extent of the injury;

5.7.3.1.1.2 The location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma);

5.7.3.1.1.3 The number of injuries observed at one particular point in time; or

5.7.3.1.1.4 The incidence of injuries over time.

5.7.3.2 Injury that results in transfer to an acute care facility for treatment or evaluation;

5.7.3.3 Injury that requires periodic neurologic reassessment as ordered by a licensed independent practitioner up to 24 hours;

5.7.3.4 Areas of contusions or bruises caused by staff to a dependent individual;

5.7.3.5 Injury sustained by a totally dependent individual;

5.7.3.6 A burn greater than first degree;

5.7.3.7 Any serious unusual and/or life-threatening injury.

5.7.4 Entrapment which causes the individual injury or immobility of body or limb or which requires assistance from another person for the individual to secure release.

5.7.5 Suicide or attempted suicide.

5.7.6 Poisoning.

5.7.7 Any drug overdose including a drug overdose from illegal drugs.

5.7.8 Medication/treatment error or omission when:

5.7.8.1 It results in discomfort for the individual;

5.7.8.2 It jeopardizes the individual's health or safety; or

5.7.8.3 It requires monitoring as ordered by a licensed independent practitioner for up to 48 hours

5.7.9 Fire within an IBSER home.

5.7.10 Utility interruption lasting more than eight hours in one or more major service(s) including electricity, water supply, plumbing, heating or air conditioning, fire alarm, sprinkler system or telephones.

5.7.11 Structural damage or unsafe structural conditions.

5.7.12 Water damage that impacts individual health, safety or comfort.

5.7.13 Unexpected deaths.

5.7.14 An epidemic outbreak or illness requiring social distancing.

5.8 Incidents of alleged abuse, neglect or mistreatment must be reported to the Department within 2 hours of occurrence. Other reportable incidents shall be communicated to the Department within 8 hours of occurrence.

5.9 All reportable incidents must be thoroughly investigated by the IBSER and a written report provided to the Department within 5 business days of the incident. The written report must include all information as outlined in subsection 5.5.

5.10 The authorized provider shall maintain records and reports of fire safety, health, sanitation, and environmental inspections required by local and state laws and regulations.

5.10.1 The provider shall document actions taken to correct deficiencies noted in these reports. Corrective actions shall include:

5.10.1.1 The corrective action taken immediately for each resident or area impacted;

5.10.1.2 How the staff will act to protect residents in a similar situation;

5.10.1.3 What measures will be taken or what systems will be changed to ensure that the incident does not recur; and

5.10.1.4 How the staff will measure the success of the interventions put in place.

5.10.2 All corrective action plans must be sent to the Department for approval within 10 business days of the receipt of the report.

5.11 Personnel Records:

5.11.1 A licensee must develop, adopt and maintain on file a personnel record for every employee and volunteer.

5.11.2 The personnel record must contain the following:

5.11.2.1 Employment application;

5.11.2.2 Name, current address and phone number of the employee;

5.11.2.3 Verification of education where specified by these requirements;

5.11.2.4 Documentation of training received prior to and during employment at the IBSER or program, including titles and hours of in-service training;

5.11.2.5 Work history;

5.11.2.6 Three references from persons who are unrelated to the employee or volunteer, one of which must be from any previous employer;

5.11.2.7 Results of tuberculosis screening

5.11.2.8 Documentation of annual influenza vaccination or refusal.

5.11.2.9 Verification of completed criminal history record information check and abuse registry information check;

5.11.2.10 Verification of drug screening;

5.11.2.11 Employee job description;

5.11.2.12 Verification of receipt by the employee or volunteer of his or her current job description;

5.11.2.13 A copy of a valid Driver's License if required to transport residents;

5.11.2.14 An annual employee performance evaluation;

5.11.2.15 Annual competency evaluation for LLAM trained employees;

5.11.2.16 Employee disciplinary actions and history;

5.11.2.17 If applicable, license/certification number and expiration date; and

5.11.2.18 All other reports required by statute or regulation.

16 Del. Admin. Code § 3320-5.0

23 DE Reg. 43( 7/1/2019) (final)