16 Del. Admin. Code § 3310-6.0

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

Section 3310-6.0 - Records and Reports

6.1 There shall be a separate record maintained on each individual as per DDDS standards.

6.2 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.

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

6.4 Records shall be retained for 6 years after discharge. For a minor, records shall be retained for three years after age of majority.

6.5 Incident reporting

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

6.5.1.1 The name of the individual(s) involved;

6.5.1.2 The date, time and place of the incident;

6.5.1.3 A detailed description of the incident;

6.5.1.4 A list of other parties involved, including witnesses;

6.5.1.5 Witness statements;

6.5.1.6 The nature of any injuries sustained;

6.5.1.7 individual(s) outcome(s); and

6.5.1.8 Follow-up action:

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

6.5.1.8.2 The corrective action taken immediately for each individual or area impacted;

6.5.1.8.3 How the staff will act to protect individuals in a similar situation;

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

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

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

6.7 Reportable incidents shall be communicated immediately to the DDDS and within 8 hours to the DHCQ.

6.8 Reportable incidents are as follows:

6.8.1 Abuse as defined in 16 Del.C. § 1131, or reasonable suspicion of same.

6.8.1.1 Physical abuse with injury if individual to individual and physical abuse with or without injury if staff to individual or any other person to individual.

6.8.1.2 Any sexual act between staff and an individual and any non-consensual sexual act between individuals or between an individual and any other person such as a visitor.

6.8.1.3 Emotional abuse whether staff to individual, individual to individual or any other person to individual.

6.8.2 Neglect, mistreatment or financial exploitation as defined in 16 Del.C. § 1131, or reasonable suspicion of same.

6.8.3 Individual elopement under the following circumstances:

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

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

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

6.8.4 Significant injuries.

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

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

6.8.4.1.1.1 The extent of the injury;

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

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

6.8.4.1.1.4 The incidence of injuries over time.

6.8.4.2 Injury which results in medical or dental treatment other than first aid provided in the home.

6.8.4.3 Areas of contusions or bruises caused by staff to a dependent individual during ambulation, transport, transfer or bathing.

6.8.4.4 Significant error or omission in medication/treatment, including drug diversion, which causes the individual discomfort or jeopardizes the individual's health and safety.

6.8.4.5 A burn greater than first degree.

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

6.8.5 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.

6.8.6 Suicide or attempted suicide.

6.8.7 Poisoning.

6.8.8 Fire within a neighborhood home.

6.8.9 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.

6.8.10 Structural damage or unsafe structural conditions.

6.8.11 Water damage which impacts individual health, safety or comfort.

6.8.12 Deaths.

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

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

6.9.1.1 The corrective action taken immediately for each individual or area impacted;

6.9.1.2 How the staff will act to protect individuals in a similar situation;

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

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

16 Del. Admin. Code § 3310-6.0

25 DE Reg. 765( 2/1/2022) (final)