16 Del. Admin. Code § 3360-15.0

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

Section 3360-15.0 - Records And Reports

15.1 There shall be a separate record maintained at the adult day care facility for each participant which shall contain:

15.1.1 Admission record: Including participant's name, birth date, home address, identification numbers, such as social security, Medicaid, Medicare, date of admission, physician's name, address and telephone number, diagnosis, names, addresses and telephone numbers of family members, friends, or other designated people to be contacted in the event of illness or an emergency;

15.1.2 A written history and physical examination performed by or under the direction of a physician within 6 months prior to admission;

15.1.3 Results of a medical evaluation or screening test for tuberculosis indicating the absence of active tuberculosis in an infectious stage within 1 year prior to admission;

15.1.4 Application and enrollment forms;

15.1.5 Assessment (initial and reassessments);

15.1.6 Nutritional status assessment as needed;

15.1.7 Individual plan of care (initial and reviews) and revisions;

15.1.8 Signed authorizations for releases of medical information and photos, as appropriate;

15.1.9 Signed authorization for participant to receive emergency medical care if necessary;

15.1.10 Ancillary reports;

15.1.11 Attendance and service records;

15.1.12 Transportation plans;

15.1.13 Where appropriate, medical information sheet; documentation of physicians' order; treatment, therapy, medication, and professional notes;

15.1.14 Progress notes, chronological and timely, including a monthly assessment of health, functional, and psychosocial status of participants;

15.1.15 Discharge plan;

15.1.16 Current photograph (taken as necessary) depicting an accurate likeness of the participant;

15.1.17 Advance healthcare directive form that complies with DE Code, Title 16, Part II, Chapter 25 or a statement that none has been signed.

15.1.18 A copy of the written agreement between the participant and the adult day care program including any updates made to the original reflecting changes in services or arrangements; and,

15.1.19 Written acknowledgment that the participant or the participant's representative has been fully informed of the participant's rights.

15.2 All participants' medical records shall be maintained in accordance with professional standards.

15.3 All program records shall be available for review by authorized representatives of the Department and to legally authorized persons; otherwise such records shall be held confidential. The consent of the participant or her/his representative if the participant is incapable of making decisions shall be obtained before any personal information is released from her/his records as authorized by these regulations or Delaware law.

15.4 The adult day care facility records shall be retained for a minimum of five (5) years before being destroyed.

15.5 Records shall be protected from loss, damage, and unauthorized use.

16 Del. Admin. Code § 3360-15.0

25 DE Reg. 776( 2/1/2022) (Final)