Rule 111-8-1-.16 - Records(1)Participant Records. An individual file for each participant shall be established and maintained at the adult day center and shall include the following: (a) The participant's full name, address, telephone number, date of birth, marital status, and living arrangement;(b) At least two emergency contacts to include name, address, telephone number, and relationship to participant;(c) Name, address and telephone number of the participant's primary health care provider;(d) A signed participant agreement;(e) Any powers of attorney, guardianship orders, or any other documents which identify authorized representatives of the participant, if applicable;(f) All individual plans of care including updates;(g) Copies of all signed authorizations for the center to receive and provide confidential information on the participant, if applicable;(h) Signed authorization for the participant to receive emergency medical care from any licensed medical practitioner, if such emergency care is needed by the participant;(i) A medical examination report conducted within six months prior to admission or within thirty (30) days after admission, and updated annually, signed by a licensed physician, physician's assistant or nurse practitioner;(j) A statement signed by the participant or representative acknowledging receipt of center policies;(k) An activity participation record for each participant;(l) Medication Assistance Records; and(m) A record of incidents, accidents, injuries, illnesses and emergencies involving the participant.(2)Adult Day Health Centers. In addition to the above, adult day health centers shall maintain the following records: (a) Progress notes including the written report of staff discussions, conferences, consultation with family or other interested parties; and(b) Evaluation of a participant's progress, and any other information regarding a participant's situation.(3)Center Records. The center shall maintain the following center records: (a) Copies of activities schedules;(b) Copies of menus served to participants, if applicable;(c) Monthly fees collected and fees to be collected;(d) A daily record of attendance of participants by name; and(e) A written record of all serious or unusual incidents affecting participants, employees or volunteers of the center.(4) All records shall be retained for a minimum of three years.Ga. Comp. R. & Regs. R. 111-8-1-.16
O.C.G.A. § 49-6-81.
Original Rule entitled "Records" adopted. F. Dec. 18, 2014; eff. Jan. 7, 2015.