La. Admin. Code tit. 48 § I-5057

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-5057 - Client Records

A. Client records shall be accurately documented and maintained in the HCBS provider's office. Current progress notes shall be maintained at the home. The provider shall have a written record for each client which shall include:

1. other identifying data including:

a. name;

b. date of birth;

c. address;

d. telephone number;

e. social security number;

f. legal status; and

g. proof of interdiction or continuing tutorship, if applicable.

2. a copy of the client's ISP or Medicaid comprehensive plan of care, as well as any modifications or updates to the service plan;

3. the client's history including, where applicable:

a. family data;

b. next of kin;

c. educational background;

d. employment record;

e. prior medical history; and

f. prior service history;

4. the service agreement or comprehensive plan of care;

5. written authorization signed by the client or, where appropriate, the legally responsible person for emergency care;

6. written authorization signed by the client or, where appropriate, the legally responsible person for managing the client's money, if applicable;

7. an accurate financial record of each client's personal funds which includes a written record of all of the financial transactions involving the personal funds of the client deposited with the provider;

a. the client (or his legal representative) shall be afforded access to such record; and

b. the financial records shall be available through quarterly statements;

c. Repealed.

8. required assessment(s) and additional assessments that the provider may have received or is privy to;

9. the names, addresses and telephone numbers of the client's physician(s) and dentist;

10. written progress notes or equivalent documentation and reports of the services delivered for each client for each visit. The written progress notes shall include, at a minimum:

a. the date and time of the visit and services;

b. the services delivered;

c. who delivered or performed the services;

d. observed changes in the physical and mental condition(s) of the client, if applicable; and

e. doctor appointments scheduled or attended that day;

11. health and medical records of the client, including:

a. a medical history, including allergies;

b. a description of any serious or life threatening medical condition(s); and

c. a description of any medical treatment or medication necessary for the treatment of any medical condition;

d. Repealed.

12. a copy of any signed and dated advance directive that has been provided to the HCBS provider, or any physician orders, signed and dated, relating to end of life care and services.

B. HCBS providers shall maintain client records for a period of no less than six years.

La. Admin. Code tit. 48, § I-5057

Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 38:82 (January 2012), Amended by the Department of Health, Bureau of Health Services Financing, LR 432515 (12/1/2017).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and R.S. 40:2120.1.