La. Admin. Code tit. 48 § I-6869

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

Section I-6869 - Record Keeping

A. Administrative Records. The ARCP shall have an administrative record that includes:

1. the articles of incorporation or certified copies thereof, if incorporated, by-laws, operating agreements, or partnership documents, if applicable;

2. the written policies and procedures approved annually by the owner/governing body that address the requirements listed in this Subchapter;

3. the minutes of formal governing body meetings;

4. the organizational chart of the ARCP;

5. all leases, contracts, and purchase of service agreements to which the ARCP is a party, which includes all appropriate credentials;

6. insurance policies; and

7. copies of incident/accident reports.

B. Personnel Records. An ARCP shall maintain a personnel record for each employee. At a minimum, this file shall contain the following:

1. the application for employment, including the resume of education, training, and experience, if applicable;

2. a criminal history check, prior to an offer of employment, in accordance with state law;

3. evidence of applicable professional or paraprofessional credentials/certifications according to state law, rule or regulation;

4. documentation of any state or federally required medical examinations or medical testing;

5. employees hire and termination dates;

6. documentation of orientation and annual training of staff;

7. documentation of a valid drivers license, documentation of a valid chauffers or commercial drivers license with passenger endorsement, if applicable, and Louisiana DMV record for any employee that transports residents;

8. documentation of reference checks; and

9. annual performance evaluations. An employees annual performance evaluation shall include his/her interaction with residents, family, and other providers.

C. Resident Records. An ARCP shall maintain a separate record for each resident. Such record shall be current and complete and shall be maintained in the ARCP in which the resident resides and readily available to ARCP staff and department staff. Each record shall contain the information below including but not limited to:

1. residents name, marital status, date of birth, sex, Social Security number, and previous home address;

2. date of initial residency and date of termination of residency;

3. location of new residence following move-out;

4. name, address and telephone number of the residents representative;

5. names, addresses, and telephone numbers of individuals to be notified in case of accident, death, or other emergency;

6. name, address, and telephone number of a physician to be called in an emergency;

7. ability to ambulate;

8. residents plan/authorization for routine and emergency medical care;

9. the pre-residency assessment and service agreement;

10. assessment and any special problems or precautions;

11. individual PCSP, updates, and quarterly reviews;

12. continuing record of any illness, injury, or medical or dental care when it impacts the residents ability to function without assistance with ADLs and IADLs or impacts the services the resident requires, including but not limited to all orders received from licensed medical practitioners;

13. a record of all personal property and funds which the resident has entrusted to the ARCP;

14. written and signed acknowledgment that the resident has been informed and received verbal explanation and copies of his/her rights, the house rules, written procedures for safekeeping of his/her valuable personal possessions, written statement explaining his/her rights regarding personal funds, and the right to examine his/her record;

15. advance directives and/or Louisiana physician orders for scope of treatment (LaPOST), if any;

16. requirements for assistance in emergency evacuation; and

17. documentation of any third party services provided and documentation of any notifications provided to the resident's representative regarding services.

D. Maintenance and Storage of Records. All records shall be maintained in an accessible, standardized order and format and shall be retained and disposed of in accordance with state laws. An ARCP shall have sufficient space, facilities, and supplies for providing effective storage of records. The ARCP shall maintain the residents records in the following manner.

1. Each resident and/or residents legal representative, if applicable, upon written or oral request, shall have the right to inspect and/or copy his or her records during normal business hours in accordance with state and federal law.

a. After receipt of his/her records for inspection, the ARCP shall provide, upon request and two working days notice, at a cost consistent with the provisions of applicable state law, photocopies of the records or any portions thereof.

2. The ARCP shall not disclose any resident records maintained by the ARCP to any person or agency other than the ARCP personnel, law enforcement, the department, or the attorney generals office, except upon expressed written consent of the resident or his or her legal representative, or when disclosure is required by state or federal law or regulations.

3. The ARCP shall maintain the original records in an accessible manner for a period of five years following a residents death or vacating the ARCP.

4. The original resident records, while the resident maintains legal residence at the ARCP, shall be kept on the ARCP premises at all times, unless removed pursuant to subpoena.

5. In the event of a CHOW, the resident records shall remain with the ARCP.

6. An ARCP which is closing shall notify the department of the plan for the disposition of residents records in writing within 30 days prior to closure. The plan shall include where the records will be stored and the name, address and phone number of the person responsible for the resident and personnel records.

7. If the ARCP closes, the ARCP owner(s) shall store the resident records for five years from the date of closure within the state of Louisiana.

E. Confidentiality and Security of Records

1. The ARCP shall have written procedures for the maintenance and security of records specifying:

a. who shall supervise the maintenance of records;

b. who shall have custody of records; and

c. to whom records may be released. Release shall be made in accordance with any and all federal and state laws.

2. The ARCP shall have a written procedure for protecting clinical record information against loss, destruction, or unauthorized use.

3. The ARCP shall ensure the confidentiality of all resident records, including information in a computerized record system, except when release is required by transfer to another health care institution, law, third-party payment contractor, or the resident. Information from, or copies of, records may be released only to authorized individuals, and the ARCP shall ensure that unauthorized individuals cannot gain access to or alter resident records.

4. Employees of the ARCP shall not disclose or knowingly permit the disclosure of any information concerning the resident or his/her family, directly or indirectly, to any unauthorized person.

5. The ARCP shall obtain the residents, and if applicable, the residents representatives written, informed permission prior to releasing any information from which the resident or his/her family might be identified, except to the department. Identification information may be given to appropriate authorities in case of an emergency.

La. Admin. Code tit. 48, § I-6869

Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 41:1107 (June 2015), Amended by the Department of Health, Bureau of Health Services Financing, LR 471504 (10/1/2021).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and R.S. 40:2166.1-2166.8.