La. Admin. Code tit. 48 § I-4951

Current through Register Vol. 50, No. 9, September 20, 2024

Section I-4951 - Records-Administrative and Consumer

A. All provider records must be maintained in an accessible, standardized order and format and must be retained and disposed of in accordance with state laws.

B. A provider must have sufficient space, facilities and supplies for providing effective record keeping services.

C. Upon agency closure, all provider records must be maintained according to applicable laws, rules and regulations.

D. A provider must have a written record for each consumer which must minimally include:

1. identifying data recorded on a standardized form including the following:

a. name;

b. home address;

c. home telephone number;

d. date of birth;

e. sex;

f. race or ethnic origin;

g. closest living relative;

h. education;

i. marital status;

j. name and address of current employment, school, or day program, as appropriate;

k. date of initial contact;

l. court and/or legal status, including relevant legal documents;

m. names, addresses, and phone numbers of other persons or providers involved with the consumer's service plan. This shall include the consumer's qualified, licensed physician or other licensed health care practitioner who is acting within the scope of practice of his/her respective licensing board(s) and/or certification(s);

n. other identifying data as indicated;

o. date the information was gathered;

p. signature of the staff member gathering the information.

2. Interdiction Status. A notation on the inside of the front cover that the consumer has been interdicted if this information is known.

3. Limited health records including a description of any serious or life threatening medical condition of the consumer. This must include a description of any current treatment or medication necessary for the treatment of any serious or life threatening medical condition or known allergies.

E. A provider must ensure that all entries in records are legible, signed by the person making the entry and accompanied by the date on which the entry was made.

F. Entries must be made in consumer records when services are provided to and/or on behalf of consumer in accordance with the following:

1. All entries and forms in the consumer's record that are completed by the provider must be in ink, are legible, be dated, be signed and shall include the functional title of the person making the entry.

2. An error in the consumer's record made by staff must be corrected by drawing a line through the erroneous information. The word "error" must be written beside the correction, and the correction must be initialed.

3. Correction fluid must never be used in a consumer's record.

G. Consumer record material must be organized in a manner which encourages staff to use it as a communication tool.

1. The location of documents within the record must be consistent among all the provider's records.

2. The record must be appropriately thinned so that current material shall be easily located in the record.

H. Each record must document the need for case management services and the following, at a minimum:

1. medical, social, psychiatric, psychological and other pertinent information regarding the consumer's disability, illness, or condition which will document eligibility for case management services for the targeted population;

2. necessary assessments and other information concerning the consumer's medical, social, familial, cultural, developmental, legal, educational, vocational, psychiatric and economic status, as appropriate, to support the initial service plan, and modifications in the service plan;

3. documentation of the need for ongoing case management and other identified services;

4. written service plan signed and dated by the case manager and the consumer and/or guardian shall be placed in the consumer's record;

5. description of all contacts, services delivered and/or action taken identifying the persons involved in service delivery, the date and place of service, the content of service delivery and the duration of the contact;

6. progress notes written at least monthly to document progress towards specified goals;

7. summary of services provided and progress towards goals, as well as the reason for the closure of the case at the time of termination; and,

8. any joint agreement with the consumer for closure.

I. The provider must utilize the tracking and/or data system for the Program Office of the targeted population being served or a comparable system which tracks the same data elements and allows reporting of data to the program office.

J. The provider must sign an agreement with the appropriate Program Office regarding the exchange of consumer-related data.

K. The record must contain at least six months of current information.

L. Information older than six months may be kept in storage but shall be available for review.

M. The records are maintained until audited and all audit questions answered or for six years from the time of payment, whichever is longer.

N. When a consumer transfers to another provider, at a minimum, copies of the following information must be sent to the requesting provider upon receipt of a release of information signed by the consumer:

1. most current service plan;

2. current assessments upon which service plan is based;

3. number of services used in the calendar year; and

4. last quarter's progress notes;

O. A nonredisclosure clause must accompany all information released to the requesting provider on all Office of Alcohol and Drug Abuse consumers;

P. The receiving provider must bear the cost of copying which shall not to exceed the community's competitive copying rate.

Q. A written policy must govern the disposal of consumer records and confidentiality of consumer information must be protected at the time of disposal.

R. A provider must have a written record for each employee which includes:

1. the application for employment and/or resume'

2. references

3. any required medical examinations

4. all required documentation of appropriate status which includes:

a. valid driver's license for operating provider vehicles or transporting consumers.

b. verification of professional credentials/certification required to hold the position including the following:

i. current licensure

ii. relevant licensure

iii. relevant education

iv. relevant training

v. relevant experience

5. periodic, at least annual, performance evaluations.

6. employee's starting and terminations dates along with salary paid.

S. An employee must have reasonable access to his/her personnel file and must be allowed to add any written statement he/she wishes to make to the file at any time.

T. A provider must not release a personnel file without the employee's written permission except in accordance with state law.

La. Admin. Code tit. 48, § I-4951

Promulgated by the Department of Health and Human Resources, Office of the Secretary, Division of Licensing and Certification, LR 13:246 (April 1987), amended by the Department of Health and Hospitals, Office of the Secretary, LR 20:891 (August 1994), Amended by the Department of Health, Bureau of Health Services Financing, LR 471306 (9/1/2021).

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