Section 144-117-8 - Assessments, Service Plans and Consumer Records8.1Comprehensive Assessment. Each consumer attending the program shall have a comprehensive written assessment. The assessment shall commence no later than the first day of program participation and shall be completed within thirty (30) calendar days.8.2 If the provider does not use the Department approved assessment tool, the assessment shall include at a minimum:8.2.1 Identification and background information. 8.2.1.1 . Individual's name, address and Social Security number;8.2.1.2 . Age, date of birth;8.2.1.5 . Living arrangements;8.2.1.6 Responsible party and emergency contacts;8.2.1.7 Advanced directives;8.2.1.8 Previous occupation(s), special interests and hobbies;8.2.1.9 Primary language spoken;8.2.1.10 Primary care physician's name, address and telephone number.8.2.2 . Medical history.8.2.2.1 Medical diagnoses;8.2.2.2 List of prescribed medications;8.2.2.3 Professional medical services;8.2.2.4 Nursing treatments or services received at home;8.2.3 Functional status. 8.2.3.2 Communication/hearing;8.2.3.3 Nutritional status, including weight;8.2.3.4 Oral/dental status;8.2.3.7 Activities of daily living performance including locomotion, transfer ability, eating, personal hygiene, dressing, toilet use and bathing;8.2.3.8 Use of assistive devices.8.2.4 . Cognition status. 8.2.4.1 Spatial orientation;8.2.4.2 Memory for events;8.2.4.3 Memory and use of information.8.2.5 . Behavior.8.2.5.3 Behavioral demands on others;8.2.5.4 Danger to self and others;8.2.5.5 Awareness of needs/judgment.8.2.6 . Support services.8.2.6.1 Family caregiver(s) status;8.2.6.2 Other informal support network.8.3The assessment process. 8.3.1 The assessment is conducted with the consumer, guardian and/or designated representative. Upon completion, staff completing the assessment must date and sign the assessment.8.3.2 If the assessment is completed by a designated Department assessor within six (6) weeks prior to the consumer's participation in the program, the Adult Day Services provider may use this assessment and shall include a copy of this assessment in the record.8.4Review of assessments. Each consumer assessment must be reviewed as often as necessary, but not less than once every six (6) months. The assessment shall be revised to assure continued accuracy of the assessment. 8.4.1Reassessments. Each consumer must have a comprehensive assessment completed every twelve (12) months.8.5Service Plan. A service plan must be developed for each individual admitted to the program. The service plan shall be developed in cooperation with the consumer, the guardian or designated representative within seven (7) calendar days of completion of the assessment. At least one (1) staff person shall be responsible for the development and monitoring of service plans. The service plan shall be reviewed and updated as often as necessary, but no less than every six (6) months. Each program shall have a written policy/procedure to govern the development, implementation and management of service plans.8.5.1 The service plan shall be based on the comprehensive assessment and shall contain at a minimum:8.5.1.1 An assessment of the consumer's problems, needs, strengths and resources;8.5.1.2 Measurable goals, time frames and objectives for meeting identified problems and needs;8.5.1.3 A reflection of staff approach to maintain or improve functional abilities of the consumer;8.5.1.4 An accurate reflection of the consumer's assessment;8.5.1.5 Plans for coordinating with other health and social service agencies for the delivery of services, if applicable.8.6Progress Notes. Consumer records shall include at least monthly progress notes noting observations of the consumer and progress which the consumer has made in relation to the service plan, as well as any improvement or decline in physical or mental function. The progress note shall include the signature of the person making the notation and the actual date of the progress note.8.7Consumer Records. In addition to the assessment, service plan and monthly progress notes, each Adult Day Services Program shall maintain comprehensive and complete consumer files which include at a minimum:8.7.1 Listing of dates and hours of consumer attendance;8.7.2 Consumers' records and information pertaining to their personal, medical and mental health status, which are confidential. Consumers and their legal representatives shall have access to all records pertaining to the consumer at reasonable times, in the presence of the provider or his/her representative, within one (1) business day of the request. Consumers and their legal representatives are entitled to have copies made of their record within one (1) business day of the request. The licensee and employees shall have access to confidential information about each consumer only to the extent needed to carry out the requirements of the licensing regulations or as authorized by any other applicable state of federal law. The written consent of the consumer or his/her legal representative shall be required for release of information to any other person except authorized representatives of the Department or the Long Term Care Ombudsman Program. The Department shall have access to these records for determining compliance with these regulations. Records shall not be removed from the facility, except as may be necessary to carry out these regulations. Upon admission, each consumer shall sign and date a written consent which lists individuals, groups, or categories with whom the program may share information (e.g., sons, daughters, family members or duly authorized licensed practitioners, etc.). A written consent to release of information shall be renewed and dated every thirty (30) months, pursuant to 22 M.R.S.A. §1711-C(4). Consent may be withdrawn at any time.8.7.3 Signed physician orders for prescribed medications, prescribed diet and treatments to be administered while at the program;8.7.4 An assessment of limitations, if any, to consumer participation in the program;8.7.5 Transportation arrangements to the program;8.7.6 Discharge planning considerations and date and reason for discharge;8.7.7 Copies of incident or accident reports.8.8Medication Records. When medications are administered to consumers during program operation, the following shall be included in the individual consumer record:8.8.1 An individual medication administration record shall be kept for each consumer of all treatments, drugs and medications ordered by the duly authorized licensed practitioner, including the name of the drug, the dosage, route and the time(s) to be given;8.8.2 An individual medication administration record shall be kept for each consumer for all over-the-counter medications administered by program staff and ordered by the duly authorized practitioner, including the name of the drug, the dosage, route and time(s) to be given. Written authorization from the consumer or legal representative must be obtained prior to all medication administration at the program site;8.8.3 An entry shall be made by program staff on the medication administration record to indicate whenever a medication, including a medication ordered to be administered as needed, or a treatment is started, given, refused or discontinued. A prescribed medication shall not be discontinued except with evidence of a stop order. A stop order shall be signed and dated by the duly authorized licensed practitioner for prescriptions ordered without an end date;8.8.4 Medication errors and reactions shall be recorded in the consumer's record. Medication errors include errors of omission as well as errors of commission. Errors in documentation or charting are errors of omission;8.8.5 No medication shall be administered without a written order signed by a duly authorized practitioner or person licensed to prescribe medications.8.9Consumer Records. All consumer records must be kept confidential in controlled access files. Records shall be kept at the program site or at the agency central office for a minimum of five (5) years after the consumer ceases to participate in the program. Should the Adult Day Services Program cease to operate, the provider is responsible for storing all consumer and program records for five (5) years and the program license shall be forwarded to the Department within thirty (30) days of program termination.10-144 C.M.R. ch. 117, § 8