Md. Code Regs. 10.21.17.08

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.21.17.08 - Records

A. General Requirements.

(1) The program shall, either manually or electronically:

(a) Establish a record for an individual who receives services from the program; and

(b) Ensure that entries in the record are dated, signed, and include the signer's degree or license, or if the signer has no degree or license, the signer's staff position.

(2) The program director shall ensure that individuals' program records are:

(a) Maintained in a manner that is consistent with the medical records confidentiality and disclosure requirements of:

(i) Maryland Confidentiality of Medical Records Act, Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland; and

(ii) Relevant federal statutes and regulations, including the Health Insurance Portability Act, 42 U.S.C. § 1320D et seq., and implementing regulations at 45 CFR Parts 160 and 164;

(b) Located so that the records are convenient and available to designated staff;

(c) Managed by a designated staff member who is responsible for appropriate records control, including storage, security, and indexing of records; and

(d) Subject to the requirements of confidentiality laws and regulations, are made available to the Department, the Administration's ASO, the CSA, and the Office of Inspector General, as necessary to carry out required activities.

B. Contents of Record. When an individual is enrolled in a program, the program shall maintain a record of, at a minimum:

(1) Identifying information, including but not limited to:

(a) Name, sex, race, marital status, and date of birth of the individual;

(b) Address and telephone number; and

(c) As permitted by law, Social Security number;

(2) Name, address, and telephone number of the individual to be contacted in case of emergency;

(3) Dates of enrollment and initial service;

(4) Source of referral;

(5) If the individual has been referred upon discharge from an inpatient facility:

(a) A copy of the aftercare plan and discharge summary; or

(b) Documentation that the program has requested a copy of the aftercare plan and discharge summary;

(6) If an individual has been court-ordered to receive evaluation or treatment, a copy of the court order;

(7) Documentation of verification of the individual's financial information, or, if the individual is a minor, the minor's parent's financial information necessary to implement the Department's requirements on the setting of charges and collection of fees;

(8) Presenting problem and history of the presenting problem, including, if known, precipitating factors and, if any, history of substance abuse;

(9) Either, if indicated and relevant:

(a) Copies of reports and recommendations of prior treatment, tests, and evaluations, including, when received, a report or summary of current physical examination; or

(b) Documentation that the program has requested a copy of any reports and recommendations of prior treatment, tests, and evaluations;

(10) For a minor who is enrolled in a program, copies of legal documents related to the minor's status, including but not limited to:

(a) Court orders; and

(b) Custody agreements;

(11) For a minor who is enrolled in a program, an emergency contact form, which is up-to-date and which includes:

(a) The name, address, and daytime telephone number of the primary caretaker;

(b) The name, address, and telephone number of the primary care provider; and

(c) If available, the names, addresses, and daytime telephone numbers of at least two individuals to be contacted in case of emergency when the primary caretaker cannot be reached;

(12) The consent forms, signed by the individual or the individual's parent or guardian, as appropriate, for:

(a) Participation in the program and activities provided by the program; and

(b) Releasing information to or requesting information from other agencies, including the CSA, and health care providers;

(13) Documentation of the clinical information as required in the chapter under this subtitle for specific program requirements;

(14) If applicable, names and either addresses or telephone numbers of the individual's psychiatrist, therapist, case manager, primary care provider, managed care organization, and insurance carrier; and

(15) The individual's discharge plan and summary.

Md. Code Regs. 10.21.17.08

Regulations .08 adopted effective January 14, 2008 (35:1 Md. R. 19)