Tenn. Comp. R. & Regs. 1240-07-10-.08

Current through January 8, 2025

Section 1240-07-10-.08 - PARTICIPANTS' RECORDS

(1) A record of each participant shall be maintained by the center for at least one (1) year after disenrollment.

(2) Each record shall contain, at a minimum, the following information regarding the participant or their primary caregiver in the event the participant is unable to make their own decisions:

(a) Acknowledgment of receipt of participant bill of rights;

1. The following list of rights shall be given to any prospective participant in the adult day service:

(i) The right to self-determination within the adult day services setting, including the opportunity to:

(I) Participate in developing or changing one's plan for services;

(II) Decide whether or not to participate in any given activity;

(III) Be involved to the extent possible in program planning and operation;

(IV) Refuse treatment and be informed of the consequences of such refusal; and

(V) End participation in the adult day services center at any time.

(ii) The right to be treated as an adult, with consideration, respect and dignity, including privacy in treatment and in care for personal needs;

(iii) The right to a thorough initial assessment, development of an individualized plan of care, and a determination of the required level of care;

(iv) The right to confidentiality and the guarantee that no personal or medial information will be released to persons not authorized under law to receive it without the participant or their legal representative's written consent;

(v) The right to voice grievances about care or treatment without discrimination or reprisal;

(vi) The right to be free from harm, including isolation, excessive medication, abuse, neglect and/or financial exploitation;

(vii) The right to be fully informed, at the time of acceptance into the program, of services and activities available and related charges; and

(viii) The right to communicate with others and be understood by them to the extent of the participant's capability.

(b) Name, address, age, and other identifying information;

(c) Primary caregiver and/or responsible party;

(d) Emergency contact information for primary caregiver or a responsible party and medical provider for the participant;

(e) A copy of any known existing and currently effective power of attorney, any health care proxy, any advanced care directive, and any physician's orders for scope of treatment (POST) involving the participant;

(f) A copy of any existing and currently effective conservatorship and/or guardianship documents involving the participant;

(g) A pre-enrollment assessment, which shall include:

1. Brief psycho-social history to include: likes/dislikes, diet, living situation, family and social contacts, daily routines/schedule, habits, interests, hobbies, and spiritual preferences;

2. Basic health history to include: current medical diagnosis, current prescription and non-prescription medications (see 1240-07-10-.13) , standing orders, physical disabilities or medical conditions requiring specific modes of care and/or adaptive devices (including allergies and special dietary requirements), and any existing mental health or psychiatric diagnosis, if relevant or present;

3. Documentation, if available, showing the last date that the participant was seen by a physician;

4. Current behavioral history to include: strengths, limitations in activities of daily living, behaviors impacting care and treatment;

5. Physician order for non-emergency restraint, if applicable; and

6. Additional information provided by the caregiver, family, responsible party or staff necessary for the provision of comprehensive individualized care and support.

(h) A transportation plan which shall provide:

1. A list of individuals or entities authorized to transport the participant; and

2. Necessary and appropriate documentation to transport individual participants.

(3) The record for each participant shall also include the participant's individualized plan.

(a) The participant and his/her family/responsible parties shall be encouraged and invited to be involved in the development of the individualized plan and all subsequent revisions.

(b) Participant records shall show evidence of regular communication with the participant and/or responsible party about the individualized plan including changes to the plan and other pertinent information.

(c) Plans shall be reviewed and updated as indicated by the participant's change in status, but at least every three (3) months.

(d) All plans, including all revisions, updates, changes, etc. shall be signed and dated by the adult day services director or designee; participant or responsible party as defined in these rules, and any third-party service providers, if applicable. If any party refuses to participate in the planning process and/or sign the plan, the plan must include a statement of this along with a brief explanation of the reason for refusal.

(e) The plan shall contain the following information regarding the participant:

1. Mental and Physical Conditions.

(i) The participant's cognitive, emotional, and physical conditions shall be recorded upon intake into the adult day services center.

(ii) This plan shall include how these conditions will be accommodated, maintained and/or enhanced by the services provided.

2. Alzheimer's Specific Programs.

(i) Participants with Alzheimer's disease or other dementia shall be provided activities designed to stimulate memory that are based on best practices or special service specific to assistance with these diseases.

3. Goals and Services.

(i) The goal and services shall be clearly stated and shall specifically address the participant's individual needs and desired outcomes of the participant.

(ii) The needs in this individualized plan shall address the personal, social, emotional, physical, cognitive strengths and, where appropriate, the educational needs of the participant.

(iii) The goal and services shall demonstrate how the participant will benefit from participation in the program.

(iv) The plan shall demonstrate how the specific services are going to be implemented in order to meet the stated goal established for the participant.

4. Progress.

(i) At the end of every three (3) month period (quarterly), a specific written progress report shall identify how the plan has been implemented and identify the specific outcomes.

(ii) If, upon review, it is determined that adequate progress towards the goal has not been achieved, the individualized plan shall be revised.

5. Any accommodation provided to meet the individual needs of the participants.

6. Changes in the participant's mood, behavior, diet, medications, or other personal circumstances that are observed by the staff shall be documented with signatures and dates in the participant's record.

(4) Daily attendance records shall be maintained.

(5) A written record of incidents, accidents, injuries, illnesses and emergencies involving the participant shall be maintained and shall be reported to the participant's responsible party no later than the end of the day on which it occurred.

(6) An adult day services center located on the premises of, and operated by, a licensed nursing home, a licensed hospital, a licensed assisted-care living facility, a licensed home for the aged, or a licensed residential hospice shall clearly separate and identify participant records and activities related to the adult day services center.

(7) Records concerning participants shall be made available to emergency medical personnel whether treatment is rendered on site or participant is transported to a health care facility.

(8) Release of Information.

(a) Except as provided in subparagraph (b) below, no information from the record of a participant shall be released or disclosed except as required by law or regulation, or with the permission of the participant or participant's responsible party.

(b) Information from any records of the center, including the records of individual participants, shall be provided upon request to the Department's Adult Day Services licensing staff or to law enforcement officials or Adult Protective Services staff of the Department in order to investigate allegations of abuse, neglect or exploitation of any participant.

Tenn. Comp. R. & Regs. 1240-07-10-.08

Original rule filed December 14, 1999; effective 2/27/2000. Repeal and new rule filed February 23, 2018; effective 5/24/2018. Amendments filed October 25, 2022; effective 1/23/2023.

Authority: T.C.A. §§ 4-5-201, et seq.; and 71-2-401, et seq.