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I.EXECUTIVE ORDERS - page 214 / 359

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7.a signed physician's order, issued prior to use, when restraints in any form are being used;
8.any grievances or complaints filed by the participant and the resolution or disposition of these grievances or complaints;
9.a log of the participant's attendance and absences;
10.a physician's signed and dated orders for medication, treatment, diet, and/or restorative and special medical procedures required for the safety and well-being of the participant;
11.progress notes that:
a.document the delivery of all services identified in the individualized service plan;
b.document that each staff member is carrying out the approaches identified in the individualized service plan that he/she is responsible for;
c.record the progress being made and discuss whether or not the approaches in the individualized service plan are working;
d.record any changes in the participant's medical condition, behavior or home situation which may indicate a need for a change in the individualized service plan; and
e.document the completion of incident reports, when appropriate; and

NOTE: Each individual responsible for providing direct services shall record progress notes at least weekly, but any changes to the participant's condition or normal routine should be documented on the day of the occurrence.

12.discharge planning and referral.

C.All entries made by center staff in participants' records shall be legible, signed and dated.

D.The medications and treatments administered to participants at the center must be charted by the appropriate staff.

E.The center shall ensure that participant case records are available to staff who are directly involved with participant care.

AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and 40:2120.41-46.

HISTORICAL NOTE:Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 34:2183 (October 2008).

§4235.Retention of Records

A.All records shall be maintained in an accessible, standardized order and format and shall be retained and disposed of according to state laws. An ADHC center shall have sufficient space, facilities and supplies for providing effective record-keeping services.

B.All records concerning past or present medical conditions of participants are confidential and must be maintained in compliance with the provisions of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. The expressed written consent of the participant must be obtained prior to the disclosure of medical information regarding the participant.

C.The participant's medical record shall consist of the active participant record and the ADHC center's storage files or folders. As this active record becomes bulky, the outdated information shall be removed and filed in the ADHC center's storage files or folders. The active medical records shall contain the following information:

1.the necessary admission records;
2.at least six months of current pertinent information relating to the participant's active ongoing care; and
3.if the ADHC center is aware that a participant has been interdicted, a statement to this effect shall be noted on the inside front cover of the record.

D.Upon request, the ADHC center shall make all records, including participant records, available to the applicable federal and state regulatory agencies in order to determine the center’s compliance with applicable federal and state laws, rules and regulations.

AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and 40:2120.41-46.

HISTORICAL NOTE:Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 34:2184 (October 2008).

§4237.Confidentiality and Security of Records

A.A center shall have written procedures for the maintenance and security of records specifying who shall supervise the maintenance of records, who shall have custody of records, and to whom records may be released. Records shall be the property of the ADHC center and as custodian, the center shall secure records against loss, tampering or unauthorized use.

B.A center shall maintain the confidentiality of all participants' case records. Employees of the center shall not disclose or knowingly permit the disclosure of any information concerning the participant or his/her family, directly or indirectly, to any unauthorized person.

C.A center shall obtain the participant's written, informed permission prior to releasing any information from which the participant or his/her family might be identified, except for authorized federal and state agencies or another program with professional interest in the participant.

D.The ADHC center shall safeguard the confidentiality of participant information and shall release confidential information only under the following conditions:

1.by court order; or
2.by the participant's written authorization, unless contraindicated as documented in the participant's record by the attending physician.

AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and 40:2120.41-46.

HISTORICAL NOTE:Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 34:2184 (October 2008).

Subchapter C.Participant Rights

§4239.Statement of Rights

A.Each participant shall be informed of his/her rights and responsibilities regarding the ADHC center. The regulations of the ADHC center and all rules governing participant conduct and behavior shall be fully explained to the participant. Before or upon admission, the ADHC center shall provide a copy of the participant rights document to each participant. Each participant must acknowledge receipt of this document in writing and the signed and dated acknowledgment form shall be filed in the participant's record.

B.If the ADHC center changes its participant rights policies, each participant must acknowledge receipt of the change(s) in writing and the acknowledgment shall be filed in the participant's records.

Louisiana Register   Vol. 34, No. 10   October 20, 2008

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