Title: Section 1007.14 - Records

Section 1007.14 Records

(a) The operator shall collect and maintain such information, records or reports as set forth in this Part and as otherwise determined by the department.

(b) The department or its designee may examine the books and records of any facility to determine the accuracy of the annual financial statement, or for any other reason deemed appropriate by the department to effectuate the purposes of these regulations.

(c) Recipient Records.

(1) The operator shall maintain true, complete, accurate and current records for each recipient.

(2) Records shall be maintained at the facility and shall be available for review and inspection by the department.

(3) Records shall be maintained in a manner that assures recipient privacy, security and confidentiality;

(4) Records shall be accessible to medical respite program staff to use solely in the provision of medical respite services, as well as emergency services.

(d) At a minimum, the operator shall maintain:

(1) For each recipient:

(i) the signed admission agreement;

(ii) the signed consents or authorizations necessary to permit sharing of the recipient’s health information and other medical respite program information, including, without limitation, for purposes of payment, care coordination, and discharge planning;

(iii) the reasonable accommodation requests, decisions, and fulfillment measures, if applicable;

(iv) an inventory of any personal property held in custody for the recipient by the operator;

(v) a copy of the service plan, as updated;

(vi) a record of the services provided to the recipient throughout the temporary residence, including copies of any applications submitted, the outcomes or pending nature of those applications, and the forwarding of that information to the next residence and/or a care manager or care coordinator;

(vii) personal data, including identification of the recipient’s next of kin, family and sponsor, and the name and address of the person or persons to be contacted in the event of an emergency;

(viii) a copy of the recipient’s assessment(s);

(ix) documentation that the notice of discharge was timely provided; and

(x) a copy of the discharge summary and the discharge notices and any appeals and the related decision.

(e) Program Records.

(1) The operator shall maintain true, complete, accurate and current records that document operation and maintenance of the facility.

(2) At a minimum, the medical respite program shall retain in hard copy or electronically:

(i) daily census reports

(ii) incident reports;

(iii) copies of grievances made and the operator’s responses to the same;

(iv) a copy of each version of the recipient’s code of conduct, facility rules and recipient’s rights;

(v) a current list of all recipient who require evacuation assistance during an emergency and the type of assistance required;

(vi) a chronological admission and discharge register, consisting of a listing of recipients registered in and discharged from such facility by name, age and sex of recipient, and place from or to which the recipient is registered or discharged;

(vii) program records, including policies and procedures, agreements with contractors, emergency plans and records of evacuation drills;

(viii) food service records, including menus and food purchase records;

(ix) records of maintenance of the physical plant;

(x) staff records, including personnel procedures, job descriptions, staffing schedules, identification of individual employees, and payment records; and

(xi)  certificates or reports issued by local and other State jurisdictions related to the facility operations, on file and readily accessible for department review, or posted, if required.

(f) Records Retention.

(1) Records required by the department, excepting financial records of the previous operator, shall be retained in the facility upon change of operator.

(2) Records relating to a recipient shall be retained for six years after death or discharge of a recipient or longer if required under applicable law, regulation or managed care organization contract.

(3) Program records, business records, and records relating to application or renewal for an operating certificate shall be retained for ten years.

(4) These records shall be maintained at the facility, unless written authorization is given by the department for record retention in another location, and shall be available for review and inspection by the department.