DAR File No. 27802

Human Services, Services for People with Disabilities

R539-5

Preparation and Maintenance of Client Records

NOTICE OF PROPOSED RULE

DAR File No.: 27802
Filed: 04/01/2005, 08:46
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

The repealing of this rule is proposed after a comprehensive revision and consolidation of the Division's rules.

Summary of the rule or change:

The changes involve repealing the current rule and replacing it with a new rule moving some information into the Provider's service contract with the Division. The rule is repealed in its entirety. (DAR NOTE: The proposed new rule for R539-5 is under DAR No. 27801 in this issue.)

State statutory or constitutional authorization for this rule:

Sections 62A-5-102 and 62A-5-103

Anticipated cost or savings to:

the state budget:

None--This revision does not alter the basic operations or functions of the Division and, therefore, does not result in either a cost or savings to the state.

local governments:

None--Local government funding is not used. Therefore, there is no cost to local governments.

other persons:

None--This revision does not alter the basic operations or functions of the Division and, therefore, does not result in either a cost or savings to other persons.

Compliance costs for affected persons:

This revision does not alter the basic operations or functions of the Division. Provider requirements now appear in their current service contracts. This does not result in either cost or savings to Providers or other affected persons.

Comments by the department head on the fiscal impact the rule may have on businesses:

None--This revision does not alter the basic operations or functions of the Division. Provider requirements now appear in their current service contracts. This does not have a fiscal impact on service Providers. Lisa-Michele Church, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Direct questions regarding this rule to:

Suzie Totten at the above address, by phone at 801-538-4197, by FAX at 801-538-4279, or by Internet E-mail at stotten@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

05/16/2005

This rule may become effective on:

05/17/2005

Authorized by:

Lisa-Michele Church, Executive Director

RULE TEXT

R539. Human Services, Services for People with Disabilities.

[R539-5. Preparation and Maintenance of Client Records.

R539-5-1. Provider Records for Individuals.

A. Policy.

Each provider shall be required to maintain an individual record for each person receiving services. Each record will contain all information required by the Office of Licensing (OL), Division of Services for People with Disabilities (DSPD), DSPD Regional Office, and Medicaid Provider Manual for Home and Community-Based Services. All record information will be treated as confidential, locked and secured to protect the primary interests of the recipient.

B. Procedures.

1. Each individual record will contain the following demographic and program information, unless the competent recipient objects to the inclusion of any item:

a. Name, birth date, individual I.D. and Medicaid numbers (if applicable);

b. Photo of individual receiving services;

c. Name, address, and telephone number of the individual's guardian, or other emergency contact person, and instructions on how to contact that person;

d. Name and telephone number of the individual's primary care physician, and medical insurance, if any;

e. Health information to include, for example, prescribed medication(s), allergies, and chronic complaints;

f. Reports of physical and dental examinations, and records of illness, accidents, or injuries;

g. Reports of behavioral or other incidents involving the recipient;

h. Authorization for emergency medical treatment;

i. Administration of medication, first aid, and referrals to health care facility (if applicable);

j. A social history, psychological evaluation, and documentation of eligibility for services;

k. Annual Individual Program Plan (IPP), including semi-annual review;

l. Admission and termination dates and documentation;

m. Monthly progress notes and supporting data collection sheets. Data collection sheets not maintained in the individual's record shall be available for review;

n. Documentation of persons reviewing an individual's record to include signature, title, date, and reason for examining the record. Provider staff shall have access to those portions of the record which directly relates to their work assignment;

o. Release of information forms when appropriate. DSPD approval must be obtained prior to release of records to anyone except the recipient of services and legal representative.

2. The purchase of service provider must develop and maintain written documentation for each Home and Community-Based Services Waiver for which billing is made, that includes at least the following:

a. Name of the recipient;

b. The specific services rendered;

c. The date and hours of attendance;

d. Who rendered the services;

e. The setting in which the services were rendered to include, for example, day treatment facility, recipient's home;

f. The relationship of the services to the treatment regimen described in the IPP;

g. Updates or description of the recipient's progress (semi-annual and annual reviews).

3. The provider will deliver the individual records to the DSPD regional office upon written request.

4. When the records contain information which would be classified as confidential or private, pursuant to 63-2-101 through 108, the Provider will observe the requirements of 63-2-202 in safeguarding and releasing information.

A. Policy.

Each individual receiving services shall receive training, support, and opportunities to manage finances to the maximum extent possible. Acknowledging that individuals served in DSPD have income sources not originating with DSPD/DHS (including for example, SSI, SSA, employment income), the Division requires Providers to document the handling of the personal funds in a fashion that is least intrusive to the individual, and in a manner that is in keeping with the intent of the income source.

A. Policy.

Providers shall set up written policies which include a description of the program services to be offered, philosophy, objectives and the population to be served. The Provider will comply with the OL and DSPD policy and record requirements.

B. Procedures.

1. The Provider shall maintain service records which include the following information:

a. Name and address of the facility, and owner or sponsoring agency;

b. Agency or corporate organizational chart including names of consultants and employees;

c. Job descriptions for all personnel including volunteers with ongoing involvement;

d. Policy specifying the amount of time family or friends may stay as overnight guests;

e. Grievance procedures for individuals receiving services.

(1) A copy shall be given to each individual which will be read and explained to each individual and guardian, and shall be documented by a statement signed by the individual and guardian and maintained in the individual's record.

(2) Individuals receiving services shall be provided with the telephone number of the DSPD case manager and the 24-hour emergency number of the DSPD regional office at which the case manager works;

f. Financial policy regarding management of the finances of the individuals receiving services, room and board charges, and food stamps consistent with R539-5-2.A. The policy must ensure that all individual funds managed by the Provider are released at the time of discharge, or upon demand to the individual or legal guardian after outstanding bills are paid.

(1) The Provider shall have a written agreement signed by the recipient and legal representative which specifies in advance the fees, absenteeism, vacations, leave policy, extra costs charged for care and services, obligations concerning payment of such charges and the Provider's refund policy.

(2) Providers will assist individuals, receiving their services, in applying for unearned income benefits for which an individual may be entitled, including Food Stamp benefits.

(a) Food Stamp benefits shall be managed as per Office of Family Support (OFS) Regulations, and may be used to supplement food costs of the group home and supervised apartment services in which the recipient of food stamps resides;

(b) The receipt and disbursement of food stamps will be properly documented by the Provider.

(3) Where a parent or guardian is representative payee for an individual, the Provider shall receive all service fees from the payee.

(4) The Provider may act as representative payee for an individual receiving group home or supervised apartment services, if necessary and when requested in writing by the individual or the individual's guardian.

g. Civil Rights Policy, to include R539-2-1, R539-2-3, Section 504 of the Rehabilitation Act of 1973 (P.L. 93-112), and the American with Disabilities Act of 1990 (P.L. 101-336);

h. Emergency procedures for injury, illness, and death of an individual receiving services, that are readily accessible in the facility. These procedures shall include instructions on when to notify the guardian, DSPD, and DSPD regional office;

i. Emergency procedures for fire and disaster including a plan for evacuation shall be posted at each facility.

(1) A training program covering these procedures for individuals receiving services shall be developed, and conducted quarterly;

(2) Documentation of quarterly evacuation drills shall be maintained by the Provider;

j. R539-2-6 regarding abuse or neglect of individuals with disabilities. This policy shall be available in the facility. Each employee shall read and sign a statement indicating that the employee has read the policy. This statement must be maintained in the employee's personnel file;

k. Operating policies, procedures, and personnel practices.

2. The Provider shall orient the prospective service recipient regarding the Individual Program Plan (IPP) process and the involvement of the individual receiving services in that process;

3. Individuals who are sponsored by agencies or individuals other than DSPD shall receive the same level of service from the Provider as individuals who are sponsored by DSPD.

4. Each Provider shall maintain the following records where applicable.

a. A license stating the maximum number of individuals allowed to reside in the facility;

b. Documentation of compliance with zoning, life safety, health, and fire inspections as required for licensure, if appropriate;

c. Copies of any contracts or agreements with other service agencies or individuals in the community regularly providing services through the auspices of the Provider to the individuals receiving services in the program;

d. Records of operational costs and revenue according to accounting principles acceptable to the Department of Human Services;

e. Individual service documentation shall include: sponsorship of each individual, DSPD, and private; record of payments to the Division; and reimbursement requests (Forms 520, 1032). These records must be maintained for five years from the date of discharge;

f. Accurate records on each individual receiving services shall be maintained in locked files or otherwise secured. The records shall contain at least the items stated in R539-5-1.

g. A Provider who contracts with federal, state, county, city or other agencies to utilize facilities for which the Provider realizes a financial benefit shall ensure those benefits are used to benefit the individuals receiving services from the Provider. The provider shall maintain documentation of this in its administrative fiscal record.

KEY: disabled persons*, social services

1993

Notice of Continuation December 18, 2002

62A-5-103]

ADDITIONAL INFORMATION

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For questions regarding the content or application of this rule, please contact Suzie Totten at the above address, by phone at 801-538-4197, by FAX at 801-538-4279, or by Internet E-mail at stotten@utah.gov

For questions about the rulemaking process, please contact the Division of Administrative Rules (801-538-3764). Please Note: The Division of Administrative Rules is NOT able to answer questions about the content or application of these administrative rules.