404 Neb. Admin. Code, ch. 5, § 006

Current through June 17, 2024

Section 404-5-006 - RECORD KEEPING

The provider must maintain accurate, current, and complete administrative records and records specific to participants in services.

006.01PARTICIPANT RECORDS. The participant's records must contain information that includes, but is not limited to:

(A) Date of entry into services with the provider;

(B) Name, gender, and birth date of the participant;

(C) Current physical description or current photo of the participant;

(D) The language or means of communication utilized by the participant;

(E) Legal status of participant, and name, telephone number, and address of guardian, if applicable;

(F) Name, phone number, and address of persons to contact in an emergency;

(G) Name, phone number, and address of the participant's current personal physician and other health care professionals, if applicable;

(H) Relevant medical information including but not limited to: history of seizures, illness, physician orders, treatments, medications, medication history, known allergies, immunizations, physician contacts, emergency room visits, dental visits, counseling visits, and hospitalizations;

(I) Records of incidents and accidents;

(J) Consents as appropriate;

(K) Records of emergency safety intervention usage and the rationale for use;

(L) Individual support plan (ISP);

(M) Documentation of delivery of services and supports;

(N) The participant's rights notification;

(O) Notice of charges;

(P) Name of service coordinator and phone number;

(Q) Accounting of the participant's funds, if managed by provider;

(R) Notification of termination of services with the provider, if applicable; and

(S) Social history information.

006.02ADMINISTRATIVE AND PARTICIPANT RECORD KEEPING REQUIREMENTS. The provider must keep administrative and participant records that:

(A) Have time frames for the completion, routing, and filing of all records or documents as required and as appropriate to the participant;

(B) Are sufficient, current, and accurate to verify the delivery of services and comply with state and federal laws and regulations; and

(C) Are dated, legible, and clearly identify the person making the entry. In the case of electronic records, signatures may be replaced by an approved, uniquely identifiable electronic equivalent.

006.03RECORD MAINTENANCE REQUIREMENTS. Providers must maintain, for six years, records relating to the participant and the provision of services.

404 Neb. Admin. Code, ch. 5, § 006

Adopted effective 11/19/2022