Section 16.04.17.400 - AGENCY PARTICIPANT RECORD REQUIREMENTSEach agency certified under these rules must maintain accurate, current, and complete participant and administrative records. Each participant record must clearly document the date, time, duration, and type of service, and include the signature of the individual providing the service, for each service provided. Each participant record must contain the following information:
01.Profile Sheet. Each participant record must include a profile sheet containing the following:a. Name, current address, and current phone number of the participant;c. Gender and marital status;e. Names, addresses, and current phone numbers of legal guardian if applicable, family, advocates, friends, and persons to be contacted in case of an emergency;f. Names, addresses, and current phone number of physician, pharmacy, dentist, and other health care providers as applicable;g. A list, or an attached list, of current medications, diet, and all other treatments prescribed for the participant; andh. Current diagnoses or reference to a current history and physical.02.Authorized Plan of Service. The agency must obtain a current authorized plan of service from the paying entity.03.Participant Rights. Each agency must document upon initiation of services, that each participant and their guardian, where applicable, have been informed of their rights, access to grievance procedures, and the names, addresses, and telephone numbers of protection and advocacy services. This information must be provided in easily understood terms both verbally and in writing.04.History and Physical. Results of a most current history and physical.05.Functional Assessment. An age-appropriate functional assessment must be completed or obtained by the agency within thirty (30) days of the initiation of service. The functional assessment must be used for the development of program plans and include: a. An assessment reflecting the person's functional abilities in the following areas: self-direction, money management, daily living skills, socialization, mobility, behavior shaping, and other therapeutic programs; andb. The results and summary signed with credentials and dated by the qualified residential habilitation professional.06.Psychological or Psychiatric Assessment. When a participant has had a psychological or psychiatric assessment for the purpose of treatment, the results of the assessment must be maintained in the participant's record and used when developing program objectives.07.Program Plan. Each participant must have a program plan that includes goals and objectives specific to their authorized residential habilitation program. Program plans that include participant's name, baseline statement, measurable objectives, start date, written instructions to staff, service environments, and target date.08.Record of Significant Incidents, Accidents, Illnesses, and Treatments.09.Daily Medication Log, When Applicable.10.Daily Record of the Date, Time, Duration, and Type of Service Provided.11.Service Delivery and Progress Notes. Documentation of service delivery and progress notes that correspond with the program plans when services are delivered to the participant.12.Status Review. Residential habilitation agencies must review each participant's progress to ensure revisions are made for progress, regression, or inability to maintain independence. The review of progress must be documented on a status review document. The status review document identifies the participant's progress toward goals defined in the plan of service.13.Termination Procedures. The agency must develop and implement termination policies and procedures that address how the agency will ensure safety of the participant and community to the extent possible in the event that emergency conditions exist or the participant no longer in need of or desires services. a. Emergency conditions warranting termination of services include:i. A change in the participant's condition resulting in an increased level of care beyond the scope of the agency's ability to provide care for the participant.ii. Significant behavior concerns including physical aggression by the participant that puts the health and safety of the agency's staff or other participants in jeopardy and behavior management techniques have failed to reduce the risk to staff or others.b. In the instance where the participant is no longer in need of or desires services, the agency must ensure that the procedures include written notice of no less than thirty (30) days for termination, include a transition plan, and a copy of the agency's grievance process. For the purposes of this chapter, a transition plan is an interim plan developed by the agency defining activities to assist the participant to transition out of residential habilitation services from that agency.c. Services may be terminated prior to thirty (30) days if both parties agree in writing to the termination conditions. The agency may not terminate services when to do so would pose a threat of endangerment to the participant or others. The participant is entitled to appeal the termination utilizing the agency's grievance process regardless of the reason for termination.d. The agency must notify the participant and their guardian, if applicable, no less than thirty (30) days prior to a change of ownership to ensure informed choice in the services they receive.Idaho Admin. Code r. 16.04.17.400