La. Admin. Code tit. 48 § I-5547

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-5547 - Records

A. A complete record shall be maintained for each individual that is adequate for:

1. planning and continuous evaluation of the individual's habilitation and educational program;

2. furnishing documentary evidence of the individual's progress and of this response to his habilitation programs; and

3. protecting the legal rights of the individual facility, and staff.

B. All entries in the individual's records shall be legible, dated, and authenticated by the signature and identification of the person making the entry.

C. Symbols and abbreviations are to be used in record entries only if a legend is provided to explain them.

D. The following information shall be entered in the individual's record at the time of admission to the facility:

1. identification data on the individual; including name, date and place of birth, date of admission, citizenship status, Social Security number, legal status, sex, race, height, weight, color of hair, color of eyes, identifying marks, and a recent photograph;

2. the individual's family history; including the parents' names, their birthdates and birth places, their marital status, their educational backgrounds, religious affiliations, and their employment records;

3. the individual's medical history, both physical and mental, including any prior institutionalization;

4. the type and legal status of the individual's admission to the facility and his legal competency statusl

5. the sources of the individual's support, including Social Security, veterans' benefits, other forms of governmental assistance or insurance;

6. reports on the pre-admission evaluation and any other histories, evaluations, and examinations;

7. the immunization record. If immunization records are not complete, a statement from a physician with reasons for incomplete immunization;

8. written authorizations for field trips, photos, emergency medical assistance, inclusion in research projects, etc.

E. Other information which shall be included in the individual's record is as follows:

1. his grievances, if any;

2. any inventory of his life skills;

3. records of subsequent physical or mental examinations;

4. a copy of his plan and any modifications thereto and an appropriate summary to guide the facility's staff in implementing his program;

5. a monthly summary of his response to his program, prepared by qualified professionals involved in the treatment, including an analysis of the successes and failures of the plan and a recommendation for any modification deemed necessary. A summary of the person's response to his program shall be forwarded at least quarterly to the funding agency;

6. a copy of the plan for the individual which will take effect when he leaves the facility and a summary of the steps that have been taken to implement that program;

7. the history and present status with respect to medication and a record of any seizures, illnesses, treatments thereof, and immunizations;

8. a signed order by the appropriate qualified professional for any physical restraints and a record of all periods of justification and authorization for each;

9. a summary of family visits and contracts, as well as attendance and leaves, from the facility;

10. a description of any extraordinary incident or accident in the facility involving the individual to be entered by a staff member noting his personal knowledge of the incident or accident or other source of information, including any reports of investigations or mistreatment of the individual, as required elsewhere in these standards.

F. At the time of discharge or transfer from the facility, a discharge summary shall be prepared and shall be available to the parents or the funding agency. With the permission of the parent, the discharge summary shall also be forwarded to any facility which the student attends subsequently.

G. The records for each individual shall be readily available to the appropriate qualified professionals and staff members who are directly involved with the particular individual.

H. The parent, tutor, or guardian of the child shall also be permitted access to these records.

I. All information contained in an individual's record shall be considered privileged and confidential.

J. The record is the property of the facility, whose responsibility it is to secure the record against loss, defacement, tampering, or use by unauthorized persons.

K. There shall be written policies governing access to duplication of and dissemination of information from the record.

L. Written consent of the individual, if competent and of the age of majority, or his guardian shall be required for the release of information to persons not otherwise authorized to receive it.

M. The individual's records shall be maintained in an organized manner appropriate to the needs of the facility and the individual served.

N. Records shall be retained for a period consistent with the statute of limitations, of the Department of Health, Education, and Welfare regulations.

O. There shall be available sufficient, appropriately qualified staff and necessary supporting personnel to facilitate the accurate processing, checking, indexing, filing, and prompt retrieval of records and record data.

The following standards must be met in addition to the general standards by all facilities caring primarily for mentally ill.

La. Admin. Code tit. 48, § I-5547

Promulgated by the Department of Health and Human Resources, Office of the Secretary, Division of Licensing and Certification, LR 13:246 (April 1987).

AUTHORITY NOTE: Promulgated in accordance with R.S. 46:1971 through 1980.