10A NCAC 06R .0508. RECORDS

(a)  Individual Participant Records.  Each adult day care program shall maintain records to document the progress of each participant and to document program operation.  These records shall be kept in a locked file. An individual folder for each participant shall be established and maintained and include the following:

(1)           a signed application recording:

(A)          participant's full name;

(B)          address and telephone number;

(C)          date of birth, marital status and living arrangement of participant;

(D)          time of day participant will arrive and time of day participant will leave the program;

(E)           travel arrangements to and from the program for the participant;

(F)           name, address and telephone number of at least two family members or friends who are responsible for the participant and can be contacted in emergencies;

(G)          name, address and telephone number of a licensed medical service provider who will see the participant on request; and

(H)          personal concerns and knowledge of the caregiver that may have an impact on the  participant's care plan.

(2)           copies of all current and former signed authorizations for the day care program to receive and give out confidential information on the participant.  The current authorization shall include the name of the party from whom information is requested and to whom information is given.  The current authorization shall be dated within the prior 12 months and obtained each time a request for participant information is made.

(3)           a signed authorization for the participant to receive emergency medical care from any licensed medical practitioner, if emergency care is needed by the participant;

(4)           a medical examination report conducted within three months before enrollment and updated annually, signed by a licensed physician, physician's assistant or nurse practitioner. The report shall include information on:

(A)          current diseases and chronic conditions and the degree to which these diseases and conditions require observation by day care staff, and restriction of normal activities by the participant;

(B)          presence and degree of psychiatric problems;

(C)          amount of direct supervision the participant requires;

(D)          any limitations on physical activities;

(E)           listing of all medications with dosages and times medications are to be administered; and

(F)           most recent date participant was seen by doctor.

(5)           assessment forms as identified in  Rule .0501(a)(2) and (b)(1) and (b)(2) of this Section.

(6)           progress notes which are the written report of staff discussions, conferences, consultation with family or other interested parties, evaluation of a participant's progress and any other information regarding a participant's situation. 

(7)           service plans for the participant, including scheduled days of attendance, for the preceding 12 months.

(8)           a signed authorization if the participant or his responsible party will permit photographs, video, audio recordings or slides of the participant to be made by the day care program, whether for medical documentation, publicity, or any other purpose.  The authorization shall specify how and where such photographs, videos, audio recordings or slides will be used, and shall be obtained prior to taking any photographs, videos, audio recordings or slides of the participant. 

(9)           a statement signed by the participant, a family member or other responsible party (when applicable) acknowledging receipt of the program policies and agreeing to uphold program policies pertaining to the participant.

(b)  The adult day program shall keep the following program records a minimum of six years:

(1)           copies of activity schedules;

(2)           monthly records of expenses and income, including fees collected, and fees to be collected;

(3)           all bills, receipts and other information which document expenses and income;

(4)           a daily record of attendance of participants by name;

(5)           accident reports;

(6)           a record of staff absences, annual leave and sick leave, including dates and names of substitutes;

(7)           reports on emergency and fire drills;

(8)           individual personnel records on all staff members including:

(A)          application for employment;

(B)          evidence of a state criminal history check on each employee providing direct care;

(C)          job description;

(D)          medical certification of absence of a health condition that would pose a risk to others;

(E)           written note or report on any personnel action taken with the employee;

(F)           written report of annual employee review;

(G)          CPR and first aid training documentation; and

(H)          signed statement to keep all participant information confidential.

(9)           a copy of all written policies, including:

(A)          program policies;

(B)          personnel policies;

(C)          agreements or contracts with other agencies or individuals;

(D)          plan for emergencies; and

(E)           evacuation plan;

(10)         program evaluation reports; and

(11)         control file of DSS-5027 (SIS Client Entry Form) for all participants for whom Social Services Block Grant (Title XX) reimbursement is claimed.

 

History Note:        Authority G.S. 131D‑6; 143B‑153;

Eff. July 1, 1978;

Amended Eff. February 1, 2008; July 1, 2007; March 1, 1992; July 1, 1990; January 1, 1981.