340:100-3-40. Community records
(a) Purpose. Oklahoma Administrative Code (OAC) 340:100-3-40 sets forth requirements for:
(1) contract provider records maintenance;
(2) document transfer to a history file for service recipient records the contract provider maintains; and
(3) information transfer when a service recipient changes contract providers.
(b) General requirements. Records, electronic or paper, the contract provider maintains are indexed, orderly, well-maintained, readily accessible, and current. Records contain adequate documentation of services rendered. Electronic records meet the requirements per OAC 317:30-3-4.1.
(1) All service recipient records are available for the service recipient, his or her legal guardian, contract provider staff, and Oklahoma Human Services (OKDHS) authorized agents to review upon request.
(2) The service recipient record is maintained with:
(A) an index;
(B) the service recipient's name on the record and on each page;
(C) discernable section tabs; and
(D) documents secured in the record.
(3) All entries in the record:
(A) are made per OAC 317:30-3-15;
(B) are in chronological order;
(C) are legible;
(D) include the date and time of each entry, with legible identification of the person making the entry; and
(E) include, when the entry is health-related:
(i) a description of the concern; and
(ii) action taken.
(4) The provider ensures compliance, per OAC 340:2-8-1 through OAC 340:2-8-13 and OAC 340:100-3-2, pertaining to personal information protection, use, and release. The provider holds personal information regarding service recipients, including names, addresses, photographs, evaluation records, and all other records confidential. Information is not disclosed, directly or indirectly, unless the adult service recipient or legal guardian consent in writing.
(c) Home record for service recipients receiving community residential supports, group home services, or non-residential habilitation training specialist (HTS) services. The in-home contract provider maintains a current service record for each service recipient receiving community residential supports, per OAC 340:100-5-22.1; group home service, per OAC 340:100-6; or non-residential HTS services, per OAC 340:100-5-35.
(1) Documents contained in each home record are not removed and include:
(A) guardianship documents and other legal documents;
(B) current Individual Plan packet and addendum copies; ¢ 1
(C) applicable health-related documents including, but not limited to:
(i) Form 06HM005E, Referral Form for Examination or Treatment, physician orders, discharge summaries, emergency room reports;
(ii) special instructions, or the Health Care Plan;
(iii) individually-identified data forms relevant to the service recipient's current health status;
(iv) a Dyskinesia Identification System: Condensed User Scale (DISCUS) or Abnormal Involuntary Movement Scale (AIMS), when required, per OAC 340:100-5-29;
(v) current immunization record;
(vi) current medication administration records;
(vii) the most recent lab, x-ray, and consultation reports, and pharmacological evaluation, when applicable;
(viii) miscellaneous health-related consultations and correspondence; and
(ix) Form 06HM073E, Referral Form for Psychiatric Treatment or Examination;
(D) miscellaneous documents relating to the service recipient including, but not limited to:
(i) observation notes;
(ii) Form 06CB035E, Site Visit Report, completed by all professional contract providers;
(iii) standing medical orders and protocols;
(iv) applicable data collection sheets; and
(v) documentation of program coordination staff home visits;
(E) quarterly residential progress reports; and
(F) Form 06MP070E, Access to Home Record and Verification of Monitoring Requirement, certifying that all authorized persons accessing the service recipient information contained within the home record were informed and understand the penalties for misuse of confidential and protected information, per Section 1533.1 of Title 21 of the Oklahoma Statutes.
(2) In unusual circumstances, at the Team's request, and with Developmental Disabilities Services field administrator's written approval, a service recipient's home record or specified document types from the record may be maintained at a location other than the service recipient's home.
(d) Retention. Each contract provider retains a record for each service recipient receiving services from the provider.
(1) There is a yearly transfer of all documents more than three months old from the provider agency's records to a history file, unless otherwise specified, per OAC 340:10-3-40.
(2) The provider agency retains original records for a six-year period or until any pending litigation involving the service recipient is completed, whichever occurs last.
(e) Transfers between agencies. When a service recipient changes provider agencies, within seven-calendar days of the transfer, the agency provides the new agency with a paper or electronic copy of the current home record and any health documents the Team requests.
(f) Other provider records. The provider maintains service records that substantiate service provision, service recipient eligibility, and service outcomes.
(1) Records are maintained for a six-year period after OKDHS makes the final payment and all pending matters are closed.
(2) The provider maintains copies of all claims, substantiating documents, and records regarding agency fiscal status within corporate offices in Oklahoma.
1. Individual Plan (Plan) packet. The Developmental Disabilities Services case manager provides to the home record and to the service recipient's Personal Support Team, items (1) through (12). The:
(1) Agreement to Implement Individual Plan (Plan);
(2) annual medical report;
(3) assessment information from providers used to develop the Plan;
(4) documentation of Consumer Choice and Consent to Implement the Plan;
(5) Client Contact Manager Consumer Data Sheets;
(6) Form 15GR006E, Notice of Grievance Rights - Developmental Disabilities Services (DDS) service recipient, or Form 15GR007E, Notice of Grievance Rights - Hissom class member;
(7) health summary, when applicable;
(8) Oklahoma Health Care Authority Form LTC-300, Long Term Care Assessment;
(9) Plan, including Person-Centered Assessment, and all addenda, including social and developmental histories;
(10) protective intervention protocol, when applicable;
(11) psychological evaluation; and
(12) Team Review of Advocate/Guardian Participation for Hissom Class Members only.