SECTION 340:100-3-40. Community records

(a)   Purpose. Oklahoma Administrative Code (OAC) 340:100-3-40 sets forth requirements for:

(1)   maintenance of records by contract providers;

(2)   transfer of documents to a history file for service recipient records maintained by the contract provider; and

(3)   transfer of information when a service recipient changes contract providers.

(b)   General requirements. Records, electronic or paper, maintained by the contract provider are indexed, orderly, well-maintained, readily accessible, and current. Records must contain adequate documentation of services rendered. Electronic records must meet the requirements, in OAC 317:30-3-4.1.

(1)   All service recipient records are available for review, upon request, by the service recipient, his or her legal guardian, contract provider staff, and Oklahoma Department of Human Services (DHS) authorized agents.

(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 with OAC 340:2-8-1 through OAC 340:2-8-13 and OAC 340:100-3-2 pertaining to protection, use, and release of personal information. The provider holds personal information regarding service recipients, including names, addresses, photographs, records of evaluation, and all other records confidential. Information is not disclosed, directly or indirectly, unless consent is obtained in writing from an adult service recipient or the legal guardian.

(c)   Home record for service recipients receiving community residential supports, group home services, or non-residential habilitation training specialist (HTS) services. A current record of services is maintained by the contract provider in the home 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 (Plan) packet and addendum copies;

(C)   applicable health-related documents including, but not limited to:

(i)   Form 06HM039E, Continuous Medical Record, per OAC 340:100-3-40.1;

(ii)   Form 06HM005E, Referral Form for Examination or Treatment, physician orders, discharge summaries, and emergency room reports;

(iii)   Form 06HM006E, Health Status and Medication Review;

(iv)   special instructions or the Health Care Plan;

(v)   individually-identified data forms relevant to the service recipient's current health status;

(vi)   a Dyskinesia Identification System: Condensed User Scale (DISCUS) or Abnormal Involuntary Movement Scale (AIMS), when required, per OAC 340:100-5-29;

(vii)   current immunization record;

(viii)   current medication administration records;

(ix)   the most recent lab, x-ray, and consultation reports, and pharmacological evaluation, when applicable;

(x)   miscellaneous health-related consultations and correspondence; and

(xi)   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 reports on progress; 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 a service recipient's home record or specified types of documents from the record may be maintained at a location other than the service recipient's home, when requested by the Team and approved in writing by the Developmental Disabilities Services field administrator.

(d)   Retention. Each contract provider retains a record for each service recipient receiving services from the provider.

(1)   Transfer of all documents more than three months old from the provider agency's records to a history file occurs yearly, unless otherwise specified, per OAC 340:10-3-40.

(2)   The provider agency retains original records for a period of six years 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, the agency provides the new agency with a paper or electronic copy of the current home record and any health documents requested by the Team within seven- calendar days of the transfer.

(f)   Other provider records. The provider must maintain service records that substantiate the provision of services, eligibility of service recipients, and outcome of services.

(1)   Records are maintained for a period of six years after DHS 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.

[Source: Added at 17 Ok Reg 3102, eff 6-7-00 (emergency); Added at 18 Ok Reg 1254, eff 5-11-01; Amended at 25 Ok Reg 986, eff 5-15-08; Amended at 28 Ok Reg 897, eff 6-1-11; Amended at 29 Ok Reg 822, eff 7-1-12; Amended at 36 Ok Reg 1880, eff 9-16-19]