LAC 50:VII.30703. Admission Records

A. At the time of admission to the ICF/MR, information shall be entered into the client's record which shall identify and give a history of the client. This identifying information shall at least include the following: 1. a recent photograph; 2. full name; 3. sex; 4. date of birth; 5. ethnic group; 6. birthplace; 7. height; 8. weight; 9. color of hair and eyes; 10. identifying marks; 11. home address, including street address, city, parish and state; 12. Social Security Number; 13. medical assistance identification number; 14. Medicare claim number, if applicable; 15. citizenship; 16. marital status; 17. religious preference; 18. language spoken or understood; 19. dates of service in the United States Armed Forces, if applicable; 20. legal competency status if other than competent; 21. sources of support: social security, veterans’ benefits, etc.; 22. father's name, birthplace, Social Security Number, current address, and current phone number; 23. mother's maiden name, birthplace, Social Security Number, current address, and current phone number; 24. name, address, and phone number of next of kin, legal guardian, or other responsible party; 25. date of admission; 26. name, address and telephone number of referral agency or hospital; 27. reason for admission; 28. admitting diagnosis; 29. current diagnosis, including primary and secondary DSM III diagnosis, if applicable; 30. medical information, such as allergies and general health conditions; 31. current legal status; 32. personal attending physician and alternate, if applicable; 33. choice of other service providers; 34. name of funeral home, if appropriate; and 35. any other useful identifying information. Refer to Admission Review for procedures. B. First Month After Admission. Within 30 calendar days after a client's admission, the ICF/MR shall complete and update the following: 1. review and update the pre-admission evaluation; 2. develop a prognosis for programming and placement; 3. ensure that an interdisciplinary team completes a comprehensive evaluation and designs an individual habilitation plan (IHP) for the client which includes a 24-hour schedule. C. Entries into Client Records During Stay at the ICF/MR. The following information shall be added to each client's record during his/her stay at the ICF/MR: 1. reports of accidents; seizures, illnesses, and treatments for these conditions; 2. records of immunizations; 3. records of all periods where restraints were used, with authorization and justification for each, and records of monitoring in accordance with these standards; 4. reports of at least an annual review and evaluation of the program, developmental progress, and status of each client, as required in these standards; 5. behavior incidents and plans to manage inappropriate behavior; 6. records of visits and contacts with family and other persons; 7. records of attendance, absences, and visits away from the ICF/MR; 8. correspondence pertaining to the client; 9. periodic updates of the admission information (such updating shall be performed in accordance with the written policy of the ICF/MR but at least annually); and 10. appropriate authorizations and consents. D. Entries at Discharge. At the time of a client's discharge, the QMRP or other professional staff, as appropriate, shall enter a discharge summary into the client's record. This summary shall address the findings, events, and progress of the client while at the ICF/MR and a diagnosis, prognosis, and recommendations for future programming.