Participant Health Records

(A) All Programs shall provide conveniently located and suitably equipped areas for the recording and storage of health records. (B) All Programs shall maintain on the premises, in accordance with acceptable professional standards of practice, a separate, complete, accurate, systematically organized, and current health record for each participant from the time of admission to the time of discharge. All entries shall be dated and signed. The participant health record shall be kept at the nursing station. (C) The participant health record shall, at minimum, include: (1) Participant information including the participant's name, social security number, date of birth, gender, marital status, religion, home address, any public and private insurance information, and date and time of enrollment. (2) The name, address, and phone number of the participant's identified contact person and legally authorized representative. (3) Documentation from primary care providers including orders or prescriptions for Services, physical examinations, and initial treatment orders, as described at 105 CMR 158.035. (4) The participant enrollment agreement. (5) Participant clinical information, including: (a) A copy of the most recent physical examination; (b) The primary care provider orders; (c) Medical history; (d) TB screening; (e) A list of known allergies; (f) Information concerning participant's dietary requirements; (g) The medication administration record; (h) The results of all assessments; (i) Correspondence with family, therapists, primary care providers, physicians, health care consultants, or others pertaining to the health care of the participant; (j) Consultation notes from any health care provider who visits or examines the participant at the Program. (k) The participant's attendance record; (l) Relevant legal documentation that may include signed authorizations for release of information, advanced directives, or health care proxy; (m) Plans of care; (n) An inventory of participant's personal belongings maintained at the program; and (o) Documentation regarding transfers and discharges, as required in 105 CMR 158.034. (6) Any notification provided by Program Director pursuant to 105 CMR 158.030(K) shall be recorded in writing in the participant's health record. (7) Professional documentation as applicable, including but not limited to the following: (a) Nursing notes and assessments; (b) Rehabilitation services notes and assessments; (c) Therapeutic activity notes and assessments; (d) Service coordination notes and assessments; (e) Dietary notes and assessments; and (f) Assistance provided with ADL or a staff log of care provided to participant. (D) Participant health records shall be: (1) Readily accessible to clinical personnel; (2) Readily accessible to the Department upon request and in the manner in which it is requested; (3) Safeguarded against loss, destruction, or unauthorized use; (4) Maintained in compliance with state and federal privacy and security laws and regulations, including HIPAA; and (5) Maintained on-site for at least the most recent 24 months. (E) A Program shall maintain participant health records for at least seven years. In the event a Program discontinues operations, the Program shall make arrangements for storage of all health records for at least seven years, and shall notify the Department as to the location of the records and the person responsible for their maintenance. (F) A Program may implement and use electronic health records. A Program that implements and uses electronic health records shall: (1) Comply with all requirements of 105 CMR 158.000; (2) Establish, follow, and make accessible to all users written policies and procedures for the use of electronic health records; (3) Adequately train all personnel in the use of the electronic health records in order to ensure safe and quality participant care and to ensure the privacy and security of participants' health information; (4) Ensure security of records by implementing password protections and audit trails to verify entries and access and by maintaining up-to-date antivirus software and appropriate network security. Any data on a portable storage device, mobile computing device, or wireless transmission shall be adequately encrypted; (5) Establish and follow written policies and procedures regarding electronic signatures. Electronic health records must be designed to ensure integrity, authenticity, and non- repudiation of data entered; (6) Ensure a minimum of two participant identity checks prior to data entry; (7) Ensure the system includes redundancy and other protections against possible loss, deletion, or destruction of information; (8) Ensure the required health record and pharmaceutical information is and will be available at all times including during emergencies such as flooding or loss of electrical power; and (9) Report any breach of confidential information to the Department, state, and federal authorities as required.