Individual Records

(1) Purpose. The purposes of 115 CMR 4.03 are to set forth requirements of record keeping to ensure: (a) Sufficient information to promote coordination and continuity of services and supports; (b) Sufficient specificity to provide a basis for accountability in the provision of services and supports; (c) Sufficient flexibility to be no more intrusive to the individual or cumbersome to the provider than is necessary to meet the legitimate service needsofthe individual and the documentation needs of the Department; and (d) Sufficient uniformity in records (organization and types of data collected) to serve as the basis for Departmental service and program planning. (2) General Requirements. (a) Individual records shall be legible and all entries shall be dated. All entries to individual records by any providers subject to 115 CMR 4.00 shall be signed. (b) Individual records shallcontaininformation which is accurate, complete, timely, and relevant to the individual's needs for services or supports. (c) Individual records shall be written in standard English, with second language translation (or availability of interpretive services) where necessary for the individual. Abbreviations, symbols, and professional jargon should be avoided in order to promote the understanding of the record by a lay person. If abbreviations and symbols or jargon are used, a key shall be provided. (d) Except where specifically stated to the contrary in 115 CMR 4.03 or elsewhere in 115 CMR, providers may meet therequirements of115 CMR 4.03 through the use of forms or record formats meeting the requirements of 115 CMR 4.00. (3) Identifying Information. (a) Individual records maintained by providers (including facilities) and area offices shall maintain the following information in written form at a location accessible to service coordinatorsorprovider staff: 1. The individual's full name; 2. The individual's social security number; 3. Religion or religious preference, if any, and only if disclosure is volunteered by the individual, family or guardian; 4. Language(s) of the individual and family or guardian, if other than English; 5. Summary of health insurance, financial support and other entitlements; 6. Identification of family, guardian, conservator, and other interested persons, including current addresses and telephone numbers; 7. Legal competency, including: a. Current legal status; b. Type of guardianship, if any; c. Date and court of adjudication, if applicable; d. Person(s) requesting adjudication; e. Date of and reason for request; f. A statement about the individual's capability in fact to give informed consent; 8. All providers of services or supports, both currently and during the past two years; 9. Employment history, including list of employers, dates of employment, and position(s) held; 10. For individuals receiving residential services, capacity for evacuation, including: a. Assessment and Individual Safety Plan; b. Cause of failure, if applicable; c. Basis for determination; d. Date(s) of determination and redetermination; 11. Suchother information as may be required by the Department consistent with the scope and purpose of 115 CMR 4.03. (4) Emergency Information. Each individual's area office and provider record shall contain, in readily accessible and duplicable form, descriptive and other information of use in finding an individual if missing, or otherwise in an emergency, as more fully set forth in 115 CMR 4.03(4)(a) through (n): (a) A photograph taken after the age of 18 years but taken within the last five years and after any significant change in the appearance of the individual; (b) Name (and nicknames, if any); (c) Age; (d) General physical characteristics, including gender, weight, height, build, hair and eye color, and any identifying marks or distinguishing items (for example, hearing aids, eye glasses); (e) The name(s) and telephone number(s) of a friend or relative to be contacted in the event of an emergency; (f) If the individual has a legal guardian, the name and telephone number of the guardian; and (g) Information concerning the individual's health insurance (including Medicaid) status and the name of a person to be contacted with respect to the individual's medical status and needs. (h) General nature of abilities and physical handicaps; (i) Special medical problems, including allergies and medication needs; (j) Pattern of movement, if missing previously; (k) Personal characteristics and likely response to search efforts (such as tendency to hide); (l) Name, telephone number, and addresses of family members, past residences, work, school, or daytime whereabouts, and places frequented; (m) Name, telephone number, and address of the individual's treating physician(s); and (n) Name and telephone number of individual's service coordinator and the designated contact person for each provider serving the individual. (5) Assessments. Each individual's area office and provider record shallcontaincurrent assessment reports and reports of the individual's current leveloffunctioning, as theypertain to the services of the provider. When assessments are being completed by an outside agency or by referral, the name of the agency or consultant referral should be documented. (6) Individual Service Plan. (115 CMR 4.03(6) through (9) Reserved.) (10) MedicalInformation. Each individual's area office and provider record shall contain the following information: (a) Summary reports of the individual's most recent physical and dental examinations, as required in 115 CMR 6.51, except that only the area office and the individual's residential provider shall be required to maintain the medical and dental examination summary report; (b) A record of special diets prescribed for the individual, if any, upon recommendation of a physician; (c) Upon recommendation of a physician, a record of frequency and type of all seizures, in order to assess the effects of anti-convulsant medication, other therapies, and environmental factors; (d) Alist ofany conditions requiring ongoing management by health care professionals, including a summary of necessary treatment(s) for each condition; (e) Any information concerning the individual's HIV status shall be maintained confidentiallyand strictly in accordance with the written policy of the Department. (11) Incident Reporting. Each individual's area office and provider record shall contain documentation of incidents in accordance with the requirements set forth in 115 CMR 5.00. (12) Restraints. Each individual's area office and provider record shall contain documentation concerning any utilization of mechanical, chemical, or physical restraints, and of any limitation of movement specifically exempted from the definition of emergency restraint at 115 CMR 2.00, in accordance with the documentation requirements of 115 CMR 5.00. (13) Behavior Modification Plans. Each individual's area office and provider record shall contain documentation concerning any behavior modification plans developed for the individualpursuant to 115 CMR 5.10, in accordance with the documentation requirements of 115 CMR 5.10. (14) Referral/Transfer Information. Upon an individual's referral or transfer, the individual's area office and provider record shall contain a statement explaining the purpose of the referral or transfer. (15) Access to and Transmission of Records. Each individual's area office and provider record shall contain a listing of all record accesses and transmissions, in accordance with the consent and documentation requirements for record access and release contained in 115 CMR 4.05.