Additional Requirements Applicable to Some Record Holders

(1) Area offices and Facilities. In addition to the requirements for individual records listed in 115 CMR 4.03, which apply to all providers and area offices holding individual records, individual records maintained by area offices and facilities shall contain the following information: (a) Date found eligible for Department services; (b) Address of the individual at the time of entry into Department service system and current address and phone number; (c) Department area of service; (d) Historical information on past service providers; and (e) Status as a class member under the Ricci v. Okin (Civil No. 72-469-T) consolidated consent decree cases of the United States District Court for the District of Massachusetts. (2) Providers Only. In addition to the requirements for individual records listed in 115 CMR 4.03, whichapplyto all providers and area offices holding individual records, individual records maintained by providers (including facilities) shall contain the following information: (a) Progress Notes. Each individual's provider record shall contain notations on at least a quarterly basis, as follows: 1. Observation of the individual's progress toward each goal, outcome, and objective; 2. Observations of any events pertinent to the individual's growth and development, including but not limited to behavioral incidents and significant activities and events; 3. Notations shall be behavioral and measurable as appropriate, and shall include the individual's level of participation and interest in and response to the services and supports offered by the provider; (b) Medication. Each individual's provider record shall also contain the documentation required by 115 CMR 5.06 relating to medication; (c) Immunizations and Tests. A record of the individual's past and current immunizations and tuberculintests, as well as a record of the individual's receipt of age-appropriate screeningtests(for example, mammograms, cholesterol levels) as made available by the area office, except that this requirement shall apply to the individual's residential provider only; (d) Financial Transactions. Each individual's residential provider record shall contain a record of the financial transactions of the individual with the provider, including delegated responsibility for the management of individual funds, in accordance with the requirements of 115 CMR 5.00. (e) Human Rights Training. Every residential, day, or site-based-respite provider record, and every specialized home care placement agency provider record shall contain confirmation of the individual's annual training by the human rights officer in the exercise of his or her human rights.