Record Keeping Requirements

PURPOSE: This rule describes the minimum requirements for administrative, participant and program records that the adult day care provider shall maintain. (1) The adult day care provider shall maintain administrative records that include at least: (A) Written personnel policies which address, at a minimum, the staffing requirements found in 19 CSR 30-90.040; (B) An organizational chart depicting lines of supervision and responsibility; (C) Individual personnel records for both paid staff and volunteer staff who are counted in the staffing ratio that include the following: 1. Position title and written job description of the work tasks, responsibilities and qualifications of the job duties to be performed by each person; 2. Name, address, home telephone number, date of birth and Social Security number; 3. Licensure, certification or other documentation of professional qualification; such as copies of license, certification, as applicable; 4. Educational background; 5. Employment history, documentation of references checked prior to employment including the results of the criminal background checks and, if applicable, a copy of any good cause waiver granted by the department; 6. Documentation of Employee Disqualification List (EDL) or Family Care Safety Registry checks; 7. Annual evaluation of work performance; 8. Documentation of orientation and inservice training received; 9. Record of dates and hours worked for at least the previous calendar year; 10. Copies of contracts with consultants, as applicable; 11. Documentation of any communicable disease and a physician’s or the physician’s designated agent’s written release stating that the employee or volunteer may return to work; and 12. Documentation of any current certification in first aid and cardiopulmonary resuscitation; (D) Fiscal records that include documentation of program income and expenditures in accordance with generally accepted accounting procedures. However, either cash basis, accrual basis or modified accrual basis may be used as appropriate for the adult day care provider’s business entity and tax status; (E) Records of orientation and in-service training provided to staff and volunteers; and (F) Inspection reports, for the past three (3) years from the local health authority, local fire authority, department, or division and any state or local inspecting authority. (2) The adult day care provider shall maintain individual participant records that include at least: (A) Identifying information consisting of the participant’s name; address; home telephone number; sex; date of birth; legal guardian, if applicable; the name and telephone number of the person to be notified in case of emergency and at least one (1) alternate; next of kin; travel directions between the home and program location and transportation arrangements, if applicable; (B) Physician’s pre-admission medical report and recommendations and subsequent medical information; (C) Individual plan of care and progress notes; (D) A chart of medications administered and any reactions noted, if applicable; (E) Documentation of any prescribed or modified diet provided; (F) Daily attendance log for the previous calendar year; and (G) Documentation regarding any accidents or incidents. (3) The adult day care provider shall maintain program records that include, at a minimum, copies of: (A) Current written program description in accordance with 19 CSR 30-90.050; (B) Current list of participants’ rights; (C) Schedule of daily group activities planned and record of activities actually conducted for the previous four (4) calendar months; (D) Weekly menus of meals planned and records of actual meals served for the previous four (4) calendar months; (E) Emergency medical plan; and (F) Fire safety plan. (4) Records or any information regarding adult day care program participants shall be confidential and no information shall be released without a written release of information signed by the participant or legal guardian except that records shall be available to the division for investigation of any complaint, program inspection, monitoring or technical assistance purposes. (5) Records shall be maintained for no less than five (5) years unless otherwise specified in this rule. Current records shall be kept on site within the adult day care program. Inactive records may be maintained at another central location but in no case outside the state of Missouri. Any record requested by the department or the division shall be made available within twenty-four (24) hours of the request. AUTHORITY: sections 660.050, RSMo Supp. 2003 and 660.418, RSMo 2000.* This rule was originally filed as 13 CSR 15-8.060. Original rule filed Oct. 15, 1984, effective Jan. 11, 1985. Moved to 19 CSR 30-90.060, effective Aug. 28, 2001. Amended: Filed Sept. 14, 2004, effective March 30, 2005. *Original authority: 660.050, RSMo 1984, amended 1988, 1992, 1993, 1994, 1995, 2001 and 660.418, RSMo 1984, amended 1993, 1994.