Sec. 10.12.04.26. Records

A. Records. The center shall maintain records that are needed to operate the center, as required by the Department, and to document the progress of the participants.

B. Retention. The center shall maintain participants' records for at least 5 years from the date of discharge, except as provided in Health-General Article, §4-403, Annotated Code of Maryland.

C. Confidentiality. The center shall maintain records so that they are accessible only to the director, the staff, emergency personnel, and to funding and monitoring agencies. The center may not discuss or reveal the contents of the records with any persons other than those listed above without the participant's written permission.

D. Required Records.

(1) Participant Records. The center shall maintain at least the following information for each participant:

(a) Name, age, sex, address, and telephone number;

(b) Name and telephone number of the individual to be notified in case of emergency;

(c) Next of kin;

(d) Medicare, Medicaid, or private insurance member enrollment numbers related to health care benefits;

(e) Name and address of primary care provider, with changes noted and dated when change occurs;

(f) Functional assessment with original and revised versions noting participant progress;

(g) Assessment of the home environment at the time of intake and as needed, or at change of home address;

(h) Individual plan of care;

(i) Admission physical and subsequent additional information;

(j) Medications and adverse drug reactions; and

(k) Accidents.

(2) Personnel Records. The center shall maintain the following information for each staff member:

(a) Name, age, sex, address, and telephone number;

(b) Educational background;

(c) Employment history and notes on references;

(d) Performance evaluations and attendance;

(e) Individual to be notified in case of emergency;

(f) Documentation that the individual is free from tuberculosis, measles, mumps, rubella, and varicella as evidenced by:

(i) Physician’s statement;

(ii) Positive disease histories affirmed by employee’s signature;

(iii) Antibody serology’s of titer;

(iv) Skin tests; or

(v) Statement of vaccinations, affirmed by the employee signature;

(g) Evidence that the annual influenza vaccine has been advised;

(h) Any impairment which would hinder the performance of assigned responsibilities; and

(i) Documentation of a criminal history records check in accordance with Health-General Article, §19-1901, Annotated Code of Maryland;

(j) The official driving record and a copy of a valid driver's license if driving is a condition of employment; and

(k) Copies of written agreements with consultants, including services to be provided.

(3) Volunteer Records.

(a) The center shall urge that volunteers accept annual influenza vaccination and tuberculin testing as considered necessary by the center.

(b) The center shall give appropriate health care information to such volunteers to provide maximum protection to residents.

(c) The center shall maintain documentation of the discussion between the center and the volunteer concerning influenza vaccine and tuberculin testing.

(4) Administrative and Fiscal Records. The center shall maintain the following administrative and fiscal records:

(a) Expenditures with substantiating documentation;

(b) Current and projected annual operating budgets, including specific cost allocations and formula for determining projected expenditures, and including accurate per diem costs;

(c) Fee charged, and fee schedule, if appropriate;

(d) Records of in-service training offered by the center;

(e) Current inspection reports from the health and fire departments;

(f) The daily schedule of activities;

(g) Daily menu of meals and snacks served for a 30-day period;

(h) Attendance records; and

(i) Audit reports.