Minnesota Administrative Rules

4668.0810 CLIENT RECORDS.

Subpart 1.

Maintenance of client record.

A class F home care provider licensee must maintain a record for each client at the housing with services establishment where the services are provided. The client record must be readily accessible to personnel authorized by the licensee to use the client record.

Subp. 2.

Security.

A class F home care provider licensee must establish and implement written procedures for security of client records, including:

A.

the use of client records;

B.

the removal of client records from the establishment; and

C.

the criteria for release of client information.

Subp. 3.

Retention.

A class F home care provider licensee must retain a client's record for at least five years following the client's discharge or discontinuation of services. Arrangements must be made for secure storage and retrieval of client records if the licensee ceases business.

Subp. 4.

Transfer of client.

If a client transfers to another home care provider or other health care practitioner or provider or is admitted to an inpatient facility, a class F home care provider licensee, upon request of the client, must send a copy or summary of the client's record to the new provider or facility or to the client.

Subp. 5.

Form of entries.

Except as required by subpart 6, items F and G, documentation of a class F home care service must be created and signed by the staff person providing the service no later than the end of the work period. The documentation must be entered into the client record no later than two weeks after the end of the day service was provided. All entries in the client record must be:

A.

legible, permanently recorded in ink, dated, and authenticated with the name and title of the person making the entry; or

B.

recorded in an electronic media in a manner that ensures the confidentiality and security of the electronic information, according to current standards of practice in health information management, and that allows for a printed copy to be created.

Subp. 6.

Content of client record.

The client record must be accurate, up to date, and available to all persons responsible for assessing, planning, and providing assisted living home care services. The record must contain:

A.

the following information about the client:

(1)

name;

(2)

address;

(3)

telephone number;

(4)

date of birth;

(5)

dates of the beginning and end of services;

(6)

names, addresses, and telephone numbers of any responsible persons;

(7)

primary diagnosis and any other relevant current diagnoses;

(8)

allergies, if any; and

(9)

the client's advance directive, if any;

B.

an evaluation and service plan as required under part 4668.0815;

C.

a nursing assessment for nursing services, delegated nursing services, or central storage of medications, if any;

D.

medication and treatment orders, if any;

E.

the client's current tuberculosis infection status, if known;

F.

documentation of each instance of assistance with self-administration of medication and of medication administration, if any;

G.

documentation on the day of occurrence of any significant change in the client's status or any significant incident, including a fall or a refusal to take medications, and any actions by staff in response to the change or incident;

H.

documentation at least weekly of the client's status and the home care services provided, if not addressed under item F or G;

I.

the names, addresses, and telephone numbers of the client's medical services providers and other home care providers, if known;

J.

a summary following the discontinuation of services, which includes the reason for the initiation and discontinuation of services and the client's condition at the discontinuation of services; and

K.

any other information necessary to provide care for each individual client.

Subp. 7.

Confidentiality.

A Class F home care provider licensee must not disclose to any other person any personal, financial, medical, or other information about the client, except:

A.

as may be required by law;

B.

to staff, another home care provider, a health care practitioner or provider, or an inpatient facility that requires information to provide services to the client, but only the information that is necessary to provide services;

C.

to persons authorized in writing by the client or the client's responsible person to receive the information, including third-party payers; or

D.

to representatives of the commissioner authorized to survey or investigate home care providers.

Subp. 8.

Schedule of fines.

For a violation of the following subparts, the stated fine shall be assessed:

A.

subpart 1, $100;

B.

subpart 2, $100;

C.

subpart 3, $50;

D.

subpart 4, $100;

E.

subpart 5, $50;

F.

subpart 6, $100; and

G.

subpart 7, $350.

Statutory Authority:

MS s 144A.45

History:

24 SR 141; L 2006 c 282 art 19 s 19

Published Electronically:

July 3, 2013