(a) Purpose.  OAC 340:100-3-40 sets forth requirements for:

• (1) maintenance of records by contract providers;
• (2) transfer of documents to a history file for service recipient records maintained by the contract provider; and
• (3) transfer of information when a service recipient changes contract providers.

(b) General requirements.  Records maintained by the contract provider are indexed, orderly, well-maintained, readily accessible, and current.  Records must contain adequate documentation of services rendered.

• (1) All service recipient records are available for review by the service recipient, his or her legal guardian, and staff and authorized agents of Oklahoma Department of Human Services.  Copies of records are available upon request by such persons.
• (2) The service recipient record is maintained with:
  • (A) an index;
  • (B) identification of the service recipient's name on the record and on each page;
  • (C) section tabs clearly marked; and
  • (D) documents secured in the record.
• (3) All entries in the record:
  • (A) are made per OAC 317:30-3-15;
  • (B) are made in chronological order;
  • (C) are legible;
  • (D) include date and time of each entry, with legible identification of the person making the entry; and
  • (E) include, if the entry is health-related:
    • (i) description of concern; and
    • (ii) action taken.
• (4) The provider ensures compliance with OAC 340:2-8-1 through 340:2-8-13 and OAC 340:100-3-2 pertaining to protection, use, and release of personal information.  The provider holds confidential all personal information regarding service recipients, including names, addresses, photographs, records of evaluation, and all other records.  Information is not disclosed, directly or indirectly, unless consent is obtained in writing.

(c) Home record for service recipients receiving community residential supports or group home services.  A record of services is maintained by the contract provider in the home for each service recipient receiving community residential supports, per OAC 340:100-5-22.1, or group home services, per OAC 340:100-6.

• (1) Documents contained in each home record include:
  • (A) items that are not removed from the record, including guardianship documents and other legal documents;
  • (B) copy of current Individual Plan (Plan) packet;  • 1
  • (C) health-related documents including, but not limited to:
    • (i) Form 06HM039E, Continuous Medical Record, per OAC 340:100-3-40.1;
    • (ii) Form 06HM005E, Referral Form for Examination or Treatment, physician orders, discharge summaries, and emergency room reports;
    • (iii) Form 06HM006E, Health Status and Medication Review;
    • (iv) special instructions or Health Care Plan;
    • (v) individually identified data forms relevant to service recipient's current health status;
    • (vi) Dyskinesia Identification System:  Condensed User Scale (DISCUS) or Abnormal Involuntary Movement Scale (AIMS), if required, per OAC 340:100-5-29;
    • (vii) current immunization record;
    • (viii) medication administration records from previous months;
    • (ix) most recent lab, x-ray, and consultation reports, and pharmacological evaluation, if applicable; and
    • (x) miscellaneous health-related consultations and correspondence;
  • (D) miscellaneous documents relating to the service recipient including, but not limited to:
    • (i) observation notes;
    • (ii) Form 06CB035E, Site Visit Report, completed by all professional contract providers and program coordination staff;
    • (iii) implementation strategies; and
    • (iv) applicable data collection sheets;
  • (E) quarterly residential reports on progress; and
  • (F) Form 06MP070E, Access to Home Record and Verification of Monitoring Requirement, certifying that all authorized persons accessing the service recipient information contained within the home record were informed and understand the penalties for misuse of confidential and protected information per Section 1533.1 of Title 21 of the Oklahoma Statutes.
• (2) In unusual circumstances a service recipient's home record or specified types of documents from the record may be maintained at a location other than the service recipient's home, if requested by the Team and approved in writing by the Developmental Disabilities Services Division area manager.

(d) Retention.  Each contract provider retains a record for each service recipient receiving services from the provider.

• (1) Transfer of all documents more than three months old from the provider agency record to a history file occurs yearly, unless otherwise specified per OAC 340:10-3-40.
• (2) The provider agency retains original records for a period of six years or until any pending litigation involving the service recipient is completed, whichever occurs last.

(e) Transfers between agencies.  When a service recipient changes provider agencies, the agency provides the new agency with a copy of the current home record and any health documents requested by the Team.

(f) Other provider records.  The provider must maintain service records that substantiate the provision of services, eligibility of service recipients, and outcome of services.

• (1) Records are maintained for a period of six years after the Oklahoma Department of Human Services has made final payment and all pending matters are closed.
• (2) The provider maintains copies of all claims, substantiating documents, and records regarding agency fiscal status within corporate offices in Oklahoma.