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340:100-3-40. Community records
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Revised 5-15-08
(a) Purpose. OAC 340:100-3-40 sets forth requirements for:
(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.
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(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 to such persons.
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(2) The service recipient record is maintained with:
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(A) an index;
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(B) identification of the service recipient's name on the record and on each page;
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(C) section tabs clearly marked; and
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(D) documents secured in the record.
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(3) All entries in the record:
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(B) are made in chronological order;
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(C) are legible;
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(D) include date and time of each entry, with legible identification of the person making the entry; and
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(E) include, if the entry is health-related:
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(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.
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(1) Documents contained in each home record include:
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(A) items that are not removed from the record, including guardianship documents and other legal documents;
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(B) copy of current Individual Plan (Plan) packet; • 1 -
(C) health-related documents, including, but not limited to:
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(ii) Form 06HM007E, Physical Status Review;
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(iii) Form 06HM005E, Referral Form for Examination and Treatment, physician orders, discharge summaries, and emergency room reports;
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(iv) Form 06HM006E, Health Status and Medication Review;
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(v) special instructions or Health Care Plan;
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(vi) individually identified data forms relevant to service recipient's current health status;
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(vii) Dyskinesia Identification System: Condensed User Scale (DISCUS) or Abnormal Involuntary Movement Scale (AIMS), if required, per OAC 340:100-5-29; -
(viii) current immunization record;
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(ix) medication administration records from previous months;
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(x) most recent lab, x-ray, and consultation reports, and pharmacological evaluation, if applicable; and
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(xi) miscellaneous health-related consultations and correspondence;
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(D) miscellaneous documents relating to the service recipient, including, but not limited to:
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(i) observation notes;
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(ii) Form 06CB035E, Site Visit Report, completed by all professional contract providers and program coordination staff;
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(iii) implementation strategies; and
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(iv) applicable data collection sheets; and
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(E) monthly residential reports on progress.
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(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 DDSD area manager.
(d) Retention. Each contract provider retains a record for each service recipient receiving services from the provider.
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(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.
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(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.
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(1) Records are maintained for a period of six years after OKDHS has made final payment and all pending matters are closed.
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(2) The provider maintains copies of all claims, substantiating documents, and records regarding agency fiscal status within corporate offices in Oklahoma.
INSTRUCTIONS TO STAFF 340:100-3-40
Revised 5-15-08
1. Individual Plan packet. The Developmental Disabilities Services Division (DDSD) case manager provides to the home record and service recipient's Personal Support Team:
(1) Form 06MP002E, Request for Authorization, when required;
(2) Individual Plan (Plan);
(3) Level of Care screen printout;
(4) Plan of Care screens printout;
(5) assessment information used to develop the Plan;
(6) psychological assessment;
(7) annual medical report;
(8) social or developmental history;
(9) freedom of choice forms;
(10) right to fair hearing form;
(11) Client Contact Manager (CCM) consumer data sheet;
(12) Form 06HM007E, Physical Status Review, if applicable;
(13) protective intervention plan, if applicable;
(14) medical history or Continuous Medical Record Summary, if applicable; and
(15) Oklahoma Health Care Authority (OHCA) Form LTC-300, Long Term Care Assessment, when required.
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