Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 558 - LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES › Subchapter C - MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES › Division 4 - PROVISION AND COORDINATION OF TREATMENT SERVICES › Section 558.301 - Client Records

Current through Reg. 49, No. 28; July 12, 2024
(a) In accordance with
					 accepted principles of practice, an agency must establish and maintain a client
					 record system to ensure that the care and services provided to each client are
					 completely and accurately documented, readily accessible, and systematically
					 organized to facilitate the compilation and retrieval of information.
(1) An agency must establish a record for
					 each client and must maintain the record in accordance with and contain the
					 information described in paragraph (9) of this subsection. An agency must keep
					 a single file or separate files for each category of service provided to the
					 client and the client's family. Hospice services provided to a client's family
					 must be documented in the clinical record.
(2) The agency must adopt and enforce written
					 procedures regarding the use and removal of records, the release of
					 information, and when applicable, the incorporation of clinical, progress, or
					 other notes into the client record. An agency may not release any portion of a
					 client record to anyone other than the client except as allowed by
					 law.
(3) All information regarding
					 the client's care and services must be centralized in the client's record and
					 be protected against loss or damage.
(4) The agency must establish an area for
					 original active client record storage at the agency's place of business. The
					 original active client record must be stored at the place of business (parent
					 agency, branch office, or ADS ) from which services are provided. Original
					 active client records must not be stored at an administrative support site or
					 records storage facility.
(5) The
					 agency must ensure that each client's record is treated with confidentiality,
					 safeguarded against loss and unofficial use, and is maintained according to
					 professional standards of practice.
(6) A clinical record must be an original, a
					 microfilmed copy, an optical disc imaging system, or a certified copy.
(A) An original record is a signed paper
					 record or an electronically signed computer record. A signed paper record may
					 include a physician's stamped signature if the agency meets the following
					 requirements:
(i) An agency must have on file
					 at the agency a current written authorization letter from the physician whose
					 signature the stamp represents, stating that he is the only person authorized
					 to have the stamp and use it.
(ii)
					 The authorization letter must be dated before a stamped record from the
					 physician was accepted by the agency.
(iii) An agency must obtain a new
					 authorization letter from the physician annually. A physician authorization
					 letter is void one year from the date of the letter.
(iv) The authorization letter must be
					 manually signed by the physician and include a copy of the stamped signature
					 that the physician will use.
(B) Computerized records must meet all
					 requirements of paper records, including protection from unofficial use and
					 retention for the period specified in subsection (b) of this section.
(C) An agency must ensure that entries
					 regarding the delivery of care or services are not altered without evidence and
					 explanation of such alteration.
(7) Each entry to the client record must be
					 current, accurate, signed, and dated with the date of entry by the individual
					 making the entry. The record must include all services whether furnished
					 directly or under arrangement. Correction fluid or tape must not be used in the
					 record. Corrections must be made by striking through the error with a single
					 line and must include the date the correction was made and the initials of the
					 person making the correction.
(8)
					 Inactive client records may be preserved on microfilm, optical disc or other
					 electronic means and may be stored at the parent agency location, branch
					 office, ADS, administrative support site, or records storage facility. Security
					 must be maintained, and the record must be readily retrievable by the
					 agency.
(9) Each client record must
					 include the following elements as applicable to the scope of services provided
					 by the agency:
(A) client application for
					 services including, but not limited to, the following information:
(i) the client's full name;
(ii) sex;
(iii) date of birth;
(iv) the name, address, and telephone number
					 of each parent or legal guardian of a minor child;
(v) the name, address, and telephone number
					 of any other person, as identified by the individual;
(vi) the physician's name and telephone
					 numbers, including emergency numbers; and
(vii) services requested;
(B) initial health assessment,
					 pertinent medical history, and subsequent health assessments;
(C) care plan, plan of care, or
					 individualized service plan, as applicable. The care plan or the plan of care
					 must include, as applicable, medication, dietary, treatment, and activities
					 orders. An individualized service plan for a personal assistance service client
					 must comply with § 558.404 of this chapter (relating to Standards Specific
					 to Agencies Licensed to Provide Personal Assistance Services). A plan of care
					 for a hospice client must comply with § 558.821 of this chapter (relating
					 to Hospice Plan of Care;
(D)
					 clinical and progress notes. Such notes must be written the day service is
					 rendered and incorporated into the client record within 14 working
					 days;
(E) current medication
					 list;
(F) medication administration
					 record (if medication is administered by agency staff). Notation must also be
					 made in the medication administration record or in the clinical notes of
					 medications not given and the reason. Any adverse reaction must be reported to
					 a supervisor and documented in the client record;
(G) acknowledgement of hospice agency's
					 policy regarding disposal of controlled substance prescription drugs;
(H) records of supervisory
					 visits;
(I) complete documentation
					 of all known services and significant events. Documentation must show that
					 effective interchange, reporting, and coordination of care occurs as required
					 in §558.288 of this division (relating to Coordination of
					 Services);
(J) for clients 60 years
					 and older, acknowledgment of the client's receipt of a copy of the right and
					 responsibilities listed in Texas Human Resources Code Chapter 102;
(K) acknowledgment of the client's receipt of
					 the agency's policy relating to the reporting of abuse, neglect, or
					 exploitation of a client;
(L)
					 documentation that the client has been informed of how to register a complaint
					 in accordance with §558.282(d) of this division (relating to Client
					 Conduct and Responsibility and client Rights);
(M) client agreement to and acknowledgment of
					 services by home health medication aides, if home health medication aides are
					 used;
(N) discharge summary,
					 including the reason for discharge or transfer and the agency's documented
					 notice to the client, the client's physician (if applicable), and other
					 individuals as required in §558.295 of this division (relating to Client
					 Transfer or Discharge Notification Requirements);
(O) acknowledgement of receipt of the notice
					 of advance directives;
(P) services
					 provided to the client's family (as applicable); and
(Q) consent and authorization and election
					 forms, as applicable.