Washington Administrative Code › Title 388 - Social and Health Services, Department of › AGING AND ADULT SERVICES › Chapter 388-71 - Home and community services and programs › ADULT DAY SERVICES › Section 388-71-0746 - What are the adult day center's client records requirements?

Current through Register Vol. 24-14, July 15, 2024
(1) If the client's
				  record is hand-written it must be legibly written in ink, dated, and signed by
				  the recording person with his/her title. Identification of the author may be a
				  signature, initials, or other unique identifier within the requirements of
				  applicable licensing standards and center policy. All hand-written
				  documentation must be legible to someone other than the author. If signature is
				  a unique identifier, such as initials, there must be a key readily available
				  for use by the department or their designee. The negotiated care plan must have
				  the center's author's full name and title on the signature line.
(2) If the client's record is an automated
				  electronic record then it must be within a secured client record system to
				  ensure confidentiality for all records, in accordance with state and federal
				  laws, including but not limited to the Health Insurance Portability and
				  Accountability Act (HIPAA). If electronic signature is a unique identifier then
				  there must be a key readily available for use by the department or their
				  designee. The negotiated care plan must have the center's author's full name
				  and title on the signature line.
(3) Progress notes must be entered into the
				  file chronologically and timely. Adult day health centers' professional
				  interventions must be charted directly after providing the service. Adult day
				  care centers must have progress summary notes at least monthly. Client dates
				  and hours of attendance are to be kept daily.
(4) Consultation, care plan reviews and
				  updating orders, hardcopy or electronic records, must be dated and initialed by
				  the center's reviewer(s) or authorizing practitioner. The authorizing
				  practitioner must update the skilled clinical orders at least annually or when
				  a significant change occurs warranting a change in the skilled clinical
				  intervention. The authorizing practitioner does not need to review the care
				  plan but does need to update skilled clinical orders as outlined
				  above.
(5) Documentation of
				  medication use must include the name of the medication, dosage, frequency of
				  administration, route of administration, site of injection if applicable, date
				  and time and signature or initials of the person administering the medication,
				  title, and date.
(6) If the client
				  records are thinned or archived, per your policy and procedure, all records
				  must be readily available to the federal, state, or agency designee for
				  monitoring purposes.
(7)
				  Department-contracted adult day health centers must comply with all other
				  applicable documentation requirements under WAC
				  182-502-0020.
Statutory Authority:
						RCW
						74.04.050,
						74.04.057,
						74.04.200,
						74.08.090,
						74.09.520, and
						74.39A.030. 03-06-024, §
						388-71-0746, filed 2/24/03, effective
						7/1/03.