Haw. Code R. § 11-800-54 - Records

(a) Each home shall maintain an administrative notebook including but not limited to;

(1) Emergency procedures and an evacuation map;

(2) Appropriate program policies and procedures; and

(3) A list of applicable community resources.

(b) The home shall maintain separate notebooks for each client in a manner that ensures legibility order, and timely signing and dating of each entry in black ink. Each client notebook shall be a permanent record and shall be kept in detail to:

(1) Permit effective professional review by the case management agency and the department; and

(2) Provide information for necessary follow-up care for the client.

(c) The content of each client notebook shall be consistent with standards established by the department and shall contain:

(1) Client's vital information;

(2) Client's current individual service plan, and when appropriate, a transportation plan approved by the department;

(3) Current copies of the client's physician's orders;

(4) Client's emergency management procedures;

(5) Medication schedule checklist;

(6) Daily documentation of the provision of services through personal care or skilled nursing daily check list, RN and social worker monitoring flow sheets, client observation sheets, and significant events that may impact the life, health, safety, or welfare of, or the provision of services to the client, including but not limited to adverse events;

(7) Expenditure records; and

(8) Personal inventory.

(d) All client records and reports are confidential, as provided in section 11-800-16, and shall not be released without the written consent of the client or the client's legal representative, or the case management agency, as applicable. The case management agency shall be informed of any request for the release of information concerning clients and shall retain a copy of the client's written consent to release information.

(e) When a client leaves a home, all records and reports kept by the home shall be given to the case management agency.

Notes

Haw. Code R. § 11-800-54

[Eff 11/13/2018] (Auth: HRS §§ 321-481, 321-483, 321-485, 346-14) (Imp: HRS §§ 321-481, 321-483, 321-485, 346-14)