Kan. Admin. Regs. § 26-52-14 - Records
(a) Each applicant
and each licensee shall develop and implement policies and procedures for the
creation and maintenance of an organized recordkeeping system for the center,
which shall include the following:
(1)
Provisions shall be made for the identification, security, confidentiality,
control, retrieval, preservation, and disposal of all records for patients,
staff members, and volunteers, and for center records.
(2) All records shall be available at the
center for review by the department.
(b) Patient records. Each licensee shall
assign a unique number to each patient. Each patient's name and patient number
shall appear on each center-generated document, which shall be signed and dated
by the responsible staff member. Each licensee shall maintain an individual
record for each patient, which shall include the following information:
(1) sufficient information to identify the
patient;
(2) any agency or person
responsible for the patient;
(3)
the request for voluntary admission signed by a voluntary patient submitted
pursuant to
K.S.A. 59-29c04 and amendments thereto, or the
written application for emergency observation and treatment for a proposed
patient submitted pursuant to
K.S.A. 59-29c06 or
59-29c07, and amendments
thereto;
(4) the admission health
check completed by a physician;
(5)
an inventory of the patient's personal possessions at the time of admission and
discharge from the center;
(6)
treatment plan;
(7) each evaluation
conducted pursuant to
K.S.A. 59-29c08, and amendments thereto;
(8) any affidavit or petition filed with the
district court where the center is located pursuant to
K.S.A. 59-29c08, and amendments thereto;
(9) physical health records relating to a
patient's medical history, allergies, immunizations, infectious disease,
illness, injury, and any dietary restrictions;
(10) treatment notes;
(11) physician orders;
(12) medication administration
records;
(13) nursing
notes;
(14) behavioral health
professional orders;
(15)
laboratory test results;
(16)
direct care staff member notes;
(17) progress notes;
(18) consultations related to the patient's
treatment, medical care or discharge plan;
(19) critical incident reports;
(20) discharge plan; and
(21) notifications or other correspondence
provided to the guardian of a patient.
(c) Each patient record shall be confidential
and made available only to the department, staff members and consultants
authorized by the center, or as authorized by
K.S.A. 59-2979, and amendments thereto;
K.S.A. 65-5603, and amendments thereto;
K.S.A. 60-427, and amendments thereto; and
42 U.S.C.
290dd-2.
(d) The records of each patient shall be
maintained for at least 10 years following the last discharge of the
patient.
(e) Before closing of a
center for any reason, the licensee shall arrange for preservation of patient
records for the mandatory retention period and shall notify the department why
the center is closing, and provide the address and contact person for the
location where patient records will be maintained.
(f) staff member records. Each licensee shall
maintain an individual record for each staff member, which shall include the
following information:
(1) The application
for employment or written agreement for the staff member to work at the center,
including the staff member's qualifications;
(2) a copy of each applicable current
professional license, certificate, or registration;
(3) the staff member's current job
responsibilities and job duties;
(4) a health record that meets the
requirements of this article, including a record of the results of each health
examination and each tuberculosis test;
(5) a copy of a valid driver's license of a
type appropriate for the vehicle being used, for each staff member who
transports any patient;
(6)
documentation of all orientation and in-service training required in this
article;
(7) documentation of
training in documentation of the patient record;
(8) a copy of each grievance or incident
report concerning the staff member, including documentation of the resolution
of each report; and
(9)
documentation that the staff member has read, understands, and agrees to all of
the following:
(A) The requirements of
mandatory reporting of suspected patient abuse, neglect, and
exploitation;
(B) all statutes and
regulations governing crisis intervention centers;
(C) the center's policies and procedures that
are applicable to the job responsibilities and job duties of the staff member;
and
(D) the confidentiality of
patient information.
(g) Volunteer records. Each licensee shall
maintain an individual record for each volunteer at the center, which shall
include the following:
(1) The application for
volunteering at the center;
(2) the
volunteer's responsibilities at the center;
(3) a health record that demonstrates
compliance with this article, including a record of the results of each health
examination and each tuberculosis test, for each volunteer in contact with
patients;
(4) documentation of all
orientation and in-service training required for volunteers in this
article;
(5) a copy of each
grievance or incident report concerning the volunteer, including documentation
of the resolution of each report; and
(6) documentation that the volunteer has
read, understands, and agrees to all of the following:
(A) The requirements of mandatory reporting
of suspected patient abuse, neglect, and exploitation;
(B) all statutes and regulations governing
crisis intervention centers;
(C)
the center's policies and procedures that are applicable to the job
responsibilities and job duties of the volunteer; and
(D) the confidentiality of patient
information.
(h) Center records. Each applicant and each
licensee shall complete and maintain center records. Center records shall
include the following information:
(1)
Documentation of the requests submitted to the department for background checks
to meet the requirements of this article;
(2) documentation of each approval granted by
the department for each change, exception, or amendment;
(3) the current and all past versions of the
center's policies and procedures that were effective during the ten-year period
immediately preceding the effective date of the current policy;
(4) all documentation required by this
article for emergency plans, fire and tornado drills, and written policies and
procedures on care and treatment of the patients;
(5) all documentation specified in this
article for the inspection and maintenance of security devices, including
locking mechanisms and any delayed-exit mechanisms on doors;
(6) documentation of approval of any public
or private water, sewage systems, and utilities as specified in this
article;
(7) documentation of
compliance with all local and state building codes, fire safety requirements,
and zoning codes;
(8) all
documentation specified in this article for transportation of
patients;
(9) documentation of
vaccinations and veterinary records for any animal kept on the
premises;
(10) a copy of each
contract and each agreement; and
(11) information available to the department
for each 12-month period commencing on July 1st of
each year and ending on June 30th of each year
regarding the following:
(A) The number of
admissions and discharges and length of stay for each patient admitted to the
crisis intervention center;
(B) the
number of voluntary patients and proposed patients who were denied admission to
the center and the reason for the denial;
(C) the number of voluntary patients admitted
pursuant to
K.S.A. 59-29c04, and amendments thereto, and whether
the admission was for mental health treatment, alcohol or substance abuse
treatment, or treatment for co-occurring conditions of mental health and
alcohol or substance abuse;
(D) the
number of involuntary patients admitted pursuant to
K.S.A. 59-29c06, and amendments thereto, and whether
the admission was for mental health treatment, alcohol or substance abuse
treatment, or treatment for co-occurring conditions of mental health and
alcohol or substance abuse;
(E) the
number of involuntary patients admitted pursuant to
K.S.A. 59-29c07, and amendments thereto, and whether
the admission was for mental health treatment, alcohol or substance abuse
treatment, or treatment for co-occurring conditions of mental health and
alcohol or substance abuse;
(F) the
number of voluntary patients who are admitted to the center two or more times,
and whether the readmission was for mental health treatment, alcohol or
substance abuse treatment, or treatment for co-occurring conditions of mental
health and alcohol or substance abuse; and
(G) the number of involuntary patients who
are admitted to the center two or more times, and whether the readmission was
for mental health treatment, alcohol or substance abuse treatment, or treatment
for co-occurring conditions of mental health and alcohol or substance
abuse.
Notes
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No prior version found.