| (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.
(b) An agency must adopt and enforce a written policy
relating to the retention of records in accordance with this subsection.
(1) An agency must retain original client records for
a minimum of five years after the discharge of the client.
(2) The agency may not destroy client records that
relate to any matter that is involved in litigation if the agency
knows the litigation has not been finally resolved.
(3) There must be an arrangement for the preservation
of inactive records to insure compliance with this subsection.
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| Source Note: The provisions of this §558.301 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; amended to be effective May 1, 2008, 33 TexReg 1136; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427 |
