{"ref":"LA-HC-REC-01","title":"Client Records: Content, Security, Retention, and Access","category":"Records","summary":"Sets out what the Agency keeps in each client record under LAC 48:I.5057, what stays in the client’s home, how entries are made and corrected, where records are stored and protected, who may see or receive them, and how long they are kept: at least six years, and for LT-PCS six years from the date of the last payment period.","inShort":["Every client has one complete record at the office; current progress notes stay in the client’s home folder.","Never take client records out of the office, and keep the home folder in the client’s home.","Write in ink, sign with your name, title and full date; fix mistakes with one line, \"error\" and your initials.","Never use correction fluid, never backdate, and never sign for someone else.","Send any request for records or copies to the privacy official the same day."],"primaryCitation":"LAC 48:I.5057","citations":["LAC 48:I.5057","LAC 48:I.5029.B.1","LAC 48:I.5029.B.2","LAC 48:I.5029.B.12","LAC 48:I.5031.A.3","LAC 48:I.5031.C.2","LAC 48:I.5031.D.6","LAC 48:I.5032.A.6.b","LAC 48:I.5049.A.7","LAC 48:I.5017.F.1","LAC 48:I.5021.D.7","LAC 48:I.5026.F","Medicaid Services Manual, Chapter 30, §30.8","La. R.S. 51:3074"],"federalCitations":["45 CFR §164.502(b)","45 CFR §164.502(g)","45 CFR §164.508","45 CFR §164.524","45 CFR §164.528","45 CFR §164.530(j)","42 CFR Part 2"],"surveyorAsks":["Show me the record for this client: identifying data and legal status, service plan, history, service agreement, emergency care authorization, assessments, physician and dentist, progress notes, medical information and any advance directive.","What records do you keep in the client’s home? Show me the current progress notes there."],"forms":[{"ref":"LA-HC-REC-01-A","title":"Authorization to Release Client Information"},{"ref":"LA-HC-REC-01-B","title":"Client Record Audit Checklist"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (LAC 48:I.5057)","5. What Each Client Record Holds","6. Records Kept in the Client’s Home","7. Entries, Signatures and Corrections","8. Organization of the Record","9. Where Records Are Kept and How They Are Protected","10. Client Access to the Record","11. Releasing Information to Others","12. Access by LDH and Other Authorities","13. How Long Records Are Kept","14. Transfer, Discharge and Closure","15. Responsibilities","16. Records and Compliance Monitoring","17. Staff Training","18. References","19. Related Policies and Forms","20. Approval","21. Revision History"],"version":"1.0","sample":false,"pack":"la-hca","state":"Louisiana","service":"Home care","guides":[{"path":"/guides/home-care-agency-policies/","h1":"What policies does a home care agency need?"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}