8.05 Participant Case Records
Home and Community Based Services Manual
8.05 Participant Case Records
The information in the Home and Community Based Services (HCBS) Web Tool is the participant’s official electronic record. DSDS staff shall document and upload information accurately and timely in order to ensure the participant’s record is up to date. HCBS participant’s records shall be maintained for seven (7) years.
The Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS) may receive a request for a copy of the HCBS participant’s case record. A caserecord request shall be processed by the appropriate DSDS staff. DSDS staff shall document and upload information accurately and timely in order to ensure the participant’s case record is up to date. Any verbal request for the participant case record shall be documented in Case Notes in the participant’s electronic case record. Any written request shall be uploaded to the participant’s electronic case record, with corresponding notation in Case Notes. DSDS staff shall complete the case record request no later than thirty (30) business days from receipt of the request. Staff shall refer to Adult Protective Services Policy 1706.40 for guidance in processing requests received for hotline investigation records.
A participant and/or their legal representative, acting on behalf of the participant, may request the participant’s electronic case record either verbally or in writing using the Authorization for Disclosure of Consumer Medical Health Information Form. The Authorization for Disclosure should be uploaded to the participant’s electronic record when received. Any requestor, other than the participant or legal representative, must provide an Authorization for Disclosure of Consumer Medical Health Information Form signed by the participant or legal representative. The participant and/or legal representative can ask for the electronic case record be sent directly to them to provide to others.
Additionally, DSDS staff may receive requests for documentation of HCBS eligibility. A participant and/or their legal may request this information either verbally or in writing using the Authorization for Disclosure of Consumer Medical Health Information Form. The participant may request the records be sent directly to them or, if the records are to be sent to the participant’s legal representative, staff shall advise the legal representative to use this form. Any requestor other than the participant or legal representative must provide an Authorization for Disclosure of Consumer Medical Health Information Form signed by the participant and/or legal representative.
The participant’s information shall be entered into the Participant Level of Care (LOC) Eligibility Letter (see Policy 8.00 Appendix 8) to respond to these types of requests. The Participant LOC Eligibility Letter shall only be completed in response to a request for documentation of eligibility. This letter is only to be utilized after the initial assessment or reassessment has been completed.
A subpoena for records may be received requesting a copy of the participant’s case record. For this type of request, prior to the release of the record, either 1) the participant or legal representative will need to authorize the disclosure through use of the Authorization for Disclosure of Consumer Medical Health Information or 2) the request must be reviewed by the Office of General Counsel (OGC) for validity.
Once it is determined that the participant’s case record is to be released, DSDS staff shall perform a thorough review of the record and redact any confidential information prior to release of the record.
Items to be redacted are as follows:
- Protected Health Information (PHI) regarding persons other than the HCBS participant.
- Social Security Number (SSN)/Departmental Client Number (DCN) of persons other than the requesting party.
- SSN/DCN of the participant may need to be redacted in situations where asubpoena has been received for a copy of the case record.
- Information received from third parties (e.g., DMH, hospital records, and physician records).
Requested documents may include but are not limited to the following:
- Prescreen
- All case notes
- InterRAI HC
- Saint Louis University Mental Status (SLUMS)
- Self-Direction Assessment Questions
- Participant Choice Statement
- Health Care Professional Inquiry
- Adverse Action Information
- HCBS Assessment Attestation