Current through Register Vol. 48, No. 12, March 22, 2024
a) Service
delivery contracts and related documents executed by each resident or
resident's representative shall be maintained by the establishment from the
date of execution until three years after the date the contract is terminated.
(Section 105 of the Act)
b) An
establishment shall maintain a resident's record that contains at least the
following:
1) The resident's name and Social
Security number;
2) The date of the
resident's acceptance into the establishment and the last address of the
resident;
3) The names, addresses,
and telephone numbers of the following:
A)
The resident's representative, if applicable;
B) The resident's primary health care
provider; and
C) An individual or
relative to be contacted in the event of emergency, significant change in the
resident's condition, or termination of residency;
4) The establishment contract and any
amendments;
5) Documentation of
orientation to the evacuation plan;
6) Notation of assessments and evaluations
conducted pursuant to Section
295.4000;
7) The service plan, its amendments and
updates;
8) A health care
directive, if disclosed and applicable;
9) Notation of known accidents, incidents or
injuries;
10) Documentation of any
significant change in a resident's behavior or physical, cognitive, or
functional condition that would trigger an assessment or evaluation, and action
taken by employees to address the resident's changing needs;
11) A written notice of termination of
residency, if applicable;
12)
Documentation of relocation assistance provided to the resident, if
applicable;
13) A negotiated risk
agreement, if applicable;
14) Any
express waiver of confidentiality;
15) If applicable, letters of guardianship,
the resident's representative designation form, or durable power of attorney
for health care; and
16) Orders
from a licensed health care provider for medication that is to be administered
by the establishment.
c)
The resident, resident's representative, resident's guardian, or health care
power of attorney is responsible for alerting the establishment of any changes
to the information contained in the record.
d) An establishment shall ensure that a
resident's record is:
1) Confidential and
only released with written permission from the resident or the representative,
or as otherwise provided by law;
2)
Maintained at the establishment;
3)
Legibly recorded in ink or electronically recorded;
4) Retained for 3 years from the date of
termination of residency (closed records may be retained off-site);
and
5) Available for review by the
resident or the resident's representative during normal business hours or at a
time agreed upon by the resident and the manager.
e) An establishment shall ensure that a
resident's financial records are maintained separate from a resident's record
and are accessible only to individuals designated by the
establishment.
f) The following
resident records and supporting documents shall be made available for on-site
inspection by the Department upon request at any time:
1) Service delivery contracts and related
documents executed by each resident or resident's representative, including,
but not limited to, negotiated risk agreements;
2) Records supporting compliance with each
individual contract and with this Part; and
3) Incident and accident reports that are
required to be submitted to the Department. (Section 105 of the Act)