Current through Register No. 40, October 3, 2024
(a) Separate
records for each individual shall be maintained by the residence administrator
at the residence.
(b) Each
individual living in a community residence shall have specified in his or her
service agreement the number of hours of daily supervision required.
(c) Each individual's record shall include:
(1) The names, addresses, and telephone
numbers of persons to be notified in an emergency;
(2) The individual's current individual
service agreement;
(3) The
individual's fire safety assessment and, if applicable, fire safety
plan;
(4) The individual's personal
safety assessment and personal safety plan, if determined necessary according
to
He-M 1001.06(ad)
;
(5) Progress notes, in accordance with the
service agreement, that document residential services provided; and
(6) Medical information including:
a. The names, addresses, and telephone
numbers of the individual's physician, dentist, therapists, and any other
licensed practitioners;
b. Medical
orders;
c. Medical
history;
d. A copy of the
nurse-trainer assessment and approval for medication self-administration as
required by
He-M
1201.05, if applicable;
e. A copy of the annual health assessment of
the individual pursuant to
He-M 1001.06(a)
;
f. Known allergies, if any;
g. Other pertinent medical information;
and
h. A medication log completed
at the residence pursuant to
He-M
1201.08 for all current medications.
(d) Attendance records
shall be completed by the residence administrator or other provider such that:
(1) The date and whether or not residential
services were provided to the individual shall be recorded;
(2) When a leave of absence occurs, the
record shall indicate the date and time of the individual's departure and
return and the reason for the absence; and
(3) Attendance records shall be on file at
the community residence.
(e) Outdated information may be removed from
the community residence record but shall be maintained in the individual's
record and accessible by the area agency for 6 years.
(f) When service provision is to be
transferred from one provider or area agency to another, the transferring
agency shall provide the following information regarding the individual:
(1) Medical history, including diagnosis and
annual health assessments for the past 3 year period, if available;
(2) Any known allergies;
(3) Assessment for self-administration of
medication pursuant to
He-M
1201.05, if applicable;
(4) Current medications and a medication list
with the times medications are administered;
(5) Current medication orders and medication
administration consent forms;
(6)
Current medication administration authorizations of any staff transferring with
the individual;
(7) For
informational purposes, copies of the past 2 months of records of medication
administration performed pursuant to He-M 1201;
(8) Dental health information;
(9) Pertinent personal information, such as:
a. Use of adaptive equipment;
b. Sleep patterns; and
c. Preferences and dislikes;
(10) Any applicable protocols,
such as those for:
a. Feeding;
b. Swallowing;
c. Medication administration;
d. Behavioral support; and
e. Seizures;
(11) Most recent service agreement;
and
(12) List of contacts and
emergency information.
(See Revision Note at part heading for He-M 1001) #5867,
eff 9-1-94, EXPIRED: 9-1-00
New. #7681, eff 4-23-02; ss by
#9696, INTERIM, eff 4-23-10, EXPIRES: 10-20-10; ss by #9776-A, eff
10-1-10
