Current through Register Vol. 35, No. 6, March 26, 2024
There must be maintained a complete record on file for each
adult receiving care within a facility licensed pursuant to these regulations,
which must contain at least the following:
A.
Personal information:
(1) name of participant;
(2) date of birth;
(3) sex;
(4) home address (mailing address and
location of residence) and telephone number;
(5) name of responsible party;
(6) current place of employment, address and
work telephone number of responsible party.
B.
Emergency information.
(1) record of any allergies or medical
conditions the participant may have;
(2) name and telephone number of two persons
to be called in case of emergency when the responsible party cannot be
reached;
(3) name and telephone
number of physician or emergency medical facility authorized by guardian to be
called in case of illness or emergency;
(4) permission for emergency medical
transportation and guardian's consent for treatment.
D.
Date
of disenrollment.
E. The
following must be recorded in each participant's file when applicable:
(1) accidents and illnesses which require
first aid or medical attention;
(2)
observation of recent bruises, injuries or signs of abuse or neglect;
(3) use of physical restraints.
F. Medications prescribed for the
resident, including time and dosage.
G. Written authorization from the
participant, responsible party or guardian, must be in the participants record
for the removal of the participant's from the grounds of the facility to
participate in field trips, nature walks, or other activities whether or not
the activity includes transportation by vehicle.
H. Daily attendance of the
participant.
I. Enrollment
agreement signed by the participant, responsible party or guardian which
clearly outlines the following:
(1) services
to be provided by the facility and costs for the same;
(2) acknowledgement by the participant,
responsible party or guardian that they clearly understand the policies of the
facility and agree to them.
J. General:
(1) each participant's record must be kept on
file in the facility at least six (6) months after disenrollment.
(2) participant's records must be made
available to those persons authorized by law or regulation to review or inspect
such records, such as guardians, staff, or representatives of the licensing
authority.
(3) participant's
records must be complete with all documentation at the time of admission, to
include drop ins.
