§ 5320.64. Resident records.
(a) The provider shall maintain individual resident records which shall be reviewed by the resident or a designee and the Department or its authorized agents upon request.
(b) The provider shall retain resident records for at least 4 years after the resident has left the LTSR.
(c) The provider shall divide the resident records into two sections: a clinical and nonclinical section.
(1) The clinical section of the resident records shall, at a minimum, contain the following information:
(i) The resident’s name.
(ii) The resident’s gender, race and ethnicity.
(iii) The resident’s birth date.
(iv) The resident’s Social Security number.
(v) The name, telephone number and address of the designated person to be contacted in case an emergency, illness or injury, transfer, termination of service, or death occurs to the resident or in the case of LTSR closure.
(vi) The names and telephone numbers of the resident’s personal physician and dentist, if any.
(vii) The dates of entrance into the LTSR, transfers and discharges.
(viii) The most recent annual physical examination.
(ix) The principal mental health diagnosis as designated in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM IV) or most recent edition available from the American Psychiatric Association, 1700 18th Street, NW, Washington, D.C. 20009. The International Classification of Diagnoses, Clinical Modification (ICD-9-CM), available from HCIA, Inc., 300 East Lombard Street, Suite 1500, Baltimore, Maryland 21202, telephone (800) 568-3282, shall be used for the purpose of classifying diseases.
(x) A copy of the resident’s treatment plan and progress notes describing the treatment and rehabilitative services provided with the resident’s response to those services as well as reviews and periodic reexaminations.
(xi) A copy of the written contract between the provider and the resident.
(xii) Physicians’ orders for medication to be administered at the LTSR as well as other medical orders to be carried out at the LTSR, and records of medication administration.
(xiii) The initial assessment and most recent update.
(xiv) Dietary restrictions, if any.
(2) The nonclinical section of the resident records shall, at a minimum, contain the following information:
(i) An inventory of the personal property, except consumable items, which the resident brings to the LTSR.
(ii) An inventory of the resident’s property entrusted to the provider for safekeeping.
(iii) The financial records of the resident receiving assistance with financial management.
(iv) The reason for the termination of services, or transfer of the resident or reason for death, as applicable, to be included as part of a discharge summary.
(v) Documentation of the resident’s current commitment status.
(vi) Written authorization for admission signed by the county administrator.
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