Subchapter G. PERSONAL CARE SERVICES/RESIDENT RECORDS
Sec.
5320.61. Tasks of daily living.
5320.62. Personal care.
5320.63. Resident funds.
5320.64. Resident records.
5320.65. Recordkeeping.§ 5320.61. Tasks of daily living.
The direct-care staff shall provide residents with assistance and skill training in tasks of daily living as needed. These tasks include:
(1) Securing transportation.
(2) Shopping.
(3) Making and keeping appointments.
(4) Care of personal possessions.
(5) Use of the telephone.
(6) Use of interpersonal skills.
(7) Self-care skills.
(8) Use of social and leisure activities.
(9) Securing health care.
§ 5320.62. Personal care.
The direct-care staff shall provide residents with assistance and skill training in personal care, as needed, including the following:
(1) Bathing.
(2) Oral hygiene.
(3) Hair grooming and shampooing.
(4) Dressing and care of clothes.
§ 5320.63. Resident funds.
The provider shall develop written policies and procedures addressing:
(1) Costs and liabilities for service according to the Letter of Agreement between the LTSR provider and the county administrator, described in § 5320.11 (relating to prerequisites to licensure) and in the resident/provider contract described in § 5320.33 (relating to resident/ provider contract; information on resident rights).
(2) Training for residents who require assistance in the management of their financial affairs.
(3) Maintenance of a separate and current individual record of financial transactions made on behalf of the resident that is available on request to the resident or the resident’s designated person, if any.
(4) Financial assistance by the provider, which shall include:
(i) Written receipts and quarterly statements of transactions, deposits and expenditures made on behalf of residents as well as disbursement of funds. The provider shall obtain written acknowldgement by the resident of the receipt of funds.
(ii) Provisions for the availability to the resident of documented accounting of deposits, receipts of funds, dispersal of funds and the current balance.
(iii) Assistance with financial arrangements if a resident’s accumulated cash assets (after per diem care costs) exceeds $200. The provider shall notify the resident and offer assistance in establishing an interest-bearing account in the resident’s name at a local financial institution protected by the Federal Deposit Insurance Corporation, or another appropriate arrangement indicated by the resident.
(iv) Transfer of the resident’s funds and possessions to the administrator or the executor of the resident’s estate, together with an itemized written account upon the death of a resident. A signed receipt shall be obtained and retained by the provider.
(v) Providing the resident with an itemized written account of funds upon termination of service. A balance remaining on the resident’s account with the provider shall be immediately returned to the resident.
§ 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.
§ 5320.65. Recordkeeping.
Provision of services and the resident’s progress toward treatment goals shall be documented by direct-care staff completing a progress note in the resident’s record at least weekly, or more often as warranted by specific changes in the resident’s behavior status. Additionally, special treatment interventions ordered in the treatment plan shall be documented by the direct-care or consulting direct-care staff authorized to provide the special treatment on a monthly basis or more frequently if warranted.
No part of the information on this site may be reproduced for profit or sold for profit.
This material has been drawn directly from the official Pennsylvania Code full text database. Due to the limitations of HTML or differences in display capabilities of different browsers, this version may differ slightly from the official printed version.
