5123:2-3-13 Individual records.

 

 

 

TO BE RESCINDED

 

5123:2-3-13                 Individual records.

 

 

 

(A)  Purpose

 

The purpose of this rule is establish standards to ensure that records of the individual are readily accessible for implementation of services and supports and for department review during surveys and to ensure the confidentiality of information contained in those records.

 

(B)  Confidentiality of records

 

All information contained in an individual's record shall be considered privileged and confidential. The licensee shall have written policies and procedures specifying confidentiality of records as it pertains to access to, duplication of, and dissemination of information from the record. Records shall be maintained in such a manner to ensure their confidentiality and protect them from unauthorized disclosure of information.

 

(C)  Records at the residential facility

 

Records for the current calendar year and the previous twelve months shall be maintained at the residential facility for each individual and shall be made available for review by licensure and other representatives of the department. These records shall include, but not be limited to, the following:

 

(1)  A current photograph of the individual.

 

(2)   Legal status of the individual.

 

(3)    Records of accidents, injuries, seizures, major unusual incidents, and unusual incidents and the treatment or first aid measure administered for each. Information pertaining to abuse/neglect investigations and other confidential information may be maintained at a location other than the residential facility, but shall be provided to licensure for review at the facility upon request.

 

(4)   All medical and dental examinations and the most recent immunization records as appropriate to age.

 

(5)      Medication and treatment records which shall indicate the person who prescribed the medication and treatment and the date, time, and person who administered the medication and treatment.

 

 

 

 

(6)   Records of planned absences from the residential facility for twenty-four hours or longer as well as notations of the time of the individual's return.

(7)   Plans and other related documentation and notations of progress.

(8)    Reconciliations of the individual's account transaction records as required in paragraph (J)(2)(i) of rule 5123:2-3-14 of the Administrative Code.

(9)     Authorization for emergency medical treatment reviewed annually by the licensee and updated and signed as circumstances dictate. Evidence of an annual review shall be present.

(10)   Evidence of consents for the participation in services including, but not limited to, medical treatments, behavior management programs, and the use of psychotropic medications.

(D)  Permanent records

Permanent records for each individual shall be maintained by the licensee at an accessible location and such records shall be provided to licensure for review at the residential facility upon request. The licensee shall develop a records retention schedule for all permanent records in accordance with applicable state and federal requirements. Permanent records shall include, but not be limited to, the following:

(1)   Admission and referral records;

(2)   All medical and dental examinations, and immunization records as appropriate to age;

(3)   All medication and treatment records;

(4)    All records of the individual's account transaction record as defined in rule 5123:2-3-14 of the Administrative Code;

(5)   Records of negotiable items owned by the individual which can be converted to cash or transferred such as bonds or promissory notes;

(6)   Investigative files resulting from major unsual incidents or unusual incidents;

(7)   Records of clothing and personal belongings; and

(8)   Discharge summaries which shall be prepared within seven days following the individual's discharge. The summary shall include the individual's progress during residence and new address of residence.

Replaces:                                                     5123:2-3-16

Effective:                                                     01/01/2006

R.C. 119.032 review dates:                         09/30/2005

CERTIFIED ELECTRONICALLY

Certification

12/05/2005

Date

Promulgated Under:                           119.03

Statutory Authority:                           5123.04, 5123.19

Rule Amplifies:                                  5123.04, 5123.19

Prior Effective Dates:                         10/31/77, 6/12/81, 9/30/83, 11/16/90, 12/9/91,

5/18/95, 4/27/00