Or. Admin. Code § 309-035-0130 - Records

(1) Records must be maintained to document the legal operation of the program, personnel practices, and resident services and supports provided. All records must be properly obtained, accurately prepared, safely stored, and readily available or electronically accessible within the setting. All entries in records required by these rules must be in ink, indelible pencil, or approved electronic equivalent prepared at the time or immediately following the occurrence of the event being recorded, be legible, and be dated and signed by the person making the entry. In the case of electronic records, signatures may be replaced by an approved, uniquely identifiable electronic equivalent.

(2) Records documenting the legal operation of the program must include but not limited to:

(a) Certificate of occupancy for proposed use of the setting by the county or city having jurisdiction, any building inspection reports, zoning verifications, fire inspection reports, or other documentation pertaining to the safe and sanitary operation of the program issued during the development or operation of the program;

(b) Application for license, related correspondence, and site inspection reports;

(c) Program operating budget and related financial records;

(d) Payroll records, program staff schedules and time sheets;

(e) Safety data sheets;

(f) Fire drill documentation;

(g) Fire alarm and sprinkler system maintenance and testing records;

(h) Incident reports; and

(i) Policy and procedure manual.

(3) Personnel records must document and include:

(a) Job descriptions for all positions; and

(b) Separate program staff records including, but not limited to:

(A) Written documentation of program staff identifying information and qualifications;

(B) Background check approval;

(C) Documentation that Hepatitis B inoculations have been given or made available;

(D) Performance appraisals; and

(E) Documentation of pre-service orientation and other training.

(4) Resident service records must be maintained for each resident and include:

(a) An easily accessible summary sheet that includes, but is not limited to, the resident's legal name for billing purposes, chosen name, previous address, date of admission to the program, pronouns, gender identity, date of birth, marital status, legal status, religious preference, health provider information, evacuation capability, DSM diagnosis, physical health diagnosis, medication allergies, food allergies, information indicating whether advance mental health and health directives have been executed, and the name of individuals to contact in case of emergency;

(b) The names, addresses, and telephone numbers of the resident's legal representative, legal guardian or conservator, parents, next of kin, supervisory entity, or other significant persons, physicians or other medical practitioners, dentist, case manager or therapist, day program, school, or employer, and any governmental or other agency representatives providing services to the resident, as applicable;

(c) A current mental health assessment, conducted within the last year, and background information identifying the resident's residential service needs;

(d) Advance mental health and medical health directives, burial plans, or location of these;

(e) A residential service plan and copy of plans from other service providers;

(f) A person-centered service plan;

(g) Documentation of the resident's progress as described in OAR 410-120-1360(2), OAR 410-172-0620, and OAR 410-172-0045 and any other significant information including, but not limited to, progress notes, progress summaries, any use of seclusion or restraints, and correspondence concerning the resident; and

(h) Health-related information and up-to-date information on medications.

(i) Current copies of documentation relating to guardianship, conservatorship, commitment status, advance directives, or any other legal restrictions;

(5) The program must retain all referral packets, screening materials, and screening responses-placement determinations for a minimum of three years from the date of the referral.

(6) The program must establish a resident service record upon the resident's admission. Prior to admission or within five days after an emergency admission, the program must determine with whom communication needs to occur and make good faith efforts to obtain the needed authorizations for release of information. The record established upon admission must include the materials reviewed in screening the individual, the summary sheet, and any other available information.

(7) All resident service records must be kept confidential as required by law. A signed release of information must be obtained for any disclosure from a resident service record, except as otherwise authorized by law. Release of information is not required to provide information to the resident's legal representative or supervisory entity.

(8) In accordance with ORS 179.505, the program must obtain and maintain authorizations for the disclosure of any confidential information concerning prospective residents and current residents in the form and manner described in ORS 192.566:

(a) Unless required or allowed by state or federal law, a provider must not disclose any personally identifiable information regarding:

(A) A resident's sexual orientation.

(B) Whether a resident is LGBTQIA2S+.

(C) A resident's gender transition status.

(D) A resident's human immunodeficiency virus status.

(b) Programs must take appropriate steps to minimize the likelihood of inadvertent or accidental disclosure of information described in subsection (a) of this section to other residents, visitors, or staff, except to the minimum extent necessary for staff to perform their duties. Appropriate steps may include policies and procedures, training, or other documented actions or plans that address record disclosure by the provider and staff. The licensee or administrator must notify the individual or individuals legal guardian or representative if a resident is affected by a disclosure of information.

(9) A resident or the resident's legal representative must be allowed to review and obtain a copy of the resident service record as required by ORS 179.505(9).

(10) If a resident or the individual's legal representative disagrees with the content of the individual service record, or otherwise desires to provide documentation for the record, the individual or the individual's legal representative may provide material in writing that must become part of the individual service record.

(11) All resident service records must be stored in a weatherproof and secure location. Access to records must be limited to the program administrator and direct care staff unless otherwise allowed in these rules.

(12) Pertinent information from records of a resident being transferred to another facility must be transferred with the individual. A signed release of information must first be obtained in accordance with applicable laws and rules.

(13) If a program changes ownership or program administrator, all individual and personnel records must remain at the setting. Prior to the dissolution of any program, the program administrator must notify the Division in writing as to the location and storage of individual service records or those records must be transferred with the individual.

(14) The program must keep all records, except those transferred with a resident, for a period of three years.

Notes

Or. Admin. Code § 309-035-0130

MHD 9-1984 (Temp), f. & ef. 12-10-84; MHD 9-1985, f. & ef. 6-7-85; MHD 4-1998, f. 5-21-98, cert. ef. 6-1-98; MHD 4-2005, f. & cert. ef. 4-1-05; MHS 13-2016(Temp), f. 9-6- 16, cert. ef. 9-7-16 thru 3-3-17; MHS 2-2017(Temp), f. 3-3-17, cert. ef. 3-4-17 thru 8-30-17; MHS 5-2017, f. & cert. ef. 6/8/2017; BHS 41-2023, temporary amend filed 10/12/2023, effective 10/15/2023 through 4/11/2024; BHS 6-2024, amend filed 04/11/2024, effective 4/11/2024; BHS 4-2025, amend filed 02/28/2025, effective 3/1/2025

Statutory/Other Authority: ORS 413.042 & 443.450

Statutes/Other Implemented: ORS 413.032, 443.400 - 443.465 & 443.991