55 Pa. Code § 2800.252 - Content of resident records
Each resident's record must include the following information:
(1) Name, gender,
admission date, birth date and Social Security number.
(2) Race, height, weight at time of
admission, color of hair, color of eyes, religious affiliation, if any, and
identifying marks.
(3) A photograph
of the resident that is no more than 2 years old.
(4) A language, speech, hearing or vision
need which requires accommodation or awareness of during oral or written
communication.
(5) The name,
address, telephone number and relationship of a designated person to be
contacted in case of an emergency.
(6) The name, address and telephone number of
the resident's physician or source of health care.
(7) The current and previous 2 years'
physician's examination reports, including copies of the medical evaluation
forms.
(8) A list of prescribed
medications, OTC medications and CAM.
(9) Dietary restrictions.
(10) A record of incident reports for the
individual resident.
(11) A list of
allergies.
(12) Documentation of
health care services and orders, including orders for the services of visiting
nurse or home health agencies.
(13)
The initial assessment, the preliminary support plan and the most current
version of the annual assessment.
(14) A final support plan.
(15) Applicable court order, if
any.
(16) The resident's medical
insurance information.
(17) The date
of entrance into the residence, relocations and discharges, including the
transfer of the resident to other residences owned by the same legal
entity.
(18) An inventory of the
resident's personal property as voluntarily declared by the resident upon
admission and voluntarily updated.
(19) An inventory of the resident's property
entrusted to the administrator for safekeeping.
(20) The financial records of residents
receiving assistance with financial management.
(21) The reason for termination of services
or transfer of the resident, the date of transfer and the
destination.
(22) Copies of transfer
and discharge summaries from hospitals, if available.
(23) If the resident dies in the residence, a
copy of the official death certificate.
(24) Signed notification of rights, grievance
procedures and applicable consent to treatment protections specified in §
2800.41 (relating to notification
of rights and complaint procedures).
(25) A copy of the resident-residence
contract.
(26) A termination notice,
if any.
(27) A record relating to
any exception request under §
2800.229 (relating to excludable
conditions; exceptions).
(28)
Ongoing resident progress notes.
Notes
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