(b) The following information shall be contained in each resident’s record:

1. (1) Resident's name and residential address prior to admission;
2. (2) Resident's sponsor’s name, residential address, home telephone number, and business telephone;
3. (3) Name and regular emergency telephone numbers of the resident’s attending physicians;
4. (4) Reports of referring source;
5. (5) Reports of outside service referrals;
6. (6) Resident's individual service plan;
7. (7) Name and home telephone of the program manager for the resident;
8. (8) Evaluation reports from each service;
9. (9) Reports of staff conferences concerning the resident;
10. (10) The resident’s home health care service plan;
11. (11) A copy of the resident’s rights statement signed by the resident or the resident’s sponsor;
12. (12) Written authorization from the resident’s attending physician for any medications being received by the resident;
13. (13) Any correspondence pertinent to the resident;
14. (14) A list of all insurance policies insuring the life of a resident of which the facility is a beneficiary; and
15. (15) A signed copy of the facility’s admission/discharge and transfer agreement with the resident.

(c) The facility shall maintain all resident records as follows:

1. (1) All information and documents shall be organized in a systematic fashion and affixed to the record binder;
2. (2) All resident records shall be maintained at a central location;
3. (3) A designated staff member shall be responsible for the control of all resident records;
4. (4) An indexing and filing system shall be maintained for all resident’s records; and
5. (5) Resident records shall be stored under lock with reasonable protection against fire, water, and other hazards.

(d) The facility shall protect the confidentiality of resident records as follows:

1. (1) Each resident or the resident’s sponsor shall have the right to inspect the resident’s records during normal business hours;
2. (2) Provide access to the agents, representatives, and employees of Office of Long-Term Care in furtherance of the performance of official duties;
3. (3) The facility shall not disclose any resident’s records to any person or agency other than the resident, the resident’s sponsor, the personnel of the facility, or personnel of the Office of Long-Term Care, except upon express written consent of the resident, unless the disclosure is required by state or federal law; and
4. (4) Any inspection, investigative reports, or written complaints which are accessible to the public shall not disclose the identity of any resident.

(e)

1. (1) Upon discharge or death, a copy of the resident’s discharge report or death certificate shall be placed in the resident’s record.
2. (2) The records of discharged or deceased residents must be retained for three (3) years but may be stored separate from the records of present residents.