b) An establishment shall maintain a resident's record that contains at least the following:

1. 1) The resident's name and Social Security number;
2. 2) The date of the resident's acceptance into the establishment and the last address of the resident;

3. 3) The names, addresses, and telephone numbers of the following:

   1. A) The resident's representative, if applicable;
   2. B) The resident's primary health care provider; and
   3. C) An individual or relative to be contacted in the event of emergency, significant change in the resident's condition, or termination of residency;
4. 4) The establishment contract and any amendments;
5. 5) Documentation of orientation to the evacuation plan;
6. 6) Notation of assessments and evaluations conducted pursuant to Section 295.4000;
7. 7) The service plan, its amendments and updates;
8. 8) A health care directive, if disclosed and applicable;
9. 9) Notation of known accidents, incidents or injuries;
10. 10) Documentation of any significant change in a resident's behavior or physical, cognitive, or functional condition that would trigger an assessment or evaluation, and action taken by employees to address the resident's changing needs;
11. 11) A written notice of termination of residency, if applicable;
12. 12) Documentation of relocation assistance provided to the resident, if applicable;
13. 13) A negotiated risk agreement, if applicable;
14. 14) Any express waiver of confidentiality;
15. 15) If applicable, letters of guardianship, the resident's representative designation form, or durable power of attorney for health care; and
16. 16) Orders from a licensed health care provider for medication that is to be administered by the establishment.

d) An establishment shall ensure that a resident's record is:

1. 1) Confidential and only released with written permission from the resident or the representative, or as otherwise provided by law;
2. 2) Maintained at the establishment;
3. 3) Legibly recorded in ink or electronically recorded;
4. 4) Retained for 3 years from the date of termination of residency (closed records may be retained off-site); and
5. 5) Available for review by the resident or the resident's representative during normal business hours or at a time agreed upon by the resident and the manager.

f) The following resident records and supporting documents shall be made available for on-site inspection by the Department upon request at any time:

1. 1) Service delivery contracts and related documents executed by each resident or resident's representative, including, but not limited to, negotiated risk agreements;
2. 2) Records supporting compliance with each individual contract and with this Part; and
3. 3) Incident and accident reports that are required to be submitted to the Department. (Section 105 of the Act)