PURPOSE: This rule prescribes requirements for a uniform system of recordkeeping in day programs serving people who are mentally ill or mentally disordered as required by section 630.710, RSMo.

1. (1) Records shall be kept on all clients admitted to any day program and shall be retained for a minimum of seven (7) years following discharge of the client.
2. (2) All active records shall be current and readily available for review by the department or other authorized persons.
3. (3) Records shall be stored in such a manner as to properly safeguard the confidentiality of their contents.

4. (4) Individual client records shall be kept at the day program location during the hours the client is involved in the program and include the following:

   1. (A) Admission forms containing client’s name, address, phone number, Social Security number, language spoken or used in natural home if not English; name, address and telephone number of parents, guardians, next of kin or other responsible party to be notified in case of emergency; date of admission, diagnosis and legal competency status; and the name, address and telephone number of personal physician or health facility providing medical care and pay sources, if known;
   2. (B) The individualized program plan;
   3. (C) The client’s drug chart if medications are administered at the day program; and
   4. (D) Reports of any sudden change in condition, injury, accident or deviation from routine delivery of services shall be entered at the time of occurrence.
5. (5) Entries in the client’s record shall be signed and dated by the person making the entry.
6. (6) The program shall make available for public inspection to staff, clients, their families or legal representative and the public a complete copy of each official notification from the department of violations, deficiencies, licensing approvals, disapprovals and responses, a description of services and charges for services.
7. (7) Each day program shall maintain a personnel file for each employee containing Social Security number, home address, phone number, reference information, educational background, work experience with dates of employment, reasons for leaving, record of attendance at orientation and other training courses, job description, periodic job performance evaluations, copies of applicable licenses and renewals for qualified mental health professionals and documentation of education and experience. Reports of tine tests or chest X-rays and statements that the employee is free from communicable diseases also shall be kept on each employee. Mentally Ill or Mentally Disordered

Individual personnel records must be made available for licensing inspections at the day program at the time of inspection.

1. (8) The program shall furnish to the department the reports and records relevant to these rules as may be requested. Proper safeguards to protect the rights of clients and employees shall be maintained.
2. (9) Every program shall keep a current table of organization on file.
3. (10) Each day program shall keep a record of the names and number of hours worked by employees.
4. (11) If an epidemic outbreak occurs, the program shall maintain a record of it.

AUTHORITY: sections 630.050 and 630.705, RSMo (1994).* Emergency rule filed June 17, 1986, effective July 1, 1986, expired Oct. 29, 1986. Original rule filed June 17, 1986, effective Nov. 13, 1986. Amended: Filed Jan. 2, 1990, effective June 11, 1990. Amended: Filed July 17, 1995, effective March 30, 1996.

*Original authority: 630.050, RSMo (1980), amended 1993, 1995 and 630.705, RSMo (1980), amended 1982, 1984, 1985, 1990.