PURPOSE: This rule prescribes requirements for a uniform system of recordkeeping in all community residential facilities and Psychiatric Group Homes II as required by section 630.710, RSMo.

1. (1) The facility shall keep records on all residents admitted to the facility and shall retain these records for at least five (5) years following the death or discharge of the residents.
2. (2) The facility shall keep active records complete with current information and readily available for review by the department, the state fire marshal’s inspectors or other persons authorized by law.
3. (3) Records shall be stored in a manner so as to properly safeguard confidentiality.

4. (4) Individual resident records shall include the following:

   1. (A) Admissions forms containing resident’s name, Social Security number, date of birth, place of birth, sex, race, height, weight, color of hair, color of eyes, identifying marks, religion, marital status, photograph sufficiently recent to be used for identification purposes and language spoken or used in natural home if not English; name, address and the telephone number of parents, guardians, next of kin or other responsible party; date of admission, diagnosis and age at onset of disability if known; type and legal status of admission to the facility, sources of financial support and insurance including burial plans and the name, address and telephone number of personal physician;
   2. (B) Signed consent for placement signed by the appropriate department representative and the client or guardian;
   3. (C) Reports of any sudden change in condition, injury, accident or deviation from routine delivery of services shall be entered at the time of occurrence;
   4. (D) Reports of comprehensive evaluations and annual physical examinations, including vision and hearing screening where indicated;
   5. (E) Medications and treatment orders, records of all drugs and medical treatment administered, special diets, immunization records, report of corrective dental work, results of laboratory tests, pelvic examinations, complete blood counts, tuberculin control tests, urinalysis, record of seizures and record of menses;
   6. (F) Restraint and protective devices orders, if any;
   7. (G) Individualized education plan (IEP) and school record, if attending;
   8. (H) Plans for educational/vocational goals and activities;
   9. (I) Quarterly height if in developmental period, and monthly weight; and
   10. (J) The individualized habilitation or treatment plan, including data collection on behavioral objectives and progress.
5. (5) The facility shall have entries in the resident’s record signed and dated by the person making the entry.
6. (6) If consultation services are either required or paid for by the department, the consultant shall make written reports of findings and recommendations. Recommendations regarding individual residents shall be entered in the resident's personal file. Recommendations regarding the facility as a whole shall be entered in the facility file. 9 CSR 40-4
7. (7) The facility shall retain on its premises, and make available for public inspection to staff, residents, their families or legal representative, and the public, a complete copy of each official notification from the department of violations, deficiencies, licensure approvals, disapprovals and responses, a description of services and charges for services.
8. (8) Each facility shall maintain a permanent chronological resident registry book showing the date of admission, name of resident, date of discharge and destination at time of discharge.
9. (9) The head of the facility shall implement a uniform bookkeeping system which is adequate to meet the needs of the facility and is consistent with standard accounting practice.
10. (10) The facility shall maintain a record of each resident’s money and valuable belongings kept on his/her behalf. The record shall be initialed at the time of admission and shall be kept current with written receipts for all personal possessions and funds received by or deposited with the facility and for all disbursements made to or on behalf of the residents. The facility shall keep a record of the resident’s clothing at admission.

11. (11) The facility shall maintain separate bookkeeping accounts with backup documentation, receipts and notations for each of the following:

    1. (A) Personal spending and clothing;
    2. (B) Medication; and
    3. (C) Each additional special service paid for by the department.
12. (12) The facility shall maintain a record of scheduled and unscheduled fire and catastrophic drills. The record shall indicate any failures on the part of staff or residents to respond properly during the drill.
13. (13) The facility shall maintain on file all statements of its policies and procedures.
14. (14) Each facility shall maintain a personnel file for each employee containing an application for employment which shall include the Social Security number, home address, phone number, health records, reference letters, educational background, work experience with date of employment, reasons for leaving, record of attendance at initial training courses and other workshops, type of position to be filled in the facility and periodic job performance evaluations. Reports of tuberculin control tests and statements that the employee has been screened for communicable diseases shall also be kept on each employee. Individual personnel records must be made available to the inspectors at the facility at the time of the inspection.
15. (15) The facility shall furnish the department with reports as may be requested. Proper safeguards to protect the rights of residents and employees shall be maintained.
16. (16) Every facility shall keep a current table of organization on file.
17. (17) Each facility shall keep a record of the names and number of hours worked by employees.
18. (18) Each facility shall keep a signed agreement, approved by the department, with a hospital or center capable of providing treatment to residents in a medical emergency.
19. (19) Each facility shall keep records of epidemic outbreaks in the facility file.
20. (20) The facility shall maintain and make available to the department other records that the department may require.
21. (21) In each Psychiatric Group Home II, a sign-out log shall be maintained. Each resident shall be required to notify staff and to sign out before leaving the premises and to sign in upon returning. Sign-out logs will include where the resident is going and expected time of return.

AUTHORITY: sections 630.050 and 630.705, RSMo (1994).* Original rule filed Oct. 13, 1983, effective Jan. 15, 1984. Amended: Filed March 14, 1984, effective Aug. 15, 1984. 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.