PURPOSE: This rule prescribes requirements for a uniform system of recordkeeping in day programs 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 five (5) 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 and include the following:

   1. (A) Admission forms containing client’s name, place of residence, home telephone number, Social Security number, date of birth, place of birth, sex, race, height, weight, color of hair, color of eyes, identifying marks, religion, marital status, a photograph sufficiently recent to be used for iden- 9 CSR 40-9

tification, 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; date of admission, diagnosis and age at onset of disability, type and legal status of admission to the program; and the name, address and telephone number of personal physician. If a client refuses to provide a photograph, this shall be documented in the record;

1. (B) Current comprehensive evaluation reports;
2. (C) Special diets, and for the children, immunization records;
3. (D) The individualized program plan;
4. (E) The client’s drug chart if medications are administered at the day program; and
5. (F) Reports of any sudden change in condition, injury, accident or deviation from routine delivery of services shall be entered at the time of occurrence.

1. (5) Entries in the client’s record shall be signed and dated by the person making the entry.
2. (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.
3. (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 training courses, periodic job performance evaluations, copies of applicable licenses and renewals, and for qualified mental retardation professionals, 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. Individual personnel records shall be made available for licensing inspections at the day program at the time of inspection.
4. (8) The day program shall furnish to the department those reports as may be requested. Proper safeguards to protect the rights of residents and employees shall be maintained.
5. (9) Every day program shall keep a current table of organization on file.
6. (10) Each day program shall keep a record of the names and number of hours worked by employees.
7. (11) Each day program shall maintain in the day program file a record of epidemic outbreaks.
8. (12) The day program shall maintain and make available to the department such other records that the department may require.

AUTHORITY: sections 630.050 and 630.705, RSMo (1994).* Original rule filed Oct. 13, 1983, effective Jan. 15, 1984. Amended: Filed Feb. 4, 1986, effective July 1, 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.