1. (1) At the time of admission, a separate file must be established for each category A, category B, category C, or category D resident. This file must be maintained on site in a safe and secure manner and must preserve the resident's confidentiality.

2. (2) The file shall include at least the following:

   1. (a) a completed resident agreement, in accordance with ARM 37.106.2823;
   2. (b) updates of resident/provider agreements, if any;
   3. (c) the service plan for all category A residents;
   4. (d) resident's weight on admission and at least annually thereafter for category A residents or more often as the resident, or the resident's licensed health care professional, determine a weight check is necessary;

   5. (e) reports of significant events including:

      1. (i) documentation of the notice to the resident's practitioner;
      2. (ii) steps taken to safeguard the resident; and
      3. (iii) facility contacts with family members or another responsible party;
   6. (f) a record of communication between the facility and the resident or their representative if there has been a change in the resident's status or a need to discharge; and
   7. (g) the date and circumstances of the resident's final transfer, discharge, or death, including notice to responsible parties and disposition of personal possessions.
3. (3) The resident file must be kept current. The file must be retained for a minimum of three years following the resident's discharge, transfer or death.

Authorizing statute(s): 50-5-103, 50-5-226, 50-5-227, MCA

Implementing statute(s): 50-5-225, 50-5-226, 50-5-227, MCA

History: NEW, 2002 MAR p. 3638, Eff. 12/27/02; AMD, 2004 MAR p. 1146, Eff. 5/7/04; AMD, 2022 MAR p. 1857, Eff. 9/24/22.