1. (a) Separate records for each individual shall be maintained by the residence administrator at the residence.
2. (b) Each individual living in a community residence shall have specified in their service agreement the number of hours of daily supervision required.

3. (c) Each individual's record shall include:

   1. (1) The names, addresses, and telephone numbers of persons to be notified in an emergency;
   2. (2) The individual's current individual service agreement;
   3. (3) The individual’s fire safety assessment and, if applicable, fire safety plan;
   4. (4) The individual’s personal safety assessment and personal safety plan, if determined necessary according to He-M 1001.06 (ab) and (ae);
   5. (5) Progress notes, in accordance with the service agreement, that document residential services provided;

   6. (6) Medical information including:

      1. a. The names, addresses, and telephone numbers of the individual's physician, dentist, therapists, and any other licensed practitioners;
      2. b. Medical orders;
      3. c. Medical history;
      4. d. The dates of medical testing, to include, but not be limited to, colonoscopies, mammograms, pap smears, prostate-specific antigen (PSA) tests, bone density tests, dental work, and eye exams;
      5. e. A copy of the nurse-trainer assessment and approval for medication self-administration as required by He-M 1201.05, if applicable;
      6. f. A copy of the annual health assessment of the individual pursuant to He-M 1001.06(a);
      7. g. Known allergies, if any;
      8. h. A copy of the individual’s do not resuscitate (DNR) order, if applicable;
      9. i. Health Risk Screening Tool (HRST) monthly data tracker information;
      10. j. Other pertinent medical information;
      11. k. A medication log completed at the residence pursuant to He‑M 1201.07 for all current medications; and
      12. l. Any correspondence related to medical information relevant to the individual; and
   7. (7) If applicable, documentation that the individual or guardian refused to provide the medical information required in (6) above.

4. (d) Attendance records shall be completed by the residence administrator or other provider such that:

   1. (1) The date and whether or not residential services were provided to the individual shall be recorded;
   2. (2) When a leave of absence occurs, the record shall indicate the date and time of the individual's departure and return and the reason for the absence; and
   3. (3) Attendance records shall be on file at the community residence.
5. (e) Outdated information may be removed from the community residence record but shall be maintained in the individual's record and accessible for 6 years.

6. (f) When service provision is to be transferred from one provider agency to another, the transferring agency shall provide the following information regarding the individual:

   1. (1) Medical history, including diagnosis and annual health assessments for the past 3-year period, if available;
   2. (2) Any known allergies;
   3. (3) Assessment for self-administration of medication pursuant to He-M 1201.05, if applicable,
   4. (4) Current medications and a medication list with the times medications are administered;
   5. (5) Current medication orders and medication administration consent forms;
   6. (6) Current medication administration authorizations of any staff transferring with the individual;
   7. (7) For informational purposes, copies of the past 2 months of records of medication administration performed pursuant to He-M 1201;
   8. (8) Dental health information;

   9. (9) Pertinent personal information, such as:

      1. a. Use of adaptive equipment;
      2. b. Sleep patterns; and
      3. c. Preferences and dislikes;

   10. (10) Any applicable protocols, such as those for:

       1. a. Feeding;
       2. b. Swallowing;
       3. c. Medication administration;
       4. d. Behavioral support; and
       5. e. Seizures;
   11. (11) Most recent service agreement; and
   12. (12) List of contacts and emergency information.

Source. (See Revision Note at part heading for He-M 1001) #5867, eff 9-1-94, EXPIRED: 9-1-00 New. #7681, eff 4-23-02; ss by #9696, INTERIM, eff 4-23-10, EXPIRES: 10-20-10; ss by #9776-A, eff 10-1-10, EXPIRED 10-1-18 New. #12650, INTERIM, eff 10-24-18, EXPIRED 4-22-19 New. #12775, eff 5-7-19; ss by #14255, eff 5-23-25, EXPIRES: 5-23-35