1. (a) The adult family care provider shall maintain on site a legible, current, and accurate record for each resident based on services provided at the AFCR.

2. (b) At a minimum, resident records shall contain the following:

   1. (1) A copy of the admissions contract and all documents required by He-P 813.15;

   2. (2) Identification data, which shall include:

      1. a. Vital information including the resident’s name, date of birth, and marital status;
      2. b. If a resident is present only for respite care as described in He-P 813.24, the resident’s home address and phone number;
      3. c. The resident’s religious preference, if known;
      4. d. The name, address, and telephone number of an emergency contact person;
   3. (3) The names and telephone numbers of the resident’s licensed practitioners;
   4. (4) The names, employers, business addresses, and telephone numbers of individuals contracted by the resident to provide services at the AFCR;
   5. (5) Copies of all executed legal directives, such as durable power of attorney and living will;
   6. (6) A record of the health examination(s) conducted by a licensed practitioner, which includes the information required by He-P 813.18(p) unless the licensed practitioner or resident documents refusal;

   7. (7) Written, dated and signed orders for the following:

      1. a. All medications;
      2. b. Treatments; and
      3. c. Special diets;
   8. (8) All assessments and plans;
   9. (9) Documentation that the resident or representative has participated in the development of the person-centered plan;
   10. (10) All admission and progress notes;

   11. (11) If services are provided at the AFCR by individuals not employed by the AFCR, documentation, which shall include:

       1. a. The name of the agency providing the services;
       2. b. The date services were provided; and
       3. c. The name of the person providing the services;

   12. (12) Documentation of any alteration in the resident’s daily functioning such as:

       1. a. Signs and symptoms of illness; and
       2. b. Any action that was taken, including practitioner notification;
   13. (13) Documentation of specialized care;
   14. (14) Documentation of unusual incidents;
   15. (15) The resident’s or representative’s consent for release of information;
   16. (16) Transfer or discharge planning and referrals;
   17. (17) Notification to the resident or representative of involuntary room change, transfer or discharge;

   18. (18) The medication record, including:

       1. a. The medication name, strength, dose, frequency and route of administration;
       2. b. The date and time the medication was taken;
       3. c. Effects of over the counter medications;
       4. d. Documentation of medication errors or resident refusal to take the medication; and
       5. e. Notice to the resident’s licensed practitioner of any undesirable effects;
   19. (19) Emergency data sheet, which contains the information required by He-P 813;
   20. (20) Documentation of any resident refusal of care or services; and
   21. (21) Documentation of nurse delegation as required by He-P 813.18(y), if applicable.

3. (c) Resident records shall be available to:

   1. (1) The resident;
   2. (2) The AFCR and oversight agency staff as required by their job responsibilities;
   3. (3) Any individual(s) given written authorization by the resident or representative; and
   4. (4) The department and its agents.
4. (d) The adult family care provider shall arrange for retention of and access to resident records for 6 years from the date the resident leaves the AFCR or for 4 years from the date the AFCR ceases operation.

Source. #8595, eff 4-1-06; ss by #9899-A, eff 3-29-11 (from He-P 813.22); ss by #12740, INTERIM, eff 3-20-19, EXPIRED: 9-16-19 New. #12934, eff 12-6-19