N.Y. Comp. Codes R. & Regs. tit. 18, § 487.10 – Records and reports.

(a) The operator shall collect and maintain such information, records or reports as determined by the department to be necessary.
(b) The department or its designee may examine the books and records of any facility to determine the accuracy of the annual financial statement, or for any other reason deemed appropriate by the department to effectuate the purposes of these regulations. The Justice Center shall have access to any residential care facility within its jurisdiction and adult care facilities in which a resident received mental health services as described in section 487.7(d)(8)(iv), (9)(ii), and (10) of this Part, and to information, reports or records in such facility's possession as needed to carry out the functions, powers and duties of the Justice Center. The department and the Justice Center shall, when required by law, or when so directed by the department or the Justice Center and except as otherwise prohibited by law, be permitted to share information obtained in their respective investigations of incidents.
1. (1) The operator shall maintain complete, accurate and current records for each resident.
2. (2) These records shall be maintained in the facility and shall be available for review and inspection by department staff designees.
3. (3) Records shall be maintained in a manner which assures resident privacy and accessibility to staff to use in the provision of routine and emergency services.
4. (4) At a minimum, the operator shall maintain:
  1. (i) financial records for each resident which contain, at a minimum, a copy of the current admission agreement, documentation of the status of the resident's payment account, personal fund account, and a current inventory of any personal property held in custody for the resident by the operator;
  2. (ii) personal records for each resident which contain, at a minimum: personal data, including identification of the resident's next of kin, family and sponsor; the name and address of the person or persons to be contacted in the event of emergency; copies of the resident's medical evaluations and other medical information, copies of the resident’s mental health evaluations, summaries of the social evaluations; and details of referral and such other correspondence and papers as are available to document the physical, mental and social status of the resident; and
  3. (iii) records which are readily available to food service staff and enable staff to plan for and accommodate prescribed dietary regimens, allergies and individual food preferences.
    (d) Facility records.
5. (1) The operator shall maintain complete, accurate and current records which document operation and maintenance of the facility in accord with applicable law and regulation.
6. (2) These records shall be maintained in the facility, unless written authorization is given by the department for record retention in another location, and shall be available for review and inspection by department staff and designees.
7. (3) Records must be maintained in a manner which assures individual residents' rights to confidentiality and privacy, provided that confidential HIV-related information concerning residents must be maintained in accordance with section 485.11(g)(9)-(15) of this Title.
8. (4) Confidential HIV-related information concerning employees, volunteers, applicants for employment and prospective residents must be maintained in accordance with section 485.11(g)(9)-(15) of this Title.
9. (5) At a minimum, the operator shall maintain:
  1. (i) individual resident records as stipulated in subdivision (c) of this section;
  2. (ii) resident records stipulated elsewhere in these regulations, including daily census reports and incident reports;
  3. (iii) a chronological admission and discharge register, consisting of a listing of residents registered in and discharged from such facility by name, age, sex of resident, and place from or to which the resident is registered or discharged;
  4. (iv) program records, including service procedures, activities schedules, agreements with external service providers, emergency plans and records of evacuation drills;
  5. (v) food service records, including menus and food purchase records;
  6. (vi) records of maintenance of the physical plant and environmental standards;
  7. (vii) staff records, including personnel procedures, job descriptions, staffing schedules and payment records;
  8. (viii) certificates or reports issued by local and other State jurisdictions related to the facility operations, on file and readily accessible for department review, or posted, if required; and
  9. (ix) records documenting the development, implementation and, at a minimum, the biannual updating of quality assurance activities for each area of facility operation. These must include, at a minimum, the development and maintenance of performance standards, measurement of adherence to such standards and to applicable State and local laws and regulations, identification of performance failures, design and implementation of corrective action.
10. (6) The records and reports required to be maintained by the operator pursuant to this subdivision shall not be posted or otherwise made available to the public.
  (e) Facility reports.
  The operator shall submit to the department:
11. (1) Annual financial statement.
  1. (i) The operator of an adult home or residence shall file an Annual Financial Statement (DSS-2963) with the department on or before the 15th of day of the sixth calendar month after the close of its fiscal year. Such statement shall clearly set forth all financial information pertaining to the operation of such facility in accordance with generally accepted accounting principles, including but not limited to revenues and expenses by categories during such fiscal year, together with such other information as may be required by the department, and shall, for all facilities with a capacity of 10 or more residents, be accompanied by an opinion signed by an independent licensed accountant that such financial statement represents the financial operations and position of the facility.
  2. (ii) The operator of a not-for-profit adult home which submits a charitable organization annual report to the Secretary of State or the residential health care facilities annual report to the Department of Health may submit copies of those reports, together with such other data as may be necessary to satisfy the requirement in subparagraph (i) of this paragraph.
  3. (iii) An operator shall maintain and make available all such books and records as may be required by the department to determine the accuracy of any and all information contained in the financial report filed by the operator.
12. (2) A quarterly statistical information report.
13. (3) For facilities with a certified capacity of 80 beds or more in which twenty percent or more of the resident population are persons with serious mental illness as defined in section 487.2(c) of this Part, a quarterly statistical information report which must:
  1. (i) identify the quarter being reported on;
  2. (ii) contain a census report, which shall include a roster of residents who are persons with serious mental illness as defined in section 487.2(c) of this Part;
  3. (iii) for any residents admitted during the quarter reported on, the prior residence, and for any residents discharged during the quarter being reported on, the discharge location; and
  4. (iv) contain the number of resident deaths which occurred during the quarter being reported on.
14. (4) For facilities with a certified capacity of 80 beds or more in which 20 percent or more of the resident population are persons with serious mental illness as defined in section 487.2(c) of this Part, a monthly admissions report identifying all persons admitted to the facility during the prior calendar month.
  (f) Mandated forms.
  The department mandates utilization of the following forms:
15. (1) Personal Data Sheet (DSS-2949).
16. (2) Daily Census Record (DSS-2900).
17. (3) Incident Report (DSS-3123).
18. (4) Medical Evaluation (DSS-3122).
19. (5) Inventory of Resident Property (DSS-3027).
20. (6) The following personal allowance account forms must be used unless prior written authorization for substitutions has been given by the department:
  1. (i) Statement of Offering (DSS-2853).
  2. (ii) Personal Allowance Summary (DSS-2855).
  3. (iii) Personal Allowance Ledger.
21. (7) Mental Health Evaluation.
(c) Resident records.
(g) The operator shall post the following documents:
1. (1) the operating certificate;
2. (2) the inspection report for the most recent complete or summary inspection, with any related follow-up inspection reports;
3. (3) statement of rights of residents;
4. (4) weekly menus;
5. (5) monthly activities schedules;
6. (6) evacuation procedures;
7. (7) notice prohibiting employee acceptance of remuneration, tips or gratuities;
8. (8) schedule of times residents may have access to their personal allowance accounts; and
9. (9) procedures for presenting grievances and recommendations.
  (h) Records retention.
10. (1) Records required by the department, excepting financial records of the previous operator, shall be retained in the facility upon change of operator.
11. (2) Records relating to an individual shall be retained for three years after death or discharge of a resident.
12. (3) Program records, business records and records relating to application or renewal for an operating certificate shall be retained for seven years.
(i) Except as otherwise prohibited by law, the operator of a facility, as defined in section 488(4) of the Social Services Law and who is not otherwise subject to article six of the Public Officers Law, shall make records available for public inspection and copying to the extent required by subdivision six of section 490 of the Social Services Law and regulations of the Justice Center.