1. (a) A separate record shall be kept for each individual.
2. (b) Entries in an individual’s record must be legible, dated and signed by the person making the entry.

3. (c) Each individual’s record must include the following information:

   1. (1) Personal information, including:

      1. (i) The name, sex, admission date, birthdate and Social Security number.
      2. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.
      3. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual’s natural home, if other than English.
      4. (iv) The religious affiliation.
      5. (v) The next of kin.
      6. (vi) A current, dated photograph.
   2. (2) Incident reports relating to the individual.
   3. (3) Physical examinations.
   4. (4) Dental examinations.
   5. (5) Assessments as required under § 6500.151 (relating to assessment).
   6. (6) Individual plan documents as required by this chapter.
   7. (7) Copies of psychological evaluations and assessments of adaptive behavior, as necessary.

Authority

The provisions of this § 6500.182 amended under sections 201(2), 403(b), 403.1(a) and (b), 911 and 1021 of the Human Services Code (62 P.S. § § 201(2), 403(b), 403.1(a) and (b), 911 and 1021); and section 201(2) of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § 4201(2)).

Source

The provisions of this § 6500.182 amended August 27, 2010, effective August 28, 2010, 40 Pa.B. 4935; amended October 4, 2019, effective in 120 days, 49 Pa.B. 5777. Immediately preceding text appears at serial pages (382049) to (382050).

Cross References

This section cited in 55 Pa. Code § 6500.183 (relating to record location); 55 Pa. Code § 6500.201 (relating to exceptions for respite care); and 55 Pa. Code § 6500.202 (relating to exceptions for emergency respite care).