3701-16-14 Recordkeeping.

Each community alternative home shall maintain the following records:

(A) An individual record for each resident which shall be stored in a manner that protects and ensures confidentiality.

(1) Staff members who have access to residents’ personal information shall not discuss or share the information with another individual working in the home unless transmission of the information is necessary to provide care to or to meet the needs of the resident. Individuals working in the home shall not discuss residents’ personal information with or in front of other residents of the home, or with persons outside of the home except as provided for in paragraph (A)(4) of this rule. Individuals working in the home shall return resident records to the storage area and not allow the records to remain open in the view of others in the home.

(2) The home shall safeguard resident records against loss, destruction, or unauthorized use. Each resident record shall be maintained by the home for at least two years after the resident is permanently transferred or discharged or dies.

(3) All resident records shall remain in the home regardless of changes in ownership, operator, or other staff except as provided under paragraph (A)(4) of this rule. Upon closure of a home, the home either shall provide the records to the resident upon request or shall arrange for the storage of records in a manner that ensures confidentiality of the information therein, for the time period specified in paragraph (A)(2) of this rule.

(4) Except as expressly approved in writing by the resident in accordance with the provisions of section 3701.243 of the Revised Code, all resident records shall be kept confidential and shall be disclosed only in the following circumstances:

(a) Release to individuals who are investigating reports of violations of Chapter 3724. of the Revised Code and Chapter 3701-16 of the Administrative Code under section 3724.11 of the Revised Code and paragraph (B) of rule 3701-16-07 of the Administrative Code;

(b) Release to another community alternative home, hospital, or other health care facility in the case of a transfer; or

(c) Release that is required by law or rule or a third-party payment contract.

(5) Each resident record shall contain all of the following items:

(a) The resident’s name, previous address, and date of birth; the date the resident began living at the home; the names, addresses, and telephone numbers of any individuals requested by the resident including the resident’s sponsor if present; the name, address, and telephone number of any referring entity; and the resident’s physician’s name, address, and telephone number;

(b) Copies of the health assessments required by rule 3701-16-17 of the Administrative Code;

(c) Notations of adverse changes in health status as required by paragraph (A)(2) of rule 3701-16-18 of the Administrative Code;

(d) Emergency information which includes the name, address, and telephone number of the individual or individuals, including the resident sponsor, to be notified in the event of an emergency and of the physician to be called; and

(e) The written resident agreement required by rule 3701-16-15 of the Administrative Code.

(B) Reports of investigations of incidents required by paragraph (B) of rule 3701-16-18 of the Administrative Code for at least two years after the date of discharge of the residents involved.

(C) Fire and evacuation procedures and records of fire drills;

(D) A current listing of the names and ages of all residents, and each resident’s admission date;

(E) Copies of all current licenses, approvals, inspections, and plans of correction;

(F) Procedures for obtaining emergency assistance;

(G) Records of heating system checks, smoke detector checks, and sprinkler system checks; and

(H) Applicable medical statements and documentation of training for volunteers and staff members, as defined in paragraph (A) of Rule 3701-16-13 of the Administrative Code. The community alternative home, at minimum, shall maintain the records required by paragraphs (C) and (G) of this rule for three years, and records required by paragraph (H) of this rule for two years after the staff member or volunteer is no longer working in the home.

R.C. 119.032 review dates: 01/20/2004 and 01/15/2009

Promulgated Under: 119.03

Statutory Authority: 3724.05(H)

Rule Amplifies: 3724.05(L), 3724.07(B)

Prior Effective Dates: 11/27/94, 11/27/88 (emer.)