5122-33-15 Recordkeeping.

Each ACF shall maintain the following records:

(A) An individual record for each resident which shall be stored at the facility in which the resident currently resides and in a manner that protects and ensures confidentiality, except that information shall be immediately accessible for an emergency.

(1) Staff members who have access to residents' personal information shall not discuss or share the information with another individual working in the facility unless transmission of the information is necessary to provide care to or to meet the needs of the resident. Individuals working in the facility shall not discuss residents' personal information with or in front of other residents of the facility, or with persons outside of the facility except as provided for in paragraph (A)(3) of this rule. Individuals working in the facility shall return resident records to the storage area and not allow the records to remain open in the view of others in the facility.

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

(3) The facility shall not release any resident records to any individual outside the facility without the resident's consent, except for the following circumstances:

(a) Release upon transfer to another adult care facility or a nursing home, residential care facility, home for the aging, hospital, or other health care facility or provider;

(b) Release to individuals who are authorized to have access under paragraph (C) of rule 5122-33-06 of the Administrative Code; or

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

(4) 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 facility; the names, addresses, and telephone numbers of any individuals designated by the resident; 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 5122-33-18 of the Administrative Code;

(c) Notations of significant change in physical health or behavioral status as required by paragraph (A)(2) of rule 5122-33-19 of the Administrative Code;

(d) Written emergency information which includes the name, address, and telephone number of the individual or individuals to be notified in the event of an emergency and of the physician to be called This information will include specific providers to be contacted in emergency situations staff members believe to be related to a known diagnosis or disability;

(e) The written resident agreement required by rule 5122-33-16 of the Administrative Code; and

(f) For residents referred by or receiving services from a mental health agency, a mental health plan for ongoing mental health services required by rule 5122-33-18 of the Administrative Code.

(B) Reports of the investigations of incidents required by paragraph (B)(3) of rule 5122-33-19 of the Administrative Code.

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

(D) A current listing of the names and ages of all residents and dates of residence;

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

(F) Procedures for obtaining general emergency assistance;

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

(H) Medical statements and documentation of training for staff members;

(I) All records and reports required by Chapter 3701-13 of the Administrative Code to be maintained and made available in accordance with that chapter; and

(J) All records and reports required by rules 5122-33-13 and 5122-33-14 of the Administrative Code.

Effective: 02/17/2012
R.C. 119.032 review dates: 11/30/2011 and 02/17/2017
Promulgated Under: 119.03
Statutory Authority: 5119.79, 5119.85
Rule Amplifies: 5119.73, 5119.79, 5119.81, 5119.85, 5119.88
Prior Effective Dates: 5-6-1991 (Emer.), 8-4-1991, 12-16-1993 (Emer.), 2-5-1994, 9-5-1997, 10-15-2000, 6-1-2006, 10-1-2010