5123:2-3-13 Individual records.

(A) Purpose

The purpose of this rule is to ensure the confidentiality of individual information and to establish standards to ensure that records of the individual are readily accessible for implementation of services and supports and for department review during surveys.

(B) Confidentiality of records

All information contained in an individual's record shall be considered privileged and confidential. Records shall be maintained in accordance with state and federal regulations in such a manner to ensure their confidentiality and protect them from unauthorized disclosure of information.

(C) Records at the residential facility

Records for the current calendar year and the previous twelve months shall be maintained at the residential facility for each individual and shall be made available for review by licensure and other representatives of the department. These records shall include, but not be limited to, the following:

(1) A current photograph of the individual.

(2) Legal status of the individual.

(3) Records of accidents, injuries, seizures, major unusual incidents, and unusual incidents and the treatment or first aid measure administered for each. Information pertaining to abuse/neglect investigations and other confidential information may be maintained at a location other than the residential facility, but shall be provided to licensure for review at the facility upon request.

(4) All medical and dental examinations and the most recent immunization records as appropriate to age.

(5) Medication and/or treatment records which shall indicate:

(a) The person who prescribed the medication and/or treatment; and

(b) The date, time, and person who administered the medication and/or treatment.

(6) Individual plans.

(7) Reconciliations of the individual's account transaction records as required in paragraph (J)(2)(i) of rule 5123:2-3-14 of the Administrative Code.

(8) A signed authorization to seek medical treatment or documentation that attempts to seek such authorization were unsuccessful. The licensee shall provide evidence of an annual review of such authorization and, in cases where authorization was not able to be obtained, evidence that attempts to obtain authorization were made on at least an annual basis.

(9) If not in the individual's plan, evidence of consents for the participation in services including, but not limited to, medical treatments, behavior support plans, and the use of psychotropic medications.

(D) Retention of records

Records for each individual shall be maintained by the licensee at an accessible location and such records shall be provided to licensure for review at the residential facility upon request. The licensee shall develop a records retention schedule for all records in accordance with applicable state and federal requirements. Records shall include, but not be limited to, the following:

(1) Admission and referral records;

(2) All medical and dental examinations, and immunization records as appropriate to age;

(3) All medication and/or treatment records;

(4) All service documentation and notations of progress;

(5) All records of the individual's account transaction record as defined in rule 5123:2-3-14 of the Administrative Code;

(6) Records of negotiable items owned by the individual which can be converted to cash or transferred such as bonds or promissory notes;

(7) Investigative files resulting from major unusual incidents or unusual incidents;

(8) Records of clothing and personal items; and

(9) Discharge summaries which shall be prepared within seven days following the individual's discharge. The summary shall include the individual's progress during residence and new address of residence.

(10) In the event of an individual's death, a discharge summary, which shall include the disposition of the individual's personal items, shall be completed within thirty days of the individual's death.

Replaces: 5123:2-3-13

Effective: 01/01/2006
R.C. 119.032 review dates: 01/01/2011
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5123.19
Rule Amplifies: 5123.04, 5123.19
Prior Effective Dates: 10/31/77, 6/12/81, 9/30/83, 11/16/90, 12/9/91, 5/18/95, 4/27/00