Pa. Code 5320.64

Resident records

This regulation requires providers operating Long-Term Structured Residences (LTSRs) to maintain individual resident records accessible to residents, their designees, and the Department upon request, and to retain those records for at least four years after a resident's departure. Records must be divided into clinical sections (including mental health diagnosis, treatment plans, medication orders, assessments, and emergency contacts) and nonclinical sections (including property inventories, financial records, discharge summaries, commitment status, and county administrator authorization). This is a record-keeping standard applicable to LTSR facilities licensed under Chapter 5320.

55 Pa. Code § 5320.64 - Resident records 

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(a)
 The provider
 shall maintain individual resident records which shall be reviewed by the
 resident or a designee and the Department or its authorized agents upon
 request.

(b)
 The provider shall
 retain resident records for at least 4 years after the resident has left the
 LTSR.

(c)
 The provider shall divide
 the resident records into two sections: a clinical and nonclinical section. 
 
(1)
 The clinical section of the resident
 records shall, at a minimum, contain the following information: 
 
(i)
 The resident's name.

(ii)
 The resident's gender, race and
 ethnicity.

(iii)
 The resident's
 birth date.

(iv)
 The resident's
 Social Security number.

(v)
 The
 name, telephone number and address of the designated person to be contacted in
 case an emergency, illness or injury, transfer, termination of service, or
 death occurs to the resident or in the case of LTSR closure.

(vi)
 The names and telephone numbers of the
 resident's personal physician and dentist, if any.

(vii)
 The dates of entrance into the LTSR,
 transfers and discharges.

(viii)

 The most recent annual physical examination.

(ix)
 The principal mental health diagnosis as
 designated in the Diagnostic and Statistical Manual of Mental Disorders, Fourth
 Edition, (DSM IV) or most recent edition available from the American
 Psychiatric Association, 1700 18th Street, NW, Washington, D.C. 20009. The
 International Classification of Diagnoses, Clinical Modification (ICD-9-CM),
 available from HCIA, Inc., 300 East Lombard Street, Suite 1500, Baltimore,
 Maryland 21202, telephone (800) 568-3282, shall be used for the purpose of
 classifying diseases.

(x)
 A copy of
 the resident's treatment plan and progress notes describing the treatment and
 rehabilitative services provided with the resident's response to those services
 as well as reviews and periodic reexaminations.

(xi)
 A copy of the written contract between
 the provider and the resident.

(xii)
 Physicians' orders for medication to be
 administered at the LTSR as well as other medical orders to be carried out at
 the LTSR, and records of medication administration.

(xiii)
 The initial assessment and most recent
 update.

(xiv)
 Dietary restrictions,
 if any.

(2)
 The
 nonclinical section of the resident records shall, at a minimum, contain the
 following information:
(i)
 An inventory of the
 personal property, except consumable items, which the resident brings to the
 LTSR.

(ii)
 An inventory of the
 resident's property entrusted to the provider for safekeeping.

(iii)
 The financial records of the resident
 receiving assistance with financial management.

(iv)
 The reason for the termination of
 services, or transfer of the resident or reason for death, as applicable, to be
 included as part of a discharge summary.

(v)
 Documentation of the resident's current
 commitment status.

(vi)
 Written
 authorization for admission signed by the county administrator.

Notes

55

 Pa. Code §
 
5320.64

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