R432-270-21. Facility Records

  (1) The facility must maintain accurate and complete records. Records shall be filed, stored safely, and be easily accessible to staff and the Department.

  (2) Records shall be protected against access by unauthorized individuals.

  (3) The facility shall maintain personnel records for each employee and shall retain such records for at least three years following termination of employment. Personnel records must include the following:

  (a) employee application;

  (b) date of employment;

  (c) termination date;

  (d) reason for leaving;

  (e) documentation of CPR and first aid training;

  (f) health inventory;

  (g) food handlers permits;

  (h) TB skin test documentation; and

  (i) documentation of criminal background screening.

  (4) The facility must maintain in the facility a separate record for each resident that includes the following:

  (a) the resident's name, date of birth, and last address;

  (b) the name, address, and telephone number of the person who administers and obtains medications, if this person is not facility staff;

  (c) the name, address, and telephone number of the individual to be notified in case of accident or death;

  (d) the name, address, and telephone number of a physician and dentist to be called in an emergency;

  (e) the admission agreement;

  (f) the resident assessment; and

  (g) the resident service plan.

  (5) Resident records must be retained for at least three years following discharge.

  (6) There shall be written incident and injury reports to document consumer death, injuries, elopement, fights or physical confrontations, situations which require the use of passive physical restraint, suspected abuse or neglect, and other situations or circumstances affecting the health, safety or well-being of residents. The reports shall be kept on file for at least three years.