Organized Record System

PURPOSE: This rule specifies the requirements for maintenance of records in all community residential programs and day programs subject to licensure by the department in accordance with 9 CSR 40-1.055, including Residential Care Facilities (RCF) and Assisted Living Facilities (ALF) dually licensed by the Department of Health and Senior Services (DHSS). (1) Maintenance of Records. An organized record system shall be maintained at the residential program or day program which ensures easily retrievable, complete, and usable records stored in a secure and confidential manner. (A) The program shall implement written policies and procedures to ensure— 1. All local, state, and federal laws and regulations related to the confidentiality of records and release of information are followed; 2. Electronic health record systems conform to federal and state regulations; 3. Individual records are retained for at least six (6) years or until all litigation, adverse audit findings, or both, are resolved; 4. Ready access to paper or electronic records requested by department staff and other authorized representatives; and 5. Services are documented in a manner to ensure the type of service rendered and the amount of reimbursement received by the program can be readily discerned and verified with reasonable certainty. (2) Registry. The program shall maintain a permanent, chronological registry documenting the date and name of each person admitted, date of discharge, and destination at time of discharge. (3) Content of Records. Individual records must include current information related to each individual’s support and services. Records must be readily available for review by department staff or other authorized representatives. (A) Individual records must include, but are not limited to: 1. First name, last name, and middle initial; 2. Date of birth; 3. Photograph, not more than one (1) year old; 4. Height and weight; 5. Language spoken; 6. Date of admission; 7. Diagnosis; 8. Signed consent by the individual or parent/guardian or other legal representative, as applicable; 9. Acknowledgment of orientation to the program; 10. Name, address, and telephone number of parent/guardian, next of kin, or other responsible party; 11. Sources of financial support/insurance and burial plans, as applicable; 12. Name and contact information of healthcare provider(s); 13. Reports of any change in condition, injury, accident, or deviation from routine delivery of services (to be entered at the time of occurrence); 14. Documentation of any referral(s) to other services or community resources and outcome of those referrals; 15. Reports of comprehensive evaluations and annual physical examinations including vision, hearing, dental, and/or laboratory screenings recommended by the individual’s primary healthcare provider, and current immunization record; 16. Signed authorization(s) to release confidential information, as applicable; 17. Crisis or other significant events; 18. Physician’s orders for adaptive equipment, as applicable; 19. Individualized education plan (IEP) and school record, if attending; 20. Plans for educational/vocational goals and activities, as applicable; 21. Quarterly height, if the individual is in a developmental period, and monthly weight; and 22. The Individual Support Plan (ISP), Individual Treatment Plan (ITP), or care plan, including documentation related to behavioral objectives and related progress. (4) Entries in Records. Authorized staff making any entry in an individual’s record must include his or her signature, title, and date, including corrections to information previously entered in the record. (5) Consultation Services. Any required consultation services that are reimbursed by the department must be documented in the individual record, including the consultant’s findings and recommendations. Recommendations regarding the program as a whole must be documented in the program’s administrative records. (6) Proof of Licensure. The department’s most recent licensing report, including any noted license violations or deficient practices and related corrective action taken by the program, shall be displayed in accessible public areas on the program premises. (7) Inventory of Personal Items. At the time of admission and at regular intervals, program staff shall inventory each individual’s personal possessions, if applicable. Separate records with backup documentation, receipts, and notations shall be maintained for— (A) Personal finances, updated monthly, at a minimum; (B) Inventory of personal possessions, updated annually; and (C) Medication, upon admission and as required in 9 CSR 40-1.075. (8) Drills. A record of scheduled and unscheduled emergency drills shall be maintained at the program. The record shall include any problems encountered on the part of staff or individuals served to respond properly during the drill and corrective action taken. (9) Personnel Records. Personnel records shall be maintained for all program employees. Records must be readily accessible to department staff and other authorized representatives. (A) Employee records shall include, but are not limited to: 1. Application for employment; 2. Education and license/certification, as required for the position; 3. Verification of completion of training courses, orientation, and other professional development; 4. Background screening; and 5. Screenings for communicable diseases. (10) Organizational Chart. An organizational chart for the overall program and job descriptions for each position shall be maintained by the program. (11) Work Schedule. A record of days and hours worked by each employee shall be maintained at the program location. (12) Program Departures. A log shall be maintained to document when an individual being served leaves the program premises. The log shall include the individual’s name and signature (or the name and signature of the family member/legal representative with whom they are departing the premises), departure time, destination, anticipated return time, and actual return time to the program. (13) Availability of Records. Program records, reports, or other data shall be made available to department staff or its authorized representatives, upon request, in a manner that protects the rights of staff and individuals served. AUTHORITY: sections 630.050 and 630.705, RSMo 2016.* Original rule filed May 14, 2020, effective Dec. 30, 2020. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 630.705, RSMo 1980, amended 1982, 1984, 1985, 1990, 2000, 2011, 2014.