Resident file

1. Upon placement, a resident's case record is confidential and must be protected from unauthorized examination unless permitted or required by law or regulation. The facility shall adopt a policy regarding the retention of resident records. 2. The resident record must include on file: a. A file inventory with dates of admission, discharge, aftercare, referral source, and emergency contact information; b. The resident's full name, date of birth, and other identifying information; c. A photo of the resident; d. The name and contact information of a custodian and parent or guardian at the time of admission, as well as contact information of additional family members approved to engage in visitation and maintain family connections; e. The date the resident was admitted and the referral source; f. Signed care agreement or contract, including financial responsibility and expectations of all parties. The placement agreement must indicate a clear division of responsibility and authority between the facility and the custodian and parent or guardian; g. Signed written consents, as applicable; h. A copy of the initial and all ongoing assessment reports completed by the department approved qualified individual or documentation indicating placement approval or denial if the resident is accepted for an emergency placement; i. A copy of required interstate compact forms, as applicable; j. If the resident is in public custody, a current court order establishing the placement authority of a public agency; k. Treatment progress reports must be provided to the resident, custodian and parent or guardian monthly, or upon request. Any progress reports received at the facility from an outside agency or professional providing services to the resident must be summarized and embedded in the resident's treatment plan; l. Ongoing documentation and case activity logs detailing progress; m. Documentation of discharge planning; n. Visitation records. The facility shall have a formal plan for visitation signed by the custodian and parent or guardian detailing opportunities for the resident to engage in onsite visitation and home visits with family; o. Education records; p. All incident reports involving the resident; and q. Documentation the clinical director, facility administrator, or designated employee has reviewed the resident case record monthly. 3. Resident medical information, including: a. Consent for medical care. The facility has obtained written, signed informed consent that gives the facility, resident's physician, or health care consultant the following authority to: (1) Provide or order routine medical services and procedures; (2) Delegate and supervise administration of medications by authorized employees and for such employees to handle, provide the medication to the resident, and provide monitoring of resident self-administration; (3) Obtain medical information, as needed, on the resident; and (4) Provide or obtain an order for medical services and procedures when there is a life- threatening situation, emergency medical procedures, including surgery, when it is not possible to reach the individual or authority authorized immediately to give signed written specific informed consent; b. Documentation about any special nutritional or dietary needs identified; c. Documentation of health history; d. Documentation of any medical treatments received while residing in the facility, including: (1) Dates and individual administering medical treatment; (2) Immunizations; (3) Laboratory tests; (4) Routine and emergency health care examinations; (5) Dental examinations and treatment; and (6) Eye examinations and treatment; e. Medication administration records; and f. A copy of the treatment plan prepared by the facility. 4. The resident record must include aftercare supports for six months postdischarge. Information to include: a. Contact information for the custodian and parent or guardian and others determined necessary for aftercare; b. Date of discharge and six-month aftercare date of completion; c. Documentation from the family engagement specialist detailing the aftercare or family treatment plan progress; d. Documentation of ongoing communication with the resident, custodian and parent or guardian, and local providers; and e. Upon six-month completion of aftercare, the resident file must include: (1) Summary of the six-month aftercare services provided; and (2) A copy of the department-approved outcomes survey.