Person Supported Records

(1) The governing body must ensure that an individual record for each person supported is maintained which, at a minimum, includes the following information: (a) The name of the person supported; (b) The address of the person supported; (c) The telephone number of the person supported; (d) The gender of the person supported; (e) The date of birth of the person supported; (f) The date of admission of the person supported; (g) The source of referral to the licensee of the person supported; (h) The name, address, and telephone number of an emergency contact person for the person supported; (i) If the licensee charges fees for its services, a written fee agreement dated and signed by the person supported or his/her legal representative (conservator, parent, guardian, MINIMUM PROGRAM REQUIREMENTS FOR ALL FACILITIES/SERVICES CHAPTER 0465-02-06 or legal custodian) prior to provision of any services other than emergency services. This agreement must include, at least, the following information: 1. The fee or fees to be paid by the person supported; 2. The services covered by such fees; and 3. Any additional charges for services not covered by the basic service fee. (j) Appropriate informed, signed, and dated consent and authorization forms for the release or obtainment of information about the person supported; and (k) Written acknowledgement that the person supported and his/her legal representative (conservator, parent, guardian or legal custodian) has been informed of the rights and responsibilities of the person supported and the licensee’s general rules affecting persons supported.