Person Supported Records

(1) The record of each person supported must contain the following information: (a) A recent photograph and a description of the person supported; (b) The social security number of the person supported; (c) The legal competency status of the person supported; (d) The sources of financial support of the person supported, including social security, veteran’s benefits and insurance; (e) The sources of coverage for medical care costs of the person supported; (f) The name, address and telephone number of the physician or healthcare agency providing medical services of the person supported; (g) Documentation of all drugs/medications prescribed or administered by the licensee to the person supported, which indicates the date prescribed, type, dosage, frequency, amount, and reason for prescription; (h) A discharge summary of the person supported, which states the date of discharge, reasons for discharge, and referral for other services, if appropriate; (i) Report of medical problems, accidents, seizures and illnesses, and treatments for such medical problems, accidents, seizures and illnesses for the person supported; (j) Report of significant behavior incidents and of actions taken for the person supported; and (k) Report of the use of restrictive behavior management techniques for the person supported.