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) Social security number of the person supported; (c) The legal competency status of the person supported, including the name of his/her legal representative (conservator, parent, guardian, or legal custodian), if applicable; (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 health agency providing medical services for the person supported; (g) Documentation of all medications prescribed or administered by the facility to the person supported, which indicates date prescribed, type, dosage, frequency, amount, reason, and side effects; (h) Documentation of medical problems, accidents, seizures and illnesses of the person supported and treatments for such medical problems, accidents, seizures and illnesses while the person supported is in the care of the facility; MINIMUM PROGRAM REQUIREMENTS FOR INTELLECTUAL AND CHAPTER 0465-02-11 DEVELOPMENTAL DISABILITIES DIAGNOSIS AND EVALUATION FACILITIES (i) Documentation of significant behavior incidents and of actions taken while the person supported is in the care of facility staff; (j) Documentation of the use of restrictive behavior-management techniques while the person supported is in the care of facility staff; (k) A list of each individual article of personal property of the person supported, valued at one hundred dollars ($100) or more including its disposition, if no longer in use; (l) Written accounts of all monies received and disbursed on behalf of the person supported; and (m) A discharge summary of the person supported, which states the date of discharge, reasons for discharge, and referral for other services, if appropriate.