Person Supported Records

(1) The record of each person supported must include 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, including the name of his/her legal representative (conservator, parent, guardian, or legal custodian), if applicable; (d) The sources of financial support including social security, veteran’s benefits and insurance of the person supported; (e) Sources of coverage for the medical care costs of the person supported; (f) The name, address and telephone number of the physician or of the healthcare agency providing medical services for the person supported; (g) Documentation of all medications administered to the person supported by the facility, which indicates the date prescribed, type, dosage, frequency, amount and reason; (h) A discharge summary of the person supported, which includes the date of discharge, reasons for discharge and referral for other services, if appropriate; (i) A list of each individual article of personal property owned by the person supported valued at fifty dollars ($50) or more, including its disposition if it is no longer in use; (j) Written accounts of all monies received and disbursed on behalf of the person supported; (k) Report 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 resides in the facility; (l) Report of significant behavior incidents of the person supported and the actions taken; and (m) Report of the use of restrictive behavior-management techniques on the person supported.