OAR 309-035-0130
Records
(1)
Records shall be maintained to document the legal operation of the program, personnel practices, and individual services and supports. All records shall be properly obtained, accurately prepared, safely stored, and readily available or electronically accessible within the setting. All entries in records required by these rules shall be in ink, indelible pencil, or approved electronic equivalent prepared at the time or immediately following the occurrence of the event being recorded; be legible; and be dated and signed by the person making the entry. In the case of electronic records, signatures may be replaced by an approved, uniquely identifiable electronic equivalent.(2)
Records documenting the legal operation of the program shall include but not limited to:(a)
Written approval for occupancy of the setting by the county or city having jurisdiction, any building inspection reports, zoning verifications, fire inspection reports, or other documentation pertaining to the safe and sanitary operation of the program issued during the development or operation of the program;(b)
Application for license, related correspondence, and site inspection reports;(c)
Program operating budget and related financial records;(d)
Payroll records, program staff schedules and time sheets;(e)
Materials safety and data sheets;(f)
Fire drill documentation;(g)
Fire alarm and sprinkler system maintenance and testing records;(h)
Incident reports; and(i)
Policy and procedure manual.(3)
Personnel records shall document and include:(a)
Job descriptions for all positions; and(b)
Separate program staff records including, but not limited to, written documentation of program staff identifying information and qualifications, criminal record clearance, T.B. test results, documentation that Hepatitis B inoculations have been given or made available, performance appraisals, and documentation of pre-service orientation and other training.(4)
Individual service records shall be maintained for each individual and include:(a)
An easily accessible summary sheet that includes, but is not limited to, the individual’s name, previous address, date of admission to the program, gender, biological sex, date of birth, marital status, legal status, religious preference, health provider information, evacuation capability, DSM diagnosis, physical health diagnosis, medication allergies, food allergies, information indicating whether advance mental health and health directives and burial plan have been executed, and the name of individuals to contact in case of emergency;(b)
The names, addresses, and telephone numbers of the individual’s representative, legal guardian or conservator, parents, next of kin, or other significant persons; physicians or other medical practitioners; dentist; case manager or therapist; day program, school, or employer; and any governmental or other agency representatives providing services to the individual;(c)
A mental health assessment and background information identifying the individual’s residential service needs;(d)
Advance mental health and medical health directives, burial plans, or location of these;(e)
A residential service plan and copy of plans from other service providers;(f)
Effective July 1, 2016, and pursuant to OAR 309-035-0115 (Licensing)(17), a person-centered service plan;(g)
Documentation of the individual’s progress and any other significant information including, but not limited to, progress notes, progress summaries, any use of seclusion or restraints, and correspondence concerning the individual; and(h)
Health-related information and up-to-date information on medications.(5)
The program shall retain all referral packets, screening materials, and screening responses-placement determinations for a minimum of three years from the date of the referral.(6)
For an individual receiving crisis-respite services, the provider shall obtain and maintain records as outlined in these rules. Because it may not be possible to obtain and maintain complete records during a crisis-respite stay, the program shall, at a minimum, maintain records that are deemed reasonable to provide services in the program.(7)
All individual service records shall be stored in a weatherproof and secure location. Access to records shall be limited to the program administrator and direct care staff unless otherwise allowed in these rules.(8)
All individual service records shall be kept confidential as required by law. A signed release of information shall be obtained for any disclosure from an individual service record in accordance with all applicable laws and rules.(9)
An individual or the representative shall be allowed to review and obtain a copy of the individual service record as required by ORS 179.505 (Disclosure of written accounts by health care services provider)(9).(10)
Pertinent information from records of an individual being transferred to another facility shall be transferred with the individual. A signed release of information shall first be obtained in accordance with applicable laws and rules.(11)
The program shall keep all records, except those transferred with an individual, for a period of three years.(12)
If a program changes ownership or program administrator, all individual and personnel records shall remain at the setting. Prior to the dissolution of any program, the program administrator shall notify the Division in writing as to the location and storage of individual service records or those records shall be transferred with the individual.(13)
If an individual or representative disagrees with the content of the individual service record, or otherwise desires to provide documentation for the record, the individual or representative may provide material in writing that then shall become part of the individual service record.(14)
The program shall establish an individual service record upon the individual’s admission. Prior to admission, within five days after an emergency admission, or within 24 hours of a crisis-respite admission, the program shall determine with whom communication needs to occur and make good faith efforts to obtain the needed authorizations for release of information. The record established upon admission shall include the materials reviewed in screening the individual, the summary sheet, and any other available information. The program shall make every effort to complete the individual service record in a timely manner. The assessment and residential service plan shall be completed in accordance with OAR 309-035-0185 (Individual Assessment and Residential Service Plan). Records on prescribed medications and health needs shall be completed as outlined in OAR 309-035-0215 (Health Services).
Source:
Rule 309-035-0130 — Records, https://secure.sos.state.or.us/oard/view.action?ruleNumber=309-035-0130.