Minnesota Administrative Rules

9555.9660 PARTICIPANT RECORDS.

Subpart 1.

Participant's written record.

A center shall develop and maintain a written record for each participant. Access to participants' records shall be governed by subpart 2. Each participant's written record shall include:

A.

an application form signed by the participant or the participant's caregiver that includes:

(1)

the participant's name, address, date of birth, sex, date of admission or readmission, living arrangement, telephone number, and source of referral;

(2)

the name and telephone number of the person to call in case of an emergency involving the participant and the name and number of another person to call if that person cannot be reached; and

(3)

the name and telephone number of the participant's physician or medical provider;

B.

a medical report dated within the three months prior to or 30 calendar days after the participant's admission to the center, signed by a physician or signed by a physician assistant or registered nurse and cosigned by a physician, that includes:

(1)

a report on a physical examination, updated annually;

(2)

a medical history of the participant;

(3)

indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply to the participant;

(4)

a release signed by the physician indicating whether the participant may engage in a structured exercise program; and

(5)

documentation that the participant is free of communicable disease or infestations, as specified in parts 4605.7000 to 4605.7090, that would endanger the health of other participants;

C.

reports received from other agencies involved in providing services or care to the participant;

D.

participant's service agreement with the center, that must specify the responsibilities of the participant and the center with respect to payment for and provision of services and shall be signed by the participant or the participant's caregiver and the center director;

E.

attendance and participation reports and progress notes that are recorded at least monthly;

F.

notes on special problems or on changes needed in medication and on the need for medication assistance;

G.

participant's needs assessment and current plan of care in compliance with part 9555.9700;

H.

a copy of the center's statement on participants' rights, signed by the participant or the participant's caregiver to indicate the participant has been informed of rights;

I.

any incident reports involving the participant, in compliance with part 9555.9720, subpart 4;

J.

copy of the individual abuse prevention plan developed for the participant as required by Minnesota Statutes, section 626.557, subdivision 14;

K.

in a center licensed as meeting group E-3 occupancy code requirements, (1) a statement signed by the center director and the participant at the time of the participant's admission specifying the basis on which the participant was determined to be capable or not capable of taking appropriate action for self-preservation under emergency conditions as that capability is defined in part 9555.9600, subpart 8; and (2) documentation that the participant has demonstrated the capability defined in part 9555.9600, subpart 8, by participating in a fire drill within at least six months of admission to the center; and

L.

discharge summary, if the participant is discharged from the center.

Subp. 2.

[Repealed, 18 SR 2748]

Subp. 3.

Right to contest.

The center shall provide each participant with written notice ensuring that each participant or participant's guardian or caregiver has been informed of the participant's right to contest the accuracy and completeness of the data maintained in the record.

Statutory Authority:

MS s 245A.09

History:

11 SR 2165; 18 SR 2748; 20 SR 858; L 2014 c 291 art 4 s 58

Published Electronically:

July 3, 2014