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(1) The provider shall maintain a written record at the community home for each resident which shall include detailed administrative, training, and educational data. The resident's record shall include at least the following:

(a) name, sex, birthdate, address, parents/relatives, guardianship, other vital statistics, admission and discharge;

(b) nature of the resident's difficulties;

(c) services needed by the resident and his/her family;

(d) the treatment plan, goals of the plan, and anticipated duration of treatment and training;

(e) measures taken to implement the plan, i.e. individual training programs;

(f) evaluation of the services the resident received;

(g) health records, psychiatric and psychological reports, educational information, assessments, official documentation and financial arrangements including resident's income and expenditures related to services provided to resident;

(h) resident's activities and incident reports;

(2) Other written records kept at the community home shall include:

(a) fire safety requirements and compliance; evacuation of residents and staff; fire safety plans and results of monthly fire drills; and

(b) a list of social service and other service personnel involved with the residents.

(3) The provider administrative file shall be maintained and shall be available upon request of the department. It shall contain at least the following current information and documents:

(a) governing structure including articles of incorporation and by-laws or other legal basis of existence;

(b) name and position of persons authorized to sign agreements of official documentation;

(c) board structure and composition with names, addresses and terms of membership;

(d) existing purchase of service agreements;

(e) insurance coverage;

(f) procedure for notifying parties of changes in facility's policy and programs;

(g) a current organizational chart;

(h) current written job descriptions for all employees, and the names of persons presently employed in those positions;

(i) records of orientation and training for each employee;

(j) personnel and programmatic policies and procedures; and

(k) written grievance procedures which are available to residents and staff.

(4) All entries shall be in ink or indelible pencil, prepared at the time or immediately following the occurrence of the event being recorded, be legible, dated and signed by the person making the entry.

(5) The provider is responsible for the accurate preparation, maintenance and storage of all resident, personal and home records.

(6) The provider shall assure that all resident records are confidential in accordance with all applicable laws and rules and departmental policy.

(7) Records for residents who have been released from the home shall be transferred with the resident or stored by the provider for a period of 5 years following the release.

(8) When the home ceases operation, the provider shall notify the department in writing as to the location and storage of resident records.

History: Sec. 53-20-305, MCA; IMP, Sec. 53-20-305, MCA; NEW, 1983 MAR p. 1839, Eff. 12/16/83; TRANS, from Dept. of SRS, 1987 MAR p. 1492, Eff. 7/1/87; TRANS, from DFS, 1998 MAR p. 667.

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