Title: Section 490.10 - Records and reports

Section 490.10 Records and reports. (a) The operator must collect and maintain such information, records, or reports as determined by the department to be necessary.

(b) The department may examine the books and records of any facility to determine the accuracy of the annual financial statement or for any other reason deemed appropriate by the department to effectuate the purposes of these regulations.

(c) Resident records.

(1) The operator must maintain complete, accurate and current records for each resident.

(2) Such records must be maintained in the facility and must be available for review and inspection by staff of the department or by designees of the department.

(3) Records must be maintained in a manner which assures resident privacy and accessibility to staff to use in the provision of routine and emergency services.

(4) The operator must maintain:

(i) financial records for each resident which contain at a minimum a copy of the current admission agreement, documentation of the status of the resident's payment account, and personal fund account and a current inventory of any personal property held in custody for the resident by the operator;

(ii) personal records for each resident which contain at a minimum personal data, including identification of the resident's next of kin, family and sponsor; the name and address of the person or persons to be contacted in the event of an emergency; copies of the residents' medical and mental health evaluations, the screening and assessments, the individual service plans, schedules and records of paid or volunteer work, if any, and such other correspondence and papers as are available to document the physical and mental status and socialization skills of the resident; and

(iii) records which are readily available to food service staff to enable staff to plan for and accommodate prescribed dietary regimens, allergies and individual food preferences.

(d) Facility records.

(1) The operator must maintain complete, accurate and current records which document operation and maintenance of the facility in accord with applicable law and regulation.

(2) Such records must be maintained in the facility, unless written authorization is given by the department for record retention in another location, and must be available for review and inspection by staff of the department or by designees of the department.

(3) Records must be maintained in a manner which assures an individual resident's rights to confidentiality and privacy.

(4) At a minimum the operator must maintain:

(i) the individual resident records referred to in subdivision (c) of this section;

(ii) resident records referred to elsewhere in these regulations including daily census reports and incident reports;

(iii) a chronological admission and discharge register consisting of a listing of residents registered in and discharged from the facility by name, age, sex of resident, and place from or to which the resident is registered or discharged;

(iv) program records, including service procedures, activities schedules, agreements with external service providers, emergency plans and records of evacuation drills;

(v) food service records, including menus and food purchase records;

(vi) records of maintenance of the physical plant and environmental standards;

(vii) staff records, including personnel procedures, job descriptions, staffing schedules, identification of individual employees, including social security numbers, and payment records; and

(viii) certificates or reports issued by local and other State jurisdictions related to the facility operations, on file and readily accessible for department review, or posted, if required.

(ix) records documenting the development, implementation and, at a minimum, the bi-annual updating of plans for quality assurance activities for each area of facility operation. These must include, at a minimum, the development and maintenance of performance standards, including infection control, measurement of adherence to such standards and to applicable state and local laws and regulations, identification of performance failures, design and implementation of corrective action.  Each plan must also include the creation of a quality improvement committee that is charged with meeting periodically, at least once every six months, to review summary findings from monitoring implementation of the facility’s plan, evaluating the effectiveness of corrective action policies, and identifying trends and improvement activities. While reviewing facility performance, the committee shall not examine personally identifiable resident incidents. Such committee shall include the administrator or operator of the facility, the resident council president or other resident representative, and representatives from frontline employees from each area of operation.

(e) Facility reports.

(1) The operator of a residence for adults must file an Annual Financial Statement (DSS-2963) with the department on or before the 15th day of the sixth calendar month after the close of its fiscal year. Such statement must clearly set forth all financial information pertaining to the operation of such facility in accordance with generally accepted accounting principles, including but not limited to revenues and expenses by categories during such fiscal year, together with such other information as may be required by the department. For all facilities with a capacity of 10 or more residents, the financial statement must be accompanied by an opinion signed by an independent licensed accountant that such financial statement represents the financial operations and position of the facility.

(2) The operator of a not-for-profit residence for adults which submits a charitable organization annual report to the Secretary of State or a residential health care facilities annual report to the Department of Health may submit copies of those reports, together with such other data as may be necessary to satisfy the requirement in paragraph (1) of this subdivision.

(3) The operator must maintain and make available all such books and records as may be required by the department to determine the accuracy of any and all information contained in the financial report filed by the operator.

(4) The operator must submit a quarterly statistical information report to the department.

(f) Mandated forms. The following forms must be utilized by operators of residences for adults:

(1) Personal Data Sheet (DSS-2949);

(2) Daily Census Record (DSS-2900);

(3) Incident Report (DSS-3123);

(4) Medical Evaluation (DSS-3122);

(5) Inventory of Resident Property (DSS-3027);

(6) The following personal allowance account forms must be used unless prior written authorization for substitutions has been given by the department:

(i) Statement of Offering (DSS-2853);

(ii) Personal Allowance Summary (DSS-2855); and

(iii) Personal Allowance Ledger.

(g) The operator must post the following documents:

(1) the operating certificate;

(2) the inspection report for the most recent complete or summary inspection, with any related follow-up inspection reports;

(3) the statement of rights of residents;

(4) weekly menus;

(5) monthly activities schedules;

(6) evacuation procedures;

(7) notice prohibiting employee acceptance of remuneration, tips or gratuities;

(8) the times residents may have access to their personal allowance accounts; and

(9) procedures for presenting grievances and recommendations.

(h) Records retention. (1) Records required by the department, excepting financial records of the previous operator, must be retained in the facility upon change of operator.

(2) Records relating to an individual must be retained at the facility for three years after the death or discharge of a resident.

(3) Program records, facility fiscal records and records relating to application for or renewal of an operating certificate must be retained at the facility for seven years.