Section 16.03.19.270 - RESIDENT RECORDSThe provider must maintain legible records for each resident admitted to the home as follows.
01.Updated Records. Records maintained by the CFH must be updated, as necessary, to reflect accurate information as changes occur.02.Maintenance of Records. The provider must ensure records are maintained and available for inspection in the home as follows:a. Admission records for two (2) years from the date of the resident's discharge from the home; andb. Ongoing records for two (2) years from the date of the record.03.Admission Records. The following records pertaining to the resident must be completed or collected as part of the initial admission process and continuing retention of the resident's records thereafter:a. A form containing general resident information including: ii. Primary residence, if other than the CFH;iii. Marital status and sex;v. The name, address, and telephone number of an individual identified by the resident or the resident's representative who should be contacted in an emergency or upon death of the resident;vi. The resident's healthcare professionals and their contact information, and the contact information for any other supportive service used by the resident;vii. Social information including social history, hobbies, and interests;viii. Information about any specific health problems that may be useful in a medical emergency; andix. Any other health-related, emergency, or pertinent information that the resident requests the provider to keep on record.b. Results of the resident's history and physical examination performed by a healthcare professional conducted no earlier than twelve (12) months prior to admission;c. A list of all medications, treatments, and special diets prescribed by a healthcare professional;d. The written admission agreement under Section 260 of these rules;e. A log of the resident rights policy review under Section 201 of these rules;f. The assessment under Section 225 of these rules;g. The plan of service under Section 250 of these rules;h. An inventory of the resident's belongings that may consist of photographs or a written descriptive list. The resident or the resident's representative may inventory any personal possession they so choose and expect returned upon the resident's transfer or discharge from the home. The belongings inventory may be updated at any time but must be reviewed at least annually;i. If the resident has a representative, a copy of the document giving the representative legal authority to act on behalf of the resident, including guardianship or power of attorney for healthcare decisions; andj. A copy of any care plan that is prepared for the resident by an outside service provider.04.Ongoing Records. The following records must be completed or collected by the provider for ongoing services to the resident: a. Any incident or accident occurring while the resident is living in the home and the staff's response, including refusal of any prescription medication. If the incident or accident occurs while the resident is receiving supportive services, the provider must obtain a written report of the event from the service provider;b. The provider's written response to any grievance under Section 200 of these rules;c. Notes or logs from the licensed nurse, home health agency, physical therapist, or any other service providers, documenting the services provided to the resident at each visit to the home;d. Documentation of changes in the resident's physical, behavioral, or mental status, and the staff's response, including usage of any PRN medication;e. When the provider is deemed to be managing the resident's funds, financial accounting records for such funds as described in Section 275 of these rules; andf. Medication records as described in Sections 400 through 402 of these rules, as applicable.Idaho Admin. Code r. 16.03.19.270