Ill. Admin. Code tit. 77 § 295.7000

Current through Register Vol. 48, No. 49, December 6, 2024

Section 295.7000 - Resident Records

a) Service delivery contracts and related documents executed by each resident or resident's representative shall be maintained by the establishment from the date of execution until three years after the date the contract is terminated. (Section 105 of the Act)

b) An establishment shall maintain a resident's record that contains at least the following:

1) The resident's name and Social Security number;

2) The date of the resident's acceptance into the establishment and the last address of the resident;

3) The names, addresses, and telephone numbers of the following:

A) The resident's representative, if applicable;

B) The resident's primary health care provider; and

C) An individual or relative to be contacted in the event of emergency, significant change in the resident's condition, or termination of residency;

4) The establishment contract and any amendments;

5) Documentation of orientation to the evacuation plan;

6) Notation of assessments and evaluations conducted pursuant to Section 295.4000;

7) The service plan, its amendments and updates;

8) A health care directive, if disclosed and applicable;

9) Notation of known accidents, incidents or injuries;

10) Documentation of any significant change in a resident's behavior or physical, cognitive, or functional condition that would trigger an assessment or evaluation, and action taken by employees to address the resident's changing needs;

11) A written notice of termination of residency, if applicable;

12) Documentation of relocation assistance provided to the resident, if applicable;

13) A negotiated risk agreement, if applicable;

14) Any express waiver of confidentiality;

15) If applicable, letters of guardianship, the resident's representative designation form, or durable power of attorney for health care; and

16) Orders from a licensed health care provider for medication that is to be administered by the establishment.

c) The resident, resident's representative, resident's guardian, or health care power of attorney is responsible for alerting the establishment of any changes to the information contained in the record.

d) An establishment shall ensure that a resident's record is:

1) Confidential and only released with written permission from the resident or the representative, or as otherwise provided by law;

2) Maintained at the establishment;

3) Legibly recorded in ink or electronically recorded;

4) Retained for 3 years from the date of termination of residency (closed records may be retained off-site); and

5) Available for review by the resident or the resident's representative during normal business hours or at a time agreed upon by the resident and the manager.

e) An establishment shall ensure that a resident's financial records are maintained separate from a resident's record and are accessible only to individuals designated by the establishment.

f) The following resident records and supporting documents shall be made available for on-site inspection by the Department upon request at any time:

1) Service delivery contracts and related documents executed by each resident or resident's representative, including, but not limited to, negotiated risk agreements;

2) Records supporting compliance with each individual contract and with this Part; and

3) Incident and accident reports that are required to be submitted to the Department. (Section 105 of the Act)

Ill. Admin. Code tit. 77, § 295.7000