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:
an application form signed by the participant or the participant's caregiver that includes:
the participant's name, address, date of birth, sex, date of admission or readmission, living arrangement, telephone number, and source of referral;
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
the name and telephone number of the participant's physician or medical provider;
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:
a report on a physical examination, updated annually;
a medical history of the participant;
indication of dietary restrictions and medication regimen, including the need for medication assistance, that apply to the participant;
a release signed by the physician indicating whether the participant may engage in a structured exercise program; and
reports received from other agencies involved in providing services or care to the participant;
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;
attendance and participation reports and progress notes that are recorded at least monthly;
notes on special problems or on changes needed in medication and on the need for medication assistance;
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;
copy of the individual abuse prevention plan developed for the participant as required by Minnesota Statutes, section 626.557, subdivision 14;
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
discharge summary, if the participant is discharged from the center.
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.
MS s 245A.09
July 3, 2014
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