(a) The facility shall establish policies and procedures to
maintain a system of records and reports which shall include the following:
(1) Copy of a current physician or primary care provider’s report of resident’s physical
examination which includes tuberculosis clearance and verification that the resident is
free from other infectious or contagious diseases;
(2) Service plan;
(3) Contracts or other documents which set forth details of services to be delivered, charges,
and other conditions agreed to between the resident and the facility; and
(4) Incident reports of any bodily injury or other unusual circumstances affecting a resident
which occurs within the facility, on the premises, or elsewhere, shall be retained by
the facility under separate cover, and be available to authorized personnel and the
department. The resident’s physician or primary care provider shall be called
immediately if medical care is necessary or indicated.
(b) The facility records and reports shall be
available for review at any time by authorized personnel
and the department.