701. Content (II).

A.The facility shall initiate and maintain on-site an organized record for each resident. The record shall
contain sufficient documented information to identify the resident and the agency and/or person responsible
for each resident; support the diagnosis, secure the appropriate care/services (as needed); justify the
care/services provided to include the course-of-action taken and results; the symptoms or other indications
of sickness or injury; changes in physical/mental condition; the response/reaction to care, medication, and
the diet provided; and promote continuity of care among providers, consistent with acceptable standards of
practice. All entries shall be written legibly in ink, typed or electronic media, and signed, and dated.

B.Specific entries/documentation shall include at a minimum:
1. Consultations by physicians or other authorized healthcare providers;
2. Orders and recommendations for all medication, care, services, procedures, and diet from physicians
or other authorized healthcare providers, which shall be completed prior to, or at the time of admission, and
subsequently, as warranted. Verbal orders received shall be documented and include the date/time of receipt
of the order, description of the order, and identification of the individual receiving the order;
3. Care/services provided, e.g., hospice, home health;
4. Medications administered and procedures followed if an error is made;
5. Special procedures and preventive measures performed;
6. Notes of observation. In instances that involve significant changes in a resident’s medical condition
and/or the occurrence of a serious incident, notes of observation shall be documented at least daily until the
condition is stabilized and/or the incident is resolved. In all other instances, notes of observation for
residents shall be documented at least monthly;
7. Time, circumstances, and condition of discharge, transfer, or death;
8. Provisions for routine and emergency medical care, to include the name and telephone number of
the resident’s physician, plan for payment, and plan for securing medications;
9. Special information, e.g., do-not-resuscitate orders, allergies, power of attorney, responsible party, etc.
10. Photograph of the resident. Resident photographs shall be at a minimum of two and one-half inches by
three and one-half inches (2 ½ by 3 ½ inches) in size, dated and no more than twenty- four (24) months old
unless significant changes in appearance have occurred necessitating a more recent photograph.

702. Assessment (II).
A written assessment of the resident in accordance with Section 101.H shall be conducted by a direct care
staff member as evidenced by his or her signature and date within a time period determined by the facility,
but no later than 72 hours after admission.

703. Individual Care Plan (II).

A.Using the written assessment, the facility shall develop within seven (7) days of admission an ICP with
participation of the resident, administrator (or designee), and/or the sponsor or responsible party when
appropriate, as evidenced by their signatures and date. The ICP shall be reviewed and/or revised as changes
in resident, needs occur, but not less than semi-annually with the resident, administrator (or designee), and/or
the sponsor or responsible party as evidenced by their signatures and date.

B.The ICP shall describe:
1. The needs of the resident, including the activities of daily living for which the resident requires
assistance, i.e., what assistance, how much, who will provide the assistance, how often, and when;
2. Requirements and arrangements for visits by or to physicians or other authorized healthcare
3. Advance directives/healthcare power of attorney, as applicable;
4. Recreational and social activities which are suitable, desirable, and important to the well- being of
the resident;
5. Nutritional needs.

C.The ICP shall delineate the responsibilities of the sponsor and of the facility in meeting the needs of
the resident, including provisions for the sponsor to monitor the care and the effectiveness of the facility in
meeting those needs. Included shall be specific goal-related objectives based on the needs of the resident
as identified during the assessment phase, including adjunct support service needs, other special needs, and
the methods for achieving objectives and meeting needs in measurable terms with expected achievement

704. Record Maintenance.

A.The licensee shall provide accommodations, space, supplies, and equipment adequate for the
protection and storage of resident records.

B.When a resident is transferred from one facility to another, a transfer summary to include at a
minimum, copies of the most recent physical examination, the two-step tuberculosis test, the ICP, and
medication administration record (MAR), shall be forwarded to the receiving facility at the time of transfer
or immediately after the transfer if the transfer is of an emergency nature. The transfer summary shall
include the data sent and the signature of the transferring facility staff member. (I)

C.The resident record is confidential and shall be made available only to individuals authorized by the
facility and/or the S.C. Code of Laws. (II)

D.Records generated by organizations/individuals contracted by the facility for care/services shall be
maintained by the facility that has admitted the resident.

E.The facility shall determine the medium in which information is stored.

F. Upon discharge of a resident, the record shall be completed within 30 days and filed in an
inactive/closed file maintained by the licensee. Prior to the closing of a facility for any reason, the licensee
shall arrange for the preservation of records to ensure compliance with these regulations. The licensee shall
notify the Department, in writing, describing these arrangements and the location of the records.

G.Records of residents shall be maintained for at least six (6) years following the discharge of the
resident. Other regulation-required documents, e.g., fire drills, activity schedules, etc., shall be retained at
least 12 months or since the last Department general inspection, whichever is the longer period.
H.Records of current residents are the property of the facility and shall be maintained at the facility and
shall not be removed without a court order.