Recordkeeping – Ohio Admin. Code 5122-33-15

Adult care facilities must maintain a record for each resident that contains the following:

• The resident’s name, previous address, date of birth, and date of admission;
• Copies of the resident’s health assessments; 
• Notations of significant changes in physical health or behavioral status as required;
• Emergency contact information;
• The written resident agreement; and
• A mental health plan for ongoing mental health services if the resident is referred by or receiving services from a mental health agency.  

All resident records must be maintained by the facility for two years after the resident is permanently transferred, discharged or dies.  The records must be stored at the facility where the resident currently resides in a manner that protects and ensures the confidentiality of the records; the facility must safeguard resident records against loss, destruction, or unauthorized use.  Individuals working in the facility must return resident records to the storage area and not allow the records to remain open in the view of others in the facility.  Staff members who have access to residents’ personal information may not discuss or share the information with another individual working in the facility unless transmission of the information is necessary to provide care to or to meet the needs of the resident.  The facility may release records outside the facility under the following circumstances:

• With the resident’s consent;
• Upon transfer of the resident to another health care facility or provider;
• To individuals who are authorized to have access by regulation; or
• If release is otherwise required by law or a third-party payment contract.

The adult care facility must also maintain reports of the investigation of incidents as required, a listing of the names and ages of all residents and dates of residence, copies of all current licenses, approvals, inspections and plans of correction and any other required record or report.