§ 6400.213. Content of records.

 Each individual’s record must include the following information:

   (1)  Personal information including:

     (i)   The name, sex, admission date, birthdate and social security number.

     (ii)   The race, height, weight, color of hair, color of eyes and identifying marks.

     (iii)   The language or means of communication spoken or understood by the individual and the primary language used in the individual’s natural home, if other than English.

     (iv)   The religious affiliation.

     (v)   The next of kin.

     (vi)   A current, dated photograph.

   (2)  Unusual incident reports relating to the individual.

   (3)  Physical examinations.

   (4)  Dental examinations.

   (5)  Dental hygiene plans.

   (6)  Assessments as required under §  6400.181 (relating to assessment).

   (7)  A copy of the invitation to:

     (i)   The initial ISP meeting.

     (ii)   The annual update meeting.

     (iii)   The ISP revision meeting.

   (8)  A copy of the signature sheets for:

     (i)   The initial ISP meeting.

     (ii)   The annual update meeting.

     (iii)   The ISP revision meeting.

   (9)  A copy of the current ISP.

   (10)  Documentation of ISP reviews and revisions under §  6400.186 (relating to ISP review and revision), including the following:

     (i)   ISP review signature sheets.

     (ii)   Recommendations to revise the ISP.

     (iii)   ISP revisions.

     (iv)   Notices that the plan team member may decline the ISP review documentation.

     (v)   Requests from plan team members to not receive the ISP review documentation.

   (11)  Content discrepancy in the ISP, The annual update or revision under §  6400.186.

   (12)  Restrictive procedure protocols and records related to the individual.

   (13)  Copies of psychological evaluations, if applicable.

   (14)  Recreational and social activities provided to the individual.


   The provisions of this §  6400.213 amended under sections 911 and 1021 of the Public Welfare Code (62 P.S. § §  911 and 1021).


   The provisions of this §  6400.213 amended through January 22, 1982, effective March 1, 1982, 12 Pa.B. 384; amended August 9, 1991, effective November 8, 1991, 21 Pa.B. 3595; amended August 27, 2010, effective August 28, 2010, 40 Pa.B. 4935. Immediately preceding text appears at serial pages (251456) to (251457).

Cross References

   This section cited in 55 Pa. Code §  6400.214 (relating to record location); 55 Pa. Code §  6400.261 (relating to exceptions for respite care); and 55 Pa. Code §  6400.262 (relating to exceptions for emergency respite care).

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