Requirements For Facility Records

The facility must develop policies and procedures in accordance with Sections 39-3316, Idaho Code, for a minimum of three (3) years. (7-1-26) 01. Paper Records. All paper records must be recorded legibly in ink. (3-15-22) IDAHO ADMINISTRATIVE CODE IDAPA 16.03.22 Department of Health and Welfare Residential Assisted Living Facilities Section 330 Page 17 02. Record Confidentiality. The facility must comply with the Health Insurance Portability and Accountability Act (HIPAA). (7-1-26) 03. Resident Care Records. Each resident must have an individual care record. Entries must be documented during each shift and completed by the person providing the care, including the date, time, name, and title of the person making the entry. (7-1-26) a. The plan of care must be available to staff at all times and include: (7-1-26) i. A copy of written, signed, and dated medication and treatment orders; (7-1-26) ii. Treatments, wound care, assistance with medications, and any delegated nursing tasks. PRN medication use (if applicable), including the reason for taking the medication and the efficacy; (7-1-26) iii. Documentation when the resident refuses care or services or the resident missed taking prescribed medication including the reason; (7-1-26) iv. Notification to the facility nurse of changes in the resident's physical or mental condition; (3-15-22) v. Nursing assessments; (7-1-26) vi. The results of any physician or authorized provider visits, including phone calls to providers including the reason and outcome; (7-1-26) vii. Copies of all signed and dated care plans prepared by outside service agencies; (3-15-22) viii. Notes regarding outside services and care provided to the resident, such as home health, hospice, or physical therapy; (3-15-22) ix. Unusual events such as incidents, accidents, or altercations, and the facility's response; and (3-15-22) x. Documentation the physician, authorized, and legal representative provider has been contacted when a resident consistently refuses medical treatment or physician orders. (7-1-26) 04. Behavior Documentation. For residents who exhibit maladaptive behaviors, the facility must maintain documentation of the following: (7-1-26) a. An assessment of maladaptive behaviors. (7-1-26) b. A behavior plan that includes interventions; (7-1-26) i. Interventions must be the least restrictive possible and must include the date and time of each maladaptive behavior, a description of the behavior, the interventions implemented and the effectiveness of each intervention. (7-1-26) 05. Discharge Records. Resident discharge documentation must include: (3-15-22) a. A copy of the written notice of discharge if applicable; (7-1-26) b. The date and the location where the resident was discharged; and (7-1-26) c. The disposition of the resident's belongings. (3-15-22) 06. Additional Resident Records. The facility must also maintain the following for each resident: IDAHO ADMINISTRATIVE CODE IDAPA 16.03.22 Department of Health and Welfare Residential Assisted Living Facilities Section 330 Page 18 (3-15-22) a. A record of all resident personal property with a value of more than fifty dollars ($50); and (7-1-26) b. A record of complaints or grievances including the date received, the investigation and the outcome. (7-1-26) 07. Resident Admission and Discharge Register. The facility must maintain an admission and discharge register listing the name of each resident, the date admitted, and the date discharged. (7-1-26) 08. Dietary Records. The facility must maintain on-site a minimum of three (3) months of dietary records including: (7-1-26) a. Planned, substitution, and therapeutic menus that have been approved and signed by a licensed registered dietitian. (7-1-26) 09. Water Supply. Laboratory reports documenting the bacteriological examination of a private water supply. (7-1-26) 10. Personnel Records. A record for each employee must be maintained and available, which includes the following: (3-15-22) a. The employee's name, address, phone number, and date of hire; (3-15-22) b. A job description that includes the purpose, responsibilities, duties, and authority; (3-15-22) c. A copy of a valid license for nursing staff; (7-1-26) d. Signed and dated record of all required staff training; (7-1-26) e. Copies of CPR and first aid certifications; (3-15-22) f. Evidence of medication training; (7-1-26) g. Criminal history and background check results; (7-1-26) h. Documentation by the licensed nurse of delegation to unlicensed staff; (7-1-26) i. A signed and dated record identifying any administrator or manager designees; and (7-1-26) j. Records of contracts with outside service providers and contract staff. (7-1-26) 11. As Worked Schedules. Work records indicating direct care staff names and shifts worked. (7-1-26) 12. Fire and Life Safety Records. The administrator must ensure the facility's records for fire and life safety are maintained. The facility must maintain on file: (3-15-22) a. The results of fire detection, alarm inspections, maintenance, and test results including: (7-1-26) i. The results of the annual inspection and tests; and (3-15-22) ii. Smoke detector sensitivity testing results. (3-15-22) b. The results of any sprinkler system inspections, maintenance, and tests; (7-1-26) IDAHO ADMINISTRATIVE CODE IDAPA 16.03.22 Department of Health and Welfare Residential Assisted Living Facilities Section 335 Page 19 c. Monthly examination of portable fire extinguishers, including initials and date and documenting the following: (7-1-26) i. Each extinguisher seal or tamper indicator is not broken; (3-15-22) ii. Each extinguisher has not been physically damaged; (3-15-22) iii. Each extinguisher gauge shows a charged condition; and (3-15-22) 331. – 334. (RESERVED)