Record Requirements

All records created or maintained by the Assisted Living Residence shall be legible, recorded in ink, and contemporaneously signed and dated to indicate the name and position of the individual who makes the record entry. Computerized records systems which meet the equivalent requirements in 651 CMR 12.05 for permanencyand accessibility, and which provide an auditable record of entries may be used as an alternative or supplement. All records must be retained for at least six years unless otherwise specified. (1) Resident Record. The Assisted Living Residence shall develop and maintain written Resident records which shall remain confidential but for the limited exception of EOAI's enforcement of 651 CMR 12.00 or to the extent the Resident record is subject to disclosure as required by law. The Resident record and related documents are considered permanent and shall be maintained for the duration of the Resident's stay in the Assisted Living Residence and for at least six years after the date of termination of the Agreement. By January 1, 2027, the Residence must maintain an electronic copy of the Resident's records, including the Resident's Service Plan, and ensure that the electronic record is accessible remotely during an emergency. The Resident record shall include, at a minimum, the following: (a) Resident assessment, documented in accordance with the requirements set forth at 651 CMR 12.04(7)(a) through (c); (b) Service Plans documented in accordance with the requirements of 651 CMR 12.04(9); (c) Progress notes, which shall document significant occurrences, either observed by or reported to Residence staff, including significant or continued changes in the Resident's behavior or memory; incidents involving injury, trauma, illness, or abuse or neglect of the Resident, including but not limited to the recording of incidents in which a Resident has been the victim of an assault by another Resident or the perpetrator of an assault on another resident, regardless of whether such a report would be required by law; alleged or actual violations of the Resident's rights as defined in 651 CMR 12.08; and changes in the Resident's Service Plan; (d) Documentation of Introductory Visits set forth at 651 CMR 12.07(8); (e) Documentation of Self-administered Medication Management, including the medication assessment required by 651 CMR 12.04(7)(a)4.a. through b.; (f) Documentation of all aspects of Limited Medication Administration, if applicable. This includes, but is not limited to, a proper written medication order from an authorized prescriber, documentation of the name, dose, route of administration, and time the medication is administered. The nurse who administers the medication shall sign or initial the documentation; (g) The following documents are also part of the Resident record, and may be kept in a separate location(s): 1. Anyapplicable guardianship orders, authorized powers of attorney, HealthCare Proxy documents, living wills, Medical Orders for Life-Sustaining Treatment (MOLST)/Portable Orders for Life-Sustaining Treatment (POLST) documents and other relevant documents affecting or directing Resident care (including Department of Public Health Comfort Care/"Do Not Resuscitate Order Verification Form", provided that their existence and location is conspicuously documented in the Resident's record and theyare immediately available in case of an emergency; 2. The original Residency Agreement and any documents which extend or amend the Residency Agreement; and 3. The Disclosure of Rights and Services required by 651 CMR 12.08(3) and, if applicable, any disclosures provided to Residents receiving Basic Health Services as required by 651 CMR 12.08(5). (h) In addition to the items required in 651 CMR 12.08(2)(a) through (g), for Residents receiving Basic Health Services from a Residence certified to provide Basic Health Services, the following shall apply: 1. the Resident record must also include, at a minimum, the following: a. active valid Medical Orders signed and dated within the past 12 months authorizing the provision of Basic Health Services, and expired Medical Orders, if applicable; b. written consent to receive Basic Health Services as referenced in 651 CMR 12.04(3)(a)2.a. from the Resident, Legal Representative, or if applicable, the Resident's Health Care Agent; c. Resident assessments conducted in accordance with 651 CMR 12.04(9); d. a record documenting each time Basic Health Services are provided to a Resident; and e. the original Residency Agreement and any supplemental documents concerning the provision of Basic Health Services. (2) Census Record. Each Residence shall maintain a current census document. Each census document shall be kept for a minimum of two years and be updated at least weekly, listing. The census document shall be available and accessible at all times. The census document must include the name of and level of assistance for each Resident, and clearly indicate: (a) Residents residing in each occupied certified Unit; (b) Residents residing in traditional Units; (c) Residents residing in Special Care Units; (d) Residents receiving Basic Health Services; (e) Residents using Transfer Assistive Devices or Mobility Assistive Devices; (f) Residents receiving oxygen; (g) Residents receiving Self-administered Medication Management; (h) Residents receiving Limited Medication Administration; (i) Residents on leave of absence; (j) Residents who will need special assistance during an emergency and what type of assistance is required; and (k) Residents who are veterans. (3) Personnel Record Requirements. The Assisted Living Residence shall develop and maintain written personnel records and maintain copies of its personnel policies and procedures. Each personnel record shall include at a minimum the following: (a) Job description signed and dated by the employee; (b) Educational preparation and work experience; (c) A copy of any current licensure or certification, including a current certification for cardiopulmonary resuscitation (CPR) and automated external defibrillation (AED) training, if applicable; (d) Documentation of completion of the 54-hour Personal Care Services Training set forth in 651 CMR 12.07(7), if applicable; (e) Documentation of attendance at Personnel Orientation as set forth in 651 CMR 12.07; (f) Documentation of the successful completion of all required trainings; (g) Documentation of reports of criminal offender record information; (h) Documentation of annual performance evaluation; (i) Documentation of attendance at in-service training; and (j) Copies of any disciplinary letters or reports. (4) Basic Health Services Personnel Records. The Residence shall develop and maintain written personnel records that identify the staff who are authorized to provide Basic Health Services and maintain records of the qualifications and applicable licenses of such staff. The Residence must also document the required trainings attended by employees providing Basic Health Services and retain all performance evaluations. (5) Communication Logs. The Residence must maintain a staff communication log for each 24-hour period that communicates information necessary to maintain the continuity of care for all Residents. The communication log must be retained for the duration of each Certification period and until the Residence is recertified. (6) Emergency Response System Logs. The Residence must record and maintain all instances of and response times to Resident emergency response system calls, including the date, time of call, time of response, name of Resident, and name(s) of responding staff. The emergency response system log must be retained for the duration of each Certification period and until the Residence is recertified. (7) SCR Hourly Safety Check Logs. The Residence must record and maintain a log of hourly safety checks performed in the SCR Units during the twelve hours overnight, including the date and time, the name of the Resident checked, and the name of the staff performing the overnight check. The SCR hourly safety check log must be retained for the duration of each Certification period and until the Residence is recertified. (8) Fall Logs. The Residence must record and maintain a detailed fall log that records all incidents of falls, including the date and time, the location, the circumstances, the injuries sustained, and the immediate staff response. This log must be reviewed regularly by Residence staff for quality assurance and improvement purposes and be made available to EOAI as requested. The fall log must be retained for the duration of each Certification period and until the Residence is recertified. (9) Quality Assurance and Performance Improvement Meeting Minutes. The Residence shall create and retain minutes of all meetings of the quality assurance and performance improvement committee held pursuant to 651 CMR 12.04(11)(g) for EOAI review. The meeting minutes must be retained for the duration of each Certification period and until the Residence is recertified.