Resident Records

(1) An ACLF shall develop and maintain an organized record for each resident and ensure that all entries shall be written legibly in ink, typed, or kept electronically, and signed, and dated. (2) Personal record. An ACLF shall ensure that the resident’s personal record includes at a minimum the following: (a) Name, Social Security Number, veteran status and number, marital status, age, sex, any health insurance provider and number, including Medicare and/or Medicaid number, and photograph of the resident; (b) Name, address and telephone number of next of kin, legal representative (if applicable), and any other person identified by the resident to contact on the resident’s behalf; (c) Name and address of the resident’s preferred physician, hospital, pharmacist and nursing home, and any other instructions from the resident to be followed in case of emergency; (d) Record of all monies and other valuables entrusted to the ACLF for safekeeping, with appropriate updates; (e) Date of admission, transfer, discharge and any new forwarding address; (f) A copy of the admission agreement that is signed and dated by the resident; (g) A copy of any advance directives, DNR Order, Durable Power of Attorney, or living will, when applicable, and made available upon request; and (h) A record that the resident has received a copy of the ACLF’s resident’s rights and procedures policy. (3) Medical record. An ACLF shall ensure that its employees develop and maintain a medical record for each resident who requires health care services at the ACLF regardless of whether such services are rendered by the ACLF or by arrangement with an outside source, which shall include at a minimum: STANDARDS FOR ASSISTED-CARE LIVING FACILITIES CHAPTER 0720-26 (a) Medical history; (b) Consultation by physicians or other authorized healthcare providers; (c) Orders and recommendations for all medication, medical/and other 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 include the time of receipt of the order, description of the order, and identification of the individual receiving the order; (d) Care/services provided, including identification of providing party; (e) Medications administered and procedures followed if an error is made; (f) Special procedures and preventive measures performed; (g) Notes, including, but not limited to, observation notes, progress notes, and nursing notes; (h) Listing of current vaccinations, (i) Time and circumstances of discharge or transfer, including condition at discharge or transfer, or death; (j) Provisions of 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; (k) Special information, e.g., do-not resuscitate orders, allergies, etc.; and (l) Copy of quarterly Alzheimer’s review, if medically indicated. (4) An ACLF shall complete a written assessment of the resident to be conducted by a direct care staff member within a time-period determined by the ACLF, but no later than seventy- two (72) hours after admission. (5) Plan of care. (a) An ACLF shall develop a plan of care for each resident admitted to the ACLF with input and participation from the resident or the resident’s legal representative, treating physician, or other licensed health care professionals or entity delivering patient services within five (5) days of admission. The plan of care shall be reviewed and/or revised as changes in resident needs occur, but not less than semi-annually by the above-appropriate individuals. (b) The plan of care shall describe: 1. The needs of the resident, including the activities of daily living and medical services for which the resident requires assistance, i.e., what assistance/care, how much, who will provide the assistance/care, how often, and when; 2. Requirements and arrangements for visits by or to physicians or other authorized health providers; 3. Advance care directive, healthcare power-of-attorney; as applicable; STANDARDS FOR ASSISTED-CARE LIVING FACILITIES CHAPTER 0720-26 4. Recreational and social activities which are suitable, desirable, and important to the well-being of the resident; and 5. Dietary needs. (6) Personal information shall be confidential and shall not be disclosed, except to the resident, the department and others with written authorization from the resident. Records shall be retained for three (3) years after the resident has been transferred or discharged. (7) An ACLF shall retain legible copies of the following records and reports for thirty-six (36) months following their issuance. The reports shall be maintained in a single file, and shall be made available for inspection during normal business hours to any resident who requests to view them. Each resident and each person assuming any financial responsibility for a resident must be fully informed, before admission, of the existence of the reports in the ACLF and given the opportunity to inspect the file before entering into any monetary agreement with the ACLF. (a) Local fire safety inspections. (b) Local building code inspections, if any. (c) Department licensure and fire safety inspections and surveys. (d) Orders of the Commissioner or Board, if any. (e) Maintenance records of all safety equipment.