When operating an Assisted Living Facility in the state of Georgia it is imperative to keep a separate resident file for each resident living in the facility. This file is where all pertinent information regarding the residents shall be kept. Check out the regulation below provided by the Georgia Department of Community Health as to what must be included:
111-8-63-.24 Residents Files
(1) An individual resident file must be maintained by the administrator or on-site manager for each resident in the assisted living community. Personal information must be treated as confidential and must not be disclosed except to the resident and his or her representative or legal surrogate if any, an authorized agent of the Department, and others to whom written authorization is given by the resident or his representative or legal surrogate if any. The resident file must be made available for inspection and/or copying to the resident or the resident’s representative or legal surrogate if any, and Department representatives, upon request.
(2) Each resident’s file must include the following information:
(a) identifying information including name, social security number, veteran status, age, sex, and previous address;
(b) name, address and telephone number of next of kin, legal guardian and/ or representative or legal surrogate, if any, or representative payee and any court order or written document designating the resident’s representative or legal surrogate, if any;
(c) name, address, and telephone number of any person or agency providing additional services to the resident. This information must include the name of the agency personnel primarily responsible were provided to the community by the person or agency, (i.e., the caseworker, case manager, or therapist); (d) admission and discharge log to include the date of admission, the prior residence of resident, referral source, agency contact and telephone number of referral source date of discharge, facility or residence discharged to and telephone number;
(e) all individual written care plans required by the rules and the rules for proxy caregivers, Chapter 111-8-100 if applicable;
(f) the name, address, and telephone number of a physician, hospital, and pharmacy of the resident’s choice;
(g) a record of all monetary transactions conducted on behalf of the resident with itemized receipts of all disbursements and deposits;
(h) a record of all monies and other valuables entrusted to the assisted living community for safekeeping; a receipt for same shall be provided to the resident or representative or legal surrogate, if any, at the time of admission and at any time thereafter when the resident acquires additional property and wishes to entrust such property to the assisted living community for safekeeping;
(i) health information including all health appraisals, diagnoses, prescribed diets, medications, and physician’s instructions;
(j) an inventory of valuable personal items brought to the assisted living community for use by the resident to be updated at any time after admission if a resident or representative or legal surrogate, if any, submits to the assisted living community a new inventory of the resident’s personal items;
(k) a signed copy of the Resident’s Rights form;
(l) a signed copy of the admission agreement;
(m) any power of attorney or document issued by a court or by the Social Security Administration or any other governmental authority which designates another person as responsible for the management of the resident’s finances;
(n) a copy of a living will and/or durable power of attorney for healthcare if executed prior to 2007 or a copy of an executed Georgia advance directive for healthcare, if any, the forms for 70 which must be made available at the time of admission and remain available to the resident upon request;
(o) any signed medical orders impacting end-of-life care, e.g. do not resuscitate, physician’s orders for life-sustaining treatment, etc.
(p) a copy of the resident’s written waiver, if any, of the personal needs allowance charge pursuant to the provisions of Rule 111-8-63-.25(p)1;
(q) a copy of any findings from a search of the National Sex Offender Registry maintained through the Department of Justice, etc.; and
(r) any informed written consents signed by the resident or resident’s representative, designating and delegating to any trained proxy caregiver, whether employed by the assisted living community or not, the performance of identified health maintenance activities.
(s) evidence the resident has received educational information on influenza disease no later than September 1 of each year. Such information shall include, but is not limited to, the risks associated with influenza disease; the availability, effectiveness, and known contraindications of influenza immunization; causes and symptoms of influenza; and the means in which it is spread. Provision of the appropriate and current Vaccine Information Statement as provided by the Centers for Disease Control and Prevention shall be deemed to comply with this regulation.
(3) The following information may be given voluntarily by the resident, guardian, or representative, or legal surrogate, if any, but may not be required of the resident:
(a) religious preference, church membership, name and telephone number of minister, priest, or rabbi, if applicable; and 71
(b) information about insurance policies and prearranged funeral and burial provisions, if any.
(4) Resident files must be maintained by the assisted living community for a period of three years after a resident’s discharge.
- It is a good idea, but not necessary, to keep a separate file for anything related to the clinical care of each resident. Oftentimes communities will keep a financial file that includes items such as; a signed copy of residents’ rights form, signed written agreement, power of attorney paperwork, a record of all financial transactions, etc.
These files are required to be kept for a period of three years.