501 GOVERNING BODY
Each Level II assisted living facility must have an owner or governing body that has ultimate authority for:
a. The overall operation of the facility;
b. The adequacy and quality of care;
c. The financial solvency of the facility and the appropriate use of its funds;
d. The implementation of the standards set forth in these regulations; and
e. The adoption, implementation and maintenance, in accordance with the requirement of state and federal laws and regulations and these licensing standards, of assisted living policies and administrative policies governing the operation of the facility.
502 GENERAL PROGRAM REQUIREMENTS
Each person or legal entity issued a license to operate a Level II assisted living facility shall provide continuous twenty-four (24)-hour supervision and services that:
a. Conform to Office of Long Term Care rules and regulations;
b. Meet the needs of the residents of the facility;
c. Provide for the full protection of residents’ rights; and
d. Promote the social, physical, and mental well being of residents.
503 CONTRACTUAL AGREEMENTS
A Level II assisted living facility shall not admit, or continue to provide care to, individuals whose needs are greater than the facility is licensed to provide. For any service required under these regulations that is not provided directly by the facility, the facility must have a written contractual agreement or contract with an outside program, resource or service to furnish the necessary service.
504 PERSONNEL AND GENERAL POLICIES AND PROCEDURES
504.1 Required Policies and Procedures Governing General Administration of the Facility
The facility must develop, maintain, and make available for public inspection the following policies and procedures.
a. Resident policies and procedures as set forth in Section 505;
b. Admission policies as set forth in Section 601;
c. Discharge and transfer policies as set forth in Section 602;
d. Incident reporting policies and procedures as set forth in Section 507, including procedures for reporting suspected abuse or neglect.
e. Policies and procedures for the management of resident personal allowance accounts as set forth in Section 505.1 and Section 603.1(3)
f. Residents’ Rights policies and procedures as set forth in Section 603.1;
g. Fire safety standards as set forth in Section 504.1.1(i) and Section 906;
h. Smoking policies for residents and facility personnel as set forth in Section 504.1.1(j) and Section 906;
i. Policy and procedures regarding visitors, mail and associates as set forth in Section 603.1(3)(K), (L), and (M);
j. Policy and procedures regarding emergency treatment plans as set forth in Section 505(l);
k. Policy and procedures for the relocation of residents in cases of emergencies (e.g., natural disasters, or utility outages)
l. Failure of a facility to meet the requirements of this subsection shall be a violation pursuant to Ark. Code Ann. § 20-10-205, et seq.
504.1.1 Each facility must have written employment and personnel policies and procedures. Personnel records shall include, as a minimum, the following:
a. Employment applications for each employee.
b. Written functional job descriptions for each employee that is signed and dated by the employee. Personnel records for each
employee shall be maintained and shall include, as a minimum:
1. description of responsibilities and work to be performed,
and which shall be updated as they change;
2. minimal qualifications, to include educational qualifications;
3. evidence of credentials, including current professional licensure or certification;
4. written statements of reference or documentation of verbal reference check – verbal check documentation must include
the name and title of the person giving the reference, the substance of any statements made, the date and time of the
call, and the name of the facility employee making the call;
5. documentation of education, documentation of continuing training, including orientation training and continuing
education units (CEUs) related to administration certification, personal care, food management, etc. CEU
documentation must include copies of the documentary evidence of the award of hours by the certifying organization;
6. documentation of attendance at in-service or on-the-job training, and orientation as required by the job description;
7. employee’s signed acknowledgement that he or she has received and read a copy of the Residents’ Bill of Rights;
8. results of the criminal record check required by law or regulation.
c. Verification that employee is at least 18 years of age;
d. Documentation that employees with communicable diseases, or with infected skin lesions, are prohibited from direct contact with
residents or with residents’ food, if direct contact will transmit the disease;
e. Verification that employee has not been convicted or does not have a substantiated report of abusing or neglecting residents or
misappropriating resident property. The facility shall, at a minimum, prior to employing any individual or for any individuals
working in the facility through contract with a third party, make inquiry to the Employment Clearance Registry of the Office of
Long Term Care and the Adult Abuse Register maintained by the Department of Human Services, Division of Aging and Adult
Services, and shall conduct re-checks of all employees every five
(5) years. Inquires to the Adult Abuse Registry shall be made by submitting a Request for Information form found in the Appendix,
addressed to Adult Protective Services Central Registry, P. O. Box 1437, Slot S540, Little Rock, AR 72203;
f. Documentation that all employees and other applicable individuals utilized by the facility as staff have successfully complete a
criminal background check pursuant to Ark. Code Ann. § 20-33- 201, et seq. and in accordance with the Rules and Regulations for
Conducting Criminal Record Checks for Employees of Long Term Care Facilities;
g. A copy of a current health card issued by the Arkansas Department of Health or other entities as provided by law;
h. Documentation that the employee has been provided a copy of all personnel policies and procedures. A copy of all personnel
policies and procedures must be made available to OLTC personnel or any other Department;
i. Documentation that policies and procedures developed for personnel about fire safety standards and evacuation of building
have been provided to the employee;
j. Documentation that policies and procedures developed for
smoking have been provided to the employee; Failure to comply with the provisions of this subsection or violation of any
policies or procedures developed pursuant to this subsection shall be a violation pursuant to Ark. Code Ann. §20-10-205, and Ark. Code Ann. §206, or may constitute a deficiency finding against the facility.
504.1.2 The facility shall meet all regulations issued by the Arkansas Department of Health regarding communicable diseases. Further, the facility must prohibit employees with a communicable disease, or with infected skin
lesions, from direct contact with residents or with residents’ food, if direct contact will transmit the disease.
504.2 Required Staffing
504.2.1.1 Each facility must designate a full-time (40 hours per week) administrator. The administrator must be on the premises during normal business hours. The administrator has responsibility for daily operation of the facility. Correspondence from the Office of Long Term Care to the facility will be through the administrator. Sharing of administrators between assisted living facilities and other types of long-term care facilities is permitted pursuant to Section 504.2.1.4.
a. The administrator shall not leave the premises housing the assisted living facility during the day tour of duty without first designating
an employee who will be responsible for the management of the facility during the administrator’s absence.
b. The facility administrator shall notify the OLTC in writing if the administrator will be absent from the facility for seven (7) or more
consecutive calendar days;
c. Each administrator will provide to the OLTC, on an annual basis, a copy of his or her current administrator certification. This
submission must be every time when the facility seeks licensure, renewal of licensure, or upon change of ownership.
d. The facility may employ an individual to act both as administrator and as the facility’s registered nurse under Section 504.2.2. At no
time may the duties of administrator take precedence over, interfere with, or diminish the responsibilities and duties associated
with the registered nurse position. In addition, when an individual is utilized or employed in a dual capacity to meet the requirements
of this section and Section 504.2.2:
1. The person employed in the dual capacity must meet all licensing and certification requirements for both positions;
2. The use of a registered nurse as administrator does not remove or negate any requirements for a criminal record
check for either position;
3. A registered nurse also employed as an administrator must meet the requirements of this section regarding remaining
on the premises of the facility; the provisions for same in Section 504.2.2 do not apply
504.2.1.2 All certifications must be current as required by the certification agency. This submission shall be made each time the facility seeks licensure, renewal of licensure, or upon a change of administrators.
504.2.1.3 The administrator must have the following minimum qualifications:
a. Must be at least 21 years of age;
c. Must have the ability and agree to comply with these regulations;
d. Must successfully complete a criminal background check pursuant to Ark. Code Ann. § 20-33-201, et seq. and in accordance with the
Rules and Regulations for Conducting Criminal Record Checks for Employees of Long Term Care Facilities;
e. Must not have been convicted, or have a substantiated report, of abusing, neglecting, or mistreating persons, or misappropriation of
resident property. An inquiry with the Adult Maltreatment Central Registry (form APS 0001), maintained by the Department of
Human Services, Division of Aging and Adult Services shall be checked prior to employment;
f. Must have no prior conviction pursuant to Ark. Code Ann. § 20- 10-401, or relating to the operation of a long term care;
g. Must be certified as an Assisted Living Facility Administrator through a certification program approved by the OLTC or must be
enrolled in a certification program with an expected completion date within four (4) months of hire. Administrators who are not
certified within this time period may no longer work as an Assisted Living Facility Administrator.
504.2.1.4 Full time means forty (40) hours per week during normal business hours. Part time means twenty (20) hours or more, but less than forty (40) hours, during normal business hours. When a structure or building houses more than one type of long-term care facility, a single administrator may be employed for all the long-term care programs housed within that structure,
building or premises, provided:
a. The person employed as administrator must meet the qualifications for, and be currently licensed or certified as, an administrator for
each type of long-term care facility for which he or she will act as administrator;
b. A second administrator shall be employed part-time when:
1. The total number of beds for all long-term care programs within the facility is more than seventy (70), and
2. The number of beds for each long-term care program within the facility is more than twenty (20) per program;
c. A second administrator shall be employed full-time when:
1. The total number of beds for all long-term care programs within the facility is more than seventy (70), and
2. The number of beds for each long-term care program within the facility is more than forty (40) per program.
504.2.2 Registered Nurse (RN)
The facility shall employ or contract with at least one (1) RN. The assisted living facility RN need not be physically present at the facility, but must be available to the facility by phone or pager. Except for participants of the Assisted Living 1915 (c) home and community based services Medicaid Waiver, the assisted living facility RN shall be responsible for the preparation, coordination, and
implementation of the direct care services plan portion of the resident’s occupancy admission agreement. An RN employed by the Division of Aging and Adult Services and who works with the Assisted Living 1915 (c) Home and Community Based Services Medicaid Waiver Program shall be responsible for Medicaid waiver participants’ direct care services plan portions of the occupancy
admission agreement. The assisted living facility RN, in conjunction with the physician, shall be responsible for the preparation, coordination and implementation of the health care services plan portion of the resident’s occupancy admission agreement and shall review and oversee all LPN, CNA and PCA personnel. The assisted living facility RN may perform all job functions and duties of LPNs, CNAs or PCAs. The RN must be licensed by, and in good standing with, the Arkansas State Board of Nursing, and must comply with all
requirements, including continuing education requirements, as established by law or regulation.
504.2.3 Licensed Practical Nurses (LPN)
The facility shall employ or contract with LPNs to provide nursing or direct care services to residents. LPNs may administer medication and deliver nursing services as provided by Arkansas law or applicable regulation. The LPN can perform all job functions and duties of a CNA or PCA. All LPNs must be licensed by, and in good standing with, the Arkansas State Board of Nursing, and
must comply with all requirements, including continuing education, as established by law or regulation.
504.2.4 Certified Nursing Assistants (CNA)
The facility shall employ CNAs to provide direct care services to residents. CNAs shall be permitted to perform the nurse aide duties set forth in Part II, Unit VII of the Rules and Regulations governing Long Term Care Facility Nursing Assistant Training Curriculum. These nurse aide duties include taking vital signs (temperature, pulse, respiration, blood pressure, height/weight); recognizing and
reporting abnormal changes; death and dying and admission/transfer/discharge. The CNA can perform all job functions and duties of PCAs. All CNAs must be certified by, and in good standing with, the State of Arkansas, and must comply with all requirements, including continuing education, as established by law or regulation. No individual who is uncertified may be employed as a CNA, with
the exception of CNA Trainees. CNA Trainees may be employed to perform those CNA duties for which they have completed their CNA training, and have been determined competent by the CNA program instructor. When utilizing CNA trainees, the facility shall have verification on file that demonstrates each trainee’s competency to perform assigned duties and shall utilize CNA trainees in the
manner and for the time permitted by Long Term Care Facility Nursing Assistant Training Program regulations. For purposes of this section, competency means skills performance approval by the trainee’s instructor.
504.2.5 Personal Care Aide (PCA)
The facility may employ PCAs. Any PCA employed by the facility to provide direct care services to residents must have:
a. Attended and successfully completed an established curriculum for personal care aides; or,
b. Completed an established curriculum for nurse aides but is not State certified.
504.3 To effectuate the intent of these regulations, the assisted living facility shall develop a staffing plan to ensure sufficient personnel/staff/employees are available to meet the needs of the residents. A facility shall meet minimum staffing ratios set forth below at all times, and shall utilize sufficient staff to meet each resident’s particular direct care needs as agreed to and specified in the
resident’s direct care services plan portion of the occupancy admission agreement.
a. The facility administrator may be counted as direct care staff on shifts on which he or she is not performing or required to perform the duties of an administrator. The administrator must meet all licensing or certification requirements for the duties that the administrator is performing.
b. The facility shall have as many personnel/staff/employees awake and on duty at all times as may be needed to properly safeguard the health, safety, or welfare of the residents. For purposes of these regulations, on duty means that the individual is on the premises of the facility, is awake, and is able to meet residents’ needs. Residents shall not be left unsupervised, as
that term is defined in subsection 601.3(a)(1). A minimum on-site staff to-resident ratio shall be one (1) staff person per fifteen (15) residents from 7:00 a.m. to 8:00 p.m., and one (1) staff person per twenty-five (25) residents from 8:00 p.m. to 7:00 a.m., but in no event shall there be fewer than two (2) staff persons on-duty at all times, one of which shall be a CNA. The facility shall designate one staff member as the on-site manager outside normal business hours. In addition to the staff requirements set forth above in this subsection, facilities shall have an administrator on-site during normal business hours, as required in Section
504.2.1.1. Staff persons who live on site but are sleeping shall not be counted for minimum staffing. All needed direct care staff may be PCAs, unless otherwise specified elsewhere in these regulations. Facilities may employ flex staffing. Flex staffing permits facilities to vary
the beginning and ending hours for shifts, so that facilities may maximize staff time to the benefit of residents. Facilities can designate that their shifts will begin earlier or later than specified above. When facilities utilize flex staffing, the shifts must meet the staffing
requirements set forth herein for the entire period of the shift. As way of example only, if a facility begins a shift at 6:00 a.m., rather than 7:00 a.m. in the example above, the minimum staffing requirement of one (1) staff person per fifteen (15) residents will be required until 7:00 p.m., and those minimums must be maintained throughout the entire period. The Office of Long Term Care shall be notified in writing when a facility implements a flex-staffing schedule. The written notice shall state the beginning and ending hours of each shift under the flex staffing.
c. Each staff person on duty may be counted as direct care staff even if they are currently involved in housekeeping, laundry or dietary activities as long as universal precautions are followed.
504.4 All staff and contracted providers having direct contact with residents as well as all food service personnel shall receive orientation and training on the following topics within the time frames specified herein, provided, however, that individuals
employed and paid by the resident, resident’s family, or a representative of the resident are exempt from this requirement:
a. Within seven (7) calendar days of hire:
1. Building safety and emergency measures, including safe operation
of fire extinguishers and evacuation of residents from the building;
2. Appropriate response to emergencies;
3 Abuse, neglect, and financial exploitation and reporting requirements;
4. Incident reporting;
5. Sanitation and food safety;
6. Resident health and related problems;
7. Medication assistance or administration;
8. Resident safety and fall prevention;
9. Resident elopement policies and procedures;
10. General overview of the job’s specific requirements;
11. Philosophy and principles of independent living in an assisted living residence.
12. Residents’ Bill of Rights;
b. Within thirty (30) calendar days of hire:
1. Communicable diseases, including AIDS or HIV and Hepatitis B; infection control in the residence and the principles of universal
precautions based on OSHA guidelines;
2. Dementia and cognitive impairment;
c. Within one hundred eighty (180) calendar days of hire:
1. Communication skills;
2. Review of the aging process and disability sensitivity training.
504.4.1 All staff and contracted providers having direct contact with residents and all food service personnel shall receive a minimum of six (6) hours per year of ongoing education and training to include in-service and on-the job training designed to reinforce the training set forth in Section
504.5 Facility staff, administrators and owners are prohibited from being appointed as, or acting as, guardian of the person or the estate, or both, for residents of the facility.
505 GENERAL REQUIREMENTS CONCERNING RESIDENTS
The facility shall:
a. Permit unrestricted visiting hours. However, facilities may deny visitation when visitation results, or substantial probability exists that visitation will result, in disruption of service to other residents, or threatens the health, safety, or welfare of the resident or other residents.
b. Make keys to residences readily available to facility personnel in the event of an emergency need to enter a residence.
c. With the exception of fish in aquariums and service animals (e.g. guide dogs), live animals shall not be permitted in common dining areas, storage areas, food preparation areas or common serving areas. Pets may be permitted in assisted living facilities if sanitary conditions and appropriate behavior are maintained. If the facility permits pets, the facility shall ensure that the facility is free of pet odors and that pets’ waste shall be disposed of regularly and properly. Pets must not present a danger to residents or guests. Current records of inoculations and license, as required by local ordinance, shall be maintained on file in the facility. For purposes of these regulations, pets mean domesticated mammals (such as dogs and cats), birds or fish, but not wild animals, reptiles, or livestock.
Parameters for pets (including behavior and health) must be set and be included in the occupancy admission agreement.
d. Require that conduct in the common areas shall be appropriate to the community standards as defined by the residents and staff.
e. Ensure that there shall be only one resident to an apartment or unit except in situations where residents are husband and wife or are two consenting adults who have voluntarily agreed in writing to share an apartment or unit that has been executed by the resident or responsible party as appropriate.
A copy of the agreement shall be maintained by the facility in each resident’s record.
f. Except in cases of spouses, or consenting adults who have agreed otherwise in writing, ensure that male and female residents do not have adjoining rooms that do not have full floor to ceiling partitions and closable solid core doors.
g. Ensure that residents not perform duties in lieu of direct care staff, but may be employed by the facility in other capacities.
h. Ensure that residents are not left in charge of the facility.
i. Ensure that a minimum of one phone jack is available in each resident’s apartment or unit for the resident to establish private phone service in his or her name. In addition, there shall be, at a minimum, one dedicated facility phone and phone line for every forty (40) residents in common areas. The phone shall allow unlimited local calling without charge. Long
distance calling shall be possible at the expense of the resident or responsible party via personal calling card, pre-paid phone card, or similar methods. Residents shall be able to make phone calls in private. “Private” can be defined as placing the phone in an area that is secluded and away from frequently used areas.
j. Ensure that residents are afforded the opportunity to participate in social, recreational, vocational, and religious activities within the community, and any activities made available within the facility.
k. Document that each resident has a physician or advance practice nurse of his or her choice who is responsible for the overall management of the resident’s health.
l. In the event of a resident’s illness or accident:
1. Notify the resident’s responsible party or next of kin and personal physician or advance practice nurse, or in the event such physician
or advance practice nurse is not available, a qualified alternate. A competent resident may decline to have someone contacted, if such
a request is in writing and is filed in the resident’s file;
2. Take immediate and appropriate steps to see that the resident receives necessary medical attention including transfer to an
appropriate medical facility;
3. Make a notation of the illness or accident in the resident’s records.
505.1 Financial Management of Resident Personal Allowance Each facility must provide for the safekeeping and accountability of resident
funds in accordance with this Section and Section 603.1(3)(N). A facility may not require the resident to deposit funds with the facility.
505.1.1 The facility must have written policies and procedures for the management
of personal funds accounts with an employee designated to be responsible
for these accounts. In addition, the facility shall ensure that:
a. Each person receiving SSI shall have the opportunity to place personal funds in an account. No fee shall be charged by the
facility for maintaining these accounts;
b. Persons who receive SSI are entitled to retain an amount from their income for personal needs consistent with federal requirements;
c. The facility shall hold personal funds in trust for the sole use of the residents, and such funds must not be commingled with the funds
of the facility or used for any purpose other than for the benefit of the resident;
d. The personal funds shall be used at the discretion of the resident or responsible party;
e. The resident may terminate his or her facility-maintained account and receive the current balance within seven (7) calendar days of
the termination of the account;
f. The facility maintains individual records for each resident who has an account that shows all debits and credits to the account, and that
maintains a running, current balance;
g. The facility documents all personal transactions and maintains all paid bills, vouchers, and other appropriate payment and receipt
documentation in the manner prescribed by the Department or by law;
h. If the facility deposits personal allowance funds, they shall be deposited in individual or collective interest bearing, federally
insured bank accounts. If these accounts are established, the facility must develop a procedure to insure the equitable
distribution of interest to each resident’s account;
i. At least quarterly, the facility supplies each resident or responsible party who has a personal account with a statement showing all
deposits, withdrawals and current balance of the resident’s personal allowance account;
j. The facility provides the Department access to required resident financial records upon request;
k. At a minimum, the resident has access to his or her personal allowance account during the hours of 9:00 a.m. to 5:00 p.m.
Monday through Friday;
l. The facility does not charge the resident additional amounts for supplies or services that the facility is by law, regulation, or
agreement required to provide under the basic charge;
m. Services or supplies provided by the facility beyond those that are required to be included in the basic charge are charged to the
person only with the specific written consent of the resident or his or her responsible party;
n. Whenever a resident authorizes a facility to exercise control over his or her personal allowance, such authorization is in writing and
signed by the resident or his or her responsible party, and the administrator of the facility or his or her designee. Any such
money shall not be commingled with the funds, or become an asset, of the facility or the person receiving the same, but shall be
segregated and recorded on the facility’s financial records as independent accounts.
505.1.2 Transfer of resident funds must meet the following requirements:
a. At the time of discharge from the assisted living facility, the resident or his or her responsible party or agent shall be provided a
final accounting of the resident’s personal account and issued the outstanding balance within seven (7) calendar days of the date of
discharge except as otherwise required by the Social Security Administration for representative payees. If the resident is being
transferred to another assisted living facility or health care facility, the resident or responsible party shall be given an opportunity to
authorize transfer of the balance to a resident account at the receiving facility except as otherwise required by the Social
Security Administration for representative payees;
b. Upon death of a resident, a final statement of the account must be made and all remaining funds shall be transferred to the resident’s
estate, subject to applicable state laws;
c. Upon change of ownership, the existing owner must provide the new owner with a written statement of all resident personal funds.
This statement shall verify that the balance being transferred in each resident fund account is true and accurate as of the date of
d. At change of ownership, the new owner must assume responsibility for account balances turned over at the change of
ownership together with responsibility for all requirements of this Section, including holding of resident’s funds in trust.
505.1.3 The facility must maintain inventory records and security of all monies, property or things of value that the facility agrees to store for the resident outside of the resident’s apartment or unit and that the resident has voluntarily authorized, in writing, the facility to hold in custody or exercise control over at the time of admission or any time thereafter.
505.1.4 If a responsible party or payee fails to pay an assisted living facility’s charges or to provide for the resident’s personal needs, the facility shall notify the Department of Human Services, Division of Aging and Adult
Services, Adult Protective Services.
506 QUALITY ASSURANCE
The Assisted Living Facility shall develop and maintain a quality assessment unit. The unit shall meet at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary, and to develop and implement appropriate plans of action to correct identified quality deficiencies The quality assessment unit shall consist of the individual or individuals identified
by the facility as having the ability to recognize and identify issues of quality deficiencies and to implement changes to facility and employee practices designed to eliminate identified issues of quality deficiencies.
Good faith attempts by the unit to identify and correct quality deficiencies will not
be used as a basis for sanctions.
507 REPORTING SUSPECTED ABUSE, NEGLECT, OR MISAPPROPRIATION OF RESIDENT PROPERTY
Pursuant to Ark. Code Ann. § 12-12-1701 et seq., the facility must develop and implement written policies and procedures to ensure incidents are prohibited, reported, investigated and documented as required by these regulations and by
Alleged or suspected abuse or neglect of residents;
Exploitation of residents or any misappropriation of resident property.
A facility is not required under this regulation to report death by natural causes.
However, nothing in this regulation negates, waives, or alters the reporting requirements of a facility under other regulations or statutes.
Facility policies and procedures regarding reporting, as addressed in these regulations, must be included in orientation training for all new personnel/staff/employees and must be addressed at least annually during in service training for all facility staff.
507.1 Next-Business-Day Reporting of Incidents
The following events shall be reported to the Office of Long Term Care by
facsimile transmission to telephone number 501-683-5306 of the completed
Incident & Accident Intake Form (Form DMS-731) no later than 11:00 a.m. on the next business day following discovery by the facility.
a. Any alleged, suspected, or witnessed occurrences of abuse, including verbal statements or gesturers, or neglect to residents.
b. Any alleged, suspected, or witnessed occurrence of misappropriation of resident property or exploitation of a resident.
c. Any alleged, suspected, or witnessed occurrences of sexual abuse to residents by any individual.
In addition to the requirement of a facsimile report by the next business day on
Form DMS-731, the facility shall complete a Form DMS-742 in accordance with
Section 507.5. Forms DMS-731 and DMS-742 are found in the Appendix.
507.2 Incidents or Occurrences that Require Internal Reporting Only – Facsimile Report or Form DMS-742 Not Required
The following incidents or occurrences shall require the facility to prepare an internal report only and does not require a facsimile report or Form DMS-742 to be made to the Office of Long Term Care. The internal report shall include all
content specified in Section 507.3, as applicable. Facilities must maintain these incident report files in a manner that allows verification of compliance with this provision.
a. Incidents where a resident attempts to cause physical injury to another resident without resultant injury. The facility shall maintain written reports on these types of incidents to document “patterns” of behavior for
b. All cases of reportable disease as required by the Arkansas Department of Health.
c. Loss of heating, air conditioning, or fire alarm system for a period of
greater than two (2) hours.
507.3 Internal-Only Reporting Procedure
Written reports of all incidents and accidents shall be completed within five (5) days after discovery. The written incident and accident reports shall be comprised of all information specified in forms DMS-731 and DMS-742 as applicable.
All written reports will be reviewed, initialed, and dated by the facility administrator or designee within five (5) days after discovery.
1. All reports involving accident or injury to residents will also be reviewed, initialed, and dated by the facility registered nurse within five (5) days of the review by the facility administrator.
2. The direct care services and health care services plan portions of the occupancy admission agreement shall be reviewed by the registered nurse and:
a. Shall be amended upon any change of a resident’s condition or need for services;
b. Copies of the amended versions of the direct care services and health care plan, or both of them, shall be attached to the written
report of the incident or accident. Reports of incidents specified in Section 507.2 will be maintained in the facility
only and are not required to be submitted to the Office of Long Term Care. All written incident and accident reports shall be maintained on file in the facility for a period of three (3) years from the date of occurrence or report, whichever is
507.4 Other Reporting Requirements
The facility’s administrator or designee is also required to make any other reports as required by state and federal laws and regulations.
507.5 Abuse Investigation Report The facility must ensure that all alleged or suspected incidents involving resident
abuse, exploitation, neglect, or misappropriations of resident property are thoroughly investigated. The facility’s investigation must be in conformance with the process and documentation requirements specified on the Form DMS-742, and must prevent the occurrence of further incidents while the investigation is in progress.
The results of all investigations must be reported to the facility’s administrator or designated representative and to other officials in accordance with state law, including the Office of Long Term Care, within five (5) working days of the
facility’s knowledge of the incident. If the alleged violation is verified, appropriate corrective action must be taken.
The DMS-742 shall be completed and mailed to the Office of Long Term Care by the end of the 5th working day following discovery of the incident by the facility. The DMS-742 may be amended and re-submitted at any time circumstances
507.6 Reporting Suspected Abuse or Neglect
The facility’s written policies and procedures shall include, at a minimum, requirements specified in this section.
507.6.1 The requirement that the facility’s administrator or his or her designated agent immediately reports all cases of suspected abuse or neglect of residents of an assisted living facility to the local law enforcement agency in which the facility is located as required by Ark. Code Ann. § 12-12- 1701 et seq. and as amended.
507.6.2 The requirement that the facility’s administrator or his or her designated agent report suspected abuse or neglect to the Office of Long Term Care as specified in this regulation.
507.6.3 The requirement that all facility personnel/staff/employees who have reasonable cause to suspect that a resident has been subjected to conditions or circumstances that have resulted in abuse or neglect are required to immediately notify the facility administrator or his or her designated agent (this does not negate that all mandated reporters employed by or contracted with the facility shall report immediately to the local law enforcement agency in which the facility is located as required
by Ark. Code Ann. § 12-12-1701 et seq.
507.6.4 The requirement that, upon hiring, each facility employee be given a copy of the abuse or neglect reporting and prevention policies and procedures and sign a statement that the policies and procedures have been received and read. The statement shall be filed in the employee’s personnel file.
507.6.5 The requirement that all facility personnel receive annual, in-service training in identifying, reporting and preventing suspected abuse or neglect, and that the facility develops and maintains policies and procedures for the prevention of abuse and neglect and accidents.
507.7 When the Office of Long Term Care makes a finding that a facility employee or personnel of the facility committed an act of abuse, neglect or misappropriation of resident property against a resident, the name of that employee or personnel shall be placed in the Employment Clearance Registry of the Office of Long Term Care. If the employee or personnel
against whom a finding is made is a CNA, the name of the CNA will be placed in the CNA Registry of the Office of Long Term Care. Further, the Office of Long Term Care shall make report of its finding to the
appropriate licensing or enforcement agencies.
508 RESIDENT RECORDS
508.1 The assisted living facility must maintain a separate and distinct record for each resident. The record must contain:
a. Resident’s name;
b. Resident’s last address;
c. Date the resident began residing at the facility;
d. Name, office telephone number, and emergency telephone number of each physician or advance practice nurse who treats the resident;
e. Name, address, and telephone number of the responsible party, or if no responsible party, the person who should be contacted in the event of an emergency involving death of the resident;
f. All identification numbers such as Medicaid, Medicare or Medipak, Social Security, Veterans Administration and date of birth;
g. Any other information that the resident requests the assisted living facility to keep on record;
h. A copy of the resident’s signed “Residents’ Bill of Rights” Statement;
i. A copy of the current occupancy admission agreement that includes the resident’s direct care services plan, health care services plan updated within the specified time frames and transfer/discharge plan (when applicable);
j. On admission, and each time there is a change in services provided the resident, a written acknowledgement that the resident or his or her responsible party has been notified of the charges for the services provided;
k. Information about any specific health problem of the resident that might be necessary in a medical emergency. Such records should specify any medication allergies. If none, state “no known allergies”;
l. A brief medical history;
m. A list of all current medications, including strength and dosage, kept by the facility for the resident;
n. Name of the resident’s or his or her responsible party’s preferred pharmacy;
o. An entry shall be made at any time the resident’s status changes or in the event of an unusual occurrence. This documentation shall include:
3. Physician or advance practice nurse visits;
4. Problem with staff members or others;
6. Physical injury sustained;
7. Changes in the resident’s mental or physical condition;
p. Copy of any compliance agreement;
q. A copy of court orders, letters of guardianship, or power of attorney if applicable;
r. Copy of advance directive, if applicable;
s. Discharge date.
508.2 The facility must maintain the resident’s records in the following manner:
a. Each resident shall have the right to inspect his or her records during normal business hours in accordance with state and federal law;
b. The facility must not disclose any resident records maintained by the facility to any person or agency other than the facility personnel, the OLTC or the Attorney General’s Office except upon expressed written consent of the resident or his or her responsible party unless the disclosure is required by state or federal law or regulation;
c. Each facility must provide a locked file cabinet or locked room for keeping resident’s medical, social, personal, and financial records;
d. The facility must maintain the original records in an accessible manner for
a period of five (5) years following the death or discharge of a resident;
e. The original resident records shall be kept on the facility premises at all times, unless removed pursuant to subpoena.
f. In the event of a change of ownership, the resident records shall remain with the facility.
g. If the facility closes, the resident records shall be stored by the owner of the facility within the State of Arkansas for five (5) years.
h. The facility shall take reasonable actions to protect the resident records from destruction, loss, or unauthorized use.