A. Administrative File.
A Provider shall have an administrative file to include:
1. articles of Incorporation or certified copies thereof, if incorporated, or partnership documents, if applicable;
2. current copy of the approved constitution and/or bylaws of the governing authority, with a current roster of the membership to include addresses of the
3. written policies and procedures approved by the owner/governing body that addresses the following:
a. confidentiality and security of files;
d. resident’s rights;
e. grievance procedure;
f. safekeeping of personal possessions, if applicable;
g. residents’ funds, if applicable;
h. emergency and evacuation procedures;
i. abuse and neglect;
j. critical incidents;
k. admissions and discharge procedures; and,
4. minutes of formal Governing Body meetings;
5. organizational chart of the Provider;
6. all leases, contracts, and purchase-of-service agreements to which the provider is a
party, which includes all appropriate credentials;
7. insurance policies. Every Provider shall maintain in force at all times a
comprehensive general business insurance policy or policies in an amount
adequate to cover all foreseeable occurrences. The insurance shall include
coverage for any personal or professional negligence, malpractice, or misconduct
by facility owners or employees; coverage for any injuries received by any
resident while being transported by facility staff or third-party contractors; and
coverage for any injuries sustained by any resident while in the facility. The
policies shall be without limitations or exclusions of any kind; and,
8. copies of Incident/Accident Reports.
B. Organizational Communication
1. A Provider shall establish procedures to assure written communication among
staff to provide continuity of services to all residents.
2. Direct care employees shall have access to information concerning residents that
is necessary for the effective performance of the employee’s assigned tasks.
C. Confidentiality and Security of Files.
A Provider shall have written procedures for the maintenance and security of records specifying who shall supervise the maintenance of
records, who shall have custody of records, and to whom records may be released. Procedures shall address the following.
1. A Provider shall maintain the confidentiality of all residents’ records. Employees
of the facility shall not disclose or knowingly permit the disclosure of any
information concerning the resident or his/her family, directly, or indirectly, to any
2. A Provider shall obtain the resident’s or legal representative’s written, informed permission prior to releasing any information from which the resident or his/her family might be identified, except to the DSS, Bureau of Licensing. Identification information may be given to appropriate authorities in cases of an emergency.3. The Provider shall have a procedure by which representatives or family of residents are given an opportunity to receive information about the individual
resident in care of the facility.4. A Provider may use material from records for teaching and research purposes if names are deleted and other identifying information is disguised or deleted.
A Provider shall have written policies and procedures regarding the photographing and audio or audiovisual recordings of residents.
1. No resident shall be photographed or recorded without the resident’s prior informed, written consent. Such consent cannot be made a condition for
admission into, remaining in, or participating fully in the activities of, the facility. Consent agreements must clearly notify the resident of his/her rights under this
regulation must specify precisely what use is to be made of the photograph or
recordings, and are valid for a maximum of one year from the date of execution.
Residents are free to revoke such agreements at any time, either orally or in
2. All photographs and recordings shall be used in a way that respects the dignity and confidentiality of the resident.
E. Personnel Policies.
A Provider shall have written personnel policies that include:
1. a plan for recruitment, screening, orientation, ongoing training, development, supervision, and performance evaluation of staff members;
2. written job descriptions for each staff position including volunteers;
3. policies which provide for staff, upon offer of employment, to have a health assessment as defined in the Provider’s policy and procedures. These policies
shall, at a minimum, require that the individual has no evidence of active tuberculosis and that staff shall be retested on a time schedule as mandated by the
Office of Public Health. Test results dated within one (1) year prior to the offering of employment are acceptable for initial employment;
4. an employee grievance procedure;
5. abuse reporting procedures that require all employees to report any incidents of abuse or mistreatment whether that abuse or mistreatment is done by another staff
member, a family member, a resident, or any other person;
6. a written policy to prevent discrimination.
1. A Provider’s orientation program shall include training in the following topics for all employees:
a. the policies and procedures of the facility;
b. emergency and evacuation procedures;
c. resident’s rights;
d. procedures for and legal requirements concerning the reporting of abuse and critical incidents; and,
e. instruction in the specific responsibilities of the employee’s job.
2. Orientation for direct care staff shall include an additional five (5) days of
supervised training. Training, at a minimum, shall include the following:
a. training in Resident Care Services (ADL’S & IADL’s) provided by the Facility;
b. infection control to include bloodborne pathogens; and,
c. any specialized training to meet residents’ needs.
3. A new employee shall not be given sole responsibility for the implementation of a client’s program plan until this training is completed.
4. The staff member shall sign a statement certifying that such training has occurred.
5. Orientation and five (5) days of supervised training shall meet the first year’s annual training requirements.
6. All direct care staff shall receive certification in adult First Aid within the first 30
days of employment.
G. Annual Training
1. A Provider shall ensure that each direct care worker participates in in-service
training each year. Normal supervision shall not be considered for meeting this
2. The Provider shall document that direct care staff receives training on an annual basis in:
a. facility’s policies and procedures;
b. emergency and evacuation procedures;
c. resident’s rights;
d. procedures and legal requirements concerning the reporting of abuse and
e. resident care services (ADL’S & IADL’S);
f. infection control to include bloodborne pathogens;
g. any specialized training to meet residents’ needs.
3. All direct care staff shall have documentation of current certification in First Aid.
4. The Director shall participate annually in at least twelve (12) hours of continuing
education in the field of geriatrics, assisted living concepts, specialized training in
the population served and/or supervisory/management techniques.
5. The employee shall sign a statement of understanding certifying that such training
An employee’s Annual Performance Evaluation shall include his/her interaction with residents, family, and other providers.
I. Personnel Files
1. A Provider shall maintain a personnel record for each employee. At a minimum, this file shall contain the following:
a. the application for employment and/or résumé of education, training, and
b. a criminal history check, prior to an offer of employment, in accordance with state law;
c. evidence of applicable professional credentials/certifications according to state law;
d. documentation of TB test results and any other Provider required medical examinations;
e. documentation of three reference checks;
f. annual performance evaluation;
g employee’s hire and termination dates;
h. documentation of orientation and annual training; and,
i. documentation of driver’s license (if driving or transporting residents).2. A Provider shall not release an employee’s personnel file without the employee’s
written permission, except as required by state law.
J. Resident’s Records
1. A Provider shall maintain a separate record for each resident. Such record shall be current and complete and shall be maintained in the Facility or in a central
administrative location readily available to Facility staff and to the Bureau of Licensing staff.
2. Each record shall contain at least the following information:
a. resident’s name, marital status, date of birth, sex, Social Security number, and previous home address;
b. dates of admission and discharge;
c. names, addresses, and telephone numbers of responsible persons to be notified in case of accident, death, or another emergency;
d. name, address, and telephone number of a physician and dentist to be called in an emergency;
e. ambulatory status;
f. resident’s plan/authorization for routine and emergency medical care as required in §8823.D.1;
g. resident’s written authorization for a representative and their name, address, and telephone number, if applicable;
h. the pre-admission appraisal and admission agreement;
i. reports of the assessment specified in 8827.A.1 and of any special
problems or precautions;
j. individual service plan, updates, and quarterly reviews;
k. continuing record of any illness, injury, or medical or dental care, when it
impacts the resident’s ability to function or the services he or she needs;
l. a record of all personal property and funds which the resident has entrusted to the home/facility;
m. reports of any resident complaints or grievances and the conclusion or disposition of these reports;
n. incident reports; and,
o. written acknowledgments that the resident has received clear verbal explanations and copies of his/her rights, the house rules, written
procedures for safekeeping of valuable personal possessions of residents, written statement explaining the resident’s rights regarding personal
funds, and the right to examine his/her record.
3. All information and records obtained from or regarding residents shall be stored and kept confidential.
1. All records shall be maintained in an accessible, standardized order and format and shall be retained and disposed of in accordance with state laws.
2. A Provider shall have sufficient space, facilities, and supplies for providing effective record-keeping services.