General
18.1 Each assisted living residence shall have a confidential health information record for each
resident and maintain it in a manner that ensures accuracy of information.
18.2 Health information records for current residents shall be kept on site at all times.
18.3 Each assisted living residence shall implement a policy and procedure for an effective information
management system that is either paper-based or electronic. If the ALR maintains both paperbased and electronic records, there shall be a method for integration of those records that allows
effective continuity of care. Processes shall include effective management for capturing reporting,
processing, storing and retrieving care/service data and information.
18.4 At the time of admission, the resident record shall contain, at a minimum, the following items:
(A) Face sheet,
(B) Practitioner orders,
(C) Individualized resident care plan,
(D) Copies of any advance directives, and
(E) A signed copy of the resident agreement.
Confidentiality and Access
18.5 The assisted living residence shall have a means of securing resident records that preserves their
confidentiality and provides protection from loss, damage and unauthorized access.
18.6 The confidentiality of the resident record including all medical, psychological and sociological
information shall be protected in accordance with all applicable federal and state laws and
regulations.
18.7 Each resident or legal representative of a resident shall be allowed to inspect that resident’s own
record in accordance with §25-1-801, C.R.S. Upon request, resident records shall also be made
available for inspection by the state and local long-term care ombudsman pursuant to §26-11.5-
108, C.R.S., Department representatives and other lawfully authorized individuals.
Content
18.8 Resident records shall contain, but not be limited to, the following items:
(A) Face Sheet,
(B) Practitioner order,
(C) Individualized resident care plan,
(D) Progress notes which shall include information on resident status and wellbeing, as well
as documentation regarding any out of the ordinary event or issue that affects a
resident’s physical, behavioral, cognitive and/or functional condition along with the action
taken by staff to address that resident’s changing needs;
(1) The assisted living residence shall require staff members to document, before
the end of their shift, any out of the ordinary event or issue regarding a resident
that they personally observed, or was reported to them.
(E) Medication Administration Record,
(F) Documentation of on-going services provided by external service providers including, but
not limited to, family members, aides, podiatrists, physical therapists, hospice and home
care services, and other practitioners, assistants and caregivers;
(G) Advance directives, if applicable, with extra copies; and
(H) Final disposition of resident including, if applicable, date, time and circumstances of a
resident’s death along with the name of the person to whom the body is released.
18.9 The face sheet shall be updated at least annually and contain the following information:
(A) Resident’s full name, including maiden name, if applicable;
(B) Resident’s sex, date of birth, and marital status;
(C) Resident’s most recent former address;
(D) Resident’s medical insurance information and Medicaid number, if applicable;
(E) Date of admission and readmission, if applicable;
(F) Name, address and contact information for family members, legal representatives, and/or
other persons to be notified in case of emergency;
(G) Name, address and contact information for resident’s practitioner and case manager, if
applicable;
(H) Resident’s primary spoken language and any issues with oral communication;
(I) Indication of resident’s religious preference, if any;
(J) Resident’s current diagnoses; and
(K) Notation of resident’s allergies, if any.
Record Transfer and Retention
18.10 If a resident’s care is transferred to another health facility or agency, a copy of the face sheet,
individualized resident care plan and medication administration record for the current month shall
be transferred with the resident.
18.11 If an assisted living residence ceases operation, each resident’s records must be transferred to
the licensed health facility or agency that assumes that resident’s care.
18.12 Records of former residents shall be complete and maintained for at least three years following
the termination of the resident’s stay in the assisted living residence.
18.13 Such records shall be maintained and readily available at the assisted living residence location
for a minimum of six months following termination of the resident’s stay.