When a new resident is admitted into your facility you are required to provide the resident or the resident’s representative with a number of different items.One of those items has to do with how your facility handles resident’s with DNR’s.There is very specific language that is required by AHCA that needs to be included.


Title Do Not Resuscitate Orders (DNROs)

Statute or Rule 58A-5.0186 FAC

(1) POLICIES AND PROCEDURES. (a) Each assisted living facility must have written policies and procedures that explain its implementation of state laws and rules relative to Do Not Resuscitate Orders (DNROs). An assisted living facility may not require execution of a DNRO as a condition of admission or treatment. The assisted living facility must provide the following to each resident, or resident ‘ s representative, at the time of admission:

1. Form SCHS-4-2006, ” Health Care Advance Directives – The Patient ‘ s Right to Decide, ” April 2006, or with a copy of some other substantially similar document, which incorporates information regarding advance directives included in Chapter 765, F.S

2. DH Form 1896, Florida Do Not Resuscitate Order Form

(b) There must be documentation in the resident ‘ s record indicating whether a DH Form 1896 has been executed. If a DH Form 1896 has been executed, a yellow copy of that document must be made a part of the resident ‘ s record. If the assisted living facility does not receive a copy of a resident ‘ s executed DH Form 1896, the assisted living facility must document in the resident ‘ s record that it has requested a copy.

(c) The executed DH Form 1896 must be readily available to medical staff in the event of an emergency.

(2) LICENSE REVOCATION. An assisted living facility ‘ s license is subject to revocation pursuant to Section 408.815, F.S., if, as a condition of treatment or admission, the facility requires an individual to execute or waive DH Form 1896.

(3) DNRO PROCEDURES. Pursuant to Section 429.255, F.S., an assisted living facility must honor a properly executed DH Form 1896 as follows:

(a) In the event a resident experiences cardiac or pulmonary arrest, staff trained in cardiopulmonary resuscitation (CPR) or a health care provider present in the facility, may withhold cardiopulmonary resuscitation (artificial ventilation, cardiac compression, endotracheal intubation and defibrillation).

(b) In the event a resident is receiving hospice services and experiences cardiac or pulmonary arrest, facility staff must immediately contact hospice staff. The hospice procedures take precedence over those of the assisted living facility.


Take a moment and Review your resident admission package and facility DNR Policy and Procedure and make sure it meets ACHA’s standards.

As you can see above there was missing the required documentation in the admission package and policy and procedure regarding hospice patients. Which resulted in a Class III deficiency.

Here is a sample that you can use in your admission package to help you meet the AHCA requirement

DNR and Advanced Directives