Emergency Access to Records: A Common Staffing Deficiency Under 59A-36.010

Emergency Access to Records: A Common Staffing Deficiency Under 59A-36.010
Emergency Access to Records: A Common Staffing Deficiency Under 59A-36.010

Staffing compliance in Assisted Living Facilities (ALFs) goes beyond meeting required hours on paper. One of the most frequently cited—and often misunderstood—deficiencies involves access to facility and resident records during emergencies.

Florida Administrative Code 59A-36.010 Staffing Standards (3)(a)3 states:

“At least one staff member who has access to facility and resident records in case of an emergency must be in the facility at all times when residents are in the facility.”

Why This Regulation Exists

This rule is about resident safety and emergency preparedness. If there is a medical emergency, fire, elopement, or an unannounced AHCA inspection, someone on-site must be able to immediately access critical information, including:

  • Resident records 
  • Emergency contacts 
  • Medical information 
  • Facility documentation 

Having staff present is not enough if no one can access or explain the records.

How This Deficiency Commonly Occurs

This issue is seen frequently in smaller facilities, and it often looks like this:

  • The facility is technically meeting required staffing hours 
  • The administrator or manager is not on the premises 
  • Facility and resident records are locked 
  • On-site staff do not have access to the records 
  • Staff are not knowledgeable about the records 

When AHCA requests documents and staff cannot immediately provide them, surveyors view this as a direct violation of the regulation—even if staffing numbers are otherwise compliant.

Locked Records = Noncompliance

One of the most common mistakes facilities make is locking records when management is off-site.

If:

  • Records are locked 
  • Only management has access 
  • Staff cannot retrieve records during an emergency 

then the facility is out of compliance, regardless of staffing ratios.

AHCA expects at least one on-site staff member to have immediate access to facility and resident records at all times.

Knowledge Matters as Much as Access

Access alone is not enough. The on-site staff member must also:

  • Know where records are located 
  • Understand what records are required 
  • Be able to retrieve requested documents without delay 

Statements like:

  • “The administrator isn’t here.” 
  • “Those are locked.” 
  • “I don’t know where that is.” 

almost always lead to a citation.

Best Practices to Stay Compliant ✅

  • Assign at least one staff member per shift with record access 
  • Avoid locking records in a way that limits access when management is off-site 
  • Train staff on where records are kept and what AHCA may request 
  • Perform mock surveys and ask staff to retrieve documents 
  • Document who has record access on each shift 

Bottom Line

Meeting staffing hours alone does not equal compliance. If AHCA arrives and:

  • Management is not present 
  • Records are locked 
  • Staff cannot provide requested documents 

the facility is at high risk for a citation under 59A-36.010 Staffing Standards.

👉 Administrator Tip:

Ask yourself: If AHCA walked in right now, could my staff immediately access and explain our records?

 

Health Department Inspections: Why “They Never Came” Is Not an Excuse Under 64E-12.004

During an AHCA survey, one of the documents routinely requested is the most recent Health Department inspection report. This requirement applies to all assisted living facilities, yet it remains a common area of noncompliance.

Florida Administrative Code 64E-12.004 requires assisted living facilities to comply with Department of Health inspection requirements, and AHCA expects facilities to be able to produce proof of those inspections upon request.

What AHCA Expects During Surveys

When AHCA is on-site, surveyors commonly ask for:

  • The most recent Health Department inspection report 
  • Documentation showing the facility is compliant 
  • Evidence that required inspections are being maintained 

If the report cannot be produced, the facility is immediately at risk for citation—regardless of staffing levels, care quality, or overall operations.