Keeping good records

It is always an exciting time when a new resident chooses to move into your community! Many hours of work from your team have paid off and now you welcome a new member to the
“family”- but it’s not done yet! The state of Maine requires a working resident file for every person living in an Assisted Living Facility. Check out the regulations below as to what needs to
be included in the resident record, mandated by DLRS:

Consumer Records
10.1 Individual records required. For each consumer receiving assisted living services, the program must
develop and maintain individual records that include, but are not limited to, the following:
10.1.1 Name, address, mailing address (if different), and telephone number;
10.1.2 Name, address, and telephone number of a person to contact in an emergency;
10.1.3 A functional assessment and reassessments;
10.1.4 A service plan;
10.1.5 A dated release of information authorization; and
10.1.6 Documented proof of legal representation.
10.2 Assessments and reassessments.
10.2.1 A functional assessment must be completed within thirty (30) calendar days for a consumer receiving assisted living services. The assessment must include a review of the consumer’s need for assistance with ADLs, IADLs, medication administration, and nursing service. The document shall contain the date of the assessment and the signature of the assessor.
10.2.2 Reassessments shall be done at least every six (6) months thereafter, indicating the date of the
reassessment and the signature of the assessor.
10.3 Service plans. A service plan shall be signed by the consumer or his/her legal representative. The plan authorizes the program to arrange for or to provide services. The service plan must be reviewed and revised as appropriate, but at least every six (6) months, unless changes occur. The plan must describe:
10.3.1 What services will be provided;
10.3.2 The desired outcome;
10.3.3 Who will provide the services;
10.3.4 When and how often assistance will be provided; and
10.3.5 When the service will begin.
10.4 Release of information. A dated release of information authorization shall be on a form approved by the
Department, and signed by the consumer. The release of information authorization must:
10.4.1 Be in language the consumer can understand;
10.4.2. State whether or not the consumer gives permission for information to be disclosed and if
permission is given, the authorization must contain: Names of the agencies or people who are authorized to disclose information; A description of the type of information that may be disclosed; Names of the people or agencies to whom the information may be disclosed; The date the authorization will expire; and A statement that the consumer can revoke or change the release at any time.
10.5 Progress notes. Signed and dated progress notes shall be completed at least monthly on implementation of
the service plan and/or any significant changes in the consumer’s functioning.
10.6 Incident documentation. For any consumer who has sustained an injury, who has a medication reaction
or when an error is made in the documentation or administration of medication, a report shall be completed.
The report shall describe the incident and indicate the extent of the injury or reaction and necessary treatment. It shall be filed in the consumer’s record.

Pro Tip:
• Have a system for who will gather all of the resident’s documents both at time of admission as
well as collecting ongoing information needed to maintain the resident’s files.