When operating an assisted living facility keeping accurate records should be one of your top priorities as you will undoubtedly be the subject of an inspection by ADPH, served court paperwork requesting documents related to a resident’s suit, or a plethora of other instances. As the administrator, you should have your hand deeply involved with these records and audit them frequently to ensure you are covering all your bases. Check out the article below provided by ADPH for what needs to be included in your resident records:
420-5-4-.05 Records and Reports.
(1) General.
(a) Responsibility for Records. The administrator shall prepare and file all records or shall oversee the preparation and filing of records. This duty shall be assigned to other employees in the administrator’s absence.
(b) All records and reports required by these rules shall be completed in a timely manner and shall be maintained and filed in an orderly manner within the assisted living facility premises.
(c) Storage and Safety. Provision shall be made for the safe storage of records within the facility. Records shall be stored in a manner to reasonably protect them from water or fire damage. Records shall be safeguarded from unauthorized access.
(d) All facility records, including resident medical records, shall be made readily available for review and copying on demand by representatives of the State Board of Health upon request.
(2) Administrative Records and Documents.
(a) Each assisted living facility shall maintain the following records and documents. Unless otherwise specified below, a photocopy of the record or document shall be sufficient to meet this requirement.
- Original Articles of Incorporation or certified copies thereof, if the governing authority is incorporated, or partnership documents if the governing authority is a partnership or limited partnership.
- A current copy of the constitution or bylaws of the governing authority, with a current roster of the membership of the governing authority.
- Up-to-date personnel records for all employees and former employees of the facility. Personnel records for former employees shall be retained for at least 3 years after the employee leaves employment.
- Current policy and procedure manual.
(3) Resident Records.
(a) Records shall be current from the time of admission to the time of discharge or death and shall be retained in the facility for at least three years after a resident’s death or discharge.
(b) When an individual is admitted to an assisted living facility, records, and information regarding the resident shall be protected from unauthorized disclosure. Employees and authorized agents of the Department shall be permitted to review all medical records and all other records to determine compliance with these rules. With the written consent of the resident, or with the written consent of the legal guardian of an incompetent resident, the local ombudsman shall be permitted access to all records regarding the resident. Records necessary to assess a resident’s medical condition or to otherwise render good medical care shall be provided to the resident’s treating physician or physicians or to the resident or to his or her legally authorized representative. A resident or his or her legal guardian may grant permission to any other individual to review the resident’s confidential records by signing a standard release.
(c) In addition to all records required for the provision of resident care, for each resident, the assisted living facility shall maintain on its premises the required documents listed below and any other documents required by the facility’s policies and procedures:
- Statement of resident rights signed by the resident.
- Financial agreement.
- Inventory of personal effects.
- Admission record.
- Incident investigations and reports involving the resident. In addition to the above documents, the facility shall also maintain on its premises any Advance Directive or Portable Physician Do Not Attempt Resuscitation (DNAR) Order that has been executed by the resident. NOTE: Under no circumstances shall the facility require or refuse to allow a resident to execute an Advance Directive or Portable Physician DNAR Order. Advance Directives shall be typewritten or legibly written in ink and may include the appointment of a health care proxy consistent with the specific language in the Natural Death Act (Code of Alabama 22-8A-1 et. seq). A Portable Physician DNAR Order shall follow the rule and form found in the Alabama Administrative Code 420-5-19 Appendix II. These records shall be protected from unauthorized disclosure.
Top Takeaways:
- (c) Storage and Safety. Provision shall be made for the safe storage of records within the facility. Records shall be stored in a manner to reasonably protect them from water or fire damage. Records shall be safeguarded from unauthorized access.
It goes without saying that these private documents need to be kept under lock and key and away from prying eyes. The administrator and their designee (business office manager) are the only personnel I would suggest having direct access to these records.
- the facility shall also maintain on its premises any Advance Directive or Portable Physician Do Not Attempt Resuscitation (DNAR) Order that has been executed by the resident. NOTE: Under no circumstances shall the facility require or refuse to allow a resident to execute an Advance Directive or Portable Physician DNAR Order. Advance Directives shall be typewritten or legibly written in ink and may include the appointment of a health care proxy consistent with the specific language in the Natural Death Act (Code of Alabama 22-8A-1 et. seq). A Portable Physician DNAR Order shall follow the rule and form found in the Alabama Administrative Code 420-5-19 Appendix II. These records shall be protected from unauthorized disclosure.
Knowing the status of your resident’s wishes in a situation where their life is at risk is not just a requirement, it is respecting wishes during end of life. You must have this one file and readily accessible. No questions asked!