Pascal Bergeron
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A. A manager shall ensure that:

1. A medical record is established and maintained for each resident according to A.R.S.
Title 12, Chapter 13, Article 7.1;
2. An entry in a resident’s medical record is:
a. Only recorded by an individual authorized by policies and procedures to make
the entry;
b. Dated, legible, and authenticated; and
c. Not changed to make the initial entry illegible;
3. If a rubber-stamp signature or an electronic signature is used to authenticate an order, the
individual whose signature the rubber-stamp signature or electronic signature represents
is accountable for the use of the rubber-stamp signature or electronic signature;
4. A resident’s medical record is available to an individual:
a. Authorized according to policies and procedures to access the resident’s medical
record;
b. If the individual is not authorized according to policies and procedures, with the
written consent of the resident or the resident’s representative; or
c. As permitted by law; and
5. A resident’s medical record is protected from loss, damage, or unauthorized use.

B. If an assisted living facility maintains residents’ medical records electronically, a manager shall
ensure that:

1. Safeguards exist to prevent unauthorized access, and
2. The date and time of an entry in a resident’s medical record is recorded by the computer’s
internal clock.

C. A manager shall ensure that a resident’s medical record contains:

1. Resident information that includes:
a. The resident’s name, and
b. The resident’s date of birth;
2. The names, addresses, and telephone numbers of:
a. The resident’s primary care provider;
b. Other persons, such as a home health agency or hospice service agency, involved
in the care of the resident; and
c. An individual to be contacted in the event of emergency, significant change in the resident’s condition, or termination of residency;
3. If applicable, the name and contact information of the resident’s representative and:
a. The document signed by the resident consenting for the resident’s representative to act on the resident’s behalf; or
b. If the resident’s representative:
i. Has a health care power of attorney established under A.R.S. § 36-3221 or a mental health care power of attorney executed under A.R.S. § 36-3282, a copy of the health care power of attorney or mental health care power of attorney; or
ii. Is a legal guardian, a copy of the court order establishing guardianship;
4. The date of acceptance and, if applicable, date of termination of residency;
5. Documentation of the resident’s needs required in R9-10-807(B);
6. Documentation of general consent and informed consent, if applicable;
7. Except as allowed in R9-10-808(B)(2), documentation of freedom from infectious tuberculosis as required in R9-10-807(A);
8. A copy of the resident’s health care directive, if applicable;
9. The resident’s signed residency agreement and any amendments;
10. Resident’s service plan and updates;
11. Documentation of assisted living services provided to the resident;
12. A medication order from a medical practitioner for each medication that is administered
to the resident or for which the resident receives assistance in the self-administration of
the medication;
13. Documentation of medication administered to the resident or for which the resident
received assistance in the self-administration of medication that includes:
a. The date and time of administration or assistance;
b. The name, strength, dosage, and route of administration;
c. The name and signature of the individual administering or providing assistance in
the self-administration of medication; and
d. An unexpected reaction the resident has to the medication;
14. Documentation of the resident’s refusal of a medication, if applicable;
15. If applicable, documentation of any actions taken to control the resident’s sudden,
intense, or out-of-control behavior to prevent harm to the resident or another individual;
16. If applicable, documentation of a determination by a medical practitioner that evacuation
from the assisted living facility during an evacuation drill would cause harm to the
resident;
17. Documentation of notification of the resident of the availability of vaccination for
influenza and pneumonia, according to A.R.S. § 36-406(1)(d);
18. Documentation of the resident’s orientation to exits from the assisted living facility
required in R9-10-818(B);
19. If a resident is receiving behavioral health services other than behavioral care,
documentation of the determination in R9-10-813(3);
20. If a resident is receiving behavioral care, documentation of the determination in R9-10-812(3);
21. If applicable, for a resident who is unable to direct self-care, the information required inR9-10-815(F);
22. Documentation of any significant change in a resident’s behavior, physical, cognitive, or functional condition and the action taken by a manager or caregiver to address the resident’s changing needs;
23. Documentation of the notification required in R9-10-803(G) if the resident is incapable of handling financial affairs; and
24. If the resident no longer resides and receives assisted living services from the assisted
living facility:
a. A written notice of termination of residency; or
b. If the resident terminated residency, the date the resident terminated residency.

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