Record-Keeping Requirements:
Each assisted-living facility must maintain records and reports in such a manner to ensure accuracy.
4-006.12A Resident Records: Each assisted-living facility must ensure a permanent record of all assisted-living services is established for each resident. The record must be established within five working days of admission.
4-006.12A1 Content: Entries in the permanent resident record must be dated, legible and indelible. The author of each entry must be identified and authenticated. Authentication must include signature, written initials or computer entry. Resident records must contain information that includes, but is not limited to:
- Date of admission;
- Name of resident;
- Gender and date of birth;
- Physical description or photo of resident;
- Resident Services Agreement;
- Licensed practitioner’s orders where applicable;
- Significant medical conditions;
- Medications and any special diet;
- Allergies;
- Any unusual event or occurrence;
- Person to contact in emergency situations;
- Designated physician or registered nurse;
- Advance directives if available;
- Monthly documentation of assistance with activities of daily living, personal care, health maintenance activities or supervision, if such is required or requested by the resident; and
- Date and destination of discharge or
4-006.12A2 Retention: Each assisted-living facility must maintain and preserve all resident records in original, microfilm, electronic or other similar form, for a period of at least two years from date of resident’s discharge. If a resident is transferred to another licensed health care facility or service, a copy of the record or abstract must be sent with the resident. When an assisted-living facility ceases operation, all resident records must be transferred to the licensed health care facility or health care service to which the resident is transferred. All other resident records that have not reached the required time for destruction must be stored to assure confidentiality and the Department must be notified of the address where stored.
4-006.12A3 Confidentiality: The facility must keep such records confidential and available only for use by authorized persons or as otherwise permitted by law. Records must be available for examination by authorized representatives of the Department.
4-006.12A4 Access: Resident information and/records will be released only with consent of the resident or authorized representative, if applicable, or as permitted by law.
4-006.12A5 Destruction: Resident records may be destroyed only when they are in excess of retention requirements specified in 175 NAC 4- 006.12A2. In order to ensure the resident’s right of confidentiality, resident records must be destroyed or disposed of by shredding, incineration, electronic deletion or another equally effective protective measure.