1001.12 Records and Reports.

(a) The operator must collect and maintain such information, records or reports as determined by the Department to be necessary including those records set forth in Parts 485, 487and 488 of Subchapter D of this Title.

(b) The operator must maintain complete, accurate and current personal records for each resident which must be available for review and inspection by Department staff or designees and which contain at a minimum:

(1) personal data, including identification of the resident’s next of kin, family or resident’s representative, legal representative, if any, and the name and address of the person or persons to be contacted in the event of an emergency;
(2) medical evaluations and other medical information;

(3) health care proxy or other advance directives, if applicable;

(4) pre-admission evaluation and subsequent functional and social evaluations;

(5) individualized service plans;

(6) medication assistance record; and

(7) case management notes which include details of referrals, service coordination and such other correspondence and papers as are available to document the activities undertaken to meet the resident’s needs.

(c) The operator must maintain complete, accurate and current program records which document operation and maintenance of the assisted living residence with applicable law and regulations, including but not limited to:

(1) a chronological admission and discharge register consisting of a listing of residents separately identified as registered in and discharged from the assisted living residence, enhanced assisted living residence and special needs assisted living residence by name, age, sex, and place or level of care from or to which the resident is registered or discharged;

(2) a record of any complaints, actions taken to address the complaint and complaint resolution outcome;

(3) a personnel record for each employee which includes, as appropriate, records of professional licenses and registrations; verifications of employment history and qualifications for the duties assigned; signed and dated applications for employment; records of physical examinations and health status assessments; performance evaluations; dates of employment, resignations, dismissals, and other pertinent data, provided that all documentation and information pertaining to an employee’s medical condition or health status, including such records of physical examinations and health status assessments shall be maintained separate and apart from the non-medical personnel record information and shall be afforded the same confidential treatment given personal records of residents, and provided that the operator shall have access to such personnel records for all staff of contractors who provide services to residents; and

(4) copies of all approved waivers and notifications to the Department of adoption of regulation equivalencies.

(d) The operator must maintain daily census reports at the residence that specify the names of all residents in each level of licensed and/or certified care, and the room location of each resident. The operator must submit annually to the Department a census report for assisted living residents, enhanced assisted living residents and special needs assisted living residents.

(e) The operator must submit to the Department an annual financial report consistent with the requirements for adult homes and enriched housing programs in accordance with sections 487.10 and 488.10 of Title 18 of the NYCRR; provided, however, that such financial report shall clearly set forth financial information pertaining to the assisted living residence, enhanced assisted living residence and special needs assisted living residence.