481—57.16(135C) Records.
57.16(1) Resident record. The licensee shall keep a permanent record on all residents admitted to a
residential care facility with all entries current, dated, and signed. (III) The record shall include:
a. Name and previous address of resident; (III)
b. Birth date, sex, and marital status of resident; (III)
c. Church affiliation; (III)
d. Physician’s name, telephone number, and address; (III)
e. Dentist’s name, telephone number, and address; (III)
f. Name, address, and telephone number of next of kin or legal representative; (III)
g. Name, address, and telephone number of person to be notified in case of emergency; (III)
h. Mortician’s name, telephone number, and address; (III)
i. Pharmacist’s name, telephone number, and address; (III)
j. Physical examination and medical history; (III)
k. Certification by the physician that the resident requires no more than personal care and
supervision, but does not require nursing care; (III)
l. Physician’s orders for medication, treatments, and diet in writing and signed by the physician
quarterly; (III)
m. A notation of yearly or other visits to physician or other professional services; (III)
n. Any change in the resident’s condition; (II, III)
o. If the physician has certified that the resident is capable of taking prescribed medications, the
resident shall be required to keep the administrator advised of current medications, treatments, and diet.
The administrator shall keep a listing of medications, treatments, and diet prescribed by the physician
for each resident; (III)
p. If the physician has certified that the resident is not capable of taking prescribed medication, it
must be administered by a qualified person of the facility. A qualified person shall be defined as either
a registered or licensed practical nurse or an individual who has completed the state-approved training
course in medication administration; (II)
q. Medications administered by an employee of the facility shall be recorded on a medication
record by the individual who administers the medication; (II, III)
r. A notation describing condition on admission, transfer, and discharge; (III)
s. In the event of a resident’s death, notations in the resident’s record shall include the date and
time of the resident’s death, the circumstances of the resident’s death, the disposition of the resident’s
body, and the date and time that the resident’s family and physician were notified of the resident’s death;
(III)
t. A copy of instructions given to the resident, legal representative, or facility in the event of
discharge or transfer; (III)
u. Disposition of valuables. (III)
57.16(2) Incident record.
a. Each residential care facility shall maintain an incident record report and shall have available
incident report forms. (III)
b. Report of incidents shall be in detail on a printed incident report form. (III)
c. The person in charge at the time of the incident shall oversee the preparation and sign the
incident report. (III)
d. The report shall cover all accidents whether there is apparent injury or where hidden injury may
have occurred. (III)
e. The report shall cover all accidents or unusual occurrences within the facility or on the premises
affecting residents, visitors, or employees. (III)
f. A copy of the incident report shall be kept on file in the facility. (III)
57.16(3) Retention of records.
a. Records shall be retained in the facility for five years following termination of services. (III)
b. Records shall be retained within the facility upon change of ownership. (III)
c. Rescinded, effective 7/14/82.
d. When the facility ceases to operate, the resident’s record shall be released to the facility to
which the resident is transferred. If no transfer occurs, the record shall be released to the individual’s
physician. (III)
57.16(4) Reports to the department. The licensee shall furnish statistical information concerning the
operation of the facility to the department on request. (III)
57.16(5) Personnel record.
a. An employment record shall be kept for each employee consisting of the following information:
Name and address of employee, social security number of employee, date of birth of employee, date of
employment, experience and education, references, position in the home, date and reason for discharge
or resignation. (III)
b. The personnel records shall be made available for review upon request by the department. (III)