Required records by the ODH
When a resident moves into your community there are many administrative pieces that are required to be completed by the facility. In addition to your community specific move-in policies there are also required documentation issued by the Ohio Department of Health. Check out the following regulation for what needs to be included on the residents file:
Rule 3701-16-17 | Records and reports.
(A) Each residential care facility shall maintain records which shall be made available for inspection at all times when requested by the director, including:
(1) An individual record for each resident which shall be stored in a manner that protects and ensures confidentiality, except that information shall be immediately accessible for an emergency;
(a) Each resident record shall be started immediately upon admission to the residential care facility and shall include the following:
(i) The resident’s name, previous address, date of birth, sex, race, religion; the date the resident began living at the residential care facility; the names, addresses, and telephone numbers of the resident’s attending physician, nearest relative, guardian, if any, and any other individuals the resident designates to be contacted, including individuals to be notified in the event of an emergency. The residential care facility shall not coerce a resident to provide any of this information;
(ii) Copies of the health assessments required by rule 3701-16-08 of the Administrative Code;
(iii) Notations about incidents and adverse changes in health status required by rule 3701-16-12 of the Administrative Code;
(iv) The medication record required by paragraph (I)(7) of rule 3701-16-09 of the Administrative Code as well as any medicare-D plan, if any, in which the resident is enrolled and receives prescription medication;
(v) Any documentation required by paragraph (J) of rule 3701-16-10 of the Administrative Code for residents on therapeutic diets;
(vi) The written resident agreement required by rule 3701-16-07 of the Administrative Code;
(vii) The documentation required by paragraphs (J)(5) of rule 3701-16-09 and (B)(4) and (C)(3) of rule 3701-16-09.1 of the Administrative Code for residents receiving skilled nursing care provided by the residential care facility; and
(viii) A copy of risk agreements entered into under paragraph (G) of rule 3701-16-07 of the Administrative Code and the signed statement required under paragraph (H) of rule 3701-16-07 of the Administrative Code, if applicable;
(2) The incident log required by paragraph (B)(2) of rule 3701-16-12 of the Administrative Code;
(3) Copies of all current licenses, approvals and inspections required by rules 3701-16-01 to 3701-16-18 of the Administrative Code;
(4) A record of the name, address, working hours, medical statements, and training for staff members;
(5) Documentation of compliance with rule 3701-16-16 of the Administrative Code;
(6) Fire and evacuation procedures and records of fire drills required by rule 3701-16-13 of the Administrative Code;
(7) Records of heating system checks required by paragraph (A) of rule 3701-16-15 of the Administrative Code and fire extinguishing system checks;
(8) All records required by state and federal laws and regulations as to the purchase, dispensing, administering, and disposition of prescription medications including unused portions;
(9) The residents’ rights policies, procedures and records; and
(10) All other records required by Chapter 3721. of the Revised Code and rules 3701-16-01 to 3701-16-18 of the Administrative Code.
(B) All records and reports required by Chapter 3701-13 of the Administrative Code shall be maintained and made available in accordance with that chapter.
(C) The residential care facility shall maintain those records:
(1) Required by paragraphs (A)(1) and (A)(2) of this rule, for seven years following the date of the resident’s discharge except if the resident is a minor, such records shall be maintained for three years past the age of majority but not less than seven years; and
(2) Required by paragraphs (A)(3) to (A)(10) of this rule, for three years unless otherwise required by law.
Top Takeaway:
- (C) The residential care facility shall maintain those records:
(1) Required by paragraphs (A)(1) and (A)(2) of this rule, for seven years following the date of the resident’s discharge except if the resident is a minor, such records shall be maintained for three years past the age of majority but not less than seven years; and
(2) Required by paragraphs (A)(3) to (A)(10) of this rule, for three years unless otherwise required by law.
ODH may request to see records for individuals who no longer reside in your facility due to ongoing investigations, so it is imperative that you have stored these records properly. You may also be subject to litigation that will require the records to be provided to the court. If these records cannot be produced, you will certainly be in hot water.
- (A) Each residential care facility shall maintain records which shall be made available for inspection at all times when requested by the director, including: 1-10
When the ODH preforms the inspection survey they will be looking to ensure you have all of the required documentation in the residents file as well as the other pertinent reports. You need to have a system in place for periodically auditing these records and reports to stay in compliance.