Resident Records and Reports.
Each resident’s records shall be current, organized and maintained in individual
folders which shall be made available to the resident, the Licensing Division, or designated
representative upon request.
(i) Each folder shall include the following:
(A) Information from the referring agent, if applicable;
(B) History and physical performed by a physician or physician extender;
(C) Individual admission form. This form shall, at a minimum, contain
the following information:
(I) Full name of resident and former address;
(II) Date of admission;
(III) Sex, race, date of birth, social security number, and former occupation;
(IV) Name, home address, and telephone number of relative,
friend, Power of Attorney, or guardian;
(V) Name, address, and telephone number of resident’s personal
physician, dentist, ophthalmologist or optometrist;
(VI) Medicare number or other medical insurance identifying data;
(VII) A written inventory of all personal possessions; however,
this inventory need not include personal clothing;
(D) All accidents, injuries, incidents, illnesses, and allegations of
abuse, neglect or exploitation shall be reported to the resident’s family or responsible party and
be documented in the individual resident records. All such occurrences shall also be reported to
the appropriate entity for follow up and resolution. Reports of all incidents affecting the health,
welfare or safety of a resident shall be provided to the Licensing Division immediately (within
one business day). Reporting shall be done by telephone or fax. The facility’s investigation of
the incident shall be reported to the Licensing Division and the Long Term Care Ombudsman
within five (5) working days. Documentation to support the facility reporting the situation and
follow up must also be present in the resident records;
(E) An accounting of all personal funds deposited with and disbursed by the facility;
(I) Upon written authorization of a client, the facility must
hold, safeguard, manage and account for the personal funds of the client.
(1.) The facility must deposit any personal funds in
excess of $100 in an interest bearing account.
(2.) The facility must establish and maintain a system
that assures a full and complete and separate accounting according to generally accepted
accounting principles of each resident’s personal funds entrusted to the facility.
(3.) Upon the death of a resident with a personal fund
deposited with the facility, the facility must convey, within 30 days, the resident’s funds a final
accounting of those funds, to the individual or probate jurisdiction administering the resident’s estate.
(4.) The facility must not impose a charge against the
personal funds of a resident for any item or service for which payment is made under Medicaid
or Medicare except for applicable deductible and coinsurance amounts.
(F) A signed copy of the resident’s rights;
(G) The resident’s assessment and individualized assistance plan;
(H) Copies of all applicable resident assistance contracts, signed by both parties;
(I) Written acknowledgment of the receipt and explanation of all
facility policies including admission/discharge policies;
(J) Copy of all ALF 102’s; and
(K) Copy of outside contractual responsibilities, if applicable.
(ii) The resident shall be assured of confidential treatment of all information
in the record, and the resident’s written consent (or the consent of the guardian) shall be required
for the release of information to persons not otherwise authorized to receive it.
(iii) All residents’ records shall be retained in a physically secure area for a
minimum of six (6) years after the resident has left the facility and may be disposed of, by
shredding or burning, after that time.
(iv) In the event of dissolution of the facility, the manager shall notify the
Licensing Division as to the location of all residents’ records.
(v) All records shall be protected from damage by fire, water and other
hazards.(vi) All entries in each resident’s record shall be made in ink, signed and dated.
An activities program shall be available to the resident and shall be designed to
enhance each resident’s sense of physical, psychosocial, and spiritual well-being.
(i) A member of the facility’s staff shall be designated as responsible for the
resident activities program;
(ii) Space, equipment, and supplies for the activities program shall be
adequate for individual and/or group activities; and
(iii) There shall be regularly scheduled activities during weekdays, evenings