Resident Records

WAC 388-78A-2390  Resident records.  The assisted living facility must maintain adequate records concerning residents to enable the assisted living facility:

  • To effectively provide the care and services agreed upon with the resident; and
  • To respond appropriately in emergency situations.

[Statutory Authority: Chapter 18.20 RCW. WSR 13-13-063, § 388-78A-2390, filed 6/18/13, effective 7/19/13. Statutory Authority: RCW 18.20.090 (2004 c 142 § 19) and chapter 18.20 RCW. WSR 04-16-065, § 388-78A-2390, filed 7/30/04, effective 9/1/04.]

WAC 388-78A-2400  Protection of resident records.  The assisted living facility must:

  • Maintain a systematic and secure method of identifying and filing resident records for easy access;
  • Maintain resident records and preserve their confidentiality in accordance with applicable state and federal statutes and rules, including chapters 70.02 and 70.129 RCW;
  • Allow authorized representatives of the department and other authorized regulatory agencies access to resident records;
  • Provide any resident or other individual or organization ac-cess to resident records upon written consent of the resident or the resident’s representative, unless state or federal law provide for broader access;
  • Allow authorized agents, such as a management company, to use resident records solely for the purpose of providing care and services to residents and ensure that agents do not disclose such records except in a manner consistent with law; and
  • Maintain ownership and control of resident records, except that resident records may be transferred to a subsequent person licensed by the department to operate the assisted living facility.

[Statutory Authority: Chapter 18.20 RCW. WSR 13-13-063, § 388-78A-2400, filed 6/18/13, effective 7/19/13. Statutory Authority: RCW 18.20.090 (2004 c 142 § 19) and chapter 18.20 RCW. WSR 04-16-065,

  • 388-78A-2400, filed 7/30/04, effective 9/1/04.]

WAC 388-78A-2410  Content of resident records.  The assisted living facility must organize and maintain resident records in a format that the assisted living facility determines to be useful and functional to enable the effective provision of care and services to each resident. Active resident records must include the following:

  • Resident identifying information, including resident’s:
  • Name;
  • Birth date;
  • Move-in date; and
  • Sleeping room identification.
  • Current name, address, and telephone number of:(a) Resident’s primary health care provider;
  • Resident’s representative, if the resident has one;
  • Individual(s) to contact in case of emergency, illness or death; and
  • Family members or others, if any, the resident requests to be involved in the development or delivery of services for the resident.
  • Resident’s written acknowledgment of receipt of:
  • Required disclosure information prior to moving into the as-sisted living facility; and
  • Information required by long-term care resident rights per RCW 70.129.030.
  • The resident’s assessment and reassessment information.
  • Clinical information such as admission weight, height, blood pressure, temperature, blood sugar and other laboratory tests required by the negotiated service agreement.
  • The resident’s negotiated service agreement consistent with WAC 388-78A-2140.
  • Any orders for medications, treatments, and modified or ther-apeutic diets, including any directions for addressing a resident’s refusal of medications, treatments, and prescribed diets.
  • Medical and nursing services provided by the assisted living facility for a resident, including:

(a) A record of providing medication assistance and medication administration, which contains:

  • The medication name, dose, and route of administration;
  • The time and date of any medication assistance or adminis-tration;
  • The signature or initials of the person providing any medi-cation assistance or administration; and
  • Documentation of a resident choosing to not take his or her medications.

(b) A record of any nursing treatments, including the signature or initials of the person providing them.

  • Documentation consistent with WAC 388-78A-2120 Monitoring resident well-being.
  • Staff interventions or responses to subsection (9) of this section, including any modifications made to the resident’s negotiated service agreement.
  • Notices of and reasons for relocation as specified in RCW

70.129.110.

  • The individuals who were notified of a significant change in the resident’s condition and the time and date of the notification.
  • When available, a copy of any legal documents in which:
  • The resident has appointed another individual to make his or her health care, financial, or other decisions;
  • The resident has created an advance directive or other legal document that establishes a surrogate decision maker in the future and/or provides directions to health care providers; and
  • A court has established guardianship on behalf of the resi-dent.

[Statutory Authority: Chapter 18.20 RCW. WSR 13-13-063, § 388-78A-2410, filed 6/18/13, effective 7/19/13. Statutory Authority: RCW 18.20.090 (2004 c 142 § 19) and chapter 18.20 RCW. WSR 04-16-065,

  • 388-78A-2410, filed 7/30/04, effective 9/1/04.]

WAC 388-78A-2420  Record retention.  (1) The assisted living facility must maintain on the assisted living facility premises in a resident’s active record(s) all relevant information and documentation necessary for meeting a resident’s current assessed needs.

  • The assisted living facility may remove outdated information from the resident’s active records that is no longer significant or relevant to the resident’s current assessed service and care needs, and maintain it in an inactive record that must remain on the assisted living facility premises as long as the resident remains in the assisted living facility.
  • The assisted living facility must maintain all documentation filed in a closed resident record, on the assisted living facility premises for six months after the date the resident leaves the assisted living facility and on the assisted living facility premises or another location for five years after the date the resident leaves the assisted living facility.
  • All active, inactive, and closed resident records must be available for review by department staff and other authorized persons.
  • If an assisted living facility ceases to operate as a li-censed assisted living facility, the most recent licensee must make arrangements to ensure that the former residents’ records are retained according to the times specified in this section and are available for review by department staff and other authorized individuals.

[Statutory Authority: Chapter 18.20 RCW. WSR 13-13-063, § 388-78A-2420, filed 6/18/13, effective 7/19/13. Statutory Authority: RCW 18.20.090 (2004 c 142 § 19) and chapter 18.20 RCW. WSR 04-16-065, § 388-78A-2420, filed 7/30/04, effective 9/1/04.]

WAC 388-78A-2430  Resident review of records.  (1) The assisted living facility must assemble all records pertaining to a resident and make them available to a resident within twenty-four hours of the resident’s or the resident’s representative’s request to review the resident’s records per RCW 70.129.030.

(2) The assisted living facility must provide to the resident or the resident’s representative, photocopies of the records or any portions of the records pertaining to the resident, within two working days of the resident’s or resident’s representative’s request for the records.

  • For the purposes of this section, “working days” means Monday through Friday, except for legal holidays.
  • The assisted living facility may charge the resident or the resident’s representative a fee not to exceed twenty-five cents per page for the cost of photocopying the resident’s record.

[Statutory Authority: Chapter 18.20 RCW. WSR 13-13-063, § 388-78A-2430, filed 6/18/13, effective 7/19/13. Statutory Authority: RCW 18.20.090 (2004 c 142 § 19) and chapter 18.20 RCW. WSR 04-16-065,

  • 388-78A-2430, filed 7/30/04, effective 9/1/04.]

WAC 388-78A-2440  Resident register.  (1) The assisted living facility must maintain in the assisted living facility a single current register of all assisted living facility residents, their roommates and identification of the rooms in which such persons reside or sleep.

  • The assisted living facility must maintain a readily availa-ble permanent, current book, computer file, or register with entries in ink or typewritten, of all individuals who resided in the assisted living facility within the past five years, including:
  • Move-in date;
  • Full name;
  • Date of birth;
  • Date of moving out;
  • Reason for moving out; and
  • Location and address to which the resident was discharged.
  • The assisted living facility must make this register immedi-ately available to:
  • Authorized department staff;
  • Representatives of the long-term care ombud’s office; and
  • Representatives of the Washington state fire marshal when conducting fire safety inspections.

[Statutory Authority: Chapter 18.20 RCW. WSR 14-05-035, § 388-78A-2440, filed 2/12/14, effective 3/15/14; WSR 13-13-063, §

388-78A-2440, filed 6/18/13, effective 7/19/13; WSR 10-03-066, § 388-78A-2440, filed 1/15/10, effective 2/15/10. Statutory Authority: RCW 18.20.090 (2004 c 142 § 19) and chapter 18.20 RCW. WSR 04-16-065, § 388-78A-2440, filed 7/30/04, effective 9/1/04.]