What belongs in a residents file?

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 documents issued by the West Virginia OHFLAC. Check out the following regulation for what needs to be included on the resident’s file:

6.2.  Records.

 

6.2.1.  The licensee shall retain residents’ records in a secure area in the residence and shall make the records available for inspection by the Secretary.  (Class III)

 

6.2.2.  Upon a resident’s admission, the licensee shall start a record for him or her that includes:

 

6.2.2.a.  The resident’s name, social security number, date of birth, sex, marital status, and religious preference, if any;

 

6.2.2.b.  The names, addresses, and telephone numbers of the following, if applicable: the resident’s physician, dentist, legal representative, person or agency responsible for the resident’s support payments, next of kin or person to be notified in case of an emergency, and any case management agency involved in the resident’s care.

 

6.2.2.c.  All agreements or contracts entered into between the resident and the licensee;

 

6.2.2.d.  Advanced directives; allergies; the dates of appointments with physicians, dentists, or other health care providers; all contacts by the residence’s staff with the residence’s physician; and observations by licensed nurses, physicians, and others authorized to care for the resident; and

 

6.2.2.e.  Copies of all documents granting legal authority to a representative.

 

6.2.2.f.  Any other information as required in subsections 6.3., 6.4., 6.5., 6.6., 6.7., and 8. of this rule.  (Class III)

 

6.2.3.  The licensee shall keep in each resident’s record current documentation regarding the resident’s health status, any changes in health status, and staff responses to the changes.  (Class II)

Top Takeaways:

  • 2.1. The licensee shall retain residents’ records in a secure area in the residence and shall make the records available for inspection by the Secretary.  (Class III)

The resident file is one of the top areas that inspectors will review. Ensure your files are up to date and available for the immediate inspection by the survey team.

 

  • 2.2.d. Advanced directives; allergies; the dates of appointments with physicians, dentists, or other health care providers; all contacts by the residence’s staff with the residence’s physician; and observations by licensed nurses, physicians, and others authorized to care for the resident; and

The resident file should be an all-encompassing directory of the resident’s pertinent information. Audit the file on a consistent basis to be sure the inspection team will have easy access to the required information noted above.

 

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