Idaho Admin. Code r. 16.03.22.330

Current through September 2, 2024

Section 16.03.22.330 - REQUIREMENTS FOR FACILITY RECORDS

The facility must maintain complete, accurate, and authentic records which are preserved in a safe location protected from fire, theft, and water damage for a minimum of three (3) years.

01.Paper Records. All paper records must be recorded legibly in ink.

02.Electronic Records. Electronic records policies and procedures must be developed and implemented that specify which records will be maintained electronically. Policy development and implementation must ensure:

a. The facility must print and provide paper copies of electronic records upon the request of the resident, their legal guardian or conservator, advocacy and protection agencies, and the Department.

b. Security measures must be taken to protect the use of an electronic signature by anyone other than the person to which the electronic signature belongs and to protect that person's identity. The policy must specify how passwords are assigned, and the frequency they are changed.

c. Security measures must be taken to ensure the integrity of any electronic documentation.

03.Record Confidentiality. The facility must safeguard confidential information against loss, destruction, and unauthorized use.

04.Resident Care Records. An individual care record must be maintained for each resident with all entries kept current and completed by the person providing the care.

a. Entries must include the date, time, name, and title of the person making the entry. Staff must sign each entry made by them during their shift.

b. Care records of all current residents must be available to staff at all times.

c. In addition to an NSA, as described in Section 320 of these rules, each care record must include documentation of the following:

i. Comprehensive assessments, as described in Section 319 of these rules;

ii. Current medications, treatments, and diet prescribed, all signed and dated by the ordering physician or authorized provider;

iii. Treatments, wound care, assistance with medications, and any other delegated nursing tasks. Documentation must include any PRN medication use (if applicable), including the reason for taking the medication and the efficacy;

iv. Times the NSA is not followed, such as during refusal of care or services. This includes any time a medication is refused by a resident, not taken by a resident, not given to a resident, and the reason for the omission;

v. Calls to the resident's physician or authorized provider, including the reason for each call and the outcome;

vi. Notification to the facility nurse of changes in the resident's physical or mental condition;

vii. Nursing assessments, as described in Section 305 of these rules;

viii. The results of any physician or authorized provider visits;

ix. Copies of all signed and dated care plans prepared by outside service agencies;

x. Notes regarding outside services and care provided to the resident, such as home health, hospice, or physical therapy;

xi. Unusual events such as incidents, accidents, or altercations, and the facility's response; and

xii. When a resident refuses medical treatment or physician's orders, the facility must document the resident and their legal guardian have been informed of the consequences of the refusal and the resident's physician or authorized provider has been notified of the refusal.

05.Admission Records. As described in Section 39-3315, Idaho Code, resident admission documentation must include:

a. The resident's preferred providers and contact information, including physician or authorized provider, optometrist, dentist, pharmacy, and outside service providers.

b. Results of the resident's last history and physical examination, performed by a physician or authorized provider. The examination must have been conducted no more than six (6) months prior to admission.

c. Physician or authorized provider orders that are current, signed, and dated, including a list of medications, treatments, diet, and any limitations.

d. A written admission agreement that is signed and dated by the administrator and the resident or their legal guardian or conservator, and meets the requirements of Section 216 of these rules.

e. If separate from the admission agreement, a copy of the payment schedule and fee structure signed and dated by the resident or their legal guardian or conservator.

f. If the facility manages the resident's funds, a signed and dated written agreement between the facility and the resident or their legal guardian or conservator that specifies the terms.

g. A signed copy of the resident's rights, as described in Sections 550 and 560 of these rules, or a signed and dated statement that the resident or their legal guardian or conservator has read and understands their rights in a residential assisted living facility.

h. An interim care plan signed by the resident, responsible party, and the facility, completed prior to, or on the day of, admission.

i. Documentation indicating the resident has been informed of the facility's emergency procedures, including resident responsibility.

06.Behavior Documentation. For residents who exhibit maladaptive behaviors, behavior management records must be maintained in the resident record, including:

a. An assessment of maladaptive behaviors, as described in Section 319 of these rules.

b. A behavior plan that includes at least one (1) intervention specific to each maladaptive behavior.

i. Interventions must be the least restrictive possible; and

ii. Each intervention must be reviewed as appropriate, based on the severity of the behavior, to evaluate the effectiveness and continued need for the intervention.

c. Ongoing tracking of behaviors, including documentation of the date and time each maladaptive behavior was observed, the specific behavior that was observed, what interventions were used in response to the maladaptive behavior, and the effectiveness of each intervention.

07.Discharge Records. Resident discharge documentation must include:

a. When the discharge is involuntary, the facility's efforts to resolve the situation and a copy of the discharge notice, signed and dated by the resident and the facility. If the resident refuses, or is unable to sign the notice, the facility must maintain evidence that the notice was delivered to the resident and the responsible party;

b. The date and the location where the resident is discharged; and

c. The disposition of the resident's belongings.

08.Additional Resident Records. The facility must also maintain the following for each resident:

a. A record of all personal property that the resident has entrusted to the facility, including documentation to identify and track the property to ensure that personal items are kept safe and used only by the resident to which the items belong; and

b. Any complaints or grievances voiced by the resident including the date received, the investigation with outcome, and the response to the resident.

09.Resident Admission and Discharge Register. The facility must maintain an admission and discharge register listing the name of each resident, the date admitted, and the date discharged. The admission and discharge register must be produced as a separate document, apart from resident records, and kept current.

10.Hourly Adult Care Documentation. A log of those who have utilized hourly adult care must be maintained, including the dates the service was provided. Individual records must be maintained for each person utilizing hourly adult care. The individual record documentation must include:

a. Admission identification information, including contact information for the responsible party in an emergency, and the physician or authorized provider;

b. Information, such as medical and social, relevant to the supervision of the person; and

c. Care and services provided during hourly adult care, including assistance with medications.

11.Dietary Records. The facility must maintain on-site a minimum of three (3) months of dietary documentation, as follows:

a. Copies of planned menus, including therapeutic menus, that are approved, signed, and dated by a dietitian; and

b. Served menus, including therapeutic menus, which reflect substitutions made.

12.Records for Water Supply. Copies of laboratory reports documenting the bacteriological examination of a private water supply must be kept on file in the facility.

13.Personnel Records. A record for each employee must be maintained and available, which includes the following:

a. The employee's name, address, phone number, and date of hire;

b. A job description that includes the purpose, responsibilities, duties, and authority;

c. Evidence that on, or prior to hire, staff were notified in writing if the facility does or does not carry professional liability insurance. If the facility cancels existing professional liability insurance, all staff must be notified of the change in writing;

d. A copy of a current license for all nursing staff and verification from the Board of Nursing that the license is in good standing with identification of restrictions;

e. Signed evidence of training as described in Sections 620 through 641 of these rules;

f. Copies of CPR and first aid certifications;

g. Evidence of medication training as described in Section 645 of these rules;

h. Criminal history and background check results that meet Section 009 of these rules and state-only background check results;

i. Documentation by the licensed nurse of delegation to unlicensed staff who assist residents with medications and other nursing tasks;

j. When acting on behalf of the administrator, a signed document authorizing the responsibility; and

k. Copies of contracts with outside service providers and contract staff.

14.As Worked Schedules. Work records must be maintained in written or electronic format which reflect:

a. Personnel on duty, at any given time; and

b. The first and last names of each employee and their position.

15.Fire and Life Safety Records. The administrator must ensure the facility's records for fire and life safety are maintained. The facility must maintain on file:

a. Fire detection, alarm, and communication system reports:

i. The results of the annual inspection and tests; and

ii. Smoke detector sensitivity testing results.

b. The results of any weekly, monthly, quarterly, semi-annual, and annual sprinkler system inspections, maintenance, and tests;

c. Records of the monthly examination of the portable fire extinguishers, documenting the following:

i. Each extinguisher is in its designated location;

ii. Each extinguisher seal or tamper indicator is not broken;

iii. Each extinguisher has not been physically damaged;

iv. Each extinguisher gauge shows a charged condition; and

v. The inspection tag or documentation for the extinguisher must show at least the initials of the person making the monthly examination and the date of the examination.

d. Documentation for when a fire watch is instituted and a fire watch log for each round of patrol, identifying who conducted the fire watch, date, time, and situations encountered.

Idaho Admin. Code r. 16.03.22.330

Effective March 15, 2022