Iowa Administrative Code
Agency 481 - Inspections and Appeals Department
Inspections Division
Chapter 57 - Residential Care Facilities
Rule 481-57.17 - Records

Universal Citation: IA Admin Code 481-57.17

Current through Register Vol. 47, No. 6, September 18, 2024

(1) Resident record. The licensee shall keep a permanent record on every resident admitted to the residential care facility, and all entries in the permanent record shall be current, dated, and signed. (Ill) The record shall include:

a. Name and previous address of resident; (III)

b. Birth date, sex, and marital status of resident; (III)

c. Church affiliation, if designated; (III)

d. Primary care provider's name, telephone number, and address; (III)

e. Dentist's name, telephone number, and address; (III)

f. Name, address, and telephone number of next of kin or legal representative; (III)

g. Name, address, and telephone number of person to be notified in case of emergency; (III)

h. Pharmacy name, telephone number, and address; (III)

i. Mortuary name, telephone number, and address, if designated; (III)

j. Physical examination and medical history; (III)

k. Primary care provider's orders for the resident's level of care, medication, treatments, and diet. The orders shall be in writing and signed by the primary care provider quarterly; (III)

l. A notation of visits to primary care provider and other professional services; (III)

m. Documentation regarding services provided by other providers, including but not limited to home health agencies, hospice, day treatment and those providing medical, mental health and Medicaid waiver services; (III)

n. Documentation of any adverse change in the resident's condition; (II, III)

o. A notation describing the resident's condition on admission, transfer and discharge; (III)

p. A copy of instructions given to the resident, legal representative or facility in the event of discharge or transfer; (III)

q. In the event of a resident's death, notations of the date and time of the resident's death, the circumstances of the resident's death, the disposition of the resident's body, and the date and time the resident's family and primary care provider were notified of the resident's death; and (III)

r. A notation of disposition of personal property and medications upon the resident's transfer, discharge or death. (Ill)

(2) Confidentiality of resident records. Each resident shall be ensured confidential treatment of all information contained in the resident's records. The resident's written consent shall be required for the release of information to persons not otherwise authorized under law to receive the information. (II)

a. The facility shall limit access to any medical records to staff and professionals providing services to the resident. (II)

b. The facility shall limit access to the resident's personal records, e.g., financial records and social services records, to staff and professionals providing the service to the resident. Only those personnel concerned with the financial affairs of the resident may have access to the financial records. (II)

c. The resident, or the resident's responsible party, shall be entitled to examine all information contained in the resident's record and shall have the right to secure full copies of the record at reasonable cost upon request, unless the primary care provider determines that the disclosure of the record or section thereof is contraindicated, in which case this information will be deleted prior to making the record available to the resident or responsible party. This determination and the reasons for it must be documented in the resident's record. (II)

d. This subrule is not meant to preclude access to resident records by representatives of state and federal regulatory agencies.

(3) Incident record.

a. Each residential care facility shall maintain an incident record report and shall have available incident report forms. (II, III)

b. Report of incidents shall be in detail on an incident report form. (Ill)

c. The person in charge at the time of the incident shall oversee the preparation of and sign the incident report. The administrator or designee shall review, sign and date the incident report within 72 hours of the accident, incident or unusual occurrence. (II, III)

d. An incident report shall be completed for every accident or incident where there is apparent injury or where an injury of unknown origin may have occurred. (II)

e. An incident report shall be completed for every accident, incident or unusual occurrence within the facility or on the premises that affects a resident, visitor, or employee. (II, III)

f. A copy of the incident report shall be kept on file in the facility. (II, III)

(4) Retention of records.

a. Records shall be retained in the facility for five years following the termination of services to a resident. (Ill)

b. Records shall be retained within the facility upon change of ownership. (Ill)

c. When the facility ceases to operate, a copy of the resident's record shall be released to the facility to which the resident is transferred. (Ill)

d. When the facility ceases to operate, records shall be maintained for five years in a clean, dry secured storage area. (Ill)

(5) Electronic records. In addition to the access provided in 481-subrule 50.10(2), an authorized representative of the department shall be provided unrestricted access to electronic records pertaining to the care provided to the residents of the facility. (II, III)

a. If access to an electronic record is requested by the authorized representative of the department, the facility may provide a tutorial on how to use its particular electronic system or may designate an individual who will, when requested, access the system, respond to any questions or assist the authorized representative as needed in accessing electronic information in a timely fashion. (II, III)

b. The facility shall provide a terminal where the authorized representative may access records. (II, III)

c. If the facility is unable to provide direct print capability to the authorized representative, the facility shall make available a printout of any record or part of a record on request in a time frame that does not intentionally prevent or interfere with the department's survey or investigation. (II, III)

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