Current through Register 1531, September 27, 2024
All records created or maintained by the Assisted Living
Residence shall be legible, recorded in ink, and contemporaneously signed and
dated to indicate the name and position of the individual who makes the record
entry. Computerized records systems which meet the equivalent requirements in
651 CMR 12.05 for permanency and accessibility, and which provide an auditable
record of entries may be used as an alternative or supplement.
(1)
Resident Record.
The Assisted Living Residence shall develop and maintain written Resident
records which shall remain confidential but for the limited exception of EOEA's
enforcement of
651 CMR 12.00. The Resident
Record and related documents are considered permanent and shall be maintained
for the duration of the Resident's stay in the Assisted Living Residence and
for at least six years after the date of termination of the Agreement. The
Resident record shall include at a minimum, the following:
(a) Resident assessment, documented in
accordance with the requirements set forth at
651 CMR
12.04(6)(b);
(b) Service plans documented in accordance
with the requirements of
651 CMR
12.04(8);
(c) Progress notes, which shall document
significant occurrences, either observed by or reported to Residence staff,
including significant or continued changes in the Resident's behavior or
memory; incidents involving injury, trauma, illness, or abuse or neglect of the
Resident, including but not limited to the recording of incidents in which a
resident has been the victim of an assault by another Resident or the
perpetrator of an assault on another resident, regardless of whether such a
report would be required by law; alleged or actual violations of the Resident's
rights as defined in
651 CMR
12.08; and changes in the Resident's service
plan;
(d) Documentation of
Introductory Visits set forth at
651 CMR
12.07(6);
(e) Documentation of Self-administered
Medication Management, including the SAMM assessment required by
651 CMR
12.04(6)(a)3.;
(f) Documentation of all aspects of Limited
Medication Administration, if applicable. This includes, but is not limited to,
a proper written medication order from an authorized prescriber, documentation
of the name, dose, route of administration, and time the medication is
administered. The nurse who administers the medication shall sign or initial
the documentation;
(g) The
following documents are also part of the Resident record, and may be kept in a
separate location(s):
1. Any applicable
guardianship orders, authorized powers of attorney, Health Care Proxy
documents, living wills, and other relevant documents affecting or directing
Resident care (including Department of Public Health Comfort Care/"Do Not
Resuscitate Order Verification Form", provided that their existence and
location is conspicuously documented in the Resident's record and they are
immediately available in case of an emergency;
2. The original Residency Agreement and any
documents which extend or amend the Residency Agreement; and
3. The Disclosure of Rights and Services
required by
651 CMR
12.08(3).
(2) In addition to the
individual record requirements in 651 CMR 12.05(1), each Residence that exists
within a setting which does not consist exclusively of Assisted Living Units,
shall maintain a current census document, updated at least weekly, listing the
name of each Resident residing in each occupied certified unit. Each census
document shall be kept for a minimum of two years.
(3)
Personnel Record
Requirements. The Assisted Living Residence shall develop and
maintain written personnel records, and maintain copies of its personnel
policies and procedures. Each personnel record shall include at a minimum the
following:
(a) Job description;
(b) Educational preparation and work
experience;
(c) A copy of any
current licensure or Certification or, if applicable, documentation of
completion of 54-hour Personal Care Services Training set forth in
651 CMR
12.07(4);
(d) Documentation of attendance at Personnel
Orientation as set forth in
651 CMR
12.07;
(e) Documentation of reports of criminal
offender record information;
(f)
Documentation of annual performance evaluation;
(g) Documentation of attendance at in-service
training; and
(h) Copies of any
disciplinary letters or reports.
(4) The Residence must maintain a staff
correspondence log for each 24 hour period that communicates information
necessary to maintain the continuity of care for all Residents. The
correspondence log must be maintained for no less than 90 days.
