Virginia Administrative Code
Title 22 - SOCIAL SERVICES
Agency 40 - DEPARTMENT OF SOCIAL SERVICES
Chapter 73 - STANDARDS FOR LICENSED ASSISTED LIVING FACILITIES
Part V - Admission, Retention, and Discharge of Residents
Section 22VAC40-73-380 - Resident personal and social information

1. Name;

2. Last home address, and address from which resident was received, if different;

3. Date of admission;

4. Birth date or if unknown, estimated age;

5. Birthplace, if known;

6. Marital status, if known;

7. Name, address, and telephone number of all legal representatives, if any;

8. If there is a legal representative, copies of current legal documents that show proof of each legal representative's authority to act on behalf of the resident and that specify the scope of the representative's authority to make decisions and to perform other functions;

9. Name, address, and telephone number of next of kin, if known (two preferred);

10. Name, address, and telephone number of designated contact person authorized by the resident or legal representative, if appropriate, for notification purposes, including emergency notification and notification of the need for mental health, intellectual disability, substance abuse, or behavioral disorder services - if the resident or legal representative is willing to designate an authorized contact person. There may be more than one designated contact person. The designated contact person may also be listed under another category, such as next of kin or legal representative;

11. Name, address, and telephone number of the responsible individual stipulated in 22VAC40-73-550 H, if needed;

12. Name, address, and telephone number of personal physician, if known;

13. Name, address, and telephone number of personal dentist, if known;

14. Name, address, and telephone number of clergyman and place of worship, if applicable;

15. Name, address, and telephone number of local department of social services or any other agency, if applicable, and the name of the assigned case manager or caseworker;

16. Service in the armed forces, if applicable;

17. Lifetime vocation, career, or primary role;

18. Special interests and hobbies;

19. Known allergies, if any;

20. Information concerning advance directives, Do Not Resuscitate (DNR) Orders, or organ donation, if applicable;

21. Previous mental health or intellectual disability services history, if any, and if applicable for care or services;

22. Current behavioral and social functioning including strengths and problems; and

23. Any substance abuse history if applicable for care or services.