Nathan Hughey – The following records are required to be kept by Assisted Living Facilities in SC
R. 61.84, Section 700 – Resident Records.
A. The facility shall initiate and maintain an organized record for each resident. The record shall contain sufficient documented information to identify the resident and the agency and/or person responsible for each resident; support the diagnosis, secure the appropriate care/services (as needed); justify the care/services provided to include the course-of-action taken and results; the symptoms or other indications of sickness or injury; changes in physical/mental condition; the response/reaction to care, medication, and diet provided; and promote continuity of care among providers, consistent with acceptable standards of practice. All entries shall be written legibly in ink or typed, and signed, and dated.
B. Specific entries/documentation shall include at a minimum:
1. Consultations by physicians or other authorized healthcare providers;
2. Orders and recommendations for all medication, care, services, procedures, and diet from physicians or other authorized healthcare providers, which shall be completed prior to, or at the time of admission, and subsequently, as warranted. Verbal orders received shall include the time of receipt of the order, description of the order, and identification of the individual receiving the order;
3. Care/services provided;
4. Medications administered and procedures followed if an error is made;
5. Special procedures and preventive measures performed;
6. Notes of observation. In instances that involve significant changes in a resident’s medical condition and/or the occurrence of a serious incident, notes of observation shall be documented at least daily until the condition is stabilized and/or the incident is resolved. In all other instances, notes of observation for residents shall be documented at least monthly;
7. Time and circumstances of discharge or transfer, including condition at discharge or transfer, or death;
8. Provisions for routine and emergency medical care, to include the name and telephone number of the resident’s physician, plan for payment, and plan for securing medications;
9. Special information, e.g., do-not-resuscitate orders, allergies, etc.;
10. Photograph of resident. Resident photographs shall be at a minimum two and one half inches by three and one half inches (2 % by 3 % inches) in size, dated and no more than twenty-four (24) months old unless significant changes in appearance have occurred necessitating a more recent photograph.
702. Assessment (II)
A written assessment of the resident in accordance with Section 101.J. shall be conducted by a direct care staff member as evidenced by his or her signature within a time-period determined by the facility, but no later than 72 hours after admission.
703. Individual Care Plan (II)
A. The facility shall develop an ICP with participation by, as evidenced by their signatures, the resident, administrator (or designee), and/or the sponsor or responsible party when appropriate, within seven days of admission. The ICP shall be reviewed and/or revised as changes in resident needs occur, but not less than semi-annually by the above-appropriate individuals.
B. The ICP shall describe:
1. The needs of the resident, including the activities of daily living for which the resident requires assistance, i.e., what assistance, how much, who will provide the assistance, how often, and when;
2. Requirements and arrangements for visits by or to physicians or other authorized health providers;
Advanced care directives/healthcare power-of-attorney, as applicable;
4. Recreational and social activities which are suitable, desirable, and important to the well-being of the resident;
5. Dietary needs.
C. The ICP shall delineate the responsibilities of the sponsor and of the facility in meeting the needs of the resident, including provisions for the sponsor to monitor the care and the effectiveness of the facility in meeting those needs. Included shall be specific goal-related objectives based on the needs of the resident as identified during the assessment phase, including adjunct support service needs, other special needs, and the methods for achieving objectives and meeting needs in measurable terms with expected achievement dates.
704. Record Maintenance
A. The licensee shall provide accommodations, space, supplies, and equipment adequate for the protection and storage of resident records.
B. When a resident is transferred from one facility to another, a transfer summary to include at a minimum, a copy of the ICP and medication administration record (MAR), shall be forwarded to the receiving facility at the time of transfer or immediately after the transfer if the transfer is of an emergency nature. (I)
C. The resident record is confidential and shall be made available only to individuals authorized by the facility and/or the S.C. Code of Laws. (II)
D. Records generated by organizations/individuals contracted by the facility for care/services shall be maintained by the facility that has admitted the resident.
E. The facility shall determine the medium in which information is stored.
F. Upon discharge of a resident, the record shall be completed within 30 days, and filed in an inactive/closed file maintained by the licensee. Prior to the closing of a facility for any reason, the licensee shall arrange for preservation of records to ensure compliance with these regulations. The licensee shall notify DHL, in writing, describing these arrangements and the location of the records.
G. Records of residents shall be maintained for at least six years following the discharge of the resident. Other regulation-required documents, e.g., fire drills, activity schedules, etc., shall be retained at least 12 months or since the last DHL general inspection, whichever is the longer period.