481-69.25 – Tenant Documents

481-69.25 requires assisted living programs to document and maintain the documentation for each tenant including:

• An occupancy record which includes demographic information for the tenant. The minimum requirements include their name; date of birth; home address; any identification number(s); date of occupancy; the name, address and telephone number of all health professional(s); diagnosis; the name, address, and telephone number(s) of family, friends, or other designated individuals to contact in an emergency.
• Application form(s)
• Initial evaluations and updates
• Nutritional assessments as necessary
• Initial service plan and updates
• Signed authorizations for:
  • Permission to release medical information, photographs, or other media information as necessary
  • Permission to receive emergency medical care as necessary
  • Release of information, if any
  • Signed managed risk policy and any consensus agreements
  • When personal or health-related care is delegated to the program, the medical information sheet, health professionals’ orders, and nurses notes written by exception
  • Medication lists based on rules in 481-67.5
  • Advance health care directives
  • A complete copy of the occupancy agreement and any updates
  • A written acknowledgement of tenant’s rights
  • Copies of guardianship, durable power of attorney for health care, power of attorney, or conservatorship, or any other documentation of a legal representative
  • Incident reports including but not limited to:
    • Medication errors
    • Accidents
    • Falls
    • Elopements
    • The rule indicates that these need to be completed but are not required to be maintained in the tenant’s record.
    • Copy of waivers for admission/retention criteria
    • When the tenant is unable to advocate on their own behalf, or they have multiple service providers, accurate documentation must be maintained of routine personal or health-related care on task sheets. If tasks are physician ordered, they must be a part of the Medication Administration Record (MAR)

The rules also require that all tenant records be maintained for not less than three years after the transfer, discharge, or death of a tenant and protected from loss, damage and unauthorized use.

This rule is commonly cited; however, the examples of insufficient practices vary. More common examples of insufficient practices include but are not limited to:

• When nurses’ notes are not documented by exception.
• Records are not completed and/or are not maintained for a period not less than 3 years after discharge or death.
• Copies of records including occupancy agreements, evaluations, and/or service plans are not available for review.