Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 12.00 - Certification Procedures and Standards for Assisted Living Residences › Section 12.05 - Record Requirements

Current through Register 1525, July 5, 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).