Iowa Administrative Code › Agency 481 - Inspections and Appeals Department › Inspections Division › Chapter 63 - Residential Care Facility-three- to Five-bed Specialized License › Rule 481-63.14 - Records

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Resident record.
The licensee shall keep a permanent record on
				all residents admitted to a specialized residential care facility with all
				entries current, dated, and signed. (Ill) The record shall include:
a. Name and previous address of resident;
				(III)
b. Birth date, sex, and
				marital status of resident; (III)
c. Church affiliation; (III)
d. Primary care provider's name, telephone
				number, and address; (III)
e.
				Dentist's name, telephone number, and address; (III)
f. Name, address, and telephone number of
				next of kin or legal representative; (III)
g. Name, address, and telephone number of
				person to be notified in case of emergency; (III)
h. Mortuary's name, telephone number, and
				address; (III)
i. Pharmacist's
				name, telephone number, and address; (III)
j. Physical examination and medical history;
				(III)
k. Certification by the
				primary care provider that the resident requires no more than personal care and
				supervision, but does not require nursing care; (III)
l. Primary care provider's orders for
				medication, treatment, and diet in writing and signed by the primary care
				provider; (III)
m. A notation of
				yearly or other visits to primary care provider or other professional services;
				(III)
n. Any change in the
				resident's condition; (II, III)
o.
				If the primary care provider has certified that the resident is capable of
				taking prescribed medications, the resident shall be required to keep the
				administrator advised of current medications, treatments, and diet. The
				administrator shall keep a listing of medication, treatments, and diet
				prescribed by the primary care provider for each resident; (III)
p. If the primary care provider has certified
				that the resident is not capable of taking prescribed medication, it must be
				administered by a qualified person of the facility. A qualified person shall be
				defined as either a registered or licensed practical nurse or an individual who
				has completed the state-approved training course in medication administration,
				including a medication manager or certified medication aide; (II)
q. Medications administered by an employee of
				the facility shall be recorded on a medication record by the individual who
				administers the medication; (II, III)
r. A notation describing the resident's
				condition on admission, transfer, and discharge; (III)
s. In the event of a resident's death,
				notations in the resident's record shall include the date and time of the
				resident's death, the circumstances of the resident's death, the disposition of
				the resident's body, and the date and time that the resident's family and
				primary care provider were notified of the resident's death; (III)
t. A copy of instructions given to the
				resident, legal representative, or facility in the event of discharge or
				transfer; (III)
u. Disposition of
				valuables; (III)
v. Current
				individual program plans. (II, III)