Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 50 - ADULT FOSTER HOMES FOR OLDER ADULTS OR ADULTS WITH PHYSICAL DISABILITIES - STANDARDS OF OPERATION › Section 411-050-0750 - Records - Resident

Current through Register Vol. 63, No. 7, July 1, 2024
(1) An individual
			 resident record must be developed, kept current, and readily accessible on the
			 premises of the home for each individual admitted to the AFH. The record must
			 be legible and kept in an organized manner so as to be utilized by
			 staff.
(2) The record must contain
			 the following information:
(a) A complete
			 initial screening assessment and general information form (SDS 902) as
			 described in OAR 411-051-0110.
(b) Documentation on form (SDS 913) that the
			 licensee or administrator has informed private-pay residents of the
			 availability of a long-term care assessment.
(c) Documentation on form (SDS 0342A) that
			 the licensee or administrator has oriented the resident to emergency evacuation
			 procedures as described in OAR
			 411-050-0725(1).
(d) Documentation that the licensee or
			 administrator has informed all residents of the right to formulate an Advance
			 Directive.
(e) FINANCIAL
			 INFORMATION:
(A) Detailed records and
			 receipts, if the licensee manages or handles a resident's money. The Resident
			 Account Record (form SDS 713) or other expenditure forms may be used if the
			 licensee manages or handles a resident's money. The record must show amounts
			 and sources of funds received and issued to, or on behalf of, the resident and
			 be initialed by the person making the entry. Receipts must document all
			 deposits and purchases of $5 or more made on behalf of a resident.
(B) Residency Agreement signed and dated by
			 the resident or the resident's representative may be kept in a separate file,
			 but must be made available for inspection by the LLA.
(f) Medical and legal information, including,
			 but not limited to:
(A) Medical history, if
			 available.
(B) Current prescribing
			 practitioner orders.
(C) Nursing
			 instructions, delegations, and assessments, as applicable.
(D) Completed medication administration
			 records retained for at least the last six months or from the date of
			 admission, whichever is less. (Older records may be stored
			 separately).
(E) Copies of
			 Guardianship, Conservatorship, Advance Directive for Health Care, Power of
			 Attorney, and Physician's Order for Life Sustaining Treatment (POLST)
			 documents, as applicable.
(g) A complete, accurate, and current care
			 plan.
(h) Documentation that
			 supports or eliminates any individually-based limitation, as described in OAR
			 411-051-0115.
(i) A copy of the current house policies, as
			 identified in the current Residency Agreement, and the current Resident's Bill
			 of Rights, signed and dated by the resident or the resident's
			 representative.
(j) SIGNIFICANT
			 EVENTS AND INCIDENTS. A written report (using form SDS 344 or its equivalent)
			 of all significant incidents relating to the health or safety of the resident,
			 including how and when the incident occurred, who was involved, what action was
			 taken by the licensee and staff, as applicable, and the outcome to the
			 resident. A copy of the report must be sent to the resident's representative,
			 and case manager, if applicable.
(k) NARRATIVE OF RESIDENT'S PROGRESS.
			 Narrative entries describing each resident's progress must be documented at
			 least weekly and maintained in each resident's individual record. All entries
			 must be signed and dated by the person writing them.
(l) Non-confidential information or
			 correspondence pertaining to the care needs of the resident.
(m) Falsifying records or causing another to
			 do so shall result in issuance of a mandatory civil penalty as described in OAR
			 411-052-0025(2).