Ariz. Admin. Code § 9-10-811

Current through Register Vol. 30, No. 45, November 8, 2024

Section R9-10-811 - Medical Records

A. A manager shall ensure that:

1. A medical record is established and maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1;

2. An entry in a resident's medical record is:

a. Only recorded by an individual authorized by policies and procedures to make the entry;

b. Dated, legible, and authenticated; and

c. Not changed to make the initial entry illegible;

3. If a rubber-stamp signature or an electronic signature is used to authenticate an order, the individual whose signature the rubber-stamp signature or electronic signature represents is accountable for the use of the rubber-stamp signature or electronic signature;

4. A resident's medical record is available to an individual:

a. Authorized according to policies and procedures to access the resident's medical record;

b. If the individual is not authorized according to policies and procedures, with the written consent of the resident or the resident's representative; or

c. As permitted by law; and

5. A resident's medical record is protected from loss, damage, or unauthorized use.

B. If an assisted living facility maintains residents' medical records electronically, a manager shall ensure that:

1. Safeguards exist to prevent unauthorized access, and

2. The date and time of an entry in a resident's medical record is recorded by the computer's internal clock.

C. A manager shall ensure that a resident's medical record contains:

1. Resident information that includes:

a. The resident's name, and

b. The resident's date of birth;

2. The names, addresses, and telephone numbers of:

a. The resident's primary care provider;

b. Other persons, such as a home health agency or hospice service agency, involved in the care of the resident; and

c. An individual to be contacted in the event of emergency, significant change in the resident's condition, or termination of residency;

3. If applicable, the name and contact information of the resident's representative and:

a. The document signed by the resident consenting for the resident's representative to act on the resident's behalf; or

b. If the resident's representative:

i. Has a health care power of attorney established under A.R.S. § 36-3221 or a mental health care power of attorney executed under A.R.S. § 36-3282, a copy of the health care power of attorney or mental health care power of attorney; or

ii. Is a legal guardian, a copy of the court order establishing guardianship;

4. The date of acceptance and, if applicable, date of termination of residency;

5. Documentation of the resident's needs required in R9-10-807(B);

6. Documentation of general consent and informed consent, if applicable;

7. Except as allowed in R9-10-808(B)(2), documentation of freedom from infectious tuberculosis as required in R9-10-807(A);

8. A copy of resident's health care directive, if applicable;

9. The resident's signed residency agreement and any amendments;

10. Resident's service plan and updates;

11. Documentation of assisted living services provided to the resident;

12. A medication order from a medical practitioner for each medication that is administered to the resident or for which the resident receives assistance in the self-administration of the medication;

13. Documentation of medication administered to the resident or for which the resident received assistance in the self-administration of medication that includes:

a. The date and time of administration or assistance;

b. The name, strength, dosage, and route of administration;

c. The name and signature of the individual administering or providing assistance in the self-administration of medication; and

d. An unexpected reaction the resident has to the medication;

14. Documentation of the resident's refusal of a medication, if applicable;

15. If applicable, documentation of any actions taken to control the resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual;

16. If applicable, documentation of a determination by a medical practitioner that evacuation from the assisted living facility during an evacuation drill would cause harm to the resident;

17. Documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to A.R.S. § 36-406(1)(d);

18. Documentation of the resident's orientation to exits from the assisted living facility required in R9-10-818(B);

19. If a resident is receiving behavioral health services other than behavioral care, documentation of the determination in R9-10-813(3);

20. If a resident is receiving behavioral care, documentation of the determination in R9-10-812(3);

21. If applicable, for a resident who is unable to direct self-care, the information required in R9-10-815(F);

22. Documentation of any significant change in a resident's behavior, physical, cognitive, or functional condition and the action taken by a manager or caregiver to address the resident's changing needs;

23. Documentation of the notification required in R9-10-803(G) if the resident is incapable of handling financial affairs; and

24. If the resident no longer resides and receives assisted living services from the assisted living facility:

a. A written notice of termination of residency; or

b. If the resident terminated residency, the date the resident terminated residency.

Ariz. Admin. Code § R9-10-811

Adopted as an emergency effective October 26, 1988, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 88-4). Emergency expired. Readopted without change as an emergency effective January 27, 1989, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 89-1). Emergency expired. Readopted without change as an emergency effective April 27, 1989, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 89-2). Emergency expired. Readopted without change as an emergency effective July 31, 1989, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 89-3). Permanent rules adopted with changes effective October 30, 1989 (Supp. 89-4). Former Section R9-10-811 renumbered to R9-10-814; new Section R9-10-811 made by final rulemaking at 9 A.A.R. 319, effective March 31, 2003 (Supp. 03-1). Section repealed; new Section made by exempt rulemaking at 19 A.A.R. 2015, effective October 1, 2013 (Supp. 13-2). Amended by exempt rulemaking at 20 A.A.R. 1409, effective 7/1/2014.