Rule 111-8-62-.24 - Resident Files(1) An individual resident file must be maintained by the administrator or on-site manager for each resident in the home. Personal information must be treated as confidential and must not be disclosed except to the resident and his or her representative or legal surrogate, if any, an authorized agent of the Department, and others to whom written authorization is given by the resident or his representative or legal surrogate, if any. The resident file must be made available for inspection and/or copy to the Department, the resident or the resident's representative or legal surrogate, if any, upon request.(2) Each resident file must include the following information:(a) Identifying information including name, social security number, veteran status and number, age, sex, and previous address.(b) Name, address and telephone number of next of kin, legal guardian and/ or representative or legal surrogate, if any, or representative payee and any court order or written document designating the resident's representative or legal surrogate, if any.(c) Name, address and telephone number of any person or agency providing additional services to the resident. This information must include the name of the agency personnel primarily responsible, (i.e. the caseworker, case manager, or therapist).(d) An admission and discharge log to include the date of admission, prior residence of resident, referral source, agency-contact and telephone number of referral source.(e) Date of discharge, facility or residence discharged to and telephone number.(f) The name, address and telephone number of a physician, hospital and pharmacy of the resident's choice.(g) A record of all monetary transactions conducted on behalf of the resident with itemized receipts of all disbursements and deposits.(h) A record of all monies and other valuables entrusted to the home for safekeeping; a receipt for same shall be provided to the resident or representative or legal surrogate, if any, at the time of admission and at anytime thereafter when the resident acquires additional property and wishes to entrust such property to the home for safekeeping.(i) Health information including all health appraisals, diagnoses, prescribed diets, medications, and physician's instructions.(j) An inventory of all personal items brought to the home by the resident to be updated at anytime after admission if a resident or representative or legal surrogate, if any, submits to the home a new inventory of the resident's personal items.(k) A signed copy of the Resident's Rights form.(l) A signed copy of the admission agreement.(m) Any power of attorney or document issued by a court or by the Social Security Administration or any other governmental authority which designates another person as responsible for management of the resident's finances.(n) A copy of a living will and/or durable power of attorney for health care if executed prior to 2007 or a copy of the Georgia advance directive for health care and a physician's order for life-sustaining treatment, if any. At least the advance directive for health care form must be made available at the time of admission and shall remain available to the resident.(o) A copy of the resident's written waiver of the personal needs allowance charge pursuant to the provisions of Rule 111-8-62-.26(p)1.(p) Any signed medical orders impacting end of life care, e.g. do not resuscitate, physician's orders for life sustaining treatment.(q) All individual written care plans required by these rules and the rules for proxy caregivers, Chapter 111-8-100 if applicable. (r) Any informed written consents signed by the resident or resident's representative, designating and delegating to any trained proxy caregiver, whether employed by the home or not, the performance of identified health maintenance activities.(s) A copy of the search results obtained from the National Sex Offender Registry website maintained through the Department of Justice and any resulting safety plan for residents, staff and visitors.(3) The following information may be requested to be given voluntarily by the resident, guardian, or representative or legal surrogate, if any, but may not be required of the resident:(a) Spiritual preference e.g., church membership, name and telephone number of minister, priest, rabbi, or imam.(b) Information about insurance policies and prearranged funeral and burial provisions, if any.(4) Resident files must be maintained by the home for a period of three years after a resident's discharge.Ga. Comp. R. & Regs. R. 111-8-62-.24
O.C.G.A. Secs. 31-2-7, 31-2-9, 31-7-2.1, 31-7-12.3, 31-8-131, 32-32-1.
Original Rule entitled "Supplies" adopted. F. Nov. 19, 2009; eff. Dec. 9, 2009.Amended: New Title "Resident Files". F. Dec. 19, 2012; eff. Jan. 8, 2013.