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Maine Administrative Code
Department 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICESDivision 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERALChapter 113 - Regulations Governing the Licensing and Functioning of Assisted Housing Programs (includes Assisted Living Programs, Residential Care Facilities, and Private Non-Medical Institutions) (formerly 10-149 Ch. 113)
Private Non-Medical Institutions
Section 144-113-IV-11 - Administrative and Resident Records

10-144-113 Me. Code R. § IV-11

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Current through 2024-51, December 18, 2024
Section 144-113-IV-11 - Administrative and Resident Records
11.1 Individual records required. Information pertaining to a resident's stay shall be centralized in an individual record, containing the following, where applicable:
11.1.1 An identification and summary sheet that includes the following information:
11.1.1.1 Name, previous address and Social Security number of resident;
11.1.1.2 Birth date, sex and marital status;
11.1.1.3 Date of admission and source;
11.1.1.4 Religious affiliation;
11.1.1.5 Duly authorized licensed practitioner's name, address and telephone number;
11.1.1.6 Dentist's name, address and telephone number;
11.1.1.7 Name, address and telephone number of the legal guardian/conservator or legal representative;
11.1.1.8 Name, address and telephone number of the person who will make payments for boarding care (if other than the resident);
11.1.1.9 Name, address and telephone number of nearest relative or friend;
11.1.1.10 Name, address and telephone number of person to be notified in an emergency;
11.1.1.11 Day program name, telephone number, address and contact person, if applicable;
11.1.1.12 Current diagnoses and/or physical or mental disabilities and instructions as to any special care required;
11.1.1.13 Language spoken/communication method;
11.1.1.14 Discharge date, destination and reason for discharge;
11.1.1.15 Record of death, if death occurs in the facility, including:
11.1.1.15.1 Date and time of death;
11.1.1.15.2 Immediate cause of death;
11.1.1.16 Name, address and telephone number of the person to be notified and the procedures to be followed in an emergency to cover the immediate care of the resident and disposition of the body at the time of death.
11.1.2 A listing of all personal property of significant value to the resident that includes such things as jewelry, radios, television sets, dentures, appliances and other valuables. Where serial numbers are available, these shall be included as part of the record. The record shall be signed and dated by the resident or his/her legal representative. When significant items of personal property are brought into or removed from the facility, it shall be so noted in the record. It shall be noted in the record if a resident has no personal property of significant value.
11.1.3 A record or statement from the duly authorized licensed practitioner showing the date of the resident's last annual physical examination and any pertinent information on the resident's diagnosis, physical condition and medical history. If a resident has had a physical examination within one (1) year of the date of admission, a copy of the report shall be obtained and placed in the resident's record. A complete physical must be scheduled upon admission if no physical exam has been done in the past year.
11.1.4 Written and dated orders signed by a duly authorized licensed practitioner for all treatments, medications and special diets.
11.1.5 Individual medication records, kept in accordance with Section 7.12 of these regulations.
11.1.6 Other information including:
11.1.6.1 Diabetic record, if applicable;
11.1.6.2 Illnesses;
11.1.6.3 Copies of incident or accident reports in accordance with Section 11.1.7;
11.1.6.4 Visits to or by the duly authorized licensed practitioner or other health professional (e.g., dentist or audiologist);
11.1.6.5 Documentation at least monthly of observed changes in the resident's condition or behavior, progress in reaching service plan goals or other information needed to properly assess and evaluate the resident in accordance with Section 12.2 of these regulations;
11.1.6.6 Assessment and residential service plan;
11.1.6.7 Denture identification number;
11.1.6.8 Social service record;
11.1.6.9 Contract;
11.1.6.10 Documented proof of guardianship, conservatorship, representative payee, power of attorney or other legal representative, if such a relationship exists; and
11.1.7 Incident reports. An incident report shall be completed for any resident who has sustained or caused a fall, injury or accident in the facility, while being transported by the facility, or in an activity supervised by facility staff, who unsafely wanders from the facility, who is involved in an altercation with another resident, who has a medication reaction, or when an error is made in the documentation or administration of medication. The report shall describe the incident and indicate the extent of the injury or reaction and necessary treatment. The dispensing pharmacy shall be consulted regarding incidents involving medications, in order to assist in assessing adverse drug reaction, drug-drug interaction, drug-food interaction and allergies/sensitivities. If, in the opinion of the administrator or person in charge, the incident is not serious enough to call an examining duly authorized licensed practitioner, an incident report shall still be recorded in the resident's record. The administrator shall initial the record within seventy-two (72) hours. If examination and treatment by a duly authorized licensed practitioner is necessary as a result of an incident, the facility shall notify the guardian or conservator as soon as possible, within seventy-two (72) hours.
11.1.8 Refusal of care or treatment. The resident's record shall contain documentation when a resident refuses to consent to care or treatment which the facility is required to provide in accordance with the standards for resident care (Section 12) or as prescribed by a duly authorized licensed practitioner.
11.1.9 Referral/transfer form. A referral or transfer form shall be prepared when any resident is transferred from one facility to another facility, institution or agency or to another level of care within the same facility. A copy shall be kept in the resident's record at both facilities. The referral or transfer form shall contain a summary of information about the admitted/discharged resident to ensure continuity of care, including a copy of the most recent history, physical examination report, duly authorized licensed practitioner's orders and a copy of the resident's most recent assessment and service plan. [Class III]
11.1.10 Computerized records. Records may be computerized, so long as appropriate staff are adequately trained in accessing, reading and maintaining these records and the records are readily accessible and available to all appropriate staff.
11.2 Admission/discharge log. All admissions and discharges shall be recorded in a bound book, indicating the residents' names and dates of admission and discharge.
11.3 Daily census. A daily census shall be recorded and kept in the facility. In facilities with ten (10) or fewer beds, the census may be kept by omission, that is, kept as a record of resident absences from the facility and may be kept individually in each resident's record.
11.4 Personal funds.
11.4.1 Permission to management personal funds of residents. No provider or agent of a provider shall manage, hold or deposit in a financial institution the personal funds of any resident of the facility, unless written permission is received therefore from:
11.4.1.1 The resident, if the resident has no legal representative;
11.4.1.2 The resident's legal representative, if such person exists and can be reached; or
11.4.1.3 The Department, if a legal representative exists, but cannot be reached.
11.4.2 Itemized accounting. Any operator or agent who, after receiving written permission pursuant to Section 11.4.1, manages or holds the personal funds of any resident, shall maintain an up-to-date, accurate account for these funds, which shall include for each resident, a separate, itemized accounting for the use of the resident's personal funds, with supporting documentation for every expenditure in excess of two dollars ($2.00). It shall be provided to the resident on a quarterly basis for their review.
11.4.3 Depositing personal funds. The Department may require the facility to deposit in a financial institution the personal funds of a resident if the resident has a legal representative who cannot be reached.

10-144 C.M.R. ch. 113, § IV-11