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Virginia Administrative Code (Last Updated: January 10, 2017) |
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Title 22. Social Services |
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Agency 40. Department of Social Services |
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Chapter 72. Standards for Licensed Assisted Living Facilities |
Section 560. Resident records
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A. The facility shall establish written policy and procedures for documentation and recordkeeping to ensure that the information in resident records is accurate and clear and that the records are well-organized.
B. Resident records shall be identified and easily located by resident name, including when a resident's record is kept in more than one place. This shall apply to both electronic and hard copy material.
C. A back-up and security system shall be utilized for electronic documents that are part of the resident's record.
D. Any forms used for recordkeeping shall contain at a minimum the information specified in this chapter. Model forms, which may be copied, will be supplied by the department upon request, and are also available on the department's website.
E. Any physician's notes and progress reports in the possession of the facility shall be retained in the resident's record.
F. Copies of all agreements between the facility and the resident and official acknowledgment of required notifications, signed by all parties involved, shall be retained in the resident's record. Copies shall be provided to the resident, and to persons whose signatures appear on the document.
G. All records that contain the information required by these standards for residents shall be retained at the facility and kept in a locked area, except that information shall be made available as noted in subsection H of this section.
H. The licensee shall assure that all records are treated confidentially and that information shall be made available only when needed for care of the resident. All records shall be made available for inspection by the department's representative.
I. Residents shall be allowed access to their own records.
J. The resident's record shall be kept current and the complete record shall be retained for at least two years after the resident leaves the facility.
K. A current picture of each resident shall be readily available for identification purposes, or if the resident refuses to consent to a picture, there shall be a narrative physical description, which is annually updated, maintained in his file.
Historical Notes
Derived from Volume 23, Issue 06, eff. December 28, 2006.