1. (1) The licensee shall:

   1. (a) maintain accurate and complete records that are filed, stored safely, and are easily accessible to staff and the department;
   2. (b) ensure records are protected against access by unauthorized individuals;

   3. (c) maintain personnel records for each employee that are kept for at least three years after employment termination and include the following content:

      1. (i) an employee application;
      2. (ii) the date of employment and initial policies and procedures orientation;
      3. (iii) the termination date;
      4. (iv) the reason for leaving;
      5. (v) documentation of CPR, first aid, and emergency procedures training;
      6. (vi) a health inventory;
      7. (vii) a food handlers permit;
      8. (viii) tuberculosis skin test documentation;
      9. (ix) documentation of criminal background check; and
      10. (x) certifications, registration, and licenses as required.

2. (2) The licensee shall maintain in the facility a separate record for each resident that includes the following:

   1. (a) the resident's name, date of birth, and last address;

   2. (b) the name, address, and telephone number for:

      1. (i) the person who administers and obtains medications, if this is not facility staff;
      2. (ii) the individual to be notified in case of accident or death; and
      3. (iii) a physician and dentist to be called in an emergency;
   3. (c) any known allergies;
   4. (d) the admission agreement;
   5. (e) a copy of an advanced directive or living will initiated by the resident;
   6. (f) a physician's assessment;
   7. (g) a resident assessment;

   8. (h) a written plan of care;

      1. (i) physician orders;

   9. (j) daily nursing notes that include:

      1. (i) temperature;
      2. (ii) pulse;
      3. (iii) respirations;
      4. (iv) blood pressure;
      5. (v) height; and
      6. (vi) weight notations when indicated or as needed due to a change in the resident's condition;

   10. (k) a record of any resident cash, resources, or valuables entrusted to the facility; and

       1. (l) incident and accident reports.
3. (3) The licensee shall retain resident records for at least seven years following discharge.

KEY: health care facilities

Date of Last Change: May 9, 2023

Notice of Continuation: August 13, 2021

Authorizing, and Implemented or Interpreted Law: 26B-1-202; 26B-2-216