Record keeping poised to expand for ALFs

The Agency for Health Care Administration is conducting a rule hearing next week to update record keeping requirements that would connect to several newer policies which have been mandated for Assisted Living Facilities over recent years.  The proposed rule modifies s. 59A-36.015, FAC, by adding to the elements of information an ALF is required to maintain for review by legally authorized entities. Under the proposal, the 7 new elements of information that must be readily available as a facility record are:

• The facility’s policies and procedures pursuant to section 59A-36.007(10), F.A.C.*
• The facility’s abuse prevention policies and procedures
• The facility’s medication practices
• The facility’s policy on physical restraints
• The facility’s policy on assistive devices
• The facility’s policy on third-party providers
• The facility’s policy on visitation pursuant to section 408.823(2)(a), F.S.

*s. 59A-36.007(10), FAC, refers to the infection prevention rule adopted by the Agency on 8/16/21 that requires an ALF to establish certain infection control procedures.

The proposed rule also updates a reference to a resident record, specifically, the form used to capture the resident’s health assessment:

“Resident records must be maintained on the premises and include:

(b) A copy of the Resident Health Assessment form, AHCA Form 1823 or the health care practitioner’s medical examination form described in rule 59A-36.006, F.A.C.”

Other changes in the proposal touch on independent living logs and keeping weights for hospice residents.

Record keeping crosses several operational areas in an ALF. Agency representatives will review a sample of records when conducting their survey inspections. Posters, too, garner the surveyor’s attention and sometimes track to resident rights if related to reporting allegations of abuse, for example. An interview with residents will indicate whether they know how to ask for and obtain their ALF’s prior survey history.  Briefly stated, lapses in record keeping signal areas of operational weakness.

View the proposed rule.

Related: ALF Records: Duration of Maintenance Quick-reference Guide

When you need Florida Core Training

Record keeping is an area of competency and has its own module within the ALF Minimum Core Training Curriculum.