Md. Code Regs. 10.07.14.29 - Resident Record

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A. The assisted living manager shall ensure that an individual record or log is maintained at the assisted living program for each resident in a manner that ensures security and confidentiality, and which includes at a minimum:

(1) Resident Assessment Tools;

(2) Nursing assessments;

(3) Medical orders;

(4) Service plans;

(5) Care notes;

(6) Emergency data sheet;

(7) Applicable advance directive and mental health advance directive;

(8) Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form;

(9) Monthly weights or, in accordance with the health care practitioner's orders for weights, more or less frequently;

(10) Pharmacy reviews, if appropriate;

(11) Rehabilitation plans, if appropriate; and

(12) Any other records related to the care and services provided to the resident.

B. Readmission of a Resident.

(1) A resident shall be reassessed by the delegating nurse within 48 hours of readmission to the program if the following occurs:

(a) Hospitalizations or a 15-day or longer stay in any skilled facility; or

(b) There is a significant change in the resident's mental or physical status upon return to the program after an absence from the program.

(2) When the delegating nurse determines in the nurse's clinical judgment that the resident does not require a full assessment within 48 hours, the delegating nurse shall:

(a) Document the determination and the reasons for the determination in the resident's record; and

(b) Ensure that a full assessment of the resident is conducted within 7 calendar days.

C. The assisted living manager shall develop policies and procedures to ensure that all information relating to a resident's condition or preferences, including any significant change as defined in Regulation .02B(81) of this chapter, is documented in the resident's record and communicated in a timely manner to:

(1) The resident;

(2) The resident representative, as appropriate; and

(3) Health care practitioners and staff who are involved in the development and implementation of the resident's service plan, as appropriate.

D. Resident Care Notes.

(1) Appropriate staff shall write care notes for each resident:

(a) On admission;

(b) At least weekly;

(c) With any significant changes in the resident's condition, including when incidents occur and any follow-up action is taken;

(d) When the resident is transferred from the facility to another health care facility;

(e) On return from medical appointments;

(f) When seen in the facility by any health care practitioner or health care provider;

(g) On return from nonroutine leaves of absence; and

(h) When the resident is discharged permanently from the facility, including the location and manner of discharge.

(2) Staff shall write care notes that are individualized, legible, dated, timed, and signed by the writer.

E. The assisted living program shall maintain a resident's record for 5 years after the resident is discharged.

F. If an assisted living program ceases operation, the assisted living program shall make arrangements to retain records as required by §E of this regulation.

G. If the assisted living program changes ownership, the prior owner shall provide all written and electronic records of current residents to the new owner in a usable format prior to the issuance of the new license.

H. An assisted living program shall:

(1) Maintain the privacy and confidentiality of a resident's medical records and medical information;

(2) Release medical records or medical information about a resident only with the consent of the resident or resident representative, or as permitted by Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland; and

(3) Maintain and dispose of a resident's medical records in accordance with Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland.

Notes

Md. Code Regs. 10.07.14.29

Regulation .29B amended effective March 29, 2004 (31:6 Md. R. 508)
Regulations .29 adopted effective December 29, 2008 (35:26 Md. R. 2249)
Regulation .29 amended effective June 25, 2012 (39:12 Md. R. 745); adopted effective 52:8 Md. R. 357, eff. 4/28/2025.

State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.

A. All staff who administer medications to residents shall have completed the medication administration course that is taught by a registered nurse who is approved by the Maryland Board of Nursing.

B. The assisted living manager shall document completion of the medication technician training in the personnel file or other readily available record of each unlicensed staff member who administers medications.

C. All medications shall be administered consistent with applicable requirements of COMAR 10.27.11.

D. An assisted living manager shall ensure that the resident's initial assessment process identifies whether a resident:

(1) Is capable of self-administration of medication;

(2) Is capable of self-administration of medication, but requires a reminder to take medications or physical assistance with opening and removing medications from the container, or both; or

(3) Requires that medications be administered by the assisted living program staff or by a spouse or domestic partner of the resident in accordance with §F of this regulation.

E. For a resident who is capable of self-administration or, although capable, requires a reminder or physical assistance, as stated in §D(2) of this regulation, the assisted living manager shall ensure that the resident is reassessed by the delegating nurse quarterly for the ability to safely self-administer medications with or without assistance.

F. While residing in the same assisted living facility as their spouse or domestic partner, a resident may administer medications to their spouse or domestic partner providing the following documentation is maintained in the resident's record:

(1) An initial assessment by their health care provider documenting the resident's competency and ability to safely administer medications to their spouse or domestic partner;

(2) Quarterly assessments by the delegating nurse documenting the resident's continued ability to safely administer medications to their spouse or domestic partner; and

(3) Current signed medical orders.

G. Medication Review Upon Admission.

(1) The assisted living manager shall consult within 14 days of a resident's admission with the individuals set forth in §G(2) of this regulation to review a new resident's medication regime.

(2) The medication review may be conducted by a:

(a) Primary care physician;

(b) Certified registered nurse practitioner;

(d) Registered nurse, who may be the delegating nurse; or

(e) Licensed pharmacist.

H. The purpose of the review required by §G of this regulation is to review with the assisted living manager or designee:

(1) A resident's current medication profile, including all prescription and nonprescription medications and tube feedings;

(2) The potential that current medications have to act as chemical restraints;

(3) The potential for any adverse drug interactions, including potential side effects from the medications; and

(4) Any medication errors that have occurred since admission.

I. The assisted living manager, or designee, shall ensure that the review required by §G of this regulation is documented in the resident's records, including any recommendations given by the reviewer.

J. Pharmacy Review.

(1) The assisted living manager of a program shall arrange for a licensed pharmacist to conduct an on-site review of physician prescriptions, physician orders, and resident records at least every 6 months for any resident receiving nine or more medications, including over the counter and PRN (as needed) medications.

(2) The pharmacist's review shall include, but is not limited to, whether:

(a) The program is in compliance with Board of Pharmacy's requirements for packaging of medications;

(b) Each resident's medications are properly stored and maintained;

(c) Each resident receives the medications that have been specifically prescribed for that resident in the manner that has been ordered;

(d) Based on available information, the desired effectiveness of each medication is achieved, and, if not, that the appropriate authorized prescriber is so informed;

(e) Any undesired side effects, potential and actual adverse drug reactions, and medication errors are identified and reported to the appropriate authorized prescriber;

(f) The resident has a medical condition as documented in the resident's records that is not currently being treated by medication;

(g) There is drug use without current indication in the resident's records of a medical condition that warrants the use of the drug;

(h) There is drug overuse that is causing side effects as documented in the resident records;

(i) Current medication selections result in inappropriate drug dosage;

(j) The resident may be experiencing drug interactions;

(k) The resident is receiving medication, either prescribed or over-the-counter medications, as well as herbal remedies that could result in drug-drug, drug-food, or drug-laboratory test interactions;

(l) Administration times of medication need to be modified to address drug interactions or meal times, or both;

(m) The resident records need to be reviewed to assure that periodic diagnostic monitoring required by certain medications have been performed; and

(n) The resident's medication regimens need to be reviewed to determine if more cost-effective medications are available to treat current medical conditions.

(3) The pharmacist shall document the pharmacy review as required under this section in each resident's chart and this documentation shall be reviewed every 6 months as part of the assisted living program's quality assurance activities as required in Regulation .13 of this chapter.

K. The person conducting the on-site review under §G or J of this regulation shall recommend changes, as appropriate, to the appropriate authorized prescriber and the assisted living manager or designee.

L. If a resident requires that staff administer medications as defined in Regulation .02B(3) of this chapter, and the administration of medications has been delegated to an unlicensed staff person pursuant to COMAR 10.27.11, the assisted living manager shall comply with COMAR 10.27.11 by arranging for an on-site review by the delegating registered nurse at least every 45 days. The delegating nurse shall make appropriate recommendations to the appropriate authorized prescriber, and the assisted living manager or designee.

M. Safe Storage of Medication. The assisted living manager, or designee, shall ensure that:

(1) Medications are stored in the original dispensed container;

(2) Medications are stored in a secure location, at the proper temperature; and

(3) The following documentation is maintained for all residents:

(a) Name of the resident;

(b) Name of the medication;

(d) Dose;

(e) Physician's or authorized prescriber's name;

(f) Date of issuance;

(g) Expiration date;

(h) Refill limits; and

(i) Directions for use.

N. Medications and treatments shall be administered consistent with current signed medical orders and using professional standards of practice.

O. Required Documentation.

(1) A staff member shall record the documentation required under §M of this regulation for all residents for whom medications are administered, or who receive assistance in taking their medications, as defined by Regulation .02B(3)(b) of this chapter, at the time that the resident takes or receives medications.

(2) A staff member shall record the documentation required under §M of this regulation for residents who self-administer:

(a) Upon admission; or

(b) When changes in the resident's medication regimen are ordered by a physician or other authorized health care practitioner.

P. Accounting for Narcotic and Controlled Drugs.

(1) Staff shall count and record controlled drugs, such as narcotics, before the close of every shift.

(2) The daily record shall account for all controlled drugs documented as administered on the medication administration record.

(3) All Schedule II and III narcotics shall be maintained under a double lock system.

Notes

Md. Code Regs. 10.07.14.29