(1) An ACLF shall
develop and maintain an organized record for each resident and ensure that all
entries shall be written legibly in ink, typed, or kept electronically, and
signed, and dated.
record. An ACLF shall ensure that the resident's personal record includes at a
minimum the following:
(a) Name, Social
Security Number, veteran status and number, marital status, age, sex, any
health insurance provider and number, including Medicare and/or Medicaid
number, and photograph of the resident;
(b) Name, address and telephone number of
next of kin, legal representative (if applicable), and any other person
identified by the resident to contact on the resident's behalf;
(c) Name and address of the resident's
preferred physician, hospital, pharmacist and nursing home, and any other
instructions from the resident to be followed in case of emergency;
(d) Record of all monies and other valuables
entrusted to the ACLF for safekeeping, with appropriate updates;
(e) Date of admission, transfer, discharge
and any new forwarding address;
A copy of the admission agreement that is signed and dated by the
(g) A copy of any advance
directives, DNR Order, Durable Power of Attorney, or living will, when
applicable, and made available upon request; and
(h) A record that the resident has received a
copy of the ACLF's resident's rights and procedures policy.
Medical record. An ACLF shall
ensure that its employees develop and maintain a medical record for each
resident who requires health care services at the ACLF regardless of whether
such services are rendered by the ACLF or by arrangement with an outside
source, which shall include at a minimum:
by physicians or other authorized healthcare providers;
(c) Orders and recommendations for all
medication, medical/and other care, services, procedures, and diet from
physicians or other authorized healthcare providers, which shall be completed
prior to, or at the time of admission, and subsequently, as warranted. Verbal
orders received shall include the time of receipt of the order, description of
the order, and identification of the individual receiving the order;
(d) Care/services provided, including
identification of providing party;
(e) Medications administered and procedures
followed if an error is made;
Special procedures and preventive measures performed;
(g) Notes, including, but not limited to,
observation notes, progress notes, and nursing notes;
(h) Listing of current
(i) Time and
circumstances of discharge or transfer, including condition at discharge or
transfer, or death;
of routine and emergency medical care, to include the name and telephone number
of the resident's physician, plan for payment, and plan for securing
information, e.g., do-not resuscitate orders, allergies, etc.; and
(l) Copy of quarterly Alzheimer's review, if
An ACLF shall complete a written assessment of the resident to be conducted by
a direct care staff member within a time-period determined by the ACLF, but no
later than seventy-two (72) hours after admission.
Plan of care.
(a) An ACLF shall develop a plan of care for
each resident admitted to the ACLF with input and participation from the
resident or the resident's legal representative, treating physician, or other
licensed health care professionals or entity delivering patient services within
five (5) days of admission. The plan of care shall be reviewed and/or revised
as changes in resident needs occur, but not less than semi-annually by the
The plan of care shall describe:
1. The needs
of the resident, including the activities of daily living and medical services
for which the resident requires assistance, i.e., what assistance/care, how
much, who will provide the assistance/care, how often, and when;
2. Requirements and arrangements for visits
by or to physicians or other authorized health providers;
3. Advance care directive, healthcare
power-of-attorney; as applicable;
4. Recreational and social activities which
are suitable, desirable, and important to the well-being of the resident;
5. Dietary needs.
information shall be confidential and shall not be disclosed, except to the
resident, the department and others with written authorization from the
resident. Records shall be retained for three (3) years after the resident has
been transferred or discharged.
An ACLF shall retain legible copies of the following records and reports for
thirty-six (36) months following their issuance. The reports shall be
maintained in a single file, and shall be made available for inspection during
normal business hours to any resident who requests to view them. Each resident
and each person assuming any financial responsibility for a resident must be
fully informed, before admission, of the existence of the reports in the ACLF
and given the opportunity to inspect the file before entering into any monetary
agreement with the ACLF.
(a) Local fire
building code inspections, if any.
(c) Department licensure and fire safety
inspections and surveys.
of the Commissioner or Board, if any.
(e) Maintenance records of all safety
Tenn. Comp. R. &
Original rule filed
February 9, 1998; effective April 25, 1998. Amendment filed April 28, 2003;
effective July 12, 2003. Repeal and new rule filed January 24, 2006; effective
April 9, 2006. Amendment filed February 7, 2007; effective April 23, 2007.
Public necessity rule filed May 13, 2009; effective through October 25, 2009.
Emergency rule filed October 22, 2009; effective through April 20, 2010.
Amendment filed September 24, 2009; effective December 23,
Authority: T.C.A. §§
68-11-201, 68-11-202, 68-11-204,
68-11-206, 68-11-209, 68-11-224, 68-11-1801 through 68-11-1815.