Utah Admin. Code R432-300-9 - Facility Records

(1) The licensee shall:

(a) maintain accurate and complete records that are filed, stored safely, and are easily accessible to staff and the department;

(b) ensure records are protected against access by unauthorized individuals;

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

(i) an employee application;

(ii) the date of employment and initial policies and procedures orientation;

(iii) the termination date;

(iv) the reason for leaving;

(v) documentation of CPR, first aid, and emergency procedures training;

(vi) a health inventory;

(vii) a food handlers permit;

(viii) tuberculosis skin test documentation;

(ix) documentation of criminal background check; and

(x) certifications, registration, and licenses as required.

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

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

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

(i) the person who administers and obtains medications, if this is not facility staff;

(ii) the individual to be notified in case of accident or death; and

(iii) a physician and dentist to be called in an emergency;

(c) any known allergies;

(d) the admission agreement;

(e) a copy of an advanced directive or living will initiated by the resident;

(f) a physician's assessment;

(g) a resident assessment;

(h) a written plan of care;

(i) physician orders;

(j) daily nursing notes that include:

(i) temperature;

(ii) pulse;

(iii) respirations;

(iv) blood pressure;

(v) height; and

(vi) weight notations when indicated or as needed due to a change in the resident's condition;

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

(l) incident and accident reports.

(3) The licensee shall retain resident records for at least seven years following discharge.

Notes

Utah Admin. Code R432-300-9

Amended by Utah State Bulletin Number 2023-10, effective 5/9/2023