Reports and records. Each facility shall keep the following reports, records, policies and procedures on file at the facility and make them available for review upon request by the licensing authority, residents, potential residents or their surrogate decision makers:
-
- fire inspection report;
- zoning approval;
- building official approval (certificate of occupancy);
- a copy of the approved building plans;
- a copy of the most recent survey conducted by the licensing authority, to include adverse actions or appeals and complaints;
- for facilities with food establishments/kitchens that require a permit from the local health authority that has jurisdiction, a copy of the current inspection report in accordance with the applicable, municipal, or federal laws and regulations and pursuant to Subsection B of 7.6.2.8 NMAC, regarding kitchen and food management; if a facility is considered a licensed private home and not required to meet specific requirements by the local health authority, a copy of that determination must also be maintained;
- where necessary, a copy of the liquid waste disposal and treatment system permit from the local health authority that has jurisdiction;
- thirty (30) days of menus as planned, including snacks and thirty (30) days of menus as served, including snacks;
- record of monthly fire drills conducted at the facility and the fire safety evaluation system (FSES) rating, if applicable;
- written emergency plans, policies and procedures for medical emergencies, power failure, fire or natural disaster; plans shall include evacuation, persons to be notified, emergency equipment, evacuation routes, refuge areas and the responsibilities of personnel during emergencies; plans shall also included a list of transportation resources that are immediately available to transport the residents to another location in an emergency; the emergency preparedness plan shall address two types of emergencies:
- an emergency that affects just the facility; and
- a region/area wide emergency;
- a copy of this rule, Requirements for Assisted Living Facilities for Adults, 8.2 NMAC);
- for facilities with two or more residents (that are not related to the owner), a valid custodial drug permit issued by the NM board of pharmacy, that supervise administration and self-administration of medications or safeguards with regard to medications for the residents; and
- vaccination records for pets in the
- Reports and records. Each facility shall keep the following reports, records, policies and procedures on file at the facility and make them available for review upon request by the licensing authority:
- a copy of the facility license;
- employee personnel records, including an application for employment, training records and personnel actions:
- caregiver criminal history screening documentation pursuant to 1.9 NMAC
- employee abuse registry documentation pursuant to 1.12 NMAC; and
- a copy of all waivers or variances granted by the licensing
- Prior to admission to a facility a prospective resident or his or her representative shall be given a copy of the facility rules. Each facility shall have written rules pertaining to resident’s rights and shall include the following:
- resident use of tobacco and alcohol;
- resident use of facility telephone or personal cell phone;
- resident use of television, radio, stereo and cd;
- the use and safekeeping of residents’ personal property;
- meal availability and times;
- resident use of common areas;
- accommodation of resident’s pets; and
- resident use of electric blankets and
- Policies and procedures. All facilities shall have written policies and procedures covering the following areas:
- actions to be taken in case of accidents or emergencies;
- policy and procedure for updating and consolidating the residents current physician or PCP orders, treatments and diet plans every six (6) months or when a significant change occurs, such as a hospital admission;
- policy for medication errors;
- method of staying informed when residents are away from the facility (e.g., sign-out sheets or other record indicating where the resident will be, cell phone contact, etc.);
- the handling of resident’s funds, if the facility provides such services;
- reporting of incidents, including abuse, neglect and misappropriation of property, injuries of unknown cause, environmental hazards and law enforcement interventions in accordance with 1.13 NMAC;
- reporting and investigating internal complaints;
- reporting and investigating complaints to the incident management bureau;
- staff and resident fire and safety training;
- smoking policy for staff, residents and visitors;
- the facility’s bed hold policy;
- admission agreement;
- admission records;
- resident records including maintenance and record retention if the facility closes;
- program narrative;
- resident’s rights with regard to making health care decisions and the formulation of advance directives;
- personnel policies;
- identifying and safeguarding resident possessions;
- securing medical assistance if a resident’s own physician is not available;
- staff training appropriate to staff responsibilities;
- staff training for employees who provide assistance to residents with boarding or alighting from motor vehicles and safe operation of motor vehicles to transport residents;
- witnessed destruction of unused, outdated or recalled medication by the facility administrator with the consulting pharmacist present; and
- mealtimes, daily snacks, menus, special diets, resident’s personal preference for eating alone or in the dining room
- PETS: Pets are permitted in a licensed facility, in accordance with the facility’s
- Prohibited areas. Animals are not permitted in food processing, preparation, storage, display and serving areas, or in equipment or utensil washing areas. Guide dogs for the blind and deaf and service animals for the handicapped shall be permitted in dining areas pursuant to Subsection K of 6.2.9 NMAC.
- Pets shall be vaccinated in accordance with all state and local requirements and records of such vaccination shall be kept on file in the facility.
- ASSISTANCE WITH DAILY LIVING: The facility shall supervise and assist the residents, as necessary, with health, hygiene and grooming needs, to include but not limited to the following:
- eating;
- dressing;
- oral hygiene;
- bathing;
- grooming;
- mobility;
RESIDENT EVALUATION:
- A resident evaluation shall be completed by an appropriate staff member within fifteen (15) days prior to admission to determine the level of assistance that is needed and if the level of services required by the resident can be met by the
- The initial resident evaluation shall establish a baseline in the resident’s functional status and thereafter assist with identifying resident changes. The resident evaluation shall be reviewed and updated at a minimum of every six (6) months or when there is a significant change in the resident’s health status.
- The resident’s evaluation shall be documented on a resident evaluation form and at a minimum include the following abilities, behaviors or status:
- activities of daily living;
- cognitive abilities; reasoning and perception; the ability to articulate thoughts, memory function or impairment, etc;
- communication and hearing; ability to communicate needs and understand instructions,
etc;
etc.
- vision;
- physical functioning and skeletal problems;
- incontinence of bowel/bladder;
- psychosocial well-being;
- mood and behavior;
- activity interests;
- diagnoses;
- health conditions;
- nutritional status;
- oral or dental status;
- skin conditions;
- medication use and level of assistance needed with medications;
- special treatments and procedures or special medical needs such as hospice; and
- safety needs/high risk behaviors; history of falls agitation, wandering, fire safety issues,
- The resident evaluation shall include a history and physical examination and an evaluation report
by a physician or a physician extender within six (6) months of admission. A resident shall have a medical evaluation by a physician or a physician extender at least annually.
- The resident evaluation shall be reviewed and if needed revised by a licensed practical nurse, registered nurse or physician extender at the time the individual service plan is reviewed, at a minimum of every six
(6) months or when a significant change in health status occurs.
INDIVIDUAL SERVICE PLAN (ISP): An ISP shall be developed and implemented within ten calendar days of admission for each resident residing in the facility.
-
- The ISP shall address those areas of need as identified in the resident evaluation and through staff observation.
- The ISP shall detail the services that are provided by the facility as well as the services to be provided by other agencies.
- The resident evaluation and the ISP shall be reviewed and if needed revised by a licensed practical nurse, registered nurse or a physician
- The ISP shall be reviewed and or revised at a minimum of every six (6) months or when there is a significant change in the resident’s health
- The ISP shall include the following:
- a description of identified needs as noted in the resident evaluation;
- a written description of all services to be provided;
- who will provide the services;
- when or how often the services will be provided;
- how the services will be provided;
- where the services will be provided;
- expected goals and outcomes of the services;
- documentation of the facility’s determination that it is able to meet the needs of the resident.
- the level of assistance that the resident will require with activities of daily living and with medications.
- a crisis prevention/intervention plan when indicated by diagnosis or behavior;
- current orders for all medications, including those authorized for PRN usage
RESIDENT ACTIVITIES: Each facility shall provide or make available recreational and social activities appropriate to the residents’ abilities that meet their psychosocial needs and are relevant to their social history; including a balance of cognitive, reminiscence, physical and social activities. The facility shall post the activities and encourage residents to participate.