Assisted Living Documentation

1. Assisted Living Documentation DPHHS/QAD/Licensure Bureau

2. What Is An Assisted Living Facility in Montana? • Assisted Living Facilities in Montana are “licensed only” facilities, therefore are not Certified under Federal Regulations. Unlike Long-Term Care facilities (Nursing Homes), Assisted Living Facilities are not required to hire Certified Nurses Aides. The level of care provided in each facility is determined by the licensure endorsements and services each facility chooses to offer. The Assisted Living Resident Assessment, Resident Agreement , and Resident Service Plan provide the foundation and criteria for level of care and services. When considering moving into an Assisted Living Facility, please review the Resident Agreement carefully and work closely with the provider in the development of the Resident Service Plan, including Move-Out criteria, to provide clear expectations and greatest service satisfaction. Ruth Burleigh, RN/BSN/MA Health Care Facility Program Manager DPHHS/QAD/Licensure Bureau

3. History • Prior to 2001 each facility designed own system of documentation • 2001 50-5-226 (6) MCA required Department to supply OPTIONAL forms • 2003 MCA changes required ADL as foundation of assessment and level of care

4. ADMISSION PROCESSResident Needs Assessment • Prior to Move in • Within 60 days if indicated • Upon change of condition (improving or declining • Annually for Category A • Quarterly for Category B & C

5. ADMISSION PROCESSResident Service Plan • From the resident needs assessment & service plan meeting with resident and/or responsible parties specific service needs are identified • HOW these needs are to be meet • OUTCOME of services • Can be general, special, and some health care if not too complicated • ALL DIRECT CARE STAFF ARE RESPONSIBLE FOR THIS INFORMATION

6. ADMISSION PROCESSResident Agreement • The resident agreement is the contract between the facility and resident and/or responsible parties • The agreement INCLUDES the RESIDENT SERVICE PLAN • All 3 pieces: Assessment, Plan, Agreement must match the resident’s actual needs and requests.

7. DAY to DAY Documentation • Each ALF has a unique way of documentation-some use commercial systems, others notebooks, and others computer files • HOW does the facility validate that the resident is receiving the services within their contract? • *ALF is NOT a Nursing Home or Hospital

8. Medications • IF the resident needs self-medication assistance, then a Medication Self-administration Record is required. (MAR) • The specific regulations for medications must be followed. • IF the resident is independent, then no MAR is required by the STATE OF MONTANA.

9. Meals • What the facility actually served-3 months of meals provided for Department review • If a resident is not eating, report to the administrator & facility RN and document • Resident weights are to be taken upon admission, annually and as indicated by professional health care providers.

10. Activities • A calendar of activities ACTUALLY offered is to be maintained for three months for Department review • Posted monthly-change as things occur • Diverse and frequent • NOT TV • Toys R US…think young! • Photos and memories~

11. For additional information • www.dphhs.mt.gov • Click on “May we help you … License a health facility On the left hand green column heading: • ABOUT QAD • LICENSING & CERTIFICATION Assisted Living Facilities