ALTCS Documentation for Assisted Living Facilities: What You Need and Why It Matters

Why ALTCS Documentation Is Different

Accepting ALTCS-funded residents brings significant benefits to an assisted living facility — a reliable funding source, access to a large population of Arizona seniors, and alignment with the state's long-term care system. But it also brings documentation requirements that go beyond what facilities typically maintain for private-pay residents.

Gaps in ALTCS documentation can have serious consequences: delayed or denied reimbursement, compliance citations during DHS inspections, and in severe cases, termination from the ALTCS program. Understanding what is required — and building systems to maintain it — is essential for any facility that accepts ALTCS-funded residents.

Core Documentation Requirements

### Resident Assessments and Service Plans

ALTCS requires that each resident have a current, individualized service plan developed in coordination with the ALTCS managed care plan's case manager. Key requirements:

**Initial assessment** must be completed within 30 days of admission

**Service plan** must be developed based on the assessment and updated whenever there is a significant change in the resident's condition

**Annual reassessment** must be completed and documented

Service plans must reflect the resident's actual care needs — generic or template-based plans that don't reflect individual circumstances are a common citation source

### Physician Orders and Health Records

Current physician orders must be on file for all medications and treatments

Orders must be reviewed and renewed at least annually (more frequently for residents with complex medical needs)

Any change in the resident's medical condition must be documented, communicated to the physician, and reflected in updated orders

Hospitalizations must be documented, including the reason for hospitalization and any changes to care needs upon return

### Medication Administration Records (MARs)

MARs must be complete with no gaps — every medication administration must be documented at the time it occurs

Refusals must be documented

PRN (as-needed) medications require documentation of the reason for administration and the resident's response

Controlled substance logs must be maintained separately and reconciled regularly

### Incident Documentation

All incidents involving ALTCS-funded residents must be documented in detail: date, time, circumstances, injuries (if any), witnesses, and immediate response

Reportable incidents must be reported to DHS within required timeframes (24 hours for serious incidents)

Follow-up documentation must demonstrate that corrective action was taken

ALTCS managed care plans may have additional incident reporting requirements beyond DHS requirements

Building Documentation Systems That Work

The facilities that maintain the strongest ALTCS documentation don't rely on memory or manual processes. They build systems:

Standardized forms and templates. Use consistent forms for assessments, service plans, and incident reports. Templates ensure that required elements are never omitted.

Documentation at the point of care. The most reliable documentation happens immediately — not at the end of a shift or the next day. Train staff to document care as it is provided.

Regular internal audits. Designate a staff member to conduct monthly documentation audits. Review a sample of resident records for completeness and currency. Address gaps before they become inspection findings.

Clear escalation protocols. Staff need to know exactly what to do when a resident's condition changes: who to notify, what to document, and when to contact the physician or ALTCS case manager.

Working with ALTCS Case Managers

Each ALTCS-funded resident is assigned a case manager through their managed care plan (either AHCCCS or a contracted health plan). The case manager is responsible for authorizing services and monitoring the resident's care plan.

Facilities that maintain strong relationships with ALTCS case managers tend to have fewer documentation problems. Best practices:

Respond promptly to case manager inquiries and requests for documentation

Proactively notify case managers of significant changes in resident condition

Participate constructively in care plan reviews

Understand the authorization process for services that require prior approval

How CareRoots Supports ALTCS Documentation

CareRoots Health provides documentation support services for Arizona assisted living facilities, including:

Documentation audits to identify gaps before DHS inspections

Staff training on ALTCS documentation requirements

Development of documentation systems and templates

Support for corrective action plans following documentation-related citations

*This guide reflects ALTCS documentation requirements as of mid-2025. Requirements are subject to change. Always consult current AHCCCS and DHS guidance for authoritative requirements.*