Current through Register Vol. 47, No. 6, September 18, 2024
(1)
Resident record. The licensee shall keep a permanent record
about each resident with all entries current, dated, and signed. (II) The
record shall include:
a. Name and previous
address of resident; (III)
b. Birth
date, sex, and marital status of resident; (III)
c. Church affiliation; (III)
d. Physician's name, telephone number, and
address; (III)
e. Dentist's name,
telephone number, and address; (III)
f. Name, address and telephone number of next
of kin or legal representative; (III)
g. Name, address and telephone number of the
person to be notified in case of emergency; (III)
h. Funeral director, telephone number, and
address; (III)
i. Pharmacy name,
telephone number, and address; (III)
j. Results of evaluation pursuant to
62.11(135C); (III)
k. Certification
by the physician that the resident requires no more than personal care and
supervision, but does not require nursing care; (III)
l. Physician's orders for medication and
treatments shall be in writing and signed by the physician quarterly; diet
orders shall be renewed yearly; (III)
m. A notation of yearly or other visits to
physician or other professionals, all consultation reports and progress notes;
(III)
n. Any change in the
resident's condition; (II, III)
o.
A notation describing the resident's condition on admission, transfer, and
discharge; (III)
p. In the event of
a resident's death, notations in the resident's record shall include the date
and time of the resident's death, the circumstances of the resident's death,
the disposition of the resident's body, and the date and time that the
resident's family and physician were notified of the resident's death;
(III)
q. A copy of instructions
given to the resident, legal representative, or facility in the event of
discharge or transfer; (III)
r.
Disposition of personal property; (III)
s. Copy of IPP pursuant to 62.12(1);
(III)
t. Progress notes pursuant to
62.12(4) and 62.12(5). (Ill)
(2)
Confidentiality of resident
records. The facility shall have policies and procedures providing
that each resident shall be ensured confidential treatment of all information,
including information contained in an automatic data bank. The resident's or
the resident's legal guardian's written informed consent shall be required for
the release of information to persons not otherwise authorized under law to
receive it. (II)
A release of information form shall be used which includes to
whom the information shall be released, the reason for the information being
released, how the information is to be used, and the period of time for which
the release is in effect. A third party, not requesting the release, shall
witness the release of information form. (II)
a. The facility shall limit access to any
resident records to staff and consultants providing professional service to the
resident. Information shall be made available to staff only to the extent that
the information is relevant to the staff person's responsibilities and duties.
(II)
Only those personnel concerned with financial affairs of the
residents may have access to the financial information. This is not meant to
preclude access by representatives of state or federal regulatory agencies.
(II)
b. The resident, or
the resident's legal guardian, shall be entitled to examine all information and
shall have the right to secure full copies of the record at reasonable cost
upon request, unless the physician or QMHP determines the disclosure of the
record or section is contraindicated in which case this information will be
deleted prior to making the record available to the resident. This
determination and the reasons for it must be documented in the resident's
record by the physician or qualified mental health professional in
collaboration with the resident's interdisciplinary team. (II)
(3)
Incident
records.
a. Each RCF/PMI shall
maintain an incident record report and shall have available incident report
forms. (II, III)
b. The report of
every incident shall be in detail on a printed incident report form. (II,
III)
c. The person in charge at the
time of the incident shall oversee the preparation and sign the report.
(Ill)
d.
A copy of the incident report shall be kept on file in the facility available
for review and a part of administrative records. (Ill)
(4)
Retention of records.
a. Records shall be retained in the facility
for five years following termination of services to the resident even when
there is a change of ownership. (Ill)
b. When the facility ceases to operate, the
resident's record shall be released to the facility to which the resident is
transferred. If no transfer occurs, the record shall be released to the
individual's physician. (Ill)
This rule is intended to implement Iowa Code section
135C.24.
