Current through Register Vol. 46, No. 19, March 20, 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 of resident;
(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 resident's 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's
telephone number and address; (III)
i. Pharmacy's name, telephone number and
address; (III)
j. Certification by
the physician that the resident requires no higher level of care than the
facility is licensed to provide; (III)
k. Physician's orders for medication and
treatments in writing, which shall be signed by the physician quarterly, and
diet orders, which shall be renewed yearly; (III)
l. A notation of the resident's yearly or
other visits to physician or other professionals and all consultation reports
and progress notes; (III)
m.
Documentation describing any change in the resident's condition; (II,
III)
n. A notation describing the
resident's condition on admission, transfer, and discharge; (III)
o. 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)
p. A copy of instructions given to the
resident, the resident's legal representative, or receiving facility in the
event of the resident's discharge or transfer; (III) and
q. Disposition of personal property.
(III)
(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 automated 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 release of the
information, 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 signing of 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 paragraph 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. (II)
(3)
Incident records. Each
facility shall maintain an incident record report and shall have available
incident report forms. (II, III)
a. The report
of every incident shall be in detail on a printed incident report form. (II,
III)
b. The person in charge at the
time of the incident shall oversee the preparation of the report and sign the
report. (III)
c. The facility shall
maintain a copy of the incident report as part of the facility's administrative
records and shall make the record available for review. (III)
(4)
Retention of
records. A resident's 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 of the facility. (III)
When the facility ceases to operate, the resident's records
shall be released to the receiving facility. If no transfer occurs, the records
shall be released to the resident's physician. (III)
