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 rule
481-65.11
(135C); (III)
k. Certification by
the physician that the resident requires no higher level of care than the
facility is licensed to provide; (III)
l. Physician's orders for medication and
treatments in writing, signed by the physician quarterly and diet orders
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 subrule 65.12(1); (III) and
t. Progress notes pursuant to subrules
65.12(4) and 65.12(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 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 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. Each ICF/PMI 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 and sign the report. (Ill)
c. 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. 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)
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.
