Current through Register No. 40, October 3, 2024
(a) The licensee
shall maintain a legible, current, and accurate record for each resident based
on services provided at the ALR-RC.
(b) At a minimum, resident records shall
contain the following:
(1) A copy of the
resident's residential service agreement, admission agreement, or both, as
applicable, and all documents required by
He-P 804.16(b) and (c)
;
(2) Notwithstanding (1) above, financial
records may be kept in a separate file;
(3) Identification data, including:
a. The resident's name, date of birth, and
marital status;
b. If the resident
is receiving respite care as described in
He-P
804.20, the resident's home address and phone
number;
c. Resident's religious
preference, if known;
d. Resident's
veteran status, if known; and
e.
Name, address, and telephone number of an emergency contact person;
(4) The name and telephone number
of the resident's licensed practitioner(s);
(5) If services are provided at the ALR-RC by
individuals not employed by the licensee, documentation that includes the name
of the agency or individual providing the services, the date services were
provided, a brief summary of the services provided, and the business address
and telephone number;
(6)
Resident's health insurance information;
(7) Copies of any executed legal orders and
directives, such as guardianship orders issued under RSA 464-A, a durable power
of attorney for healthcare, or a living will;
(8) A record of the health examination(s) in
accordance with
He-P 804.16(r) - (t)
;
(9) Written, dated, and signed orders for the
all medications, treatments, and therapeutic diets;
(10) Results of any laboratory tests, X-rays,
or consultations performed at the ALR-RC;
(11) All assessments and care plans, and
documentation that the resident and the guardian or agent, if any, has
participated in the development of the care plan;
(12) All admission and progress
notes;
(13) Documentation of any
alteration in the resident's daily functioning such as:
a. Signs and symptoms of illness;
and
b. Any action that was taken,
including licensed practitioner notification;
(14) Documentation of medical, nursing, or
other specialized care, as applicable;
(15) Documentation of reportable
incidents;
(16) The consent for
release of information signed by the resident, guardian, or agent, if
any;
(17) Discharge planning and
referrals;
(18) Transfer or
discharge documentation, including notification to the resident and guardian,
agent, or personal representative, if any, of involuntary room change, if
applicable;
(19) The medication
record as required by
He-P 804.17(ai)
;
(20) Emergency data sheet, which contains the
information required by
He-P 804.16(x)
;
(21) Documentation of any accident or
injuries occurring while in the care of the facility and requiring medical
attention by a practitioner; and
(22) Documentation of a resident's refusal of
any care or services.
(c) The licensee shall document evidence of
immunization against influenza and pneumococcal disease for all consenting
residents, to include:
(1) That immunizations
shall be provided and reported to the department's division of public health
services immunization program in accordance with
RSA
151:9-b, I-V,
He-P
309.02, and
He-P
309.08; and
(2) The facility shall have a plan that
identifies and documents, with dates, all residents that have received or
declined to receive immunizations, to be included in the resident record in (b)
above.
(d) Resident
records and resident information shall be kept confidential and only provided
in accordance with law.
(e) The
licensee shall develop and implement a written policy and procedure document
that specifies the method by which release of information from a resident's
record shall occur.
(f) When not
being used by authorized personnel, resident records shall be safeguarded
against loss or unauthorized use or access.
(g) Records shall be retained for 4 years
after discharge, except that when the resident is a minor, records shall be
retained until the person reaches the age of 19, but no less than 4 years after
discharge.
(h) The licensee shall
arrange for storage of, and access to, resident records as required by (g)
above in the event the ALR-RC ceases operation.
(i) If the facility uses an electronic record
storage system, it shall provide computer access to all resident records for
the purpose of verifying compliance with all provisions of RSA 151 and He-P 804
for the onsite inspection. Access shall include assistance navigating the
database and printing portions of the record, if needed.
(j) All resident electronic records shall
have security provisions to ensure confidentiality.
