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 SRHCF.
(b) At a minimum, resident records shall
contain the following:
(1) A copy of the
resident's residential service agreement and/or admission contract and all
documents required by
He-P
805.16(c) ;
(2) Notwithstanding (1) above, financial
records may be kept in a separate file;
(3) Identification data, including:
a. Vital information including the resident's
name, date of birth, and marital status;
b. If the individual is receiving respite
care as described in He-P 805.20, the resident's home
address and phone number;
c.
Resident's religious preference, if known;
d. Residents 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) For individuals contracted by the SRHCF
or the resident to provide services at the SRHCF, their name, employer,
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
assessment in accordance with
He-P
805.16(m) and (n) ;
(9) Written, dated and signed orders for the
following:
a. All medications, treatments and
special diets; and
b. Laboratory
services and consultations performed at the SRHCF;
(10) Results of any laboratory tests, X-rays
or consultations performed at the SRHCF;
(11) All admission and progress
notes;
(12) For services that are
provided at the SRHCF by individuals who are not employed by the licensee,
documentation shall include the name of the agency providing the services, the
date services were provided, the name of the person providing services and a
brief summary of the services provided;
(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
practitioner notification;
(14) Documentation of medical or specialized
care;
(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, guardian or
agent, if any, of involuntary room change, transfer or discharge, if
applicable;
(19) The medication
record as required by
He-P
805.17(af) (4), (aj) and (ar)
;
(20) Information data sheet, which contains
the information required by
He-P
805.16(t) ;
(21) Documentation of nurse delegation as
required by He-P 805.17(ai)
;
(22) Documentation of any accident or
injuries occurring while in the care of the facility and requiring medical
attention by a practitioner; and
(23) 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 and shall provide to its consenting employees annual immunizations
against influenza, to include:
(1) That
immunizations shall be provided and reported in accordance with
RSA
151:9-b, I-V; and
(2) The facility shall have a plan that
identifies and documents, with dates, all residents and employees that have
received or declined to receive immunizations.
(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 SRHCF ceases operation.
