New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 44B - MANUAL OF STANDARDS FOR COMMUNITY CARE RESIDENCES
Subchapter 2A - RECORDS
Section 10:44B-2A.2 - Individual records
Universal Citation: NJ Admin Code 10:44B-2A.2
Current through Register Vol. 56, No. 18, September 16, 2024
(a) Each individual's records shall be maintained in the licensee's residence in a separate, organized binder clearly marked with his or her name. The licensee may not store any other information other than that of the individual in this binder.
1. Maintenance of the individual's records in
any place other than the licensee's residence, either permanently or
temporarily, is prohibited.
2.
Errors in documentation shall be amended by the use of a single strike through;
no text-obliterating means, such as white out, shall be
permitted.
(b) Individual's records are the property of the placing agency, and shall be relinquished to the placing agency's representative upon the individual's departure or transfer from the licensee's residence, or as otherwise necessary to safeguard the records.
(c) The licensee and alternate shall protect and maintain the confidentiality of all individual records, in accordance with N.J.A.C. 10:41.
1. Individual's records shall be stored in
such a manner as to maintain confidentiality and to provide access only to the
individual, the individual's legal guardian, the licensee, the alternate, the
placing agency, the agency providing case management services, the Office of
Licensing, or other persons authorized by law or a court of competent
jurisdiction.
2. The licensee shall
not discard any records. If necessary, the licensee shall request assistance
from the placing agency in removing records not pertinent to the individual's
current care and habilitation.
3.
The licensee shall not make copies or allow copies to be made of individual's
records without written permission of the agency providing case management
services and the individual's legal guardian indicating specifically which
records are to be duplicated and for whom.
(d) The record for each individual residing in the home (except respite placements) shall include:
1. The full name and date of birth of the
individual;
2. The date of
placement into the residence;
3.
The names and addresses of all personal physicians and dentists;
4. The name, address, and telephone numbers
of the individual's legal guardian, family members, and other interested
person(s);
5. Monthly reports
completed by the licensee, which shall include the individual's social and
behavioral status, medication changes, medical events, activities attended,
community exposure, and progress or lack of progress on objectives that is
behaviorally measurable and which corresponds to the objectives identified in
the current service plan;
6. A
seizure record, if applicable, of all seizure activity, including date, time,
duration, surrounding circumstances, and treatment given;
7. A copy of the current service plan with
the names of all members who participated in its development;
8. Annual physical examination, and the date
and results of previous Mantoux Skin Test or IGRA blood testing for
tuberculosis;
9. A medication
record, as required by
10:44B-5.2(a)1 i
through vii, if the individual receives any medication prescribed by a
physician and if the individual is not self-medicating.
i. An Over-the-Counter Medication sheet
current within a year and completed and signed by the individual's physician or
nurse practitioner.
ii. Copies of
prescriptions for all medications administered to the individual, current
within one year;
10.
Documentation of an annual oral or dental examination;
11. Documentation of any medical treatment as
required by the physician, nurse practitioner, or dentist;
12. Authorization for emergency medical
treatment signed by the legally appointed guardian of an individual or the
parent of a minor, as applicable, current within two years;
13. Medical insurance information;
14. All records related to the individual's
personal funds and assets, in accordance with
10:44B-3.2; and
15. An inventory of personal property,
maintained continuously throughout the placement.
(e) The record for each individual residing in the home as a respite placement, currently, or within the past year, shall include:
1. A placing agency's placement
agreement, which indicates each individual's name, placement, and departure
dates from the home;
2. The current
assessment document utilized for service planning by the placing agency;
and
3. The Medication
Administration Records for the duration of the respite.
Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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