New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 44C - STANDARDS FOR COMMUNITY RESIDENCES FOR PERSONS WITH HEAD INJURIES
Subchapter 2 - ORGANIZATION AND ADMINISTRATION
Section 10:44C-2.9 - Records: persons served
Universal Citation: NJ Admin Code 10:44C-2.9
Current through Register Vol. 56, No. 18, September 16, 2024
(a) A file shall be maintained for each person served in a licensed community residence for persons with head injuries.
1. The file shall be
legibly marked with the name of the person served.
(b) Files shall be maintained at the residence or at the pre-determined location stated in the program description or in revisions to the program description.
(c) A person served shall have access to his or her records, unless clinically contra-indicated and documented.
(d) The record of each person served shall include:
1. Pre-admission information, as
follows:
i. The full name, date of birth, and
gender of the person served;
ii.
The person's Medicaid numbers or medical insurance numbers;
iii. The date(s) of admission, re-admission,
transfer or discharge;
iv. The
names and addresses of persons or agencies responsible for placement;
v. The names and addresses of all personal
physicians, advanced practice nurses and dentists;
vi. The name, address and telephone number of
the legal guardian (or guardianship worker), next of kin, and other interested
person(s), and a copy of the guardianship determination, if
applicable;
vii. Religious
preference;
viii. Pre-admission
data including diagnosis, a psychological evaluation, as appropriate and/or
available and developmental history, including, but not limited to, behavioral
characteristics;
ix. The results of
a physical examination completed within one year prior to the scheduled
admission date;
x. The results of a
Mantoux Skin Test or IGRA blood test completed within the past year;
and
xi. An immunization record, as
available and as required for persons served under the age of
22;
2. The results of an
annual physical examination;
3.
Annual reports from the dentist of dental examinations and corrective work
done;
4. Seizure records, where
indicated;
5. The current
ITP;
6. Monthly reports of social
and behavioral progress of a person served to correspond to the current
ITP;
7. A medically prescribed
diet, if required;
8. Documentation
of known allergies;
9. Medication
administration records;
10. An
inventory of valuable personal possessions, including, but not limited to:
personal mementos, adaptive devices, eye glasses, hearing aids, durable medical
equipment, electronic equipment and accessories, jewelry, clothing, and
personal furniture; and
11.
Financial records pursuant to
N.J.A.C.
10:44C-2.10.
(e) The records of each person served who has been referred to other agencies for additional or concurrent services shall contain, at a minimum:
1. The place, date and
reason for referral;
2. The name of
the contact person; and
3. A report
of the outcome.
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.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
