New Mexico Administrative Code
Title 7 - HEALTH
Chapter 8 - RESIDENTIAL HEALTH FACILITIES
Part 2 - ASSISTED LIVING FACILITIES FOR ADULTS
Section 7.8.2.21 - RESIDENT RECORDS
Universal Citation: 7 NM Admin Code 7.8.2.21
Current through Register Vol. 35, No. 6, March 26, 2024
A. Record contents. A record for each resident shall be maintained in accordance with the specific requirements of this section. Entries in each resident's record shall be legible, dated and authenticated by the signature of the person making the entry. Resident records shall be readily available on site and organized utilizing a table of contents. Each resident record shall include:
(1) the admission agreement records,
as set forth in 7.8.2.20 NMAC;
(2)
the resident evaluation form, that is to be completed within
fifteen (15) days prior to admission and updated at a minimum of every six (6)
months;
(3) the current ISP, that
is to be completed within ten (10) calendar days of admission and updated at a
minimum of every six (6) months;
(4) the physical examination report; the
physical examination report shall have been completed within the past six (6)
months, by a primary care physician, a nurse practitioner or a physician's
assistant and shall be on file in the resident's record within ten (10) days of
admission;
(5) personal and
demographic information for the resident, to include:
(a) current names, addresses, relationship
and phone numbers of family members, or surrogate decision makers updated as
necessary;
(b) resident's
name;
(c) age;
(d) recent photograph;
(e) marital status;
(f) date of birth;
(g) sex;
(h) address prior to admission;
(i) religion (optional);
(j) personal physician;
(k) dentist;
(l) social history;
(m) surrogate decision maker or other
emergency contact person;
(n)
language spoken and understood;
(o)
legal documentation relevant to commitment or guardianship status;
(p) current medications list; and
(q) required diet;
(6) unless included in the admission
agreement, a separate written agreement between the facility and the resident
relating to the resident's funds, in accordance with the facility's policy and
procedures;
(7) entries by direct
care staff, appropriate health care professionals and others authorized to care
for the resident; entries shall be dated and signed by the person making the
entry and shall include significant information related to the ISP;
(8) entries that provide a written account of
all accidents, injuries, illnesses, medical and dental appointments, any
problems or improvements observed in the resident, any condition that would
indicate a need for alternative placement or medical attention and entries
reflecting appropriate follow-up; the maintenance of such written documentation
in the resident record may be by copy of an incident or accident report, if the
original incident or accident report is maintained elsewhere by the
facility;
(9) the medication
assistance record (MAR); the MAR is the document that details the resident's
medication; the MAR shall include all of the information pursuant to Subsection
G of 7.8.2.35 NMAC of this rule;
(10) progress notes completed by any contract
agency (e.g., hospice, home health); the progress notes shall include the date,
time and type of health services provided;
(11) copies of all completed and signed
transfer forms from the accepting facility when a resident is transferred to a
hospital or another health care facility and when the resident is transferred
back to the facility; and
(12) upon
the death or transfer of a resident, documentation of the disposition of the
resident's personal effects and money or valuables that are deposited with the
assisted living facility.
B. Resident records maintenance.
(1) Current resident
records shall be maintained on-site and stored in an organized, accessible and
permanent manner.
(2) The facility
shall establish a policy to maintain and ensure the confidentiality of resident
records, including the authorized release of information from the resident
records.
(3) Non-current resident
records shall be maintained by the facility against loss, destruction and
unauthorized use for a period of not less than five (5) years from the date of
discharge and readily available within twenty-four (24) hours of
request.
(4) There shall be a
policy and procedure in place for record retention in the event of facility
closure.
(5) Failure to follow
facility policies is grounds for sanctions.
Disclaimer: These regulations may not be the most recent version. New Mexico 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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