Current through Reg. 49, No. 38; September 20, 2024
(a) Index of admissions and discharges. The
facility must maintain a permanent, master index of all residents admitted to
and discharged from the facility. This index must contain at least the
following information concerning each resident:
(1) name of resident (first, middle, and
last);
(2) date of birth;
(3) date of admission;
(4) date of discharge; and
(5) social security, Medicare, or Medicaid
number.
(b) Facility
closure. In the event of closure of a facility, change of ownership or change
of administrative authority:
(1) the facility
must have in place written policies and procedures to ensure that the
administrator's duties and responsibilities involve providing the appropriate
notices, as required by § 554.2310 of this chapter (relating to Nursing
Facility Ceases to Participate); and
(2) the new management must maintain
documented proof of the medical information required for the continuity of care
of all residents. This documentation may be in the form of copies of the
resident's clinical record or the original clinical record. In a change of
ownership, the two parties will agree and designate in writing who will be
responsible for the retention and protection of the inactive and closed
clinical records.
(c)
Method of recording and correcting information. All resident care information
must be recorded in ink or permanent print except for the medication,
treatment, or diet section of the resident's comprehensive care plan.
Correction of errors will be in accordance with accepted health information
management standards.
(1) Erasures are not
allowed on any part of the clinical record, with the exception of the
medication, treatment, or diet section of the resident's comprehensive care
plan.
(2) Correction of errors will
be in accordance with accepted health information management
standards.
(d) Required
record retention. Periodic thinning of active clinical records is permitted;
however, the following items must remain in the active clinical record:
(1) current history and physical;
(2) current physician's orders and progress
notes;
(3) current RAI and
subsequent quarterly reviews; in Medicaid-certified facilities, all RAIs and
Quarterly Reviews for the prior 15-month period;
(4) current comprehensive care
plan;
(5) most recent hospital
discharge summary or transfer form;
(6) current nursing and therapy
notes;
(7) current medication and
treatment records;
(8) current lab
and x-ray reports;
(9) the
admission record; and
(10) the
current permanency plan.
(e) Readmissions.
(1) If a resident is discharged for 30 days
or less and readmitted to the same facility, upon readmission, to update the
clinical record, staff must:
(A) obtain
current, signed physician's orders;
(B) record a descriptive nurse note, giving a
complete assessment of the resident's condition;
(C) include any changes in
diagnoses;
(D) obtain signed copies
of the hospital or transferring facility history and physical and discharge
summary and a transfer summary containing this information is
acceptable;
(E) complete a new RAI
and update the comprehensive care plan if evaluation of the resident indicates
a significant change, which appears to be permanent and if no such change has
occurred, then update only the resident comprehensive care plan; and
(F) comply with § 554.805 of this
chapter (regarding Permanency Planning for a Resident Under 22 Years of
Age).
(2) A new clinical
record must be initiated if the resident is a new admission or has been
discharged for over 30 days.
(f) Signatures.
(1) The use of faxing is acceptable for
sending and receiving health care documents, including the transmission of
physicians' orders. Long term care facilities may utilize electronic
transmission if they adhere to the following requirements:
(A) The facility must implement safeguards to
assure that faxed documents are directed to the correct location to protect
confidential health information.
(B) All faxed documents must be signed by the
author before transmission.
(2) Stamped signatures are acceptable for all
health care documents requiring a physician's signature, if the person using
the stamp sends a letter of intent which specifies that he will be the only one
using the stamp, and then signs the letter with the same signature as the
stamp.
(3) The facility must
maintain all letters of intent on file and make them available to
representatives of HHSC upon request.
(4) Use of a master signature legend in lieu
of the legend on each form for nursing staff signatures of medication,
treatment, or flow sheet entries is acceptable under the following
circumstances.
(A) Each nursing employee
documenting on medication, treatment, or flow sheets signs employee's full
name, title, and initials on the legend.
(B) The original master legend is kept in the
clinical records office or director of nurses' office.
(C) A current copy of the legend is filed at
each nurses' station.
(D) When a
nursing employee leaves employment with the facility, the employee's name is
deleted from the list by lining through it and writing the current date by the
name.
(E) The facility updates the
master legend as needed for newly hired and terminated employees.
(F) The master signature legend must be
retained permanently as a reference to entries made in clinical
records.
(g)
Destruction of Records. When resident records are destroyed after the retention
period is complete, the facility must shred or incinerate the records in a
manner which protects confidentiality. At the time of destruction, the facility
must document the following for each record destroyed:
(1) resident name;
(2) clinical or medical record number, if
used;
(3) social security number,
Medicare number, Medicaid number or the date of birth; and
(4) date and signature of person carrying out
disposal.
(h)
Confidentiality. The facility must develop and implement written policies and
procedures to safeguard the confidentiality of clinical record information from
unauthorized access.
(1) Except as provided in
paragraph (2) of this subsection, the facility must not allow access to a
resident's clinical record unless a physician's order exists for supplies,
equipment, or services provided by the entity seeking access to the
record.
(2) The facility must allow
access and release confidential medical information under court order or by
written authorization of the resident or the resident representative, as in
§ 554.407 of this chapter (relating to Privacy and
Confidentiality).
