N.H. Admin. Code § He-P 804.19

Current through Register No. 50, December 12, 2024

Section He-P 804.19 - Resident Records

(a) The licensee shall maintain a legible, current, and accurate record for each resident based on services provided at the ALR-RC.

(b) At a minimum, resident records shall contain the following:

(1) A copy of the resident's residential service agreement, admission agreement, or both, as applicable, and all documents required by He-P 804.16(b) and (c) ;

(2) Notwithstanding (1) above, financial records may be kept in a separate file;

(3) Identification data, including:

a. The resident's name, date of birth, and marital status;

b. If the resident is receiving respite care as described in He-P 804.20, the resident's home address and phone number;

c. Resident's religious preference, if known;

d. Resident's 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) If services are provided at the ALR-RC by individuals not employed by the licensee, documentation that includes the name of the agency or individual providing the services, the date services were provided, a brief summary of the services provided, and the 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 examination(s) in accordance with He-P 804.16(r) - (t) ;

(9) Written, dated, and signed orders for the all medications, treatments, and therapeutic diets;

(10) Results of any laboratory tests, X-rays, or consultations performed at the ALR-RC;

(11) All assessments and care plans, and documentation that the resident and the guardian or agent, if any, has participated in the development of the care plan;

(12) All admission and progress notes;

(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 licensed practitioner notification;

(14) Documentation of medical, nursing, or other specialized care, as applicable;

(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 and guardian, agent, or personal representative, if any, of involuntary room change, if applicable;

(19) The medication record as required by He-P 804.17(ai) ;

(20) Emergency data sheet, which contains the information required by He-P 804.16(x) ;

(21) Documentation of any accident or injuries occurring while in the care of the facility and requiring medical attention by a practitioner; and

(22) 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, to include:

(1) That immunizations shall be provided and reported to the department's division of public health services immunization program in accordance with RSA 151:9-b, I-V, He-P 309.02, and He-P 309.08; and

(2) The facility shall have a plan that identifies and documents, with dates, all residents that have received or declined to receive immunizations, to be included in the resident record in (b) above.

(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 ALR-RC ceases operation.

(i) If the facility uses an electronic record storage system, it shall provide computer access to all resident records for the purpose of verifying compliance with all provisions of RSA 151 and He-P 804 for the onsite inspection. Access shall include assistance navigating the database and printing portions of the record, if needed.

(j) All resident electronic records shall have security provisions to ensure confidentiality.

N.H. Admin. Code § He-P 804.19

#9121, eff 4-3-08

Amended by Volume XXXVI Number 49, Filed December 8, 2016, Proposed by #12047, Effective 11/19/2016, Expires 5/18/2017.

Amended by Volume XXXVII Number 45, Filed November 09, 2017, Proposed by #12414, Effective 11/3/2017, Expires 11/3/2027.