N.J. Admin. Code § 8:43B-12.2

Current through Register Vol. 56, No. 23, December 2, 2024

Section 8:43B-12.2 - Client records

(a) The AFC sponsor agency's record for each client shall include:

1. A completed admission application and all records forwarded to the sponsor agency;

2. Client identification data, including the client's name, last address, date of birth, address and telephone number of the physician, advanced practice nurse, or physician assistant to be called, and the name and address of a responsible person who may be notified in the event of an emergency;

3. A copy of the client service plan, including physician orders and reports, if applicable, and progress notes by the registered professional nurse, social worker, and care manager;

4. A copy of the client's nursing and social worker assessments based on the client's needs;

5. Written authorization by the client for management of the client's personal funds by the caregiver, if applicable;

6. Documentation of the existence or nonexistence of an advance directive and documentation of the sponsor agency's inquiry to the client, family, or health care representative;

7. A copy of the written statement of all client rights signed by the caregiver and the client, or the client's legal guardian;

8. Documentation of the client's influenza vaccine and pneumococcal vaccine, or the refusal of the client to receive either or both, unless medically contraindicated; and

9. A copy of the New Jersey Office of the Long-Term Care Ombudsman Disclosure Consent Form.

N.J. Admin. Code § 8:43B-12.2

Adopted by 55 N.J.R. 377(a), effective 3/6/2023