| (a) Resident records.
(1) Records that pertain to residents must be treated
as confidential and properly safeguarded from unauthorized use, loss,
or destruction.
(2) Resident records must contain:
(A) information contained in the facility's standard
and customary admission form;
(B) a record of the resident's assessments;
(C) the resident's service plan;
(D) physician's orders, if any;
(E) any advance directives;
(F) documentation of a health examination by a physician
performed within 30 days before admission or 14 days after admission,
unless:
(i) a transferring hospital or facility has a physical
examination in the medical record; or
(ii) the resident is a Christian Scientist;
(G) documentation by health care professionals of any
services delivered in accordance with the licensing, certification,
or other regulatory standards applicable to the health care professional
under law; and
(H) a copy of the most recent court order appointing
a guardian of a resident or a resident's estate and letters of guardianship
that the facility received in response to the request made in accordance
with subsection (c) of this section.
(3) Records must be available to residents, their legal
representatives, and HHSC staff.
(b) Resident finances. The facility must keep a simple
financial record on all charges billed to the resident for care and
these records must be available to HHSC. If the resident entrusts
the handling of any personal finances to the facility, a simple financial
record must be maintained to document accountability for receipts
and expenditures, and these records must be available to HHSC. Receipts
for payments from residents or family members must be issued upon
request.
(c) Guardianship Record Requirements.
(1) A facility must request, from a resident's legally
authorized representative or the person responsible for the resident's
support, a copy of:
(A) the current court order appointing a guardian for
the resident or the resident's estate; and
(B) current letters of guardianship for the resident.
(2) A facility must request the court order and letters
of guardianship:
(A) when the facility admits an individual; and
(B) when the facility becomes aware a guardian is appointed
after the facility admits a resident.
(3) A facility must request an updated copy of the
court order and letters of guardianship at each annual assessment
and retain documentation of any change.
(4) A facility must make at least one follow-up request
within 30 days after the facility makes a request in accordance with
paragraphs (2) or (3) of this subsection if the facility has not received:
(A) a copy of the court order and letters of guardianship;
or
(B) a response that there is no court order or letters
of guardianship.
(5) A facility must keep in the resident's record:
(A) documentation of the results of the request for
the court order and letters of guardianship; and
(B) a copy of the court order and letters of guardianship.
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