| (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 §19.2310
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 §19.805 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 §19.407
of this chapter (relating to Privacy and Confidentiality).
|
| Source Note: The provisions of this §554.1912 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective October 15, 1998, 23 TexReg 10496; amended to be effective May 1, 2002, 27 TexReg 2834; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871 |
