Section 458.272 - Records regarding clientsThe operator of a treatment program shall:
1. Ensure that a record is maintained for each client. The record must include:(a) The name, age, gender, race, ethnicity and permanent address of the client.(b) If services are funded by the Division, an evaluation of the financial status of the client sufficient to determine eligibility for such services.(c) Except as otherwise provided in chapter 129 of NRS, a consent form for treatment services signed by the client or the parent or guardian of the client within 24 hours after intake or upon enrollment in the treatment program, unless the client is being provided a service related to civil protective custody.(d) Any consent to release information which satisfies the requirements set forth in 42 C.F.R. Part 2 and 45 C.F.R. Parts 160, 162 and 164.(e) The source of any referral to the treatment program.(f) Documentation of the treatment assessment performed by the operator or obtained by the operator pursuant to subsection 1 of NAC 458.246.(g) The original plan of treatment for the client and all revisions to the plan of treatment.(h) Any additional information that should be taken into consideration during the planning of treatment, determination of appropriate referrals and determination of any need for coordination of care.(i) The date, type and duration of any contact with the client, and any services provided to the client.(j) Documentation of any of the following, which must be reported to the Division within 1 business day after the event occurs: (1) An incident that may cause imminent danger to the health and safety of the client, other clients or staff, or persons outside the treatment program;(2) A problem involving the client;(3) An infraction of the rules of the treatment program by the client;(4) A sign or symptom of illness or injury of the client; and(5) The death of the client.(k) Documentation in support of services that the treatment program provides to the client, including, without limitation, any: (1) Correspondence concerning the client; and(2) Results of a test conducted on the client, including, without limitation, any test conducted by a laboratory.(l) If the client is transferred to a different location or provided a different service, including a service provided by the same operator, a copy of the case note made at the time of transfer which includes, without limitation, the: (1) Diagnosis of the client at the time of admission or intake;(2) Response of the client to treatment;(3) Diagnosis of the client at the time of transfer; and(4) Recommendations for persons who will be providing treatment to the client.(m) After the client is discharged from the treatment program:(1) Documentation that a copy of the plan for continuing care of the client, including, without limitation, any ongoing treatment or additional community resources that the client might need, referrals given to the client, personal goals relating to recreation, leisure, selffulfillment and social support, and areas in the client's life that require ongoing support, including, without limitation, transportation or employment, was provided to the client before discharge, if possible; and(2) Documentation that, not more than 5 business days after the client was discharged from the treatment program, a discharge summary was completed that meets the criteria of the Division for the discharge of a client, which includes, without limitation, the:(I) Diagnosis of the client at the time of admission or intake;(II) Response of the client to treatment; and(III) Diagnosis of the client at the time of discharge.(n) A copy of the notification, which is in the form approved by the Division and which was signed by the client, indicating: (1) The procedure for the client to register a complaint and to appeal a decision by the treatment program concerning a complaint;(2) The requirements for the confidentiality of client information set forth in 42 C.F.R. Part 2, 45 C.F.R. Parts 160, 162 and 164 and any other applicable federal or state laws governing the confidentiality of client information for the service provided; and(3) Any other rights of the client that are specified by the Division.(o) Documentation to support any claims for services or data reported to the Division.2. Ensure that each client receives a copy of the notification required pursuant to paragraph (n) of subsection 1.3. Ensure that the client records adhere to procedures for medical records.4. Ensure that the case notes for each client accurately reflect the treatment and services needed by the client, as identified in the assessment and plan of treatment required pursuant to NAC 458.246.5. Ensure that the staff readily has access to the client records to the extent authorized pursuant to 42 C.F.R. Part 2 and 45 C.F.R. Parts 160, 162 and 164.6. Maintain a system for the maintenance and protection of client information which satisfies the requirements set forth in 42 C.F.R. Part 2 and 45 C.F.R. Parts 160, 162 and 164, including, without limitation, requirements for:(a) Adequate provisions to prevent unauthorized access or theft of any form of a record of a client, including, without limitation, having electronic health records that are double password protected;(b) The locked storage of paper records;(c) Adequate provisions for a system of backup of records maintained in a computer system in case of a failure of the primary system;(d) Retention of the records of each client for not less than 6 years after the client is discharged from the treatment program, to be made available as required pursuant to 45 C.F.R. Parts 160, 162 and 164; and(e) Appropriate methods to destroy records of clients as required by federal regulation.7. Ensure that each client has access to their records as required pursuant to 42 C.F.R. Part 2 and 45 C.F.R. Parts 160, 162 and 164.Nev. Admin. Code § 458.272
Added to NAC by Bd. of Health by R120-04, eff. 10-5-2004; A by R104-14, eff. 10/27/2015; A by R117-22A, eff. 2/20/2023