N.J. Admin. Code § 10:60-5.6

Current through Register Vol. 56, No. 24, December 18, 2024

Section 10:60-5.6 - Clinical records and personnel files

(a) An individual clinical record shall be maintained for each beneficiary receiving private duty nursing service. The record shall address the physical, emotional, nutritional, environmental and social needs according to accepted professional standards.

(b) Clinical records maintained at the agency shall contain, at a minimum, the following:

1. A referral source;

2. Diagnoses;

3. A physician's/practitioner's treatment plan and renewal of treatment plan every 90 days;

4. Interim physician/practitioner orders, as necessary, for medications and/or treatment;

5. An initial nursing assessment by a registered nurse within 48 hours of initiation of services;

6. A six-month nursing reassessment;

7. A nursing care plan;

8. Signed and dated progress notes describing beneficiary's condition; and

9. Evidence that beneficiary was given information regarding advance directives.

(c) Direct supervision of the private duty nurse shall be provided by a registered nurse. Direct supervision of the clinical case shall be completed every 30 days at the beneficiary's home during the private duty nurse's assigned time. Additional supervisory visits shall be made as the situation warrants.

1. The visit to provide direct in-home supervision must occur during a nurse's scheduled shift to allow face-to-face supervision for that individual.

2. The direct in-home supervision shall be rotated among each private duty nurse until each staff member has been assessed.

3. The direct in-home supervision shall consist of a review of all documentation from each nurse assigned to the case, as well as a review of any concerns raised by the beneficiary or primary caretaker.

4. Concerns involving staff not present during the on-site visit shall be addressed with that staff member before they provide any care.

5. If required, follow-up interventions with the assessed staff may be by telephone or provided off-site.

(d) Clinical records maintained in the beneficiary's home by the private duty nurse shall contain, at a minimum, the following:

1. Diagnoses;

2. A physician/practitioner treatment plan and interim orders;

3. A copy of the initial nursing assessment and six month reassessment;

4. A nursing care plan;

5. Signed and dated current nurse's notes describing the beneficiary's condition and documentation of all care rendered; and

6. A record of medication administered.

(e) Personnel files shall be maintained for all private duty registered nurses and licensed practical nurses and shall contain at a minimum the following:

1. A completed application for employment;

2. Evidence of a personal interview;

3. Evidence of a current license to practice nursing;

4. Satisfactory employment references;

5. Evidence of a physical examination; and

6. Ongoing performance evaluation.

(f) On-site monitoring visits shall be made periodically by DMAHS staff, or a designated agency as approved by DHS, to the private duty nursing agency to review compliance with personnel, recordkeeping, and service delivery requirements.

N.J. Admin. Code § 10:60-5.6

Amended by 50 N.J.R. 1992(b), effective 9/17/2018

Amended by 54 N.J.R. 1721(a), effective 9/6/2022