N.J. Admin. Code § 8:43-13.1

Current through Register Vol. 56, No. 9, May 6, 2024

Section 8:43-13.1 - Maintenance of resident records

(a) A current, complete record shall be maintained for each resident.

(b) Records and information regarding the individual resident shall be considered confidential and the resident shall have the opportunity to examine such records, in accordance with facility policies. The written consent of the resident shall be obtained for release of his or her records to any individual not associated with the facility, except in the case of the resident's transfer to another health care facility, or as required by law, third-party payor, or authorized government agencies.

(c) All resident's medical records shall be maintained for a period of 10 years after the discharge of a resident from the home, in accordance with 26:8-5.

(d) The following records shall be maintained and shall be kept available on the premises for review at any time by representatives of the Department :

1. A register which contains a current census of all residents, along with other pertinent information, shall be maintained by each residential health care facility. The following standards for maintaining the register shall apply:

i. The administrator or the administrator's designee shall make all entries in the register and shall be responsible for its maintenance and safe-keeping;

ii. The register shall be kept up-to-date at all times. Admissions, discharges and discharge destination, and other changes shall be recorded within 48 hours;

iii. The register, which is a permanent record, shall be kept in a safe place, in a fire-resistant container; and

iv. All entries into the register shall be clear, legible, and written in ink or typed.

2. Each resident's record shall include at least the following:

i. The resident's completed admission application and all records forwarded to the facility;

ii. The resident's name, last address, date of birth, name and address of sponsor or interested agency, date of admission, date of discharge (and discharge destination) or death, the name, address and telephone number of physician, advanced practice nurse, or physician assistant to be called, and the name and address of nearest relative, guardian, responsible person, or interested agency, documentation of the existence or nonexistence of an advance directive and the facility's inquiry of the resident concerning this, together with any other information the resident wishes to have recorded;

iii. A statement by a physician, advanced practice nurse, or physician assistant of the individual's suitability for admission to the facility, as specified in 8:43-4.12(c). The administrator or the administrator's designee shall be responsible for having the certification properly completed and signed by a physician, advanced practice nurse, or physician assistant. When first contact is made regarding the placement of an individual in the facility, the administrator or the administrator's designee shall inform the individual making the inquiry that the medical certification must be completed before admission;

iv. Whenever a resident dies in the residential health care facility, the administrator or the administrator's designee shall include written documentation from the physician, advanced practice nurse, or physician assistant of the date and time of death, the name of the person who pronounced the death, disposition of the body, and a record of notification of the family:

v. A complete record of visits by physicians, advanced practice nurses, or physician assistants, as known by the facility, including dates and the physicians', advanced practice nurses' or physician assistants' comments if applicable; and

vi. Annual nursing assessments and nurse's health monitoring and maintenance notes, entered in accordance with 8:43-9.2 or more frequently based on individual resident's needs.

3. The admission agreement shall be maintained in the facility, in accordance with facility policies.

N.J. Admin. Code § 8:43-13.1

Amended by 51 N.J.R. 1272(a), effective 8/5/2019