S.C. Code Regs. § § 61-78.800.805

Current through Register Vol. 48, No. 10, October 25, 2024

Section 61-78.800.805 - Record Maintenance

A. The licensee shall adequately produce, protect, and store patient records.

B. When a patient is transferred from a Hospice to another Hospice or other type of facility, copies of appropriate supporting documentation to include at a minimum, a copy of the POC and medication record shall be forwarded, in a manner preserving confidentiality, to the receiving Hospice or other type of facility (for use by the licensed Hospice operating in the facility) at the time of transfer. (II)

C. The patient record is confidential and may be made available only to authorized individuals. Active patient records, with the exception of records utilized by providers during home visits, shall be available at all times and shall be accessible by the staff member in charge and by other authorized individuals such as representatives of the Department. (II)

D. Records generated by organizations or individuals with whom the Hospice contracts for care, treatment, or services shall be maintained by the Hospice that has admitted the patient.

E. The Hospice shall determine the medium in which information is stored.

F. Hospices employing electronic signatures or computer-generated signature codes shall ensure authentication and security.

G. Upon discharge of a patient, the patient record shall be completed and filed in an inactive or closed file within a time period as determined by the Hospice, but no later than thirty (30) days after discharge. Closed patient records shall be stored by the licensee and retained for six (6) years following the discharge of the patient. Such records shall be made available to the Department upon request.

H. Upon discharge of the Hospice patient's family from bereavement services, the bereavement information shall be filed in an inactive or closed file within a time-period as determined by the Hospice. Closed bereavement information shall be stored by the licensee and retained in accordance with patient record retention.

I. The Hospice shall store medical records in an environment which will prevent unauthorized access and deterioration. The records shall be treated as confidential and shall not be disposed of before six (6) years. Records may be destroyed after six (6) years provided that:

1. Records of minors must be retained until after the expiration of the period of election following achievement of majority as prescribed by statute; and

2. The Hospice retains a register, either electronic or paper based.

J. Licensees that store records in a format other than paper, such as, but not limited to, microfilm, before six (6) years have expired must include the entire record.

K. In the event of change of ownership, all medical records shall be transferred to the new owners.

L. Prior to the closing of a Hospice for any reason, the licensee shall arrange for preservation of records to ensure compliance with these regulations. The licensee shall notify the Department, in writing, describing these arrangements within ten (10) days of closure.

M. The Department shall have access to all Hospice records during an inspection or investigation.

N. Records of patients are the property of the Hospice and shall not be removed from the designated patient record storage area, to include on-site, off-site, or contracted storage, without court order, except when care is delivered in the home or the Hospice Facility.

EXCEPTION: When a patient is transferred from one Hospice Facility to another Hospice Facility within the same provider network (same licensed Hospice), the original record may follow the patient; the sending Hospice shall maintain documentation of the patient's transfer or discharge date and identification information. In the event of change of ownership, all active patient records or copies of active patient records shall be transferred to the new owner(s).

S.C. Code Regs. § 61-78.800.805

Replaced and amended by State Register Volume 40, Issue No. 04, eff. 4/22/2016.