W. Va. Code R. § 64-13-12

Current through Register Vol. XLI, No. 45, November 8, 2024

Section 64-13-12 - Clinical Records

12.1. Records Maintenance and Retention.

12.1.1. A nursing home shall maintain clinical records on each resident in accordance with accepted professional standards and practices that are:

12.1.1.a. Complete;

12.1.1.b. Accurately documented;

12.1.1.c. Readily accessible; and

12.1.1.d. Systematically organized.

12.1.2. All of a resident's clinical records shall be retained for the longer of the following time periods:

12.1.2.a. Five years from the date of discharge or death; or

12.1.2.b. For a minor, three years after a resident reaches 18 years of age.

12.1.3. A nursing home shall safeguard clinical record information against loss, destruction, or unauthorized use.

12.1.4. A nursing home shall ensure that each clinical record contains a photograph of the resident, unless the resident objects.

12.2. Confidentiality. A nursing home shall keep all information contained in the resident's clinical record confidential, unless the resident, or applicable legal representative, authorizes disclosure or when release is required by:

12.2.1. Transfer to another health care institution;

12.2.2. Law;

12.2.3. Third party payment contract; or

12.2.4. The resident.

12.3. Contents. The clinical record shall contain:

12.3.1. Sufficient information to identify the resident;

12.3.2. All the resident's assessments;

12.3.3. The resident's plan of care and services provided;

12.3.4. The results of any pre-admission screening conducted by the state;

12.3.5. Progress notes;

12.3.6. Physician orders; and

12.3.7. Documents describing the authority of any legal representative.

W. Va. Code R. § 64-13-12