Section 415.30 - General records

415.30 General records. The nursing home shall maintain information necessary to permit the production of the following records immediately upon request and any other records required by the provisions of this Chapter:

(a) a chronological listing of residents admitted, by name, with identifying information and the place from which the resident is admitted or transferred;

(b) a chronological listing of residents discharged, by name, including the reason for discharge, adequate identifying information and the place to which the resident is discharged or transferred;

(c) a daily census record consisting of a summary report of the daily resident census with cumulative figures for each month and each year;

(d) a resident personal nonmedical record consisting of an appropriate record for each resident, including identification of next of kin, family and sponsor, all details of the referral and admission and nonmedical correspondence and papers concerning the resident;

(e) a general fiscal record for each resident, including copies of all agreements or contracts, account records, and a current inventory of personal property held in safekeeping;

(f) an accident and incident record which shall include a clear description of every accident and any other incident involving behavior of a resident or staff member that poses a threat to a resident or staff member, the resident's version of the accident or incident unless the resident objects or is unable to give a report due to his/her medical condition, names of individuals involved and a description of medical and other services provided, by whom such are provided, and the steps taken to prevent recurrence, with a copy of the resident's version as reported given to the resident and/or the resident's designated representative;

(g) personnel records for each employee, including the administrator, containing all available pre-employment information, orientation and full in-service record;

(h) personnel policies, including statements of all policies affecting personnel and a job description for each staff position;

(i) financial records which identify all income by source and describe all expenditures by category;

(j) records for nursing service administration, including:

(1) a nursing service organization chart;

(2) a master plan for staffing; and

(3) a nursing service policies and procedures manual;

(k) records for the dietary service, including:

(1) a plan for organization, management and day-to-day operation;

(2) a master plan and weekly work schedules for staffing;

(3) a current diet manual;

(4) written and dated menus for normal and therapeutic diets, as served; and

(5) receipted invoices for food and supplies;

(l) records for activities program, including:

(1) name and qualifications of the activities director;

(2) a current roster of residents participating in the program as well as a record of resident attendance and participation at each activity for the preceding twelve months; and

(3) service policies and procedures;

(m) records for each specialized rehabilitative therapy service, including:

(1) service policies and procedures;

(2) a statistical summary, including but not limited to the frequency, type and duration of treatments given, number of residents treated and number of residents admitted and discharged from the service; and

(3) service budgets and equipment inventory;

(n) a record of staff medical policies, including any bylaws, rules and regulations adopted by the nursing home; and

(o) transfer or affiliation agreements consisting of all contracts, agreements, arrangements, understandings, and records of all efforts to establish same with hospitals, nursing homes, home health agencies, and other health institutions, agencies and services regarding the transfer of residents between the nursing home and such institutions or agencies.
 

Effective Date: 
Wednesday, April 17, 1996
Doc Status: 
Complete