10A NCAC 13G .1201. RESIDENT RECORDS

(a)  The following shall be maintained on each resident in an orderly manner in the resident's record in the family care home and made available for review by representatives of the Division of Health Service Regulation and county departments of social services.

(1)           FL-2 or MR-2 Forms and patient transfer form or hospital discharge summary, when applicable;

(2)           Resident Register;

(3)           receipt for the following as required in Rule .0704 of this Subchapter:

(A)          contract for services, accommodations and rates;

(B)          house rules as specified in Rule .0704(2) of this Subchapter;

(C)          Declaration of Residents' Rights (G.S. 131D-21);

(D)          home's grievance procedures; and

(E)           civil rights statement;

(4)           resident assessment and care plan;

(5)           contacts with the resident's physician, physician service or other licensed health professional as required in Rule .0902 of this Subchapter;

(6)           orders or written treatments or procedures from a physician or other licensed health professional and their implementation;

(7)           documentation of immunizations against influenza virus and pneumococcal disease according to G.S. 131D-9 or the reason the resident did not receive the immunizations based on this law; and

(8)           the Adult Care Home Notice of Discharge and Adult Care Home Hearing Request Form if the resident is being or has been discharged.

When a resident leaves the facility for a medical evaluation, records necessary for that medical evaluation such as Items (1), (4), (5), (6) and (7) above may be sent with the resident.

(b)  A resident financial record providing an accurate accounting of the receipt and disbursement of the resident's personal funds, if handled by the facility according to Rule .1103 of this Subchapter, shall be maintained on each resident in an orderly manner in the facility and be readily available for review by representatives of the Division of Health Service Regulation and county departments of social services.  When there is an approved cluster of licensed facilities, financial records may be kept in one location among the clustered facilities

 

History Note:        Authority G.S. 131D‑2; 143B‑165; S.L. 2002-0160; 2003-0284;

Eff. January 1, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. July 1, 1990; April 1, 1987; April 1, 1984;

Temporary Amendment Eff. July 1, 2004;

Amended Eff. July 1, 2005.