26 Tex. Admin. Code § 553.265 - Resident Records and Retention
(a)
Resident records.
(1) Records that pertain to
residents must be treated as confidential and properly safeguarded from
unauthorized use, loss, or destruction.
(2) Resident records must contain:
(A) information contained in the facility's
standard and customary admission form;
(B) a record of the resident's
assessments;
(C) the resident's
service plan;
(D) physician's
orders, if any;
(E) any advance
directives;
(F) documentation of a
health examination by a physician performed within 30 days before admission or
14 days after admission, unless:
(i) a
transferring hospital or facility has a physical examination in the medical
record; or
(ii) the resident is a
Christian Scientist;
(G)
documentation by health care professionals of any services delivered in
accordance with the licensing, certification, or other regulatory standards
applicable to the health care professional under law; and
(H) a copy of the most recent court order
appointing a guardian of a resident or a resident's estate and letters of
guardianship that the facility received in response to the request made in
accordance with subsection (c) of this section.
(3) Records must be available to residents,
their legal representatives, and HHSC staff.
(b) Resident finances. The facility must keep
a simple financial record on all charges billed to the resident for care and
these records must be available to HHSC. If the resident entrusts the handling
of any personal finances to the facility, a simple financial record must be
maintained to document accountability for receipts and expenditures, and these
records must be available to HHSC. Receipts for payments from residents or
family members must be issued upon request.
(c) Guardianship Record Requirements.
(1) A facility must request, from a
resident's legally authorized representative or the person responsible for the
resident's support, a copy of:
(A) the current
court order appointing a guardian for the resident or the resident's estate;
and
(B) current letters of
guardianship for the resident.
(2) A facility must request the court order
and letters of guardianship:
(A) when the
facility admits an individual; and
(B) when the facility becomes aware a
guardian is appointed after the facility admits a resident.
(3) A facility must request an
updated copy of the court order and letters of guardianship at each annual
assessment and retain documentation of any change.
(4) A facility must make at least one
follow-up request within 30 days after the facility makes a request in
accordance with paragraphs (2) or (3) of this subsection if the facility has
not received:
(A) a copy of the court order
and letters of guardianship; or
(B)
a response that there is no court order or letters of guardianship.
(5) A facility must keep in the
resident's record:
(A) documentation of the
results of the request for the court order and letters of guardianship;
and
(B) a copy of the court order
and letters of guardianship.
Notes
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