Nevada Administrative Code › Chapter 458 - Abuse of Alcohol and Drugs › ALCOHOL AND DRUG ABUSE PROGRAMS › Treatment Programs › Section 458.272 - Records regarding clients

Current through June 11, 2024
The operator of a treatment program shall:
1. Ensure that a record is maintained for
				each client. The record must include:
(a) The
				name, age, gender, race, ethnicity and permanent address of the
				client.
(b) If services are funded
				by the Division, an evaluation of the financial status of the client sufficient
				to determine eligibility for such services.
(c) Except as otherwise provided in chapter
				129 of NRS, a consent form for treatment services signed by the client or the
				parent or guardian of the client within 24 hours after intake or upon
				enrollment in the treatment program, unless the client is being provided a
				service related to civil protective custody.
(d) Any consent to release information which
				satisfies the requirements set forth in  42 C.F.R. Part 2 and 45  C.F.R. Parts
				160, 162 and 164.
(e) The source of
				any referral to the treatment program.
(f) Documentation of the treatment assessment
				performed by the operator or obtained by the operator pursuant to subsection 1
				of NAC 458.246.
(g) The original
				plan of treatment for the client and all revisions to the plan of
				treatment.
(h) Any additional
				information that should be taken into consideration during the planning of
				treatment, determination of appropriate referrals and determination of any need
				for coordination of care.
(i) The
				date, type and duration of any contact with the client, and any services
				provided to the client.
(j)
				Documentation of any of the following, which must be reported to the Division
				within 1 business day after the event occurs:
(1) An incident that may cause imminent
				danger to the health and safety of the client, other clients or staff, or
				persons outside the treatment program;
(2) A problem involving the client;
(3) An infraction of the rules of the
				treatment program by the client;
(4) A sign or symptom of illness or injury of
				the client; and
(5) The death of
				the client.
(k)
				Documentation in support of services that the treatment program provides to the
				client, including, without limitation, any:
(1) Correspondence concerning the client;
				and
(2) Results of a test conducted
				on the client, including, without limitation, any test conducted by a
				laboratory.
(l) If the
				client is transferred to a different location or provided a different service,
				including a service provided by the same operator, a copy of the case note made
				at the time of transfer which includes, without limitation, the:
(1) Diagnosis of the client at the time of
				admission or intake;
(2) Response
				of the client to treatment;
(3)
				Diagnosis of the client at the time of transfer; and
(4) Recommendations for persons who will be
				providing treatment to the client.
(m) After the client is discharged from the
				treatment program:
(1) Documentation that a
				copy of the plan for continuing care of the client, including, without
				limitation, any ongoing treatment or additional community resources that the
				client might need, referrals given to the client, personal goals relating to
				recreation, leisure, selffulfillment and social support, and areas in the
				client's life that require ongoing support, including, without limitation,
				transportation or employment, was provided to the client before discharge, if
				possible; and
(2) Documentation
				that, not more than 5 business days after the client was discharged from the
				treatment program, a discharge summary was completed that meets the criteria of
				the Division for the discharge of a client, which includes, without limitation,
				the:
(I) Diagnosis of the client at the time
				of admission or intake;
(II)
				Response of the client to treatment; and
(III) Diagnosis of the client at the time of
				discharge.
(n)
				A copy of the notification, which is in the form approved by the Division and
				which was signed by the client, indicating:
(1) The procedure for the client to register
				a complaint and to appeal a decision by the treatment program concerning a
				complaint;
(2) The requirements for
				the confidentiality of client information set forth in  42 C.F.R. Part 2, 45 C.F.R. Parts 160, 162 and 164 and any other applicable federal or state laws
				governing the confidentiality of client information for the service provided;
				and
(3) Any other rights of the
				client that are specified by the Division.
(o) Documentation to support any claims for
				services or data reported to the Division.