New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 370 - OVERSIGHT OF LICENSED HEALTHCARE FACILITIES AND COMMUNITY BASED WAIVER PROGRAMS › Part 14 - ASSISTED LIVING FACILITIES FOR ADULTS › Section 8.370.14.21 - RESIDENT RECORDS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Record
				contents:
A record for each resident shall be maintained in accordance
				with the specific requirements of this section. Entries in each resident's
				record shall be legible, dated and authenticated by the signature of the person
				making the entry. Resident records shall be readily available on site and
				organized utilizing a table of contents. Each resident record shall include:
(1) the admission agreement records, as set
				forth in 8.370.14.20 NMAC;
(2) the
				resident evaluation form
,
that is to be completed within 15 days
				prior to admission and updated at a minimum of every six months;
(3) the current ISP, that is to be completed
				within 10 calendar days of admission and updated at a minimum of every six
				months;
(4) the physical
				examination report; the physical examination report shall have been completed
				within the past six months, by a primary care physician, a nurse practitioner
				or a physician's assistant and shall be on file in the resident's record within
				10 days of admission;
(5) personal
				and demographic information for the resident, to include:
(a) current names, addresses, relationship
				and phone numbers of family members, or surrogate decision makers updated as
				necessary;
(b) resident's
				name;
(c) age;
(d) recent photograph;
(e) marital status;
(f) date of birth;
(g) sex;
(h) address prior to admission;
(i) religion (optional);
(j) personal physician;
(k) dentist;
(l) social history;
(m) surrogate decision maker or other
				emergency contact person;
(n)
				language spoken and understood;
(o)
				legal documentation relevant to commitment or guardianship status;
(p) current medications list; and
(q) required diet;
(6) unless included in the admission
				agreement, a separate written agreement between the facility and the resident
				relating to the resident's funds, in accordance with the facility's policy and
				procedures;
(7) entries by direct
				care staff, appropriate health care professionals and others authorized to care
				for the resident; entries shall be dated and signed by the person making the
				entry and shall include significant information related to the ISP;
(8) entries that provide a written account of
				all accidents, injuries, illnesses, medical and dental appointments, any
				problems or improvements observed in the resident, any condition that would
				indicate a need for alternative placement or medical attention and entries
				reflecting appropriate follow-up; the maintenance of such written documentation
				in the resident record may be by copy of an incident or accident report, if the
				original incident or accident report is maintained elsewhere by the
				facility;
(9) the medication
				assistance record (MAR); the MAR is the document that details the resident's
				medication; the MAR shall include all of the information pursuant to Subsection
				G of 8.370.14.35 NMAC of this rule;
(10) progress notes completed by any contract
				agency (e.g., hospice, home health); the progress notes shall include the date,
				time and type of health services provided;
(11) copies of all completed and signed
				transfer forms from the accepting facility when a resident is transferred to a
				hospital or another health care facility and when the resident is transferred
				back to the facility; and
(12) upon
				the death or transfer of a resident, documentation of the disposition of the
				resident's personal effects and money or valuables that are deposited with the
				assisted living facility.