NAC449.2749. Maintenance and contents of separate file for each resident; confidentiality of information.

     1. A separate file must be maintained for each resident of a residential facility and retained for at least 5 years after he or she permanently leaves the facility. The file must be kept locked in a place that is resistant to fire and is protected against unauthorized use. The file must contain all records, letters, assessments, medical information and any other information related to the resident, including, without limitation:

     (a) The full name, address, date of birth and social security number of the resident.

     (b) The address and telephone number of the resident’s physician and the next of kin or guardian of the resident or any other person responsible for the resident.

     (c) A statement of the resident’s allergies, if any, and any special diet or medication he or she requires.

     (d) A statement from the resident’s physician concerning the mental and physical condition of the resident that includes:

          (1) A description of any medical conditions which require the performance of medical services;

          (2) The method in which those services must be performed; and

          (3) A statement of whether the resident is capable of performing the required medical services.

     (e) Evidence of compliance with the provisions of chapter 441A of NRS and the regulations adopted pursuant thereto.

     (f) The types and amounts of protective supervision and personal services needed by the resident.

     (g) An evaluation of the resident’s ability to perform the activities of daily living and a brief description of any assistance he or she needs to perform those activities. The facility shall prepare such an evaluation:

          (1) Upon the admission of the resident;

          (2) Each time there is a change in the mental or physical condition of the resident that may significantly affect his or her ability to perform the activities of daily living; and

          (3) In any event, not less than once each year.

     (h) A list of the rules for the facility that is signed by the administrator of the facility and the resident or a representative of the resident.

     (i) The name and telephone number of the vendors and medical professionals that provide services for the resident.

     (j) A document signed by the administrator of the facility when the resident permanently leaves the facility.

     2. The document required pursuant to paragraph (j) of subsection 1 must indicate the location to which the resident was transferred or the person in whose care the resident was discharged. If the resident dies while a resident of the facility, the document must include the time and date of the death and the dates on which the person responsible for the resident was contacted to inform him or her of the death.

     3. Except as otherwise provided in this subsection, a resident’s file must be kept confidential. A resident’s file must be made available upon request at any time to an employee of the Bureau who is acting in his or her capacity as an employee of the Bureau.

     (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R052-99, 9-27-99; R073-03, 1-22-2004)