NAC458.272. Records regarding clients.

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 Health Division, an evaluation of the financial status of the client sufficient to determine eligibility for such services.

     (c) A statement from the client, signed within 24 hours after intake or upon enrollment in the treatment program, explaining that he or she is seeking service, unless the client is being provided a service related to civil protective custody.

     (d) 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.

     (e) 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.

     (f) The source of any referral to the treatment program.

     (g) Documentation of the treatment assessment performed by the operator or obtained by the operator pursuant to subsection 1 of NAC 458.246.

     (h) The history of treatment of the client.

     (i) Any sources of psychosocial stress affecting the client.

     (j) The original plan of care for the client and all revisions to the plan of care.

     (k) 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.

     (l) Documentation of and justification for any referral to appropriate services pursuant to the criteria of the Health Division and any resulting coordination of care.

     (m) Documentation of any discussion with the client concerning the results of the treatment assessment, appropriate referrals and any barriers to treatment.

     (n) The date, type and duration of any contact with the client, and any services provided to the client.

     (o) Documentation of any:

          (1) 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) Problem involving the client;

          (3) Infraction of the rules of the treatment program by the client; and

          (4) Sign or symptom of illness or injury of the client.

     (p) 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.

     (q) If the treatment program administers or dispenses medication to the client or makes medication available to the client to administer to himself or herself, documentation of all actions taken to comply with the requirements set forth in NAC 449.144.

     (r) 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:

          (1) Diagnosis of the client at the time of admission or intake;

          (2) The 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.

     (s) 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 referrals given to the client, 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 summary was completed which meets the criteria of the Health Division for the discharge of a client.

     (t) A copy of the notification, which is in the form approved by the Health 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 Health Division.

     (u) Documentation to support any claims for services or data reported to the Health Division.

     2. Ensure that each client receives a copy of the notification required pursuant to paragraph (t) of subsection 1.

     3. Ensure that the client records adhere to procedures for medical records.

     4. Ensure that the case notes for each client accurately reflect the treatment and services needed by the client, as identified in the assessment and plan of treatment required pursuant to NAC 458.246.

     5. Ensure that the staff readily has access to the client records to the extent authorized pursuant to 42 C.F.R. Part 2 and 45 C.F.R. Parts 160, 162 and 164.

     6. Maintain a system for the maintenance and protection of client information which satisfies the requirements set forth in 42 C.F.R. Part 2 and 45 C.F.R. Parts 160, 162 and 164, including, without limitation, requirements for:

     (a) Adequate provisions to prevent unauthorized access or theft of any form of a record of a client;

     (b) The locked storage of paper records;

     (c) Adequate provisions for a system of backup of records maintained in a computer system in case of a failure of the primary system;

     (d) Retention of the records of each client for not less than 6 years after the client is discharged from the treatment program, to be made available as required pursuant to 45 C.F.R. Parts 160, 162 and 164; and

     (e) Appropriate methods to destroy records of clients as required by federal regulation.

     7. Ensure that each client has access to their records as required pursuant to 42 C.F.R. Part 2 and 45 C.F.R. Parts 160, 162 and 164.

     (Added to NAC by Bd. of Health by R120-04, eff. 10-5-2004)