NAC458.306. Records regarding clients.

The operator of a drug court 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 upon intake or enrollment in the drug court 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 upon intake or enrollment in the drug court 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 drug court which referred the client to the drug court program.

     (g) Documentation of the assessment performed by the operator or obtained by the operator pursuant to NAC 458.296.

     (h) The history of treatment of the client.

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

     (j) 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.

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

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

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

     (n) 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 drug court program;

          (2) Problem involving the client; and

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

     (o) Documentation in support of services that the drug court 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.

     (p) 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 drug court 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.

     (q) 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 (p) 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 required pursuant to NAC 458.296.

     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 drug court 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)