N.J. Admin. Code § 10:44A-2.9 - Records of individuals receiving services

(a) An individual file shall be maintained for each individual receiving services in a licensed community residence for individuals with developmental disabilities.

1. The file shall be legibly marked with the individual's name.

2. The client record is the property of the Department.

(b) Files for individuals residing in group homes and supervised apartments shall be maintained at the residence.

(c) An individual shall have access to his or her records, unless clinically contraindicated and documented.

(d) Individual records shall include:

1. Pre-admission information, as follows:

i. The individual's full name, date of birth, and sex;

ii. The individual's Social Security, Medicaid numbers or medical insurance numbers;

iii. The date(s) of admission, re-admission, transfer or discharge;

iv. The names and addresses of persons or agencies responsible for placement;

v. The names and addresses of all personal physicians or advanced practice nurses and dentists;

vi. The name, address and telephone number of the legal guardian (or guardianship worker), next of kin, and other interested person(s), and a copy of the guardianship determination, if applicable;

vii. Religious preference;

viii. Pre-admission data including diagnosis, a psychological evaluation, as appropriate and/or available and developmental history, including behavioral characteristics;

ix. The SP;

x. The results of a physical examination completed within the past year;

xi. The results of a Mantoux Skin Test or IGRA blood test;

xii. In the absence of the results at subparagraph (d)1x or xi above, written certification from a physician or advanced practice nurse stating the individual is free of communicable disease shall be obtained prior to admission, and the licensee shall obtain the absent documentation as soon as possible, within a time frame approved by the Office of Licensing; and

xiii. An immunization record, as available as required for individuals under the age of 22.

2. The results of an annual physical examination;

3. Annual reports from the dentist of dental examinations, dental care, and corrective work done;

4. Seizure records, where indicated;

5. A medically prescribed diet, if required;

6. Documentation of known allergies;

7. Medication administration records;

8. An inventory of valuable personal possessions, including, but not limited to, personal mementos, adaptive devices, eyeglasses, hearing aids, durable medical equipment, electronic equipment and accessories, jewelry, clothing, and personal furniture;

9. Authorizations and acknowledgements, as required at N.J.A.C. 10:44A-4.1(e);

10. Identification of the person's capabilities and needs, including, but not limited to:

i. The ability to remain unsupervised, specific to location and length of time, including in a vehicle;

ii. The ability to self-medicate;

iii. The ability to manage their personal funds;

iv. All prescribed adaptive equipment; and

v. Any rights restrictions; and

11. The current Behavior Support Plan approved by the PT, as applicable.

Notes

N.J. Admin. Code § 10:44A-2.9

Amended by 55 N.J.R. 171(a), effective 2/6/2023