26 TAC § 553.265. Resident Records and Retention

(a) Resident records.

(1) Records that pertain to residents must be treated as confidential and properly safeguarded from unauthorized use, loss, or destruction.

(2) Resident records must contain:

(A) information contained in the facility's standard and customary admission form;

(B) a record of the resident's assessments;

(C) the resident's service plan;

(D) physician's orders, if any;

(E) any advance directives;

(F) documentation of a health examination by a physician performed within 30 days before admission or 14 days after admission, unless:

(i) a transferring hospital or facility has a physical examination in the medical record; or

(ii) the resident is a Christian Scientist;

(G) documentation by health care professionals of any services delivered in accordance with the licensing, certification, or other regulatory standards applicable to the health care professional under law; and

(H) a copy of the most recent court order appointing a guardian of a resident or a resident's estate and letters of guardianship that the facility received in response to the request made in accordance with subsection (c) of this section.

(3) Records must be available to residents, their legal representatives, and HHSC staff.

(b) Resident finances. The facility must keep a simple financial record on all charges billed to the resident for care and these records must be available to HHSC. If the resident entrusts the handling of any personal finances to the facility, a simple financial record must be maintained to document accountability for receipts and expenditures, and these records must be available to HHSC. Receipts for payments from residents or family members must be issued upon request.

(c) Guardianship Record Requirements.

(1) A facility must request, from a resident's legally authorized representative or the person responsible for the resident's support, a copy of:

(A) the current court order appointing a guardian for the resident or the resident's estate; and

(B) current letters of guardianship for the resident.

(2) A facility must request the court order and letters of guardianship:

(A) when the facility admits an individual; and

(B) when the facility becomes aware a guardian is appointed after the facility admits a resident.

(3) A facility must request an updated copy of the court order and letters of guardianship at each annual assessment and retain documentation of any change.

(4) A facility must make at least one follow-up request within 30 days after the facility makes a request in accordance with paragraphs (2) or (3) of this subsection if the facility has not received:

(A) a copy of the court order and letters of guardianship; or

(B) a response that there is no court order or letters of guardianship.

(5) A facility must keep in the resident's record:

(A) documentation of the results of the request for the court order and letters of guardianship; and

(B) a copy of the court order and letters of guardianship.