1. Policy

    

   The Agency maintains the original client health record in the local agency office for each client receiving home care services in accordance with professional standards for home care services provided by the Agency, as defined by State and Federal laws. The clinical record shall be readily available upon request to all authorized persons. All entries shall be written in ink, dated and signed full name or first initial/surname name and title. Entries into the clinical record for services rendered must be written within 24 hours and incorporated into the clinical record within fourteen working days. Records are filed in alphabetical order.

    

   1. Retention and Protection

    

   1. The Principals and Health Care Practitioner Supervisor are responsible for proper preparation, adequacy and preservation of clinical records.

    

   1. The records shall be kept for seven (7) years after the date of discharge, or as applicable by state law..

    

   1. The records of a minor shall be kept for seven (7) years after the minor becomes of age under New Jersey law, or a minimum of twenty-one (21) years or as applicable by law.

    

   1. All records are the property of the Agency.

    

   1. If ownership of the Agency changes, all records (original or microfilmed) shall remain the property of the Agency, the new owner then being responsible for their retention.

    

   1. In the event of dissolution of the Agency, the Governing Body or its representative shall notify the State Agency Licensing/Certification where the records are stored.

    

   1. All records are stored in locked files or a locked file room in the Agency or stored off-site in a locked facility. Access to keys shall be limited to the Principals, Health Care Practitioner Supervisor or other authorized Agency employees.

    

   1. Records will be destroyed, by shredding, mutilation, burning or by similar protective measures in order to preserve the client’s right to confidentiality.

    

   J.  All Clinical records for client services will be kept in blue or black ink, typed or on electronic data systems.

    

2. Confidentiality

1. All records are safeguarded against loss or unauthorized use.

    

2. Access to individual client records shall be limited to:

    

   1. The client, legal guardian, or authorized representative, but only on receipt of a written request.
   2. Authorized Agency employees and contractors providing care to the client or involved in office procedure necessitating the handling of the client record.
   3. Duly authorized state or federal health authorities, accrediting bodies or any other specifically authorized by law.

1. A client’s written consent is required for release of any medical information not authorized by law.

    

2. All requests for client medical records should be reviewed by the Principals and possibly legal counsel.

    

3. With client’s approval, an abstract of the record may accompany the client if he or she is transferred to a facility or other agency.

    

4. Records regarding child abuse, elder or dependent adult abuse, treatment for alcohol or substance abuse, mental health treatment, HIV test results or HBV status may be subject to additional legal restrictions and should not be released without approval of legal counsel or the client’s written consent.

    

1. Financial Records

    

   1. Entries to the financial record may be made by the office staff, Health Care Practitioner Supervisor, Coordinators and the Principals.

    

   1. The financial records shall contain, but is not limited to, the following:

    

2. Order for Home Care; (may be a photo copyphotocopy, if original is placed in the clinical record).

    

3. Order for Home Care Financial Addendum (government reimbursed cases excepted).

    

4. Insurance Assignment and Confirmation of Coverage.

    

5. Clinical Records
   1. The clinical record contains pertinent past and current findings in accordance with accepted professional standards.

    

   1. Entries to the clinical record may be made by any clinical staff providing client care as well as the Health Care Practitioner Supervisor. Office staff receiving information regarding the client will enter the information electronically via the scheduling software.

    

   1. The clinical record shall contain, but is not limited to, the following:

    

   1. Request for Service, if applicable
   2. Admission to Home Care including identification data, consent forms, service agreement
      1. The Service Agreement contains information on the client’s responsible party as appropriate.
   3. Client Assessment including and the name and address of the client’s physician
   4. CLIENT EMERGENCY/DISASTER PLAN and CONTACT INFORMATION
   5. Home Safety Checklist
   6. Physician Plan of Treatment which includes medical diagnosis, medication orders, dietary orders, activity orders, and safety orders, if applicable
   7. Client Plan of Care Home Health Aide
   8. Client Plan of Care Homemaker/Companion
   9. Client Plan of Care Nursing, if applicable
6. Weekly Activity Sheets (Continuous Nursing Care Progress Notes), if applicable
   1. Weekly Activity Sheets (Home Health Aide), if applicable
   2. Weekly Activity Sheets (Homemaker/Companion), if applicable
   3. Supervisory Nursing Notes

As an Agency client, you have the right to:

1. Receive a written copy of these rights and responsibilities and have them explained to you.
2. Be treated with dignity, courtesy and respect and have property respected.
3. Be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse.

1. Reasonable coordination and continuity of care throughout your home care service, including the right to be informed about the plan of service, to participate in the planning, and to be promptly and fully informed of any changes in the plan of service.
2. Receive a timely response from Agency when assistance is needed or requested.
3. Accept or decline home care services at any time. However, clients should be informed of the health consequences of this action.
4. Refuse participation in research, experimentation or educational training without punitive action being taken against you. The client understands that the staff has a responsibility to contact the appropriate supervisor when a refusal of services could result, or does result, in potential harm to the client.
5. Be fully informed of agency policies, services and charges for services, including eligibility for third party reimbursement and an explanation of all forms you are requested to sign.
6. Receive home care services regardless of race, religion, political belief, gender, social status, sexual orientation, marital status, age or handicap.

1. Receive care from sufficiently trained personnel, and to have the right of choice in providers.

1. Privacy during interview, examination and treatment; and to refuse observation by those not directly involved in care.
2. Confidentiality of all records (except as otherwise provided for by law or third party payer contracts) and all communications between clients and health care providers.
3. Access to all health records pertaining to you, the right to challenge and to have your records corrected for accuracy, and the right to transfer information from all such records.

1. Express dissatisfaction and suggest changes in any services without fear of reprisal.
   1. Formulate advance directives (known also as Living Wills) and be assured that Agency will not condition the provision of care or otherwise discriminate against you based on whether or not you have executed an advance directive. To receive notification of agency policy regarding withdrawal or withholding of resuscitative services/life sustaining treatment (i.e. CPR) in the event of a cardiac arrest or a respiratory arrest.

    

    

   As a client of the Agency, you have the responsibility to:

2. Request further information concerning anything you don’t understand.

1. Give accurate and complete health information concerning your past and present illnesses, hospitalizations, Dr.’s appointments, medications, allergies and other pertinent items.
2. Assist in developing and maintaining a safe environment.
3. Inform Agency at least 48 hours in advance of any address changes or when you will not be able to keep a visit.