Medicaid (Title XIX of the Social Security Act)
Requirements Related to Provision of Services and Resident Rights

a.) Requirements Related to Provision of Services and Resident Rights

i.) Clinical Records

Nursing facilities must maintain clinical records on all residents,39 and with the patient’s permission the facility must permit representatives of the state ombudsman to examine such records.40  The record must contain an assessment of each patient’s functional capacity and a plan of care for each patient, the results of any screenings,41 and documentation of the reasons for any discharge or transfer.42

ii.) Assessments and Plans of Care

Assessments must be conducted upon admission and at least once every 12 months.43  The facility must examine each resident at least once every three months and revise the assessment as necessary;44 if a significant change in the resident’s condition has occurred, a new assessment must be conducted45 and the appropriate state authority must be notified of the change if that resident is mentally ill or retarded.46  A registered professional nurse must conduct and coordinate assessments, sign the assessment, and certify its completeness; any other health professional completing a portion of the assessment must sign that portion and certify its accuracy.47  The assessment must describe the resident’s ability to perform daily life functions and identify any medical problems or significant impairments in the resident’s functional capacity.48

A team including the resident’s physician and a registered nurse must prepare the plan of care49 based on the results of the patient assessment.50  The plan must identify the medical, nursing and psychosocial needs of the resident and describe how such needs will be met.51  The team must review and revise the plan after every resident assessment.52  In dispensing psychopharmacologic drugs, the facility must maintain plans written by a physician that indicate the need for and proper administration of such drugs; these plans must be annually reviewed for appropriateness by an external consultant.53   

iii.) Transfers and Discharges

When transferring or discharging patients, the facility must notify the resident and an immediate family member or legal representative of the impending occurrence of and reasons for the transfer or discharge at least 30 days prior to the transfer or discharge.54  The state must annually report to the Secretary the number and disposition of residents discharged because they no longer required nursing facility or specialized services.55

iv.) Residents’ Rights

The facility must protect and promote the rights of every resident, which include:

• The right to privacy with regard to medical treatment;56
• The right to confidentiality of personal and clinical records;57
• The right to request and receive access to current clinical records;58
• The right to voice grievances with respect to treatment or care that is (or fails to be) furnished and with respect to the behavior of other residents and the right to have the facility make prompt efforts to resolve these grievances and;59

The right to examine reports of each survey, certification and complaint investigation made within the preceding three years and any plan of correction in effect.60