Section 260. Maintenance of records

A. A separate written or automated case record shall be maintained for each resident, which shall include all correspondence and documents received by the JCC relating to the care of that resident and documentation of all case management services provided.

B. Separate health care records, including behavioral health, as applicable, and medical records, shall be kept on each resident. Health care records shall be maintained in accordance with 6VAC35-71-1020 (residents' health records) and applicable statutes and regulations. Behavioral health care records may be kept separately from other medical records.

C. Each case record and health care record shall be kept up to date and in a uniform manner in accordance with written procedures. Case records shall be released in accordance with §§ 16.1-300 and 16.1-309.1 of the Code of Virginia and applicable state and federal laws and regulations.

D. The procedures for management of residents' records, written and automated, shall describe confidentiality, accessibility, security, and retention of records including:

1. Access, duplication, dissemination, and acquiring of information only to persons legally authorized according to federal and state laws;

2. Security measures to protect records from loss, unauthorized alteration, inadvertent or unauthorized access, disclosure of information, and transportation of records between service sites; and

3. Designation of the person responsible for records management.

E. Active and closed records shall be kept in secure locations or compartments that are accessible only to authorized employees and are protected from unauthorized access, fire, and flood.

F. Each resident's written case and health care records shall be stored separately subsequent to the resident's discharge in accordance with applicable statutes and regulations.

G. Residents' inactive records shall be retained as required by The Library of Virginia.

Historical Notes

Derived from Volume 29, Issue 25, eff. January 1, 2014.

Statutory Authority

§§ 16.1-309.9, 66-10, and 66-25.1 of the Code of Virginia.