SECTION 371.216. Nursing Facility Clinical Records

(a) All coded items on minimum data set (MDS) assessments must be accurate and supported by documentation in the recipient's clinical record. Completion of the MDS assessment does not remove the nursing facility provider's responsibility to document in the clinical record a detailed assessment of all relevant issues that affect the recipient.

(1) Clinical documentation must contain individualized care plans and document pertinent facts, findings, and observations about an individual's health history, including past and present illnesses, treatments, and outcomes to support the assessment and the care provided.

(2) Sources of information, such as other health care professionals and family members, utilized for the MDS assessment must be identified in the clinical record.

(3) Clinical records must include the recipient's name and the signatures, dates of signatures, and titles of individuals providing care for the recipient.

(4) Documents, such as grids and flow sheets that include entries by multiple staff members at different times, must include complete dates with initials or signatures to clearly identify who provided the care. For purposes of this paragraph, a signature may be an original handwritten signature or an electronic signature as set out in Texas Business and Commerce Code Chapter 322 (relating to the Uniform Electronic Transactions Act).

(b) MDS items that are inaccurate or unsupported by documentation in the recipient's clinical record may result in an adjustment in the RUG classification of a recipient.

(c) A nursing facility provider that utilizes an electronic clinical record system must maintain MDS assessments in the recipient's clinical record in accordance with the Resident Assessment Instrument (RAI) User's Manual.

(d) Nursing facility resident records must be maintained in accordance with the nursing facility provider's contract with HHSC and all applicable state and federal law, rules, and policy, including:

(1) 26 TAC Chapter 554 (relating to Nursing Facility Requirements for Licensure and Medicaid Certification);

(2) 1 TAC §354.1004 (relating to Retention of Records);

(3) 45 C.F.R. Parts 160 and 164; and

(4) the RAI User's Manual.

Source Note: The provisions of this §371.216 adopted to be effective February 9, 2023, 48 TexReg 503