20 CAR § 413-318 – Confidentiality

(a) The facility must keep confidential all information contained in the clients' records, regardless of the form or storage method of the records.
(b) The records will be available to Office of Long-Term Care personnel.
(c) The facility must develop and implement policies and procedures governing the release of any client information, including consents necessary from the:
1. (1) Client;
2. (2) Parents, if the client is a minor; or
3. (3) Legal guardian.
(d) Any individual who makes an entry in a client's record must:
1. (1) Make it legibly;
2. (2) Date it; and
3. (3) Sign it.
(e) The facility must provide a legend to explain any symbol or abbreviation used in a client's record.
(f) The facility must provide each identified residential living unit with appropriate aspects of each client's record.