Nursing homes/healthcare facilities must maintain all resident assessments completed within the previous 15 months in the resident’s active record and use the results of the assessments to develop, review and revise the resident’s comprehensive care plan. Assessment data must be kept in the resident’s active clinical record regardless of form of storage and must be readily and easily accessible to all professional staff members and the state survey agency. After the 15-month period, RAI information may be thinned from the clinical record and stored in the medical records department, provided that it is easily retrievable if requested. This new letter requires nursing homes/healthcare facilities to maintain 15 months of data in the resident’s active clinical record and ensure that it is easily accessible to all professional staff members and the state survey agency.

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