{"ref":"NC-HC-QA-02","title":"Client Record Review Every 90 Days","category":"Quality","summary":"Sets out the review of client records that the governing body or its designee must carry out every 90 days under 10A NCAC 13J .1004(d): a representative sample of active and closed records covering every home care service, direct and under contract, checked against the Agency's policies on Form NC-HC-QA-02-A. As the Agency's own standard, each review samples at least 10 percent of active and 10 percent of closed records, never fewer than five records, with every service represented; records removed for review come back within five working days under the sign-out log; findings are corrected within 30 days and feed the annual program evaluation.","inShort":["At least every 90 days, reviewers check a sample of active and closed client records for every service.","They check rights forms, assessments, plans of care, supervisory visits, service records and discharge papers.","If a reviewer finds a risk to a client, it is acted on the same day.","Other problems are fixed within 30 days. Never fill in a missing entry after the fact without marking it as a late entry.","Records taken out for review come back within five working days and are signed out on the log."],"primaryCitation":"10A NCAC 13J .1004(d)","citations":["10A NCAC 13J .1004(d), (e)","10A NCAC 13J .1401(c), (d)","10A NCAC 13J .1402","10A NCAC 13J .1107","10A NCAC 13J .1110","10A NCAC 13J .1202","10A NCAC 13J .1504","G.S. 131E-141","G.S. 131E-144.4"],"federalCitations":[],"surveyorAsks":["Show me your last four client record reviews. Were they no more than 90 days apart?","How did you choose the sample, and does it include closed records and every service, including contract services?"],"forms":[{"ref":"NC-HC-QA-02-A","title":"Quarterly Client Record Review Tool"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (10A NCAC 13J .1004(d))","5. Schedule","6. Choosing the Sample","7. What the Reviewers Check","8. Handling the Records During the Review","9. Findings and Follow-Up","10. Responsibilities","11. Records and Compliance Monitoring","12. Staff Training","13. References","14. Related Policies and Forms","15. Approval","16. Revision History"],"version":"1.0","sample":false,"pack":"nc-hca","state":"North Carolina","service":"Home care","guides":[{"path":"/guides/home-care-agency-policies/","h1":"What policies does a home care agency need?"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}