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N.J. Admin. Code § 10:60-3.6 - Clinical records (Personal Care Assistant Services)
New JerseyregulationNJ Division of Medical Assistance and Health Services (DMAHS)· effective 2022-09-06
What this rule requires your agency to do
- 1Clinical records shall contain at minimum: nursing assessments (most recent retained in active chart, previous three years retained onsite); a beneficiary-specific plan of care; signed and dated progress notes; documentation of the PCA supervision provided every 60 days; a PCA assignment sheet signed and dated weekly by the PCA; documentation the beneficiary was informed of medical decision-making rights; documentation of advance directive formulation; and documentation of approved nurse-delegated tasks and training on those tasks.(N.J. Admin. Code § 10:60-3.6 - Clinical records (Personal Care Assistant Services))
- 2All clinical records shall be signed and dated by the registered professional nurse in accordance with accepted professional standards.(N.J. Admin. Code § 10:60-3.6 - Clinical records (Personal Care Assistant Services))
- 3Clinical records and reports shall be maintained for each beneficiary covering medical, nursing, social, and health-related care in accordance with accepted professional standards, and shall be readily available to representatives of the Division or its agents.(N.J. Admin. Code § 10:60-3.6 - Clinical records (Personal Care Assistant Services))
Applies to: personal care
Specifies the clinical recordkeeping, retention, and documentation requirements a provider must maintain for each PCA beneficiary.
Regulatory information, not legal advice — always confirm against the cited official source. Verification reduces error; it does not certify compliance.