Cal. Code Regs. Tit. 17, § 56730 - Consumer Records

(a) Vendors shall maintain consumer information and records as confidential documents pursuant to Welfare and Institutions Code, sections 4514 through 4518, and shall also maintain consumer confidentiality as required in Health and Safety Code, sections 199.20 through 199.27.

(b) Vendors shall maintain an individual consumer case file for each consumer admitted to the program.

(c) The consumer case file shall include:

(1) The most current copies of:

(A) Emergency and personal identification information, including the consumer's address, telephone number, names and telephone numbers of residential care provider, relatives, and/or guardian or conservator, physician's name(s) and telephone number(s), pharmacy name, address and telephone number, and health plan if appropriate;

(B) A medical history which includes:

1. Current medications;

2. Known allergies;

3. Medical disabilities;

4. Infectious, contagious or communicable conditions;

5. Special nutritional needs; and

6. Immunization records.

(C) Any consumer medical, psychological, and social evaluations identifying the consumer's ability and functioning level, which shall be supplied by the regional center;

(D) Authorization for emergency medical treatment;

(E) Documentation that the consumer and/or the authorized consumer representative has been informed of his/her personal rights;

(F) The IPP as prepared and forwarded by the regional center; and

(G) Consumer IPP documentation as required by section 56720 of these regulations.

(2) All copies of:

(A) Special incident reports, if any;

(B) Case notes reflecting important events or information not documented elsewhere;

(C) Data collected that measures consumer progress in relation to his/her IPP objectives; and

(D) Documentation of reviews conducted pursuant to section 56732(c) of these regulations, including summaries of the data collection that indicate consumer performance and progress toward consumer outcomes for which the vendor is responsible.

(3) Documentation of attempts to obtain required information not contained in the consumer record.

(d) Records pertaining to the consumer shall be stored at the program site in a secure and locked place which shall be readily accessible. The vendor is authorized to keep pertinent consumer data, including, but not limited to, emergency telephone numbers, important medical data, current IPP objectives, and data collection sheets with the consumer when the consumer is participating in an activity or training at a location which is away from the program's central filing area.

(e) The individual consumer, case file shall be retained for five years following the consumer's termination from the program.

Notes

Cal. Code Regs. Tit. 17, § 56730

1. New section filed 6-26-90 as an emergency; operative 7-1-90 (Register 90, No. 36). A Certificate of Compliance must be transmitted to OAL by 10-29-90 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 6-26-90 order transmitted to OAL 9-28-90 and filed 10-29-90 (Register 90, No. 46).
3. Amendment of section filed as an emergency 6-17-93; operative 6-17-93. Submitted to OAL for printing only pursuant to SB485 (Chapter 722, Statutes of 1992) Section 147(a) (Register 93, No. 26).
4. Certificate of Compliance as to 6-17-93 order transmitted to OAL 6-20-94 and filed 8-2-94 (Register 94, No. 31).
5. Change without regulatory effect amending section heading and section filed 1-17-97 pursuant to section 100, title 1, California Code of Regulations (Register 97, No. 3).

Note: Authority cited: Section 4691, Welfare and Institutions Code. Reference: Sections 4514, 4646, 4646.5, 4648, 4648.1 and 4691, Welfare and Institutions Code.

1. New section filed 6-26-90 as an emergency; operative 7-1-90 (Register 90, No. 36). A Certificate of Compliance must be transmitted to OAL by 10-29-90 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 6-26-90 order transmitted to OAL 9-28-90 and filed 10-29-90 (Register 90, No. 46).
3. Amendment of section filed as an emergency 6-17-93; operative 6-17-93. Submitted to OAL for printing only pursuant to SB485 (Chapter 722, Statutes of 1992) Section 147(a) (Register 93, No. 26).
4. Certificate of Compliance as to 6-17-93 order transmitted to OAL 6-20-94 and filed 8-2-94 (Register 94, No. 31).
5. Change without regulatory effect amending section heading and section filed 1-17-97 pursuant to section 100, title 1, California Code of Regulations (Register 97, No. 3).