Cal. Code Regs. Tit. 22, § 87506 - Resident Records

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

(b) Each resident's record shall contain at least the following information:

(1) Resident's legal name and preferred name, as indicated by the resident.

(2) Social Security number.

(3) Gender identity and preferred pronoun, as indicated by the resident.

(4) Dates of admission and discharge.

(5) Last known address.

(6) Birthdate.

(7) Religious preference, if any, and name and address of clergyman or religious advisor, if any.

(8) Name, address, and telephone number of the resident's representative, as defined in Section 87101(r), to be notified in case of accident, death, or other emergency.

(9) Name, address and telephone number of physician and dentist to be called in an emergency.

(10) Reports of the medical assessment specified in Section 87458, Medical Assessment, and of any special problems or precautions.

(11) The documentation required by Section 87611 for residents with an allowable health condition.

(12) Ambulatory status.

(13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or needed services.

(14) Current centrally stored medications as specified in Section 87465, Incidental Medical and Dental Care Services.

(15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

(16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables.

(17) Documents and information required by the following:

(A) Section 87457, Pre-Admission Appraisal;

(B) Section 87459, Functional Capabilities;

(C) Section 87461, Mental Condition;

(D) Section 87462, Social Factors;

(E) Section 87463, Reappraisals; and

(F) Section 87505, Documentation and Support.

(c) All information and records obtained from or regarding residents shall be confidential.

(1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative.

(d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

(1) Licensing representatives shall not remove the following current records for current residents unless the same information is otherwise readily available in another document or format:

(A) Religious preference, if any, and name and address of clergyman or religious advisor, if any, as specified in Section 87506(b)(5).

(B) Name, address, and telephone number of responsible person(s) as specified in Section 87506(b)(6).

(C) Name, address, and telephone number of the resident's physician and dentist as specified in Section 87506(b)(7).

(D) Information relating to the resident's medical assessment and any special problems or precautions as specified in Section 87506(b)(8).

(E) Documentation required for residents with an allowable health condition as specified in Section 87506(b)(9).

(F) Information on ambulatory status as specified in Section 87506(b)(10).

(G) Continuing record of any illness, injury, or medical or dental care when it affects the resident's ability to function, or services needed, as specified in Section 87506(b)(11).

(H) Records of current medications as specified in Section 87506(b)(12).

(I) Any other records containing current emergency or health-related information for current residents.

(2) Prior to removing any records, a licensing representative shall prepare a list of the records to be removed, sign and date the list upon removal of the records, and leave a copy of the list with the administrator or designee.

(3) Licensing representatives shall return the records undamaged and in good order within three business days following the date the records were removed.

(e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident.

Notes

Cal. Code Regs. Tit. 22, § 87506

1. Change without regulatory effect renumbering Section 87506 to Section 87562 filed 11-17-88 (Register 88, No. 49). For prior history, see Register 88, No. 34.
2. Change without regulatory effect renumbering former section 87570 to section 87506, including amendment of section, filed 3-5-2008 pursuant to section 100, title 1, California Code of Regulations (Register 2008, No. 10).
3. Amendment of section NOTE filed 8-24-2018; operative 10-1-2018 (Register 2018, No. 34).

Note: Authority cited: Section 1569.30 and 1569.318, Health and Safety Code. Reference: Sections 1439.52, 1569.1, 1569.2, 1569.31, 1569.312 and 1569.315, Health and Safety Code; and Section 11006.9, Welfare and Institutions Code.

1. Change without regulatory effect renumbering Section 87506 to Section 87562 filed 11-17-88 (Register 88, No. 49). For prior history, see Register 88, No. 34.
2. Change without regulatory effect renumbering former section 87570 to section 87506, including amendment of section, filed 3-5-2008 pursuant to section 100, title 1, California Code of Regulations (Register 2008, No. 10).
3. Amendment of section Note filed 8-24-2018; operative 10/1/2018 (Register 2018, No. 34).