Cal. Code Regs. Tit. 22, § 87870 - Resident Records
(a)
The licensee shall ensure that a separate, complete, and current record is
maintained in the facility for each resident.
(b) Each record shall contain information
including, but not limited to, the following;
(1) Name of resident.
(2) Birthdate.
(3) Sex.
(4) Date of admission.
(5) Names, addresses, and telephone numbers
of the authorized representative.
(6) A signed copy of the admission agreement
specified in Section
87868.
(7) Name, address and telephone number of
physician, surgeon and dentist, and other medical and mental health providers,
if any.
(8) Medical assessment,
including ambulatory status.
(9)
Copy of tests for tuberculosis:
(A) Results
of a Mantoux tuberculin skin test recorded in millimeters and dated no more
than three months prior to the resident's placement into the facility,
excluding residents who have had a previously positive reaction.
(1) For a resident who has had a previously
positive reaction, there shall be written documentation to verify that he/she
tested positive for tuberculosis.
(B) Results of chest x-ray dated no more than
three months prior to the resident's placement into the facility.
(C) If the chest x-ray is abnormal or the
Mantoux tuberculin skin test is positive, a copy of the physician's statement
verifying that the resident does not have communicable tuberculosis.
(D) Copy of the test results updated once per
year, if applicable, as specified in Section
87894(d).
(10) Record of any illness or injury
requiring treatment by a physician or dentist and for which the facility
provided assistance to the resident in meeting his/her necessary medical and
dental needs.
(11) Record of
current medications, including the name of the prescribing physician, and
instructions, if any, regarding control and custody of medications.
(12) Date of termination of
services.
(13) An accounting of the
resident's cash resources, personal property, and valuables entrusted to the
licensee.
(14) The name, address,
and telephone number of any person or agency responsible for the care of a
resident, including, but not limited to, persons who have been granted durable
power of attorney for the resident or conservators for the resident and/or
his/her estate as specified in Section
87868(b)(9).
(15) Weekly weight record.
(16) Copy of the "DO NOT Resuscitate Order",
provided the resident has agreed to and signed the order.
(17) Copy of the Durable Power of Attorney
for Health Care document signed by the resident.
(18) Information regarding the resident's
individual services plan/team as specified in Section
87896.
(19) Copy of the current log as specified in
Section 87894(f).
(c) All information and records obtained from
or regarding the resident shall be confidential.
(1) The licensee shall be responsible for
safeguarding the confidentiality of resident records.
(2) Except as specified in (d) below, or as
otherwise authorized by law, the licensee and all employees shall not reveal or
make available confidential information.
(d) All resident records shall be available
to the Department 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) Name, address, and telephone number of
the resident's authorized representative(s), if any, as specified in Section
87870(b)(5) and
defined in Section
87801(a).
(B) Name, address, and telephone number of
the resident's physician, surgeon and dentist, and other medical and mental
health providers, if any, as specified in Section
87870(b)(7).
(C) Medical assessment, including ambulatory
status, as specified in Section
87870(b)(8).
(D) Results of tuberculosis skin tests,
including a current log of the results of tuberculosis skin tests, as specified
in Sections
87870(b)(9) and
(b)(19).
(E) Record of any current illness or injury
requiring treatment by a physician or dentist for which the facility provided
assistance as specified in Section
87870(b)(10).
(F) Record of current medications as
specified in Section
87870(b)(11).
(G) Name, address, and telephone number of
any person or agency responsible for the care of a resident as specified in
Section 87870 ((b)(14).
(H) Weekly weight record as specified in
Section 87870(b)(15).
(I) Copy of signed "DO NOT Resuscitate Order"
as specified in Section
87870(b)(16) and
defined in Section
87801(d).
(J) Copy of signed Durable Power of Attorney
for Health Care as specified in Section
87870(b)(17) and
defined in Section
87801(d).
(K) Information regarding the resident's
individual services plan/team as specified in Section
87870(b)(18) and
defined in Section
87801(i).
(L) 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) A resident's records shall be open to
inspection by the resident's authorized representative, if any.
(f) The information specified in (b) above
shall be updated as necessary to ensure the accuracy of the resident's
record.
(g) Original resident
records or photographic reproductions shall be retained for at least three
years following termination of service to the resident.
Notes
2. New section refiled 12-3-91 as an emergency; operative 12-3-91 (Register 92, No. 9). A Certificate of Compliance must be transmitted to OAL 4-1-92 or emergency language will be repealed by operation of law on the following day.
3. Certificate of Compliance as to 12-3-91 order transmitted to OAL 4-1-92 and filed 5-13-92, including new subsections (a)(9)-(a)(9)(D) (with renumbering) and (a)(18)-(19), and amendment of subsection (a)(14) (Register 92, No. 23).
4. Editorial correction of subsection (a)(6) (Register 2002, No. 14).
5. Amendment of subsections (a) and (d), new subsections (d)-(d)(3), redesignation and amendment of former subsection (d)(1) as subsection (e), subsection relettering and amendment of newly designated subsection (g) filed 5-9-2005; operative 6-8-2005 (Register 2005, No. 19).
Note: Authority cited: Section 1568.072, Health and Safety Code. Reference: Sections 1568.072 and 1568.08, Health and Safety Code.
2. New section refiled 12-3-91 as an emergency; operative 12-3-91 (Register 92, No. 9). A Certificate of Compliance must be transmitted to OAL 4-1-92 or emergency language will be repealed by operation of law on the following day.
3. Certificate of Compliance as to 12-3-91 order transmitted to OAL 4-1-92 and filed 5-13-92, including new subsections (a)(9)-(a)(9)(D) (with renumbering) and (a)(18)-(19), and amendment of subsection (a)(14) (Register 92, No. 23).
4. Editorial correction of subsection (a)(6) (Register 2002, No. 14).
5. Amendment of subsections (a) and (d), new subsections (d)-(d)(3), redesignation and amendment of former subsection (d)(1) as subsection (e), subsection relettering and amendment of newly designated subsection (g) filed 5-9-2005; operative 6-8-2005 (Register 2005, No. 19).
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