Cal. Code Regs. tit. 22 § 80070

Current through Register 2024 Notice Reg. No. 49, December 6, 2024

Section 80070 - Client Records

(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

(b) Each record must contain information including, but not limited to, the following:

(1) Name of client.

(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 80068.

(7) Name, address and telephone number of physician and dentist, and other medical and mental health providers, if any.

(8) Medical assessment, including ambulatory status, as specified in Section 80069.

(9) Record of any illness or injury requiring treatment by a physician or dentist and for which the facility provided assistance to the client in meeting his/her necessary medical and dental needs.

(10) Record of current medications, including the name of the prescribing physician, and instructions, if any, regarding control and custody of medications.

(11) Restricted Health Condition Care Plan, if required for the client by Section 80092.2.

(12) Functional assessment as specified in Section 80069.2.

(13) Date of termination of services.

(14) An account of the client's cash resources, personal property, and valuables entrusted as specified in Section 80026.

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

(1) The licensee shall be responsible for safeguarding the confidentiality of record contents.

(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 client 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 clients unless the same information is otherwise readily available in another document or format:

(A) Name, address, and telephone number of the authorized representative(s) as specified in Section 80070(b)(5).

(B) Name, address, and telephone number of a client's physician and dentist, and any other medical and mental health providers, as specified in Section 80070(b)(7).

(C) Medical assessment, including ambulatory status, as specified in Section 80070(b)(8).

(D) Record of any current illness or injury as specified in Section 80070(b)(9).

(E) Record of current medications as specified in Section 80070(b)(10).

(F) Restricted Health Condition Care Plan as specified in Section 80070(b)(11).

(G) Functional assessment as specified in Section 80070(b)(12).

(H) Any other records containing current emergency or health-related information for current clients.

(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 client's records shall be open to inspection by the client's authorized representative(s), if any.

(f) The information specified in (b)(1)-(b)(15) above must be updated as necessary to ensure the accuracy of the client's record.

(g) Original client records or photographic reproductions shall be retained for at least three years following termination of service to the client.

(h) A licensee of a Group Home or Adult Residential Facility that has been approved to utilize secured perimeters shall meet the requirements of the California Code of Regulations, Title 17, Division 2, Chapter 3, Subchapter 4, Article 12, Sections 56073(b), (c), (e), (m) and Sections 56071(b) through (b)(2).

(1) If the informed consent agreeing to the placement in a facility is signed by a client's legally authorized representative, the licensee shall obtain documentation showing that the authorized representative is legally entitled to act on behalf of the client, in this regard, including but not limited to any court order authorizing the individual to act on the client's behalf.

(i) In addition to these requirements, a licensee of a Group Home or Adult Residential Facility that has been approved to utilize secured perimeters shall ensure that the documents required by Title 17, Section 56073 are maintained in the client record.

Cal. Code Regs. Tit. 22, § 80070

1. New subsection (b)(12) filed 6-15-87; operative 7-15-87 (Register 87, No. 25).
2. New subsections (b)(11)-(12), subsection renumbering, and amendment of subsection (e) and NOTE filed 1-31-97 as an emergency; operative 2-1-97 (Register 97, No. 5). A Certificate of Compliance must be transmitted to OAL by 6-2-97 or emergency language will be repealed by operation of law on the following day.
3. Editorial correction of HISTORY 2 (Register 97, No. 21).
4. New subsections (b)(11)-(12), subsection renumbering, and amendment of subsection (e) and NOTE refiled 5-21-97 as an emergency; operative 6-1-97 (Register 97, No. 21). A Certificate of Compliance must be transmitted to OAL by 9-29-97 or emergency language will be repealed by operation of law on the following day.
5. New subsections (b)(11)-(12), subsection renumbering, and amendment of subsection (e) and NOTE refiled 9-29-97 as an emergency; operative 9-29-97 (Register 97, No. 40). A Certificate of Compliance must be transmitted to OAL by 1-27-98 or emergency language will be repealed by operation of law on the following day.
6. New subsections (b)(11)-(12), subsection renumbering, and amendment of subsection (e) and NOTE refiled 1-26-98 as an emergency; operative 1-27-98 (Register 98, No. 5). A Certificate of Compliance must be transmitted to OAL by 5-27-98 or emergency language will be repealed by operation of law on the following day.
7. Editorial correction of HISTORY 5 and 6 (Register 98, No. 13).
8. Certificate of Compliance as to 1-26-98 order transmitted to OAL 2-6-98; disapproved 3-23-98 (Register 98, No. 13).
9. New subsections (b)(11)-(12), subsection renumbering, and amendment of subsection (e) and NOTE refiled 3-23-98 as an emergency; operative 3-23-98 (Register 98, No. 13). A Certificate of Compliance must be transmitted to OAL by 7-21-98 or emergency language will be repealed by operation of law on the following day.
10. Certificate of Compliance as to 3-23-98 order, including further amendment of subsection (b), new subsection (b)(11), subsection renumbering and amendment of subsection (e), transmitted to OAL 7-21-98 and filed 9-1-98; amendments operative per agency request 10-1-98 (Register 98, No. 36).
11. Amendment of section and NOTE filed 5-9-2005; operative 6-8-2005 (Register 2005, No. 19).
12. Change without regulatory effect amending subsection (b), repealing subsection (b)(13), renumbering subsections, repealing subsection (d)(1)(H) and relettering subsections filed 1-5-2016 pursuant to section 100, title 1, California Code of Regulations (Register 2016, No. 2).
13. New subsections (h)-(h)(1)(i) and amendment of NOTE filed 2-9-2017 as an emergency; operative 2-9-2017 (Register 2017, No. 6). A Certificate of Compliance must be transmitted to OAL by 8-8-2017 or emergency language will be repealed by operation of law on the following day.
14. Certificate of Compliance as to 2-9-2017 order transmitted to OAL 8-3-2017 and filed 9-15-2017 (Register 2017, No. 37).

Note: Authority cited: Sections 1530 and 1531.15, Health and Safety Code. Reference: Sections 1501, 1507, 1531 and 1531.15, Health and Safety Code.

1. New subsection (b)(12) filed 6-15-87; operative 7-15-87 (Register 87, No. 25).
2. New subsections (b)(11)-(12), subsection renumbering, and amendment of subsection (e) and Note filed 1-31-97 as an emergency; operative 2-1-97 (Register 97, No. 5). A Certificate of Compliance must be transmitted to OAL by 6-2-97 or emergency language will be repealed by operation of law on the following day.
3. Editorial correction of History 2 (Register 97, No. 21).
4. New subsections (b)(11)-(12), subsection renumbering, and amendment of subsection (e) and Note refiled 5-21-97 as an emergency; operative 6-1-97 (Register 97, No. 21). A Certificate of Compliance must be transmitted to OAL by 9-29-97 or emergency language will be repealed by operation of law on the following day.
5. New subsections (b)(11)-(12), subsection renumbering, and amendment of subsection (e) and Note refiled 9-29-97 as an emergency; operative 9-29-97 (Register 97, No. 40). A Certificate of Compliance must be transmitted to OAL by 1-27-98 or emergency language will be repealed by operation of law on the following day.
6. New subsections (b)(11)-(12), subsection renumbering, and amendment of subsection (e) and Note refiled 1-26-98 as an emergency; operative 1-27-98 (Register 98, No. 5). A Certificate of Compliance must be transmitted to OAL by 5-27-98 or emergency language will be repealed by operation of law on the following day.
7. Editorial correction of History 5 and 6 (Register 98, No. 13).
8. Certificate of Compliance as to 1-26-98 order transmitted to OAL 2-6-98; disapproved 3-23-98 (Register 98, No. 13).
9. New subsections (b)(11)-(12), subsection renumbering, and amendment of subsection (e) and Note refiled 3-23-98 as an emergency; operative 3-23-98 (Register 98, No. 13). A Certificate of Compliance must be transmitted to OAL by 7-21-98 or emergency language will be repealed by operation of law on the following day.
10. Certificate of Compliance as to 3-23-98 order, including further amendment of subsection (b), new subsection (b)(11), subsection renumbering and amendment of subsection (e), transmitted to OAL 7-21-98 and filed 9-1-98; amendments operative per agency request 10-1-98 (Register 98, No. 36).
11. Amendment of section and Note filed 5-9-2005; operative 6-8-2005 (Register 2005, No. 19).
12. Change without regulatory effect amending subsection (b), repealing subsection (b)(13), renumbering subsections, repealing subsection (d)(1)(H) and relettering subsections filed 1-5-2016 pursuant to section 100, title 1, California Code of Regulations (Register 2016, No. 2).