Section 81070 - Client Records(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.(b) Each client record shall contain the following information including, but not limited to, the following: (6) Name, address, and telephone number of the client's authorized representative(s), if any.(7) A signed copy of the admission agreement specified in Section 81068.(8) Name, address and telephone number of the client's physician and dentist, and other medical and mental health providers, if any.(9) Medical assessment, including ambulatory status, as specified in Section 81069.(10) 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.(11) Record of current medications, including the name of the prescribing physician, and instructions, if any, regarding control and custody of medications.(12) Restricted Health Condition Care Plan, if required for the client by Section 81092.2.(13) Functional assessment as specified in Section 81069.2.(14) Religious preference, and name and address of clergyman or religious advisor, if any.(15) Needs and services plan and any modifications thereto, as specified in Sections 81068.2 and 81068.3.(16) An account of the client's cash resources, personal property, and valuables entrusted as specified in Section 81026.(17) Date of termination of services.(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 Section 81070(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 client's authorized representative(s) as specified in Section 81070(b)(6).(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 81070(b)(8).(C) Medical assessment, including ambulatory status, as specified in Section 81070(b)(9).(D) Record of any current illness or injury as specified in Section 81070(b)(10).(E) Record of current medications as specified in Section 81070(b)(11).(F) Restricted Health Condition Care Plan as specified in Section 81070(b)(12).(G) Functional assessment as specified in Section 81070(b)(13).(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 Section 81070(b)(1) through (b)(17) 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.Cal. Code Regs. Tit. 22, § 81070
1. New section filed 1-7-91; operative 2-2-91 pursuant to Government Code section 11346.2(d) (Register 91, No. 12).
2. Change without regulatory amending section and NOTE filed 1-5-2016 pursuant to section 100, title 1, California Code of Regulations (Register 2016, No. 2). Note: Authority cited: Section 1530, Health and Safety Code. Reference: Sections 5670 and 5671, Welfare and Institutions Code; and Sections 1501, 1502(a)(7), 1507 and 1531, Health and Safety Code.
1. New section filed 1-7-91; operative 2-2-91 pursuant to Government Code section 11346.2(d) (Register 91, No. 12).
a1 The reorganization of Chapter 2 is printed as a repealer and adoption for clarity.
2. Change without regulatory amending section and Note filed 1-5-2016 pursuant to section 100, title 1, California Code of Regulations (Register 2016, No. 2).