Section 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; (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.Cal. Code Regs. Tit. 22, § 87870
1. New section filed 6-7-91 as an emergency; operative 6-7-91 (Register 91, No. 38). A Certificate of Compliance must be transmitted to OAL by 10-7-91 or emergency language will be repealed by operation of law on the following day.
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.
1. New section filed 6-7-91 as an emergency; operative 6-7-91 (Register 91, No. 38). A Certificate of Compliance must be transmitted to OAL by 10-7-91 or emergency language will be repealed by operation of law on the following day.
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).