Cal. Code Regs. tit. 22 § 78431

Current through Register 2025 Notice Reg. No. 2, January 10, 2025

Section 78431 - Participant Health Records

(a) Each adult day health center shall maintain a standard health record for each participant which includes, but is not limited to:

(1) Identifying information including:

(A) Name, address, telephone number, birth date, Social Security and Medi-Cal numbers.

(B) Directions between home and adult day health center.

(C) Name, address and telephone number of personal physician; name, address and telephone number of responsible person.

(2) Admission data including:

(A) Referral source.

(B) Reason for application as given by referral source, participant and family or others.

(C) Number of days scheduled for attendance, method of transportation and fee.

(3) Daily records of participant's attendance and services utilized, including transportation.

(4) Records of:

(A) Referrals to other providers.

(B) Dates and substance of communication with the participant's physician, family members and other persons providing assistance.

(5) Medication records.

(6) Progress notes by providers of basic services.

(7) Assessment of the participant by the multidisciplinary team.

(8) Record of physician's health examination of participant.

(9) Individual plan of care.

(10) A written clearance by a physician for participants who have been absent for 30 days due to illness.

Cal. Code Regs. Tit. 22, § 78431