Section 82070 - Client Records(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. A separate, complete, and current record shall be maintained at the program site for each client.(b) Each record must 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 82068.(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 82069(b).(9) Record of any illness or injury requiring treatment by a physician or dentist and for which the day program 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 82092.2.(12) Date of termination of services.(13) In those cases in which the licensee handles the client's cash, an account of the client's cash resources, personal property, and valuables entrusted as specified in Sections 82026(h) through (k).(14) Needs and Services Plan as specified in Section 82068.2.(15) Modifications to the Needs and Services Plan as specified in Section 82068.3.(16) Authorization, signed and dated by the client or his/her authorized representative, to specific individuals/agencies for release of medical information, or a statement signed and dated by the client or authorized representative, that the client or authorized representative will not sign an authorization.(17) Authorization, signed and dated by the client or his/her authorized representative, for the client to receive emergency medical care, if necessary, or a statement signed and dated by the client or authorized representative, that the client will not sign an authorization.(18) Correspondence and incident reports relating to the client.(19) Reason for discharge from the center.(c) All information and records obtained from or regarding clients shall be confidential. (1) The licensee shall be responsible for safeguarding the confidentiality of client records contents.(2) Except as specified in Section 82070(d), 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 82070(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 82070(b)(7).(C) Medical assessment, including ambulatory status, as specified in Section 82070(b)(8).(D) Record of any current illness or injury as specified in Section 82070(b)(9).(E) Record of current medications as specified in Section 82070(b)(10).(F) Restricted Health Condition Care Plan as specified in Section 82070(b)(11).(G) 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 also be open to inspection by the client's authorized representative, if any.(f) The information specified in Sections 82070(b)(1)-(13) 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, § 82070
1. Renumbering of former section 82570 to new section 82070, including amendment of section and NOTE, filed 12-13-2006; operative 1-12-2007 (Register 2006, No. 50). Note: Authority cited: Sections 1530 and 1530.1, Health and Safety Code. Reference: Sections 1501, 1507 and 1531, Health and Safety Code.
1. Renumbering of former section 82570 to new section 82070, including amendment of section and Note, filed 12-13-2006; operative 1-12-2007 (Register 2006, No. 50).