Section 784.28 - Clients' Records(a) Clients' records shall be permanent, either typewritten or legibly written in ink, be capable of being photocopied and shall be kept on all clients admitted or accepted for care. All health records of discharged clients shall be completed and filed within 30 days after discharge date and such records shall be kept for a minimum of seven (7) years. All required records, either originals or accurate reproductions thereof, shall be maintained in such form as to be legible and readily available upon the request of the attending physician, the mental health rehabilitation center staff or any authorized officer, agency, or employee of either, or any other person authorized by law to make such request.(b) Information contained in the clients' records shall be confidential and shall be disclosed only to authorized persons in accordance with federal, state and local laws.(c) If a mental health rehabilitation center ceases operation, the Department shall be informed within three (3) business days by the licensee of the arrangements made for the safe preservation of the client's health records.(d) The Department shall be informed within three business days, in writing, whenever client records are defaced or destroyed prior to expiration of the required retention period.(e) If the ownership of the mental health rehabilitation center changes, both the licensee and the applicant for the new license shall, prior to the change of ownership, provide the Department with written documentation stating: (1) That the new licensee shall have custody of the clients' records and that these records or copies shall be available to the former licensee, the new licensee and other authorized persons; or(2) That other arrangements have been made by the licensee for the safe preservation and the location of the clients' records, and that they are available to both the new and former licensees and other authorized persons; or(3) The reason for the unavailability of such records.(f) Clients' records shall be current and kept in detail consistent with good medical and professional practice based on the service provided to each client. Such records shall be filed and maintained in accordance with these requirements and shall be available for review by the Department. All entries in the record shall be authenticated with the date, name, and title of the persons making the entry.(g) All current clinical information pertaining to clients' stay shall be centralized in clients' records.(h) Clients' records shall be filed in an accessible manner in the mental health rehabilitation center or in health record storage. Storage of records shall provide for prompt retrieval when needed for continuity of care. Records can be stored off the mental health rehabilitation center premises only with the prior approval of the Department.(i) Clients' records shall not be removed from the mental health rehabilitation center, except for storage after the client is discharged, unless expressly and specifically authorized by the Department.Cal. Code Regs. Tit. 9, § 784.28
1. New section filed 8-21-95 as an emergency; operative 8-21-95 (Register 95, No. 34). A Certificate of Compliance must be transmitted to OAL by 2-17-95 or emergency language will be repealed by operation of law on the following day.
2. New section refiled 2-9-96 as an emergency; operative 2-9-96 (Register 96, No. 6). A Certificate of Compliance must be transmitted to OAL by 6-8-96 or emergency language will be repealed by operation of law on the following day.
3. New section refiled 6-10-96 as an emergency; operative 6-10-96 (Register 96, No. 24). A Certificate of Compliance must be transmitted to OAL by 10-8-96 or emergency language will be repealed by operation of law on the following day.
4. New section refiled 10-8-96 as an emergency; operative 10-8-96 (Register 96, No. 41). A Certificate of Compliance must be transmitted to OAL by 2-5-97 or emergency language will be repealed by operation of law on the following day.
5. Certificate of Compliance as to 10-8-96 order transmitted to OAL 2-5-97; disapproved by OAL and order of repeal as to 10-8-96 order filed on 3-21-97 (Register 97, No. 12).
6. New section filed 3-21-97 as an emergency; operative 3-21-97 (Register 97, No. 12). A Certificate of Compliance must be transmitted to OAL by 7-21-97 or emergency language will be repealed by operation of law on the following day.
7. Certificate of Compliance as to 3-21-97 order, including renumbering of former section 784.28 to new section 784.37, and renumbering and amendment of former section 784.21 to new section 784.28, transmitted to OAL 7-21-97 and filed 8-21-97 (Register 97, No. 34). Note: Authority cited: Sections 5675 and 5768, Welfare and Institutions Code; Section 3 of Chapter 678 of the Statutes of 1994. Reference: Sections 5675 and 5768, Welfare and Institutions Code.
1. New section filed 8-21-95 as an emergency; operative 8-21-95 (Register 95, No. 34). A Certificate of Compliance must be transmitted to OAL by 2-17-95 or emergency language will be repealed by operation of law on the following day.
2. New section refiled 2-9-96 as an emergency; operative 2-9-96 (Register 96, No. 6). A Certificate of Compliance must be transmitted to OAL by 6-8-96 or emergency language will be repealed by operation of law on the following day.
3. New section refiled 6-10-96 as an emergency; operative 6-10-96 (Register 96, No. 24). A Certificate of Compliance must be transmitted to OAL by 10-8-96 or emergency language will be repealed by operation of law on the following day.
4. New section refiled 10-8-96 as an emergency; operative 10-8-96 (Register 96, No. 41). A Certificate of Compliance must be transmitted to OAL by 2-5-97 or emergency language will be repealed by operation of law on the following day.
5. Certificate of Compliance as to 10-8-96 order transmitted to OAL 2-5-97; disapproved by OAL and order of repeal as to 10-8-96 order filed on 3-21-97 (Register 97, No. 12).
6. New section filed 3-21-97 as an emergency; operative 3-21-97 (Register 97, No. 12). A Certificate of Compliance must be transmitted to OAL by 7-21-97 or emergency language will be repealed by operation of law on the following day.
7. Certificate of Compliance as to 3-21-97 order, including renumbering of former section 784.28 to new section 784.37, and renumbering and amendment of former section 784.21 to new section 784.28, transmitted to OAL 7-21-97 and filed 8-21-97 (Register 97, No. 34).