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§ 76925. Client Record Service.

22 CA ADC § 76925Barclays Official California Code of Regulations

Barclays California Code of Regulations
Title 22. Social Security
Division 5. Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies (Refs & Annos)
Chapter 8.5. Intermediate Care Facilities/Developmentally Disabled--Habilitative
Article 4. Administration
22 CCR § 76925
§ 76925. Client Record Service.
(a) The client record service shall provide for the collection, organization and confidentiality of client information.
(b) Unit client records shall be kept current and complete in detail consistent with good medical and professional practice based on the service provided to each client.
(c) All required records, either originals or accurate reproductions, shall be maintained in a legible form and promptly available upon the request of all authorized users and any authorized employee or agent of the Department.
(d) All current clinical information related to the client's individual service plan shall be centralized in the individual's unit client record. It shall be immediately available to the direct care staff. Inactive records or thinned portions of the active unit client record shall be securely stored in the facility or an off-site area approved by the Department.
(e) Client record storage areas shall be clean and protect the information from loss, destruction or defacement by fire, flood, humidity, insects or unauthorized access.
(f) Information contained in the unit client records, including information contained in an automated data bank, shall be considered confidential and shall be protected from unauthorized access or use and released only to authorized persons in accordance with federal, state and local laws.
(g) Unit client records shall be retained for seven years from the last date of service, except for records of minors, which shall be kept at least three years after the client has reached the age of eighteen and, in any case, not less than seven years.
(h) The unit client record is the property of the facility and shall be maintained for the benefit of the client, the interdisciplinary professional staff/team and the facility.
(i) The Department shall be informed within three business days prior to any cessation of a facility's operation of the arrangements made for the safe preservation of the unit client records.
(j) The Department shall be informed within three business days in writing, whenever unit client records are defaced or destroyed before the termination of the required retention period.
(k) If the ownership of the facility 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 will have custody of the unit client records and these records will be available to the former licensee, the new licensee and other legally authorized persons; or
(2) That other arrangements have been made by the current licensee for the safe preservation and the location of the unit client records, and that they are available to both the new and former licensees and other legally authorized persons; or
(3) The reasons for the unavailability of the records.
(l) The facility shall maintain a perpetual alphabetical index of all clients which includes at least:
(1) Identifying data;
(2) Dates of admission and discharge;
(3) Current location of all records.

Credits

Note: Authority cited: Sections 208.4 and 1267.7, Health and Safety Code. Reference: Section 1276, Health and Safety Code.
This database is current through 5/10/24 Register 2024, No. 19.
Cal. Admin. Code tit. 22, § 76925, 22 CA ADC § 76925
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