California Code of Regulations › Title 22 - Social Security › Division 5 - Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies › Chapter 8 - Intermediate Care Facilities for the Developmentally Disabled › Article 4 - Administration › Section 76561 - Content of Records

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A
				  record shall be maintained for each client which shall include the following:
(1) Individual program plan.
(2) Report(s) of the preadmission
				  evaluation(s).
(3) Reports of
				  previous histories and evaluations.
(4) The statement of the client's
				  developmental potential and service needs that can be used as a basis for
				  programming and placement potential as required in Section
				  76313(a)(2).
(5) Drug and treatment orders.
(6) Diet orders.
(7) The comprehensive evaluation and
				  individual program plan designed by an interdisciplinary team as required in
				  Section 76313.
(8) Reports of accidents, seizures, illnesses
				  and immunizations.
(9) Records of
				  all periods of restraint with justification and authorization for
				  each.
(10) Progress notes written
				  by members of the interdisciplinary team at least monthly. In addition,
				  progress notes will be written by members of the other disciplines who are
				  requested to assess the client.
(11) Medications and treatments prescribed
				  and recorded as given.
(12) Annual
				  physical examination.
(13)
				  Temperature, pulse and respiration where indicated.
(14) Reports of all laboratory tests and
				  X-rays ordered.
(15) Discharge
				  summary to include condition, diagnosis and final disposition.
(16) At the time of permanent release or
				  transfer, a summary of findings, progress and plans shall be
				  recorded.
(17) Physician orders,
				  including drug, treatment and diet orders signed on each visit. Physicians'
				  orders recapitulated as appropriate.
(18) Consent forms for prescribed treatment
				  and medication.
(19) An inventory
				  of all client's valuables made upon admission and discharge. The inventory list
				  shall be signed by a representative of the facility and the client or the
				  client's authorized representative with one copy retained by each. The
				  inventory list shall include but not limited to the following:
(A) Items of jewelry.
(B) Items of furniture.
(C) Radios, televisions and other
				  appliances.
(D) Prosthetic
				  devices.
(E) Other valuable items
				  so identified by the client, client's parents or authorized
				  representative.
(20)
				  Name, dosage and time of administration of drugs, the route of administration
				  if other than oral and site of injection.
(21) Justification for the results of the
				  administration of all PRN medications and the withholding of scheduled
				  medications.
(22) Nursing progress
				  notes for specific medical episodes.
(23) Program staff documentations shall
				  include:
(A) A list of the client's problems
				  or needs, as identified from the individual assessment.
(B) The program objectives for resolving
				  problems or meeting needs of the client. These objectives shall be measurable,
				  observable, within time frames and subject to frequent review and
				  updating.
(C) A written plan for
				  meeting the program objectives which shall include, but not be limited to the
				  following:
1. Resources to be used.
2. Frequency of plan review and
				  updating.
3. Persons responsible
				  for carrying out the plan.
4.
				  Evaluation criteria.
(D)
				  A summary of the progress of the client shall be written at least monthly
				  evaluating the program objectives, the success or failure of the plan and any
				  other pertinent information.
(E)
				  Temperature, intake of food and liquid, restraint observation, behavior counts
				  and other similar items shall be recorded in a timely manner using a flow chart
				  or other method which meets the approval of the Department.
(F) Height and weight shall be recorded as
				  required in Section
				  76323(i) and
				  (j).
(24) The client's admission
				  record.