California Code of Regulations › Title 22 - Social Security › Division 5 - Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies › Chapter 8.5 - Intermediate Care Facilities/Developmentally Disabled-Habilitative › Article 4 - Administration › Section 76925 - Client Record Service

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(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.