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Key Concepts: Resident Records

13 key concepts from Title 22, Division 6, Chapter 8, Article 9: Resident Records, for the RCFE Administrator exam. For the searchable, bookmarkable version, use the interactive Study Guide.

Documenting Appraisal & Assessment Findings
87505 p. 143
Every facility has to document, in writing, the findings of the pre-admission appraisal and any reappraisal/assessment (per 87457 and 87463). If a physician's supporting documentation is needed, that has to be obtained too, and it can be the same assessment already required under 87458 (Medical Assessment).
Show Title 22 source text
Each facility shall document in writing the findings of the pre-admission appraisal and any reappraisal or assessment which was necessary in accordance with Sections 87457, Pre-Admission Appraisal, and 87463, Reappraisals. If supporting documentation from a physician is required, this input shall also be obtained and may be the same assessment as required in Section 87458, Medical Assessment.Part 3, Page 143
Where Records Are Kept & Basic Info Required
87506 p. 143
Each resident needs their own separate, complete, current record, kept at the facility or a central administrative location that's readily available to facility and licensing staff. At minimum, each record has to include:
  • Legal name and preferred name.
  • Social Security number.
  • Admission and discharge dates.
  • Birthdate.
  • Religious preference and clergy/advisor contact, if any.
  • Reports from the 87458 medical assessment, plus any special problems or precautions.
  • Documentation required under 87611 for residents with an allowable health condition.
Show Title 22 source text
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.Part 3, Page 143
(b) Each resident's record shall contain at least the following information: (1) Resident's legal name and preferred name, as indicated by the resident. (2) Social Security number. (4) Dates of admission and discharge. (6) Birthdate. (7) Religious preference, if any, and name and address of clergyman or religious advisor, if any. (10) Reports of the medical assessment specified in Section 87458, Medical Assessment, and of any special problems or precautions. (11) The documentation required by Section 87611 for residents with an allowable health condition.Part 3, Page 143
More Required Record Contents
87506 p. 144
The record also has to include: the resident's ambulatory status; current centrally-stored medications (per 87465); and the admission agreement and pre-admission appraisal (per 87507 and 87457).
Show Title 22 source text
(12) Ambulatory status.Part 3, Page 144
(14) Current centrally stored medications as specified in Section 87465, Incidental Medical and Dental Care Services.Part 3, Page 144
(15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.Part 3, Page 144
Confidentiality & Licensing Agency Access
87506 p. 144-145
Everything obtained from or about residents is confidential. The licensee is responsible for storing active and inactive records securely, and the licensee/staff can only reveal confidential info with the resident's (or their representative's) written consent.

Resident records still have to be available to the licensing agency for inspection, audit, and copying during normal business hours, and can be removed if needed for copying.
Show Title 22 source text
(c) All information and records obtained from or regarding residents shall be confidential. (1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative.Part 3, Page 144
(d) All resident 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:Part 3, Page 144
What Can't Be Removed & the Retention Period
87506 p. 145
When a licensing representative removes records for copying, they generally can't take certain current emergency/health-related information for current residents (religious preference and clergy contact, responsible-person contact, physician/dentist contact, medical assessment info, allowable-health-condition documentation, ambulatory status, current medications, or similar) unless it's otherwise readily available elsewhere. Before removing anything, they have to prepare, sign, and date a list and leave a copy with the administrator/designee, and return records undamaged, in good order, within 3 business days.

Original records (or photographic reproductions) have to be kept for at least 3 years after service to the resident ends. (Same 3-year rule as the Numbers & Deadlines "Resident Records Retention Period" card.)
Show Title 22 source text
(1) Licensing representatives shall not remove the following current records for current residents unless the same information is otherwise readily available in another document or format: (A) Religious preference... (B) Name, address, and telephone number of responsible person(s)... (C) Name, address, and telephone number of the resident's physician and dentist... (D) Information relating to the resident's medical assessment and any special problems or precautions... (E) Documentation required for residents with an allowable health condition... (F) Information on ambulatory status... (G) Continuing record of any illness, injury, or medical or dental care... (H) Records of current medications... (I) Any other records containing current emergency or health-related information for current residents.Part 3, Page 145
(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.Part 3, Page 145
(e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident.Part 3, Page 145
The Admission Agreement: Format & Basic Requirements
87507 p. 146
The licensee has to complete an individual written admission agreement with each resident (or their representative), printed in 12-point (or larger) black type on plain white paper (one side only), in clear, everyday language, appropriately organized and titled by section.

If the resident is deaf, hearing-impaired, or otherwise disabled per their appraisal/medical assessment, the licensee has to complete and keep a Telecommunications Device Notification form in their file.

Agreements have to be signed and dated by both sides within 7 days of admission (same window as the Numbers & Deadlines "Signing the Admission Agreement" card). The licensee keeps the original signed agreement and all modifications on file, gives the resident a copy immediately upon signing (and more copies on request), makes blank copies available to the public on request, posts a copy (or notice of its availability) publicly in the facility, and has to actually follow everything the agreement says.
Show Title 22 source text
(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. (1) The text of the admission agreement, including any attachments and modifications, shall be: (A) Printed in black type of not less than 12-point type size, on plain white paper. The print shall appear on one side of the paper only. (B) Written in clear, understandable, coherent, and unambiguous language, using words with common and everyday meanings, and shall be appropriately divided with each section appropriately titled.Part 3, Page 146
(b) The licensee shall complete and maintain in the resident's file a Telecommunications Device Notification form (LIC 9158, 11/04) for each resident whose pre-admission appraisal or medical assessment indicates he/she is deaf, hearing-impaired, or otherwise disabled in accordance with Public Utilities Code sections 2881(a) and (c).Part 3, Page 146
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission.Part 3, Page 146
(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. (e) The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. (1) The licensee shall provide blank copies of the most current approved admission agreement, modifications and attachments immediately to the public upon request. (2) The licensee shall conspicuously post in a location accessible to public view in the facility a complete copy of the approved admission agreement, modifications and attachments, or notice of their availability from the facility. (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments.Part 3, Page 146
What the Agreement Must Specify: Services & Basic Rate
87507 p. 147
The admission agreement has to specify: which basic services will be provided, which additional items/services are available, and payment provisions, including the rate for basic services, with a comprehensive description of anything covered under a single fee (like a monthly room-and-board rate).
Show Title 22 source text
(g) Admission agreements shall specify the following: (1) Basic services, as defined in Section 87101(b), to be made available. (2) Additional items and services which are available. (3) Payment provisions, including the following: (A) Rate for all basic services which the facility is required to provide in order to obtain and maintain a license. Basic services rate(s), including: 1. A comprehensive description of any items and services provided under a single fee, such as monthly fee for room, board and other items and services shall be listed.Part 3, Page 147
What the Agreement Must Specify: Payment Details
87507 p. 148
The agreement also has to specify: who pays for each item/service, when payment is due, the funding source (though the resident can refuse to disclose it), a full description of billing/payment procedures, and confirmation that an itemized monthly statement of all separate charges will be provided.
Show Title 22 source text
(D) Payor of all items and services. (E) Due Date. (F) Funding source, provided that the resident may refuse to disclose such source. (G) A comprehensive description of billing and payment procedures. (H) A provision indicating that an itemized monthly statement that lists all separate charges incurred by the resident that are collected by the facility shall be provided to the resident or the resident's representative, if any.Part 3, Page 148
Rate/Rate-Structure Modification Notice
87507 / H&S 1569.655 p. 148.1
Modification terms in the admission agreement have to include at least 60 days' prior written notice before any rate or rate-structure change, or, for SSI/SSP rate changes, as soon as the licensee is notified. (Same 60-day rule as the "Rate Increase Notice" card.)

Separately, licensees can never charge a nonrecurring lump-sum assessment: unexpected costs instead get folded into the monthly rate and amortized over 12 months.
Show Title 22 source text
(4) Modification conditions, including the requirement for the provision of at least 60 days prior written notice to the resident of any rate or rate structure change, or as soon as the licensee is notified of SSI/SSP rate changes.Part 3, Page 148.1
(a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 60 days' prior written notice to the residents or the residents' representatives setting forth the amount of the increase, the reason for the increase, and a general description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident.Part 3, Page 148.1
(b) No licensee shall charge nonrecurring lump-sum assessments... all increases in rates shall be to the monthly rate amortized over a 12-month period.Part 3, Page 148.1
Level-of-Care Rate Increase & Refund Policy Reference
H&S 1569.657 / 87507 p. 148.2
If a rate goes up specifically because a resident's level of care changed, the licensee only has to give written notice within 2 business days after starting the new level of service, with a detailed explanation of the added services and an itemized charge breakdown (rather than the usual 60-day notice).

The admission agreement also has to spell out the facility's refund policy, including how advance monthly fees are refunded after a resident's death (per H&S 1569.652).
Show Title 22 source text
(a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident's representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges.Part 3, Page 148.2
(5) Refund conditions. (A) Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident's death, pursuant to Health and Safety Code section 1569.652.Part 3, Page 148.2
Death, Property Removal & Refund Timing
H&S 1569.652 p. 148.3
When a resident dies, the facility can't require advance notice to terminate the admission agreement; fees stop accruing the moment all of the resident's personal property is removed from their living unit. The licensee also can't impede that removal, during reasonable hours, by anyone authorized by the resident/responsible person or by a court-appointed executor/administrator.

Any fees paid in advance covering time after the property is removed get refunded, to whoever is contractually responsible for the fees, or to the resident's estate if the resident paid them, within 15 days of the property being removed. (Same 15-day rule as the "Refunding Fees After a Resident's Death" card.)
Show Title 22 source text
(a) A residential care facility for the elderly shall not require advance notice for terminating an admission agreement upon the death of a resident. No fees shall accrue once all personal property belonging to the deceased resident is removed from the living unit.Part 3, Page 148.3
(b) Upon the death of a resident, a licensee shall not impede the removal of the resident's personal property from the facility during reasonable hours by an individual or individuals authorized by the resident or the resident's responsible person, as identified in the admission agreement or attachment, or by a court-appointed executor or administrator of the decedent's estate, if applicable.Part 3, Page 148.3
(c) A refund of any fees paid in advance covering the time after the resident's personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident's estate, within 15 days after the personal property is removed.Part 3, Page 148.3
Department's Record-Examination Authority
87507 p. 148.6
The admission agreement has to acknowledge the Department's (or licensing agency's) authority to examine resident records as part of evaluating the facility.
Show Title 22 source text
(6) The Department or licensing agency's authority to examine residents' records as a part of their evaluation of the facility.Part 3, Page 148.6
Family Visits Policy, General Policies & Grievance Notification
87507 p. 148.7
The agreement also has to cover: the facility's family-visit/communication policy (which has to actively encourage family involvement, per H&S 1569.313); general facility policies for residents living together (which have to be reasonable, can't violate any rights/laws, must include a procedure for residents to suggest changes, and must cover firearms retention/prohibition policy (with any permitted firearms stored per H&S 1569.282); and notification of how residents can access the facility's grievance procedure.
Show Title 22 source text
(7) The facility's policy concerning family visits and other communication with residents, pursuant to Health and Safety Code section 1569.313.Part 3, Page 148.7
Health and Safety Code section 1569.313 provides in part: "The facility's policy concerning family visits and communication shall be designed to encourage regular family involvement with the resident client and shall provide ample opportunities for family participation in activities at the facility."Part 3, Page 148.7
(8) General facility policies that are for the purpose of making it possible for residents to live together. (A) All facility policies shall be reasonable, and shall not violate any applicable rights, laws or regulations. (B) Procedures for residents to suggest changes to facility policies shall be specified. (C) All policies concerning the retention or prohibition of firearms by residents of the facility. 1. If the licensee permits residents to retain firearms at the facility, such firearms shall be stored in compliance with Health and Safety Code section 1569.282.Part 3, Page 148.7
(9) Notification of the availability of the facility grievance procedure(s) to address and resolve resident complaints regarding facility practices.Part 3, Page 148.7

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