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重点内容:住户记录

来自 Title 22 第6分部第8章「第9条:住户记录」的 13 条重点内容中文说明。如需可搜索、可收藏的版本,请使用互动学习指南

记录评估结果
87505 p. 143
每家设施须以书面形式记录入住前评估以及依据87457及87463所需进行的任何重新评估/评估结果。如需医生提供支持文件,也须一并获取——这可以与87458(医疗评估)所要求的评估为同一份。
查看 Title 22 法规原文

法规原文(英文)

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
档案的保存地点及所需基本信息
87506 p. 143
每位住户须拥有单独、完整、最新的档案——保存在设施内,或保存在设施员工及许可机构员工均能随时取用的中央管理场所。每份档案至少须包含:
  • 法定姓名及本人偏好使用的姓名。
  • 社会安全号码。
  • 入住及出院日期。
  • 出生日期。
  • 宗教偏好,以及神职人员/宗教顾问的联系方式(如有)。
  • 87458医疗评估的报告,以及任何特殊问题或注意事项。
  • 依87611对具有允许健康状况的住户所要求的记录。
查看 Title 22 法规原文

法规原文(英文)

(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
档案须包含的其他内容
87506 p. 144
档案还须包括:住户的自行走动状态;依87465集中保管的当前药物;以及依87507和87457所要求的入住协议及入住前评估。
查看 Title 22 法规原文

法规原文(英文)

(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
保密性与许可机构的查阅权
87506 p. 144-145
从住户处获得或与住户相关的所有信息均属保密信息。许可证持有人须负责安全存放在用及已停用的档案,许可证持有人/员工只能在获得该住户(或其代表)书面同意的情况下披露保密信息。

住户档案仍须在正常营业时间内供许可机构检查、审计及复印,如需复印可将档案取走。
查看 Title 22 法规原文

法规原文(英文)

(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
不得取走的内容及保存期限
87506 p. 145
许可机构代表取走档案进行复印时,通常不得取走现有住户的某些当前紧急/健康相关信息(宗教偏好及神职人员联系方式、负责人联系方式、医生/牙医联系方式、医疗评估信息、允许健康状况的记录、自行走动状态、当前用药情况或类似信息),除非该信息另有其他文件或格式可随时取得。取走档案前,须准备、签署并注明清单日期,并将清单副本留给管理员或其指定人员——并须在3个工作日内将档案完好、有序地归还。

原始档案(或影印副本)须在住户服务终止后至少保存3年。(与"数字与期限"卡片中"住户档案保存期限"相同的3年规则。)
查看 Title 22 法规原文

法规原文(英文)

(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
入住协议:格式及基本要求
87507 p. 146
许可证持有人须与每位住户(或其代表)分别订立书面入住协议,须使用12号或以上字号的黑色字体,印刷在纯白色纸张(仅单面印刷)上,措辞清晰易懂,并按章节适当分类、加以标题。

如果该住户依其评估/医疗评估结果为耳聋、听力受损或存在其他残疾,许可证持有人须在其档案中填写并保存一份电信设备告知表。

协议须在入住7天内由双方签字并注明日期(与"数字与期限"卡片中"签署入住协议"相同的时限)。许可证持有人须将已签署的协议原件及所有修改内容存档,在签字后立即给住户提供副本(并根据要求提供更多副本),应公众要求提供空白版协议,在设施内公开张贴协议副本(或其可取得方式的通知),并须实际遵守协议中的所有条款。
查看 Title 22 法规原文

法规原文(英文)

(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
协议须列明的内容:服务与基本费率
87507 p. 147
入住协议须列明:将提供哪些基本服务、有哪些额外可提供的项目/服务,以及付款条款——包括基本服务的费率,须包含对单一费用(如按月计收的食宿费率)所涵盖内容的完整说明。
查看 Title 22 法规原文

法规原文(英文)

(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
协议须列明的内容:付款细节
87507 p. 148
协议还须列明:每项项目/服务的付款人、付款到期日、资金来源(住户可拒绝披露该来源)、账单/付款程序的完整说明,以及确认将提供按月列明各项独立费用的账单。
查看 Title 22 法规原文

法规原文(英文)

(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
费率/费率结构变更通知
87507 / H&S 1569.655 p. 148.1
入住协议中的修改条款须包括:任何费率或费率结构变更前须至少提前60天以书面通知——若为SSI/SSP费率变更,则须在许可证持有人获知后立即通知。(与"费率上调通知"卡片相同的60天规则。)

另外,许可证持有人绝不得收取非经常性一次性调价费用——意外支出须并入月费率并在12个月内分摊。
查看 Title 22 法规原文

法规原文(英文)

(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
照护级别变更导致的费率上调及退款政策说明
H&S 1569.657 / 87507 p. 148.2
如果费率上调是因住户照护级别发生变化,许可证持有人只须在开始提供新照护级别服务后的2个工作日内提供书面通知——须详细说明新增服务内容并附上分项费用清单(而非通常的60天通知期)。

入住协议还须说明设施的退款政策,包括住户去世后预付月费如何退还(依《健康与安全法典》1569.652)。
查看 Title 22 法规原文

法规原文(英文)

(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
去世、财物清理与退款时限
H&S 1569.652 p. 148.3
住户去世时,设施不得要求提前通知才能终止入住协议——一旦该住户的全部个人物品从其居住单元中清空,费用即停止累计。许可证持有人也不得阻碍经该住户/负责人授权的人员,或经法院指定的遗产执行人/管理人,在合理时间内清理该财物。

任何在财物清理之后时段所预收的费用,须在财物清理完成后15天内退还给——依合同对该费用负责的个人或实体,如系住户本人支付则退还其遗产。(与"住户去世后费用退还"卡片相同的15天规则。)
查看 Title 22 法规原文

法规原文(英文)

(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
部门对档案的审查权
87507 p. 148.6
入住协议须确认部门(或许可机构)在评估设施过程中有权查阅住户档案。
查看 Title 22 法规原文

法规原文(英文)

(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
家属探访政策、一般性规定及申诉告知
87507 p. 148.7
协议还须涵盖:设施的家属探访/沟通政策(须依《健康与安全法典》1569.313积极鼓励家属参与);供住户共同生活的一般性设施规定(须合理、不得违反任何权利/法律,须包含住户提出规定修改建议的程序,并须涵盖枪支保留/禁止政策——获准保留的枪支须依《健康与安全法典》1569.282保管);以及关于住户如何获取设施申诉程序的告知。
查看 Title 22 法规原文

法规原文(英文)

(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