Every binder your California RCFE must maintain: what goes in it, who can access it, whether it must be locked, and what CDSS expects to find when an inspector opens it. Organized by binder category.
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CDSS inspectors typically look for: resident charts with appraisals, care plans, physician reports, and admission agreements; personnel files with Live Scan clearances and training records; medication records including MARs and controlled substance logs; incident and complaint logs; fire drill records; and administrator training records. The checklist organizes every required binder and its contents.
Resident charts, medication records, controlled substance logs, and trust account ledgers must be kept locked and accessible only to authorized personnel. Personnel files must also be kept confidential. CCR §§87458 and 87507 govern resident record confidentiality. CCR §87465 governs medication storage and record access requirements.
CCR §87507 requires that resident records be retained for at least three years after the date of discharge. For minors (which is unusual in RCFE settings), records must be kept until the person turns 21. When a facility closes, CDSS must be notified and arrangements made to store records appropriately.
The controlled substance log must track each controlled medication by resident name, medication name, strength, dosage, date, time, count administered, and staff signature. A beginning and ending count must be documented each shift. Any discrepancy must be reported to the administrator and the physician, and documented in the log. CDSS inspectors verify count accuracy during inspections.
Yes. The binders and records requirements are substantially the same for both capacity ranges. For 7-15 bed facilities, staffing-related records reflect the additional staffing requirements for larger facilities, but the binder categories, confidentiality rules, and retention periods are the same.