Medical Record Use and Access.

(a)

A hospice must maintain a medical record for every patient accepted for service by the hospice.

(b)

A hospice must preserve patient medical records, including, but not limited to, imaging records or reproductions thereof, for a minimum of 10 years. The 10-year retention period must be based on the date of the patient's most recent treatment or service listed in the medical record. A hospice must preserve a minor's medical record for at least one year after the minor has reached the age of 18 years or for a minimum of 10 years, whichever is longer.

(c)

Hard copy patient medical records must be stored in a confidential manner at the hospice's established place of business, or at an off-site storage facility approved by the Department pursuant to subdivision (p).

(d)

Patient medical records, whether hard copy or electronic health records, must:

(e)

A hospice must develop, implement, and maintain documented policies and procedures that address:

(f)

Pursuant to subdivision (e)(6), the authorized individual's identity must be authenticated with their unique identifier upon making any entry to the patient record. The entry must include, but is not limited to, the following:

(g)

A hospice must guarantee that entries regarding the provision of care or services provided are not altered without a written explanation of the reason for alteration. Authorized hospice personnel who make a medical record entry error or alter an entry, whether in a hard copy or electronic health record, must:

(h)

Authorized hospice personnel must correct any medical record errors including, but not limited to, record duplications or documentation in the wrong patient record within 48 hours of discovery.

(i)

Authorized hospice personnel must make an addendum in a patient's medical record if they add information after the time of original entry. An addendum must be distinct and traceable and include, but is not limited to, the date and authentication of the authorized hospice personnel making the added entry.

(j)

Authorized hospice personnel must make note of a patient mismatch error in the medical record upon discovery of the error.

(k)

A hospice must safeguard the information in all patient medical records, whether hard copy or electronic health record, from loss, natural disasters, defacement, destruction, tampering, or unauthorized access.

(l)

A hospice must not release any portion of a patient medical record to anyone other than the patient, except as allowed by law.

(m)

A hospice must complete all documentation and authenticate a patient's medical record within 30 days following the date of the patient's transfer, discharge, or death, as applicable.

(n)

If a hospice ceases operation or becomes inoperable for any reason, the hospice must retain or make arrangements for the safe preservation of all patient medical records in a confidential manner pursuant to this section, including the retention requirements pursuant to subdivision (b). The hospice must notify the Department in writing of the physical address where the medical records will be stored no later than 24 hours from the hospice ceasing operation or becoming inoperable.

(o)

If a hospice is experiencing a change of ownership pursuant to section 74824, both the current licensee and the prospective licensee must, prior to the change of ownership, submit to the Department a written medical record storage statement that is signed and dated by both parties. The statement must attest to the following:

(p)

A hospice must submit a written request to, and obtain approval from, the Department to store hard copy patient medical records at an off-site storage facility. The written request must include:

(q)

A hospice must notify in writing and obtain approval from the Department if any one of the following occurs:

(r)

Patient medical records, including, but not limited to, electronic storage media containing medical records, that are stored at an off-site facility approved by the Department must be: