1. (a) Providers shall maintain service records for all individuals receiving Title XX services.

2. (b) The service record shall contain:

   1. (1) The individual’s name, address, and telephone number;
   2. (2) The name, address, and telephone number of the individual’s primary caregiver;
   3. (3) The name and telephone number of a person who may be contacted in an emergency;
   4. (4) Documentation of the individual’s communication access needs, including modality, and the name of the communication access provider or type of device utilized, if applicable;
   5. (5) The name and telephone number of the individual’s licensed health practitioner, if applicable;
   6. (6) The name and contact information for the pharmacy used by the individual, if applicable;
   7. (7) The application described in He-E 501.06;
   8. (8) The notice of decision described in He-E 501.07;
   9. (9) The service authorization form required by He-E 501.16;
   10. (10) The person-centered plan as described in He-E 501.22;
   11. (11) Copies of correspondence related to service provision; and

   12. (12) Documentation of the following:

       1. a. The name of the Title XX service being provided, and the type of service activities, based on the service description contained in this rule;
       2. b. The dates of service provision and other related contacts with the individual;
       3. c. Changes in the individual’s health or other circumstances affecting service provision;
       4. d. Any other information or correspondence deemed relevant to service provision; and
       5. e. Documentation of any referrals made to other resources or programs.
3. (c) Service records shall be kept confidential in accordance with He-E 501.03 and all applicable federal and state laws, rules, or regulations.
4. (d) Service records shall be retained for a period of 4 years after services have ended or been terminated.

Source. #9849-A, eff 1-12-11, EXPIRED: 1-12-19 New. #12720, INTERIM, eff 1-29-19, EXPIRED: 7-29-19 New. #12936, eff 12-7-19 (formerly He-E 501.16)