55 Pa. Code § 4226.36 – Child records.

(a) The county MH/MR program and every provider that contracts with a county MH/MR program to deliver early intervention services shall maintain a separate file for each child referred or accepted for tracking or early intervention services.
(b) Entries in a child’s record shall be legible, dated and signed by the person making the entry.
(c) Each child’s record shall contain, as applicable:
1. (1) Personally identifiable information.
2. (2) Intake information.
3. (3) Child evaluation and assessment information.
4. (4) IFSPs.
5. (5) Service support plans specifying the therapy services to be provided.
6. (6) Letters of medical necessity.
7. (7) Service coordination and service delivery activity logs.
8. (8) Health records.
9. (9) Notices issued under § 4226.95 (relating to prior notice).
10. (10) Other information, as specified in this chapter.
(d) Information in the child’s record shall be kept for at least 4 four years or until any audit or litigation is resolved.
(e) A child’s record shall be kept for a least 4 years following the child’s discharge from service or until any audit or litigation is resolved.
Cross Reeferences
This section cited in 55 Pa. Code § 4226.14 (relating to documentation of other funding sources).