INDIVIDUAL RECORD

A PRS agency shall develop and maintain a record for an individual served containing the following:

1. (1) Information that identifies the individual.
2. (2) Eligibility for PRS, including diagnosis.
3. (3) Referral source, reason for referral and recommendation by an LPHA.

4. (4) A signed set of documents providing the following:

   1. (i) Documentation of consent to receive PRS that is in accordance with Federal and State laws and regulations on obtaining consent to treatment.
   2. (ii) Documentation of consent to release information that is in accordance with Federal and State laws and regulations on obtaining consent to release records.
   3. (iii) Verification that the individual received and had an opportunity to discuss the oral and written versions of the PRS statement of rights under § 5230.41 (relating to PRS statement of rights).
   4. (iv) Documentation that the individual has chosen to receive PRS as required by § 5230.31(d) (relating to admission requirements).
5. (5) An assessment and updates.
6. (6) The IRP.
7. (7) Staff documentation of IRP outcomes.

8. (8) Staff documentation of coordination with other services and supports including the following:

   1. (i) Outreach and engagement efforts with natural supports, including family members, as directed by the individual.
   2. (ii) Ongoing contacts and involvement with formal supports.
9. (9) Discharge summary.

Authority

The provisions of this § 5230.21 amended under sections 911 and 1021 of the Human Services Code (62 P.S. § § 911 and 1021).

Source

The provisions of this § 5230.21 amended January 17, 2025, effective January 18, 2025, 55 Pa.B. 463. Immediately preceding text appears at serial page (366815).