CLIENT RECORDS

1. (a) A case record must be initiated at intake for each client, be maintained through the service period, and retained at least 5 years after the client leaves the program.

2. (b) Each case record must include the following information:

   1. (1) The following client identifying information must be in the case record:

      1. (i) Name.
      2. (ii) Date of birth.
      3. (iii) Sex.
      4. (iv) Social security number.
      5. (v) Religious affiliation, if client chooses to state the affiliation.
      6. (vi) Date of entry into the CRRS.

   2. (2) The following emergency and contact information must be in the case record:

      1. (i) Name, address, telephone number, and contact person for the case management/treatment agency, if any.
      2. (ii) Name, address, and telephone numbers of client family members of significant others.
      3. (iii) Name and telephone number of the person designated by the client to be called in case of emergency.
      4. (iv) Name and telephone number of client’s personal physician or therapist, if applicable.

   3. (3) The following medical/special information must be in the case record:

      1. (i) Any dietary restrictions.
      2. (ii) Medication regimen.
      3. (iii) Medical problems, such as diabetes, heart disease and epilepsy.

   4. (4) The following program information must be in the case record:

      1. (i) Intake information.
      2. (ii) Individual’s residential service plan, dated and signed.
      3. (iii) Name of the designated staff person for the client.
      4. (iv) Service plan reviews and other reports of performance and progress which must be dated and signed.
      5. (v) Referral activity, correspondence, reports of emergencies, accidents, and illness.
      6. (vi) Dated and signed annual reassessments.
      7. (vii) Dated and signed termination summary.
      8. (viii) A copy of written agreement between the CRRS and the client.
      9. (ix) Written consent for disclosure of information.

3. (c) Client case records must be:

   1. (1) Legible and in ink or typewritten.
   2. (2) Organized and maintained according to a uniform format so that information is readily located.

4. (d) The Director or his designee shall annually:

   1. (1) Review client case records to monitor the nature and quality of the recording.
   2. (2) Prepare a written summary of the review, including date, methods used and findings.
   3. (3) Make adjustments in recording procedures as needed.

Cross References

This section cited in 55 Pa. Code § 5310.91 (relating to special requirements for community residential rehabilitation service (CRRS) serving children); and 55 Pa. Code § 5310.141 (relating to case record).