1. (1) The licensee shall maintain client information to include the following:

   1. (a) client name, address, email address, phone number, date of birth and identified gender;
   2. (b) emergency contact names, including legal guardian where applicable, and at minimum, the emergency contact's physical address, current email address or current phone numbers;
   3. (c) a program serving substance use disorder clients shall maintain compliance with an initial and annual client tuberculosis screening results in each client record;
   4. (d) any information that could affect health safety or well-being of the client including each medication, allergy, chronic condition or communicable disease;
   5. (e) intake screening and assessment;
   6. (f) discharge documentation;
   7. (g) treatment or service plan;

   8. (h) progress notes and services provided with date and signature of staff completing each entry;

      1. (i) individualized assessment for restriction of access to on-site items that could be used as weapons, for self-directed violence, or as an intoxicant;
   9. (j) any referral arrangements made by the program;

   10. (k) client or guardian signed consent or court order of commitment to services in lieu of signed consent for each treatment and non-clinical service;

       1. (l) summary of attendance and absences in treatment services;
   11. (m) any grievance or complaint made by or against the client and actions taken by the program;
   12. (n) each crisis intervention or critical incident report involving the client; and
   13. (o) any signed agreement and consent form.
2. (2) The licensee shall document a plan detailing how each program staff and client file is maintained and remains available to the office and other agencies legally authorized to access the files for seven years regardless of whether the program remains licensed.

KEY: licensing, human services

Date of Last Change: April 24, 2025

Notice of Continuation: October 3, 2022

Authorizing, and Implemented or Interpreted Law: 26B-2-104