§ 52.15. Provider records.
(a) The following requirements are in addition to the recordkeeping provisions under § 1101.51(d) and (e) (relating to ongoing responsibilities of providers):
(1) A provider shall use the Department’s designated information system to record service plan information regarding the participant as required under § 52.25 (relating to service plan).
(2) A provider shall complete and maintain documentation on service delivery.
(b) Electronic records are acceptable documentation when the provider meets the following:
(1) The electronic format conforms to Federal and State requirements.
(2) The electronic record is the original record and has not been altered or if altered shows the original and altered versions, dates of creation and the creator.
(3) The electronic record is readily accessible to the Department, the Department’s designee and State and Federal agencies.
(4) The provider creates and implements an electronic record retention policy.
(5) Electronic imaging of paper documentation must result in an exact reproduction of the original record and conform to the provider’s electronic record retention policy.
(c) The provider shall ensure records are compliant with the Health Insurance Portability and Accountability Act of 1996 (Pub. L. No. 104-191).
(d) The requirements of this section are in addition to the recordkeeping provisions in Chapters 2380 and 2390 (relating to adult training facilities; and vocational facilities), 6 Pa. Code Chapter 11 (relating to older adult daily living centers) and 28 Pa. Code Chapters 601 and 611 (relating to home health care agencies; and home care agencies and home care registries).
Cross References This section cited in 55 Pa. Code § 52.19 (relating to criminal history checks); and 55 Pa. Code § 52.43 (relating to audit requirements).
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