RECORDS
§ 5240.41. Individual records.
(a) An IBHS agency shall maintain a record for each child, youth or young adult it serves that includes the following:
(1) Identifying information.
(2) A written order for IBHS in accordance with § § 1155.32(a)(1), 1155.33(a)(1) or 1155.34(a)(1) (relating to payment conditions for individual services; payment conditions for ABA services; and payment conditions for group services).
(3) An assessment and any updates to the assessment in accordance with § § 5240.21, 5240.85, 5240.95 or 5240.102.
(4) Presenting problems.
(5) The ITP and any updates to the ITP in accordance with § § 5240.22, 5240.86, 5240.96 or 5240.102.
(6) A treatment plan if services are being provided prior to the completion of the ITP.
(7) Documentation of any efforts to coordinate care with other services and community supports if needed.
(8) Documentation of each service provided that includes the following:
(i) Date and time services were provided, duration of services and setting where services were provided.
(ii) Identification of the service provided to address a goal in the ITP.
(iii) Description of the outcome of the services provided.
(iv) Signature of the staff person providing the service.
(9) If services are not provided in accordance with the ITP and written order, an explanation of the reason why services were not provided in accordance with the ITP and written order.
(10) Consent to treatment and consent to release information forms.
(11) Discharge summary in accordance with § 5240.32 (relating to discharge summary).
(12) Documentation of any use of a manual restraint and a description of how the use was in accordance with § 5240.6 (relating to restrictive procedures), including the following:
(i) The specific behavior addressed.
(ii) The less intrusive methods of intervention used to address the behavior prior to initiating the manual restraint used.
(iii) The specific manual restraint used.
(iv) The name and training of the staff person who used the manual restraint.
(v) The duration of the manual restraint.
(vi) The name of the trained individual who observed the child, youth or young adult during the application of the manual restraint.
(vii) The child’s, youth’s or young adult’s condition following the manual restraint.
(viii) The date and time the manual restraint was used.
(ix) The date and time the treatment team was notified of the use of a manual restraint and the members of the treatment team who were notified.
(b) The record must be:
(1) Legible.
(2) Signed and dated by the staff person writing in the record.
(3) Reviewed for quality by the administrative director, clinical director or designated quality improvement staff within 6 months of the initial entry. After initial review, subsequent reviews may be limited to new additions to the record and must occur at least annually.
(c) The record shall be maintained for a minimum of 4 years after the last date of service.
Cross References This section cited in 55 Pa. Code § 1155.22 (relating to ongoing responsibilities of providers); 55 Pa. Code § 5240.6 (relating to restrictive procedures); and 55 Pa. Code § 5240.98 (relating to requirements for group services in school settings).
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