Pa. Code 5310.51

Case record

This section establishes case record requirements for Community Residential Rehabilitation Services (CRRS) under 55 Pa. Code Chapter 5310. Operators must initiate a case record at intake for each client, maintain it throughout the service period, and retain it for at least five years after discharge. Each record must include client identifying information, emergency contacts, medical/special needs, and program documentation such as residential service plans, progress reviews, and termination summaries. The Director or designee must annually review case records, document findings, and adjust recording procedures as needed.

55 Pa. Code § 5310.51 - Case record 

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(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.

(b)
 Each case record must
 include the following information:
(1)
 The
 following client identifying information must be in the case record: 
 
(i)
 Name.

(ii)
 Date of birth.

(iii)
 Sex.

(iv)
 Social security number.

(v)
 Religious affiliation, if client chooses
 to state the affiliation.

(vi)
 Date
 of entry into the CRRS.

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

 Name, address, telephone number, and contact person for the case
 management/treatment agency, if any.

(ii)
 Name, address, and telephone numbers of
 client family members of significant others.

(iii)
 Name and telephone number of the person
 designated by the client to be called in case of emergency.

(iv)
 Name and telephone number of client's
 personal physician or therapist, if applicable.

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

(ii)
 Medication
 regimen.

(iii)
 Medical problems,
 such as diabetes, heart disease and epilepsy.

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

(ii)
 Individual's
 residential service plan, dated and signed.

(iii)
 Name of the designated staff person for
 the client.

(iv)
 Service plan
 reviews and other reports of performance and progress which must be dated and
 signed.

(v)
 Referral activity,
 correspondence, reports of emergencies, accidents, and illness.

(vi)
 Dated and signed annual
 reassessments.

(vii)
 Dated and
 signed termination summary.

(viii)

 A copy of written agreement between the CRRS and the client.

(ix)
 Written consent for disclosure of
 information.

(c)

 Client case records must be: 
(1)
 Legible and
 in ink or typewritten.

(2)

 Organized and maintained according to a uniform format so that information is
 readily located.

(d)
 The
 Director or his designee shall annually:
(1)

 Review client case records to monitor the nature and quality of the
 recording.

(2)
 Prepare a written
 summary of the review, including date, methods used and findings.

(3)
 Make adjustments in recording procedures
 as needed.

Notes

55

 Pa. Code §
 
5310.51

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).

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